Decentralization Of Services Research Articles

Pediatric Tuberculosis Diagnostics: Present and Future.

The current diagnostic abilities for the detection of pediatric tuberculosis are suboptimal. Multiple factors contribute to the under-diagnosis of intrathoracic tuberculosis in children, namely the absence of pathognomonic features of the disease, low bacillary loads in respiratory specimens, challenges in sample collection, and inadequate access to diagnostic tools in high-burden settings. Nonetheless, the 2020s have witnessed encouraging progress in the area of novel diagnostics. Recent WHO-endorsed rapid molecular assays hold promise for use in service decentralization strategies, and new policy recommendations include stools as an alternative, child-friendly specimen for testing with the GeneXpert assay. The pipeline of promising assays in mid/late-stage development is expanding, and novel pediatric candidate biomarkers based on the host immune response are being identified for use in diagnostic and triage tests. For a new test to meet the pediatric target product profiles prioritized by the WHO, it is key that the peculiarities and needs of the hard-to-reach pediatric population are considered in the early planning phases of discovery, validation, and implementation studies.

An intervention pilot to facilitate harm reduction service decentralization in Vietnam

IntroductionHarm reduction services, including methadone maintenance therapy (MMT), have been decentralized to Vietnam's community health care settings. This study aims to pilot test an intervention to facilitate decentralized harm reduction service delivery in Vietnam. MethodsThe research team conducted an intervention pilot between August 2020 and May 2021 with six community MMT distribution sites in Thai Nguyen Province of Vietnam. We recruited five commune health workers (CHW) from each center (N = 30). In-person intervention training included content to correct misconceptions about harm reduction and reduce stigmatizing attitudes toward patients who use drugs and teach CHWs to self-examine and improve their service provision process. The study team developed a web-based platform to streamline CHW's patient monitoring and referral efforts. The team assessed intervention outcomes at baseline, 3-, and 6-months. CHWs in the intervention group provided acceptability ratings and feedback on the intervention at 6-months. ResultsCHWs in both intervention and control groups had similar background characteristics and outcome measures at baseline. CHWs in the intervention group, compared to those in the control group, showed a significantly higher level of improvement in adherence to service delivery protocol at 3-months. CHW in the intervention group had a significantly lower level of management-related stress compared to the control group at 6-months, although the intervention effect measured by the difference in change from baseline was not statistically significant. CHWs who participated in the final focus group reported high acceptability of the intervention. ConclusionThis intervention pilot demonstrated acceptability and promising outcomes on community-based harm reduction service delivery. Similar intervention strategies can be applied to enhance the decentralization of other chronic disease treatment services.

Health System Decentralization: Creating as Many Problems Than It Solves? Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis".

This comment draws on the study by Rotulo et al about the effects of fiscal decentralization on access, utilization and availability of healthcare resources across Italian regions. We start by discussing the recent trends in health system decentralization worldwide, and then reflect on the rationale and main benefits and the key complexities and challenges of this much debated reform. We address these issues with reference to the recent experience of Italy as well as that of other comparable highly decentralized countries, most notably Spain, paying particular attention to their similarities and contrasts. We conclude that decentralization of health services poses complex challenges and trade-offs which may require careful design of equalisation mechanisms, framework regulation and efficient coordination mechanisms by central and sub central governments.

Impacts of tuberculosis services strengthening and the COVID-19 pandemic on case detection and treatment outcomes in Mimika District, Papua, Indonesia: 2014-2021.

Indonesia is a high-burden tuberculosis (TB) country with a wide case detection gap, exacerbated by the COVID-19 pandemic. We aimed to review the epidemiology of TB in a high-endemic setting of Indonesia before and during the implementation of health system strengthening activities for TB, including during the first two years of the COVID-19 pandemic. We analysed TB program data from Mimika District, Papua, Indonesia from 2014 to 2021. Health system strengthening activities to improve the programmatic management of TB were implemented from 2017 onwards. Activities included decentralization of TB services, training and mentoring of healthcare workers, improved screening for co-morbidities, and introduction and optimisation of Xpert testing in 2018. A total of 11,803 TB cases were notified to the Mimika District Health Office over eight years (2014-21). Between 2015 and 2019, there was a 67% increase in annual case notifications, an 89% increase in bacteriologically confirmed cases and the proportion of TB cases detected in primary care increased from 26% to 46%. In 2020, coinciding with the COVID-19 pandemic, investigation of people with presumptive TB fell by 38%, but the proportion of those tested with Xpert increased. TB case notifications decreased by 19% from 1,796 in 2019 to 1,461 in 2020, but then increased by 17% to 1,716 in 2021. Routine screening for co-morbidities (HIV, diabetes) among TB patients improved over time and was not affected by the pandemic. Treatment success overall was 71% and remained relatively unchanged. Loss to follow-up and death were 18% and 3.7% respectively. Improvements in TB case finding were observed over a period in which a range of health system strengthening activities were implemented. While COVID-19 had a negative impact on the TB program in Mimika District, there are encouraging signs of recovery. Further work is needed to improve TB treatment outcomes.

Pre-diagnosis and pre-treatment attritions among presumptive MDR/RR-TB patients in Chonburi province, Thailand, 2015-2017

The low detection rate of multidrug-resistant tuberculosis (MDR-TB) is one of the major obstacles to TB control in Thailand. Thus, this study aimed to assess pre-diagnosis and pre-treatment attrition rates among patients suspected of having MDR-TB, identify factors related to pre-diagnosis attrition, and determine the turnaround times (TAT) of diagnosis and treatment pathway. A retrospective cohort analysis was conducted using a record review. Among 972 presumptive MDR-TB patients, only 354 (36.4%) underwent drug-susceptibility testing (DST). Multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) was found in 32 patients, consisting of 26 (81.2%) males and 6 (18.8%) females. Pre-diagnosis and pre-treatment attrition rates were 63.58 % and 28.1%, respectively. Furthermore, the median (interquartile range [IQR]) turnaround time for MDR-TB testing was seven days (IQR 0-62 days), and the median time to the start of MDR-TB treatment was 20 days (IQR 2-38 days). Meanwhile, the factors associated with pre-diagnosis attrition were migrants, presumptive TB cases presenting at secondary-level hospitals, TB patients identified from hospitals outside the Ministry of Public Health, and extrapulmonary TB cases. The results of this research demonstrated that only one-third of patients at risk of MDR-TB underwent DST. Therefore, it is essential for healthcare workers at all levels to be educated and trained to identify patients that are eligible for DST. In addition, other interventions such as the decentralization of laboratory services and MDR-TB treatment to secondary-care district hospitals are also urgently needed.

The National Rural Water and Sanitation Project (1985-1989) in Brazil: limits and potentials

In this article, the principles of the National Rural Water and Sanitation Project (PNSR), elaborated during the 1980s, are analyzed, discussing the advances and the limits reached in the development of rural water supply and sanitation in Brazil. The methodology used was an analysis of the content of documents and interviews with key actors. The results have demonstrated that the formulation of the PNSR promoted a new contribution of knowledge to the water and sanitation sector in Brazil, bringing innovations concerning the approach to water and basic sanitation in rural areas, especially relating to its integration with health, the processes of education and social participation, the decentralization of services, the use of appropriate technologies and community involvement in the management of services. Although it did not result in a government program, the legacy left by the PNSR has provided a great contribution in the form of studies, which are still relevant today.

Relevance of extension advisory services in climate smart agriculture : A review

Study was conducted to explore the role of extension advisory services in relation to smart agriculture to mitigate the effect of climate. Agriculture is a very prominent sector of the Indian economy accounts for (49%) of the employment and one-sixth of the GDP. The agricultural industry is supported by 500 million small holder farms. Agriculture is extremely vulnerable for climate change and water as well. Climate change affects agriculture in the Asia and Pacific region particularly in those areas that are vulnerable to natural disasters. Higher temperature reduce yield of desirable crops while encouraging weeds and pests proliferation. Changes in precipitation pattern and floods affect agriculture causing crop failures. In India, significant negative impacts occurred due to climate change reasoned to reducing the yields. In addition to advisory services advanced information on likelihood of weather help to carry out to proper management of resources for agricultural operations to minimize the risk and facilitate growth and realizes the optimum crop yield. Further, decentralization of extension services tracing the different state or district-level funding is needing exercise not always known at national level in various states or provinces spending on extension service. It plays a prominent role by creating awareness regarding adaptation of best practices regarding climate change, deforestation and planting of trees also potential to transform the vision of India’s famers about food security, poverty alleviation and sudden climatic threats. Thus, the advisory services help taking the advantage of benevolent weather and minimize adverse impact of malevolent weather.

Community-based decentralized mental health services are essential to prevent the epidemic turn of post-Covid mental disorders in Bangladesh: A call to action.

Community-based decentralized mental health services are essential to prevent the epidemic turn of post-Covid mental disorders in Bangladesh: A call to action.

A mixed methods study to assess the impact of COVID-19 on maternal, newborn, child health and nutrition in fragile and conflict-affected settings

BackgroundThe impacts of COVID-19 are unprecedented globally. The pandemic is reversing decades of progress in maternal, newborn, child health and nutrition (MNCHN), especially fragile and conflict-affected settings (FCAS) whose populations were already facing challenges in accessing basic health and nutrition services. This study aimed to investigate the collateral impact of COVID-19 on funding, services and MNCHN outcomes in FCAS, as well as adaptations used in the field to continue activities.MethodsA scoping review of peer-reviewed and grey literature published between 1st March 2020–31st January 2021 was conducted. We analysed 103 publications using a narrative synthesis approach. 39 remote semi-structured key informant interviews with humanitarian actors and donor staff within 12 FCAS were conducted between October 2020 and February 2021. Thematic analysis was undertaken independently by two researchers on interview transcripts and supporting documents provided by key informants, and triangulated with literature review findings.ResultsFunding for MNCHN has been reduced or suspended with increase in cost of continuing the same activities, and diversion of MNCHN funding to COVID-19 activities. Disruption in supply and demand of interventions was reported across different settings which, despite data evidence still being missing, points towards likely increased maternal and child morbidity and mortality. Some positive adaptations including use of technology and decentralisation of services have been reported, however overall adaptation strategies have been insufficient to equitably meet additional challenges posed by the pandemic, and have not been evaluated for their effectiveness.ConclusionsCOVID-19 is further exacerbating negative women’s and children’s health outcomes in FCAS. Increased funding is urgently required to re-establish MNCHN activities which have been deprioritised or halted. Improved planning to sustain routine health services and enable surge planning for emergencies with focus on the community/service users throughout adaptations is vital for improved MNCHN outcomes in FCAS.

From the global to the subnational scale: Landing the compositional monitoring of drinking water and sanitation services

Monitoring of access to water and sanitation services is stipulated in Sustainable Development Goals (SDG) 6.1 and 6.2, respectively. The monitoring is carried out with a global, regional and country vision. However, in most developing countries, decentralization of services in water and sanitation management has tended to the sub-national level or has shared responsibilities between national and sub-national governments. Management at the subnational level becomes more important, since everything that is done there will impact the objectives and goals of the country. However, little or nothing progress has been made in harmonizing global indicators with those at the subnational level. Therefore, in this study we have proposed a way to disaggregate information and form WASH ladders at the subnational level.The results show using disaggregated data to interpolate models at the subnational level requires overcoming three main points: the validation of the data through statistical methods, interpolation techniques that go according to the compositional characteristics of the data and the incorporation of the uncertainty of the data into the model results. It also shows that subnational behavior is heterogeneous, which a general analysis does not capture correctly, i.e., there is a masking effect of subnational trends that the country's trend does not represent. However, these have been exceptional cases in some specific categories. Finally, the applicability of non-linear models is contrasted in a broader context, an issue that is still under discussion for its application to global monitoring. This study also provides a way to disaggregate information from the global to the sub-national level, allowing any sector analyst to replicate the methodology in a broader context.

Democratic Governance Strengthening in The Implementation of Data Validation and Verification of Health Insurance Contributions Recipients

The verification and validation of field data is an effort to ensure that the data on the Health Insurance Contribution Assistance Beneficiary (PBI-JK) is valid and accurate. Therefore, this study aims to examine the implementation of verification and validation of PBI-JK data in Musi Banyuasin Regency and Palembang City from the point of view of implementing democratic governance principles. The research method used is descriptive qualitative with data collection techniques, document studies, interviews and observations. The results of the study indicate that prelist data services are carried out centrally, the role of regional social services is minimal, community participation is low, and information disclosure and public accountability are minimal. Therefore, it is necessary to strengthen democratic governance in the implementation of PBI-JK data verification and validation, through the implementation of limited decentralization of data services, the involvement of local social services, and the implementation of participatory, transparent and accountable data verification and validation.

Findings of a Nationwide Mixed-Methods Assessment of Cancer Care and Prevention Needs in Botswana

PURPOSE High-level investment in cancer prevention and control in low- and middle-income countries is urgently needed to address the predicted surge in cancer incidence, yet few assessments of health systems have systematically identified gaps in infrastructure, training, and patient care in sub-Saharan Africa. In Botswana, we evaluated the current state of cancer care and prevention, to understand the strengths, weaknesses, and needs regarding the provision of comprehensive cancer services. METHODS The study evaluated four regional hospitals designated as cancer sites by the Botswana Ministry of Health and Wellness to decentralize cancer services. A multi-site, cross-sectional evaluation using qualitative and quantitative methods was conducted. Focus Group Discussions with cancer patients, cancer survivors, caregivers, the general population, and healthcare workers were analyzed for emergent themes. Quantitative surveys assessed knowledge, attitudes and practices of health workers and hospital management staff, and cancer service gaps at health facilities. RESULTS Knowledge gaps included low awareness of cancer signs and symptoms among the general population, poor knowledge of early detection and treatment among health workers, and caregivers lacked skills to support cancer patients. Cancer screening services, other than cervical screening, were limited in all sites. Diagnosis and treatment barriers included lack of specialized personnel, equipment, timely pathology services, and drug stockouts. There were low levels of confidence in cancer management, including chemotherapy, without support from oncologists. Providers reported low patient screening uptake due lack of access and patients reported fear of diagnosis. Health facilities did not routinely notify cancers to the national registry. Radiotherapy was limited to one private hospital in the capital. CONCLUSION Decentralization of cancer services to regions will require substantial capacity building at district hospitals to strengthen fragmented screening, early diagnosis and treatment services. Health provider training needs and infrastructure gaps were substantial, with low public awareness of cancer signs, symptoms and causes.

DEVELOPMENT OF THE SOCIAL SPHERE IN MODERN TERRITORIAL COMMUNITIES

The article presents the results of the study of social services development in territorial communities in Ukraine in the context of decentralization. Based on the analysis of the literature, the contradictions and challenges that arise in the process of decentralization of social services are highlighted. The empirical part of the study included a survey of representatives of local communities from six regions of Ukraine, as well as a survey of experts from community mobilization projects. In total, 21 semi-structured interviews were conducted between August 2021 and February 2022.
 The article describes the features of social services development in communities in the context of decentralization from the standpoint of the communities themselves, namely: targeting and ways of organizing social services in communities; existing mechanisms for evaluating the effectiveness of social services in communities; factors of development of social services in territorial communities. Research has shown that social services in local communities are organized through the creation of territorial centers for social services, and the main recipients of services are families in difficult circumstances, the elderly and people with disabilities. According to the obtained data, the mechanisms for assessing the effectiveness of social services in communities are: collection of statistical data on the situation in the community; survey of service recipients; independent monitoring of the effectiveness of social services. The study proved the presence of factors in the development of social services in local communities, which can ensure the effectiveness of decentralization of social services. The following factors are highlighted: the effectiveness of assessing the needs of the population; level of interaction "local government - population - public sector"; willingness to cooperate and attract external resources.
 The interviews also provided an opportunity to identify internal and external factors that help and hinder the development of social services in local communities, ie to conduct SWOT analysis.

Reliable data delivery in ICN-IoT environments

In an IoT environment, which is characterized by a multitude of interconnected smart devices with sensing and computational capabilities, many applications are (i) content-based, that is, they are only interested in finding a given type of content rather than the location of data, and (ii) contextualized, that is, the content is generated and consumed in the proximity of the user. In this context, the Information-Centric Networking (ICN) paradigm is an appealing model for efficiently retrieving application data, and the service decentralization towards the network edge helps to reduce the core network load being the data produced by IoT devices mainly confined in the area where they are generated. MobCCN is an ICN-based data delivery protocol that we designed for operating efficiently in such context (Borgia et al., 2016, 2018), where static and mobile IoT devices are enriched with ICN functions. Specifically, MobCCN leverages an efficient routing and forwarding protocol, exploiting opportunistic contacts among IoT mobile devices, to fill the Forwarding Interest Base (FIB) tables so as to correctly forward Interest packets towards the intended data producers. In this paper, we aim to enhance the reliability of MobCCN by exploring different retransmissions mechanisms, such as retransmissions based on number of duplicate Interests that are received for the same requested content, periodic retransmissions, single path versus disjoint multi-path forwarding, hysteresis mechanism and combinations of them. Extensive simulation results show that, among the analysed MobCCN variants, the one that implements both periodic retransmissions and a hysteresis-based retransmission process ensures the highest delivery rates (up to 95%) and the shortest network path, with a very limited traffic overhead due to retransmissions.

Public Policy Management and Good Governance: Challenges and the Way Forward

The world is facing extraordinary challenges. Policymakers are attempting to develop institutions that are able to cope with rapid changes in demographics, the environment, and the economy. Policymakers are part of the system in which governments operate. Numerous external and internal pressures continuously attack this structure. Exogenous changes or fresh knowledge caused policies to be reversed or revised more frequently than necessary. In India, policymakers are confronted with an increasing number of issues caused by various types of complexity. In this complex environment, the demand for good policy making is steadily increasing. The objective of this paper is to study various facets and dimensions of good governance from public policy perspective. The paper also explores the public policy alternatives and methods to address the issues and challenges of good governance in India. During the discussion, the authors found that corruption and poor capacity building are main impediments in establishing good governance which in turn hampers the efficiency and equity in the provision of public services, thereby weakening the enforcement mechanism of public policy management principles. The paper also revealed that for effective public policy management and administration, there is a dire need to formulate and implement stringent rules and regulations against the menaces like illegal use of force, corruption, bureaucratic bungling, criminalisation of politics and other constraints hampering good governance. Therefore, to create checks and balances across tiers of government and to correct the existing distortions, the paper suggests reform strategies such as decentralisation of public services through participation of private sector, involvement of poor people in state sponsored development programmes, outcome orientation and having women representation in democratic institutions for ensuring good governance. In order to accomplish these desired social changes, enacting strong legislation with severe penalties and its rigorous execution is the need of the hour.

When Less Gold is More: Selective Attomolar Biosensing at the Nanoscale

AbstractThe development of biosensors has become increasingly important to tackle the spread of potentially pandemic pathogens and for the decentralization of healthcare services. Despite progress, achieving selective detection of ultralow concentrations of biomarkers in complex fluids with point‐of‐care devices is a standing challenge. Here, an efficient material platform for the sensing of biomarkers down to attomolar concentrations with excellent selectivity and a tuneable linear response range is reported. It is demonstrated that by decreasing the Au nanoislands on an elsewhere passivated surface, it is possible to more than double their electrochemical response to low biomarker concentrations via a gate‐type mechanism. As an exemplary application, the first sensing of glycated albumin, a key biomarker for diabetes management, in clinically relevant levels by conjugation of a selective DNA aptamer to the Au nanoisland surface is showcased. With a limit of detection of 0.55 × 10−18 m, the excellent selectivity of this platform against nonspecific biomolecules is validated. This platform shows exceptional sensitivity and selectivity in mouse serum, further highlighting its potential for clinical utility. The versatility of this platform to detect other biomarkers, like miRNAs, is also showcased. These findings provide a flexible material platform for the scalable and low‐cost engineering of future point‐of‐care biosensors.

Prevalence and determinants of death registration and certification uptake in Uganda.

Death registration in Uganda remains extremely low, yet mortality statistics are vital in health policy, planning, resource allocation and decision-making. According to NIRA, only 1% of deaths are registered annually, while Uganda Bureau of Statistics estimates death registration at 24% for the period 2011–2016. The wide variation between the administrative and survey statistics can be attributed to the restriction to only certified death registration by NIRA while survey statistics relate to all forms of death notification and registration at the different sub-national levels. Registration of deaths is of critical importance to individuals and a country’s government. Legally, it grants administrative rights in management of a deceased’s estate, and access to social (insurance and pension) benefits of a deceased person. It is also essential for official statistics and planning purposes. There is an urgent need for continuous and real-time collection of mortality data or statistics in Uganda. These statistics are of significance in public health for identifying the magnitude and distribution of major disease problems, and are essential for the design, implementation, monitoring, and assessment of health programmes and policies. Lack of such continuous and timely data has negative consequences for the achievement of both national and Sustainable Development Goals 3, 11, 16, and 17. This study assessed the determinants of death registration and certification, using a survey of 2018–2019 deaths in 2,100 households across four administrative regions of Uganda and Kampala district. Multivariate–binary logistic regression was used to model factors associated with the likelihood of a death being registered or certified. We find that around one-third of deaths were registered while death certificates were obtained for less than 5% of the total deaths. Death registration and certification varied notably within Uganda. Uptake of death registration and certification was associated with knowledge on death registration, region, access to mass media, age of the deceased, place of death, occupation of the deceased, relationship to household head and request for death certificate. There is need for decentralization of death registration services; massive sensitization of communities and creating demand for death registration.

A profile of the Visitect® CD4 and Visitect® CD4 Advanced Disease for Management of People Living with HIV

ABSTRACT Introduction CD4 testing plays an important role in clinical management and epidemiological surveillance of HIV disease. Rapid, point-of-care (POC) CD4 tests can improve patients’ access to CD4 testing, enabling decentralisation of HIV services. Areas covered We conducted a profile review of the Visitect®CD4 and the Visitect®CD4 Advanced Disease (Omega Diagnostics, UK) – the two lateral flow, equipment-free POC CD4 tests which can be used to identify people with HIV who have CD4 of less than 350 and 200 cells/μl, respectively. Using published data from independent studies, we discussed the performance and utility of these tests, highlighting the advantages as well as their limitations. Expert opinion The tests are user-friendly, acceptable to healthcare workers, feasible to implement in primary healthcare settings and can provide reliable results for clinical decision-making. Hand-on training with pictorial instructions for use are needed to enhance test’s operator confidence in interpretation of test results. Quality assurance program should be in place to ensure the quality of testing. Development of a next generation test with a cut-off of 100-cells/μl is recommended to identify patients with advanced immunosuppression for initiation of prophylaxis to reduce HIV-related death. Operational research is also needed to identify cost-effective implementation strategies in real-world settings.

Organizational model of municipal housing stock management in the contracting system–A case study of Poland

Social housing management across Europe is evolving towards a more market-oriented approach in response to the progressing decentralization of public services and privatization of public housing. In Poland, these trends are particularly related to changes in the organization of municipal housing stock management. One recommended option for such changes has become the evolution from an indirect system based on municipal units into a contracting system based on private entities.This paper presents the organizational model of municipal housing stock management in Poland in the contracting system. The model was designed as an organizational management standard for a typical urban municipality. The model was developed by integrating theoretical solutions and the results of empirical research conducted in Polish cities in view of the key organizational principles. The methodology for developing the model was based on the diagnostic-functional approach to designing organizational systems with the use of the Hijmans competence tables technique. This model strives to enhance the quality and efficiency of municipal housing management services by improving their organization in line with the New Public Management concept. The proposed model could be of interest to other countries where the management of social housing is subjected to restructuring and privatization pressure.

Health Center Performance Post Decentralization of Health Services Policy in Makassar City

The objectives of this study are: To describe and analyze the performance of the Health center after the decentralization of health service policies in Makassar City. This type of research is viewed from the research objective, so it is included in the format of qualitative research, which describes a phenomenon of problems that occur about the performance of the Health center, then is connected to the source of the problem, by confirming the service providers and referring to the theory related to the phenomenon that occurs. The results showed that the organizational performance of the Health center after the policy of decentralization of health services in the city of Makassar was still not optimal or still lacking and there was still much that needed to be addressed to be able to realize the expectations of the community.