Health System Development Research Articles

Results from the first audit of an intensive care unit in Botswana.

Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU). To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes. PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates. A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 - March 2018. Patient's mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups. The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted. This study is the first published audit for an intensive care unit in Botswana. The findings are especially relevant for the development of critical care capacity in the country during the current COVID-19 pandemic. We advocate for the establishment of an ICU registry in the country to allow ongoing accurate research in the field of critical care medicine and to improve healthcare for all critically ill patients in Botswana.

Recommendations for Mental Health Reforms in Uzbekistan: A Policy Report.

Introduction:There are large differences in the development of mental health systems of the West and the countries of the former Eastern Bloc. The latter is characterized by a more biological approach to mental health and reliance on psychiatric hospitals. In 2018, Uzbekistan authorities showed interest in reforming mental health care of the country. The policy report provides an overview of progress towards the provision of community mental health (CMH) care across Eastern Europe and recommendations for this transition within Uzbekistan.Methods:A literature search on mental health care in Uzbekistan was conducted to understand its strengths and weaknesses. Progress towards the provision of CMH care across Eastern Europe was assessed using data on the number of psychiatric beds and availability of mental health services in community settings reported within the published literature. Countries identified as making the greatest progress towards CMH care were reviewed in detail to better understand the process of reform assets and barriers.Results:Mental health care in Uzbekistan is highly institutionalized, underfunded and understaffed. Social care services are poorly developed. However, current leadership has kindled the promise of mental health reform. Georgia, Lithuania and Poland have made the most progress in terms of CMH care availability. However, due to various obstacles such as dual financial burden, high stigma and lack of political will, their programs lack social integration and/or uniform availability and underfunding along with scarcity of mental health specialists are common. On the other hand, research and evaluation, involvement of service users into service planning and cooperation with donors facilitated reform implementation.Conclusions:Uzbekistan may develop into a modern mental health system and avoid the setbacks encountered by other countries in the region, through careful financial planning, stigma reduction, improving mental health literacy, human resources strategic development and civil society engagement.

Do Maternal Microbes Shape Newborn Oral Microbes?

Strong evidence suggests that the early composition of the oral microbiota of neonates plays an important role for the postnatal development of the oral health or immune system. However, the relationship between the maternal microbiome and the initial neonatal microbiome remains unclear. In this study, 25 pregnant women and their neonates were recruited, and the samples were collected from the maternal oral cavity, amniotic fluid, placenta and neonatal oral cavity. High-throughput sequencing of 16S rRNA was performed using the Illumina MiSeq platform to analyze the correlation with microbial community structure between the maternal and the neonatal oral cavity. The results indicated that the number of shared OTUs was up to 635 in four groups. The PCoA showed that there were certain similarities in the microbial community structure of the four groups. The dominant bacterial genera of the shared OTUs were consistent with human oral microbes, including Streptococcus, Fusobacterium and Prevotella. The results showed that there might be a correlation between the maternal and neonatal oral microbiome, through the amniotic fluid and placenta.

SnapKi-An Inertial Easy-to-Adapt Wearable Textile Device for Movement Quantification of Neurological Patients.

The development of wearable health systems has been the focus of many researchers who aim to find solutions in healthcare. Additionally, the large potential of textiles to integrate electronics, together with the comfort and usability they provide, has contributed to the development of smart garments in this area. In the field of neurological disorders with motor impairment, clinicians look for wearable devices that may provide quantification of movement symptoms. Neurological disorders affect different motion abilities thus requiring different needs in movement quantification. With this background we designed and developed an inertial textile-embedded wearable device that is adaptable to different movement-disorders quantification requirements. This adaptative device is composed of a low-power 9-axis inertial unit, a customised textile band and a web and Android cross application used for data collection, debug and calibration. The textile band comprises a snap buttons system that allows the attachment of the inertial unit, as well as its connection with the analog sensors through conductive textile. The resulting system is easily adaptable for quantification of multiple motor symptoms in different parts of the body, such as rigidity, tremor and bradykinesia assessments, gait analysis, among others. In our project, the system was applied for a specific use-case of wrist rigidity quantification during Deep Brain Stimulation surgeries, showing its high versatility and receiving very positive feedback from patients and doctors.

Possible Correlation between Bacillus Calmette Guérin (BCG) Vaccination Policy and SARS-Cov-2 Transmission, Morbidity and Mortality Rates: Implications for the African Continent

Since its discovery in the Huanan Seafood Market, Hubei province, Wuhan, China, in December 2019, the 2019-novel Coronavirus has evolved rapidly into a global pandemic of devastating proportions. With the most developed health systems of the world struggling to contain the spread, there have been concerns raised about the relatively lower case and mortality figures coming out of the African continent, especially in the earlier days of the outbreak.

Forty-five years later: the challenge of optimizing assertive community treatment.

Assertive Community Treatment is an established evidenced based practice that provides intensive community treatment for individuals with severe mental illness with recurrent hospitalizations and/or homelessness. Emerging evidence indicates limitations in its implementation in terms of to the original ACT model and its current relevance. Findings from recent studies (2018-2020) reveals challenges with implementation centered around basic implementation activities, such as changes in the psychosocial context of individuals with SMI, clinicians' abilities to demonstrate competencies with new practices, and ongoing evolution of mental health systems of care worldwide. Intermediary and purveyor organizations (IPO) can provide the infrastructure to support the spread of EBPs while addressing challenges and opportunities. Thus, implementation of ACT can be accomplished when employing a rigorous framework and infrastructure that can synthesize and translate science relevant for practice. The relevance of ACT depends on its implementation that is responsive to change. An implementation science-informed approach is key to providing ACT to individuals in the critical space between the hospital and community. With this approach, we can optimize ACT as a service delivery vehicle by careful analysis of how best to furnish and evaluate the latest, most effective and efficient treatments, rehabilitation and support services.

IMPACT OF MATERNAL EXERCISE ON CORTICAL GEOMETRY AND TRABECULAR MICROARCHITECTURE IN MOUSE OFFSPRING

Exercise during gestation is safe and has many positive effects on the offspring, such as improved cardiovascular health and nervous system development. However, whether gestational exercise positively impacts skeletal development is unknown. PURPOSE: To determine whether maternal exercise throughout gestation and lactation positively impacts cortical geometry and trabecular microarchitecture of the femur in mouse male and female offspring. METHODS: In this longitudinal study, sexually mature C57BL/6 female mice were given ad lib access to a standard rodent chow. Two weeks before mating, females were randomized into two groups: voluntary wheel running treatment (EX) or sedentary control (SED). Females were mated to C57BL/6 males and continued treatment or control through both gestation and lactation. One male and one female offspring from each dam (n=7/group/sex) were selected and given ad lib access to a high-fat diet until 16 weeks of age, when final body weight was measured and femora collected. Cortical geometry of the mid-diaphysis and trabecular microarchitecture of the distal right femur were assessed via micro-computed tomography (μCT) with a voxel size of 12 μm. ANOVA or ANCOVA with final body weight (BW) as a covariate was used to determine the effects of maternal exercise on trabecular and cortical bone outcomes, respectively. RESULTS: There were no differences in BW between SED and EX male offspring. EX male offspring had smaller total area (Tt.Ar, p=0.075) and marrow area (Ma.Ar, p=0.025), and a higher cortical-to-total area ratio (Ct.Ar/Tt.Ar, p=0.017) compared to SED males. EX males had lesser trabecular thickness (p=0.049) but higher connectivity density (p=0.029) compared to SED. EX female offspring had greater BW than SED offspring (p=0.064). EX females had smaller Tt.Ar (p=0.017), Ma.Ar (p=0.033), and Ct.Ar (p=0.063) versus SED. EX female offspring had greater trabecular spacing (p=0.046) and degree of anisotropy (p=0.040), and lower trabecular number (p=0.034) compared to SED. CONCLUSION: Maternal exercise during gestation and lactation decreased cortical bone area independent of body weight and negatively impacted trabecular microarchitecture in both male and female offspring.

Systemic Solutions for Addressing Non-Communicable Diseases in Low- and Middle-Income Countries.

Non-communicable diseases (NCDs) have been on the rise in low- and middle-income countries (LMICs) over the last few decades and represent a significant healthcare concern. Over 85% of “premature” deaths worldwide due to NCDs occur in the LMICs. NCDs are an economic burden on these countries, increasing their healthcare expenditure. However, targeting NCDs in LMICs is challenging due to evolving health systems and an emphasis on acute illness. The major issues include limitations with universal health coverage, regulations, funding, distribution and availability of the healthcare workforce, and availability of health data. Experts from across the health sector in LMICs formed a Think Tank to understand and examine the issues, and to offer potential opportunities that may address the rising burden of NCDs in these countries. This review presents the evidence and posits pragmatic solutions to combat NCDs.

Examining Inequality in the Public Health Workforce Distribution in the Centers for Disease Control and Prevention (CDCs) System in China, 2008–2017

ObjectiveAllocation of human resources to address inequalities in the public health system has increasingly attracted societal and political attention. Using the Centers for Disease Control and Prevention (CDCs) system of China as an example, we evaluated inequality in the public health workforce distribution across different regions in China between 2008 and 2017, with the aim of providing information for policymakers to support resource allocation and address growing health inequities. MethodsWe used three standard public health workforce inequality indices - Gini coefficient, Theil L, and Theil T - and spatial autocorrelation analysis to explore spatial clusters of the workforce in different provinces, visualized with geographical tools. ResultsThe aggregate workforce-to-population ratio decreased from 1.47 to 1.42 per 10,000 population from 2008 to 2017, and was consistently lower than the National Health Commission's (NHC) recommended critical shortage threshold of 1.75. The workforce distribution inequality indices varied by regional socioeconomic and health system development. Geographic clustering of CDCs workforce distribution was evident, with H–H and L–L clusters in western China and the Guangdong-Fujian region, respectively. ConclusionsOur study addressed key issues for government and policymakers in allocation of public health human resources. There is an urgent need for careful identification of analytic questions that will help carry out public health functions in the new era, alongside policy implications for an equitable distribution of the public health workforce focusing on the western region and low–low cluster areas.

Development and improvement of Chinese oral public health system

The pandemic of COVID-19 in early 2020 is a big challenge to the mechanism of major epidemic prevention and control, the national public health management system, as well as medical and health resources in China. Going through the COVID-19 crisis, we should fully understand the problems and vulnerabilities of the current public health system in China, and it is imperative to deepen and strengthen the public health system which should be throughout whole life cycle and whole process. Oral cavity is the first portal of human body, while illness finds its way in by the mouth. Oral health is highly related to general health and quality of life. The outbreak has drawn the public's attention to the public health system. The establishment and improvement of the oral public health system with the concept of "public health with Chinese characteristics" should also attract people's attentions and thoughts. Furthermore it is urgent to recognize the importance of oral public health.

RESEARCH OF THE SPECIFIC DEVELOPMENT OF THE HEALTH CARE SYSTEM IN UKRAINE

In modern conditions, the priority task for Ukraine is the institutional transformation of the economy, the main purpose of which is to ensure sustain-able socio-economic development. Healthcare is one of the most important elements of social infrastructure of society. Its functioning ensures the reproduction of human potential, determines the ability of the national economy as a whole in the long term to respond promptly to changes of the business environment. The purpose of the article is to identify the main trends and to predict the future development of health care in Ukraine. The methodological basis of the research consist of the scientific works of domestic, foreign scientists and leading experts, statistical and analytical materials of state authorities. A questionnaire was selected as the method of data collection for the study. The survey was conducted among the top executives of educational institutions, local authorities, Kherson trade union organizations. The results were obtained through the use of methods such as: expert method to study the impact of market factors on health; economic and mathematical methods for predicting trends in health care; abstract-logical method for theoretical generalization and formulation of conclusions. The results of the study indicate that to improve the organization of the health care system in Ukraine, it is necessary to create approaches to the development of key indicators of the system that can be applied at both national and regional levels. The governance model under development should allow to create the approaches that will give a qualitative prediction of the main indicators of health system development, primarily at the regional level, as a basis for testing and further implementation throughout Ukraine. The construction of prognostication scenarios for the development of health care for the example of the Kherson region (Ukraine) revealed the most important factors that have a significant impact on the overall outcome: the number of first reported cases of diseases in the total in the region. According to the views of the involved experts, considering the level of correlation, the following indicators are most influential: the real disposable income of the population, the economically active population aged 15-70 years, the number of hospitals, the number of doctors of all specialties and the average medical staff. It is established that in the short term the number of economically active population aged 15-70 years and the number of doctors of all specialties and medical staff have a significant impact on the number of first registered cases of diseases. Therefore, the top management of na-tional health care institutions should first and foremost ensure the development of an effective system of motivation for workers (doctors of all specialties and medical staff) to perform functional responsibilities effectively and improve the quality of medical services provided as a basis for ensuring prompt detection of cases of disease among population especially aged 15-70 years.

Mental health literacy of Indonesian health practitioners and implications for mental health system development.

Compared to other countries in the South-East Asian region, Indonesia's mental health system remains underdeveloped from significant treatment gaps, which subsequently contribute to human rights violations of mental health patients who do not receive adequate medical care. In line with the introduction of universal health coverage in 2014, the Indonesian government plans to redress this by delegating detection and early intervention of mental health services to health practitioners without specialist training in mental health, however, there is limited evidence that they can perform this role effectively. This study aims to evaluate current workforce capacity by assessing differences in mental health literacy between Indonesian mental health and non-mental health practitioners. Compared to non-mental health practitioners, mental health practitioners are significantly less likely to hold stigmatising views towards individuals with mental illness. They are also significantly more likely to correctly recognise symptoms of depression and schizophrenia and recommend and implement evidence-based interventions for these conditions. These findings suggest that task-shifting is unlikely to be an effective solution to reduce the mental health treatment gap, and it is recommended that mental health system reform in Indonesia should initially focus on expansion and retention of the specialist mental health workforce.

Cancer Prevention in Low-Resource Countries: An Overview of the Opportunity.

Rising trends in the incidence of cancer in low- and middle-income countries (LMICs) add to the existing challenges with communicable and noncommunicable diseases. While breast and colorectal cancer incidence rates are increasing in LMICs, the incidence of cervical cancer shows a mixed trend, with rising incidence rates in China and sub-Saharan Africa and declining trends in the Indian subcontinent and South America. The increasing frequencies of unhealthy lifestyles, notably less physical activity, obesity, tobacco use, and alcohol consumption are causing a threat to health care in LMICs. Also, poorly developed health systems tend to have inadequate resources to implement early detection and adequate basic treatment. Inequalities in social determinants of health, lack of awareness of cancer and preventive care, lack of efficient referral pathways and patient navigation, and nonexistent or inadequate health care funding can lead to advanced disease presentation at diagnosis. This article provides an overview of opportunities to address cancer control in LMICs, with a focus on tobacco control, vaccination for cervical cancer, novel tools to assist with early detection, and screening for breast and other cancers.

Dealing with Covid -19: Lessons from China.

Gopichandran and Subramaniam in their editorial in IJME have appreciated the intensive Chinese efforts to contain the Covid-19 outbreak and wondered if other weak and developing health systems will be able to do the same.

Translational new frontiers in lung cancer research

Lung cancer (LC) accounts for 1.6 million death each year, remaining the leading cause of oncology-related death. This worst-case scenario is linked to poor survival associated with late diagnosis. This happens commonly in clinical practice, even in countries with strong and developed health systems, resulting in a lower chance of survival and a higher cost of treatment. Ideally, screening in an asymptomatic at-risk population could increase the chance of recognition cancerous cells, or even pre-cancerous conditions, in a majority of individuals who will results negative to the test. With this article, we aim to summarize the best new approach in LC research.

Разработка и внедрение системы менеджмента охраны здоровья и обеспечения безопасности труда на основе международного стандарта ISO 45001:2018

Разработка и внедрение системы менеджмента охраны здоровья и обеспечения безопасности труда на основе международного стандарта ISO 45001:2018

Interactive Textile Vestimentary Systems for Wellbeing

In response to the changes, international research and innovation has as a priority, the development of a sustainable health system with tools to ensure both the personalization of the medical act and the implementation of prevention activities. The motivation for the use of textile elements, in this context, addresses functional, aesthetic, social, communicative, psychic and moral aspects. The balance between functionality, durability, economy, ergonomics and beauty in the case of textile systems, that change the quality of life and add value, is the result of modern design focused on meeting the requirements of use. The paper presents the results of an experimental study for the realization and testing under static conditions of textile structures used as a support for attachment sensors or electronic functions.

Coalescing investments in school mental health in South Carolina.

Improving child and adolescent mental health requires states and jurisdictions to invest in school mental health efforts. In recent years, there has been notable expansion and improvement in school mental health services in the state of South Carolina related to a number of investments that are cumulatively promoting capacity building. This narrative overview examines the history of the school mental health movement in one southern state and details efforts by multiple key stakeholders that have coalesced to form a strong system for advancing school mental health. Resting on a strong university-community partnership, five separate initiatives are described that together provide enhanced workforce training and support and expansion of school mental health services. Themes of this work are identified with a goal of supporting and advancing the development of school mental health systems in the United States. Strong collaborations and communication efforts both within the university setting and between partners in education and community settings, along with engaged funders keen to enhance well-being of children, youth, and families statewide have set the stage for the growth and expansion of school mental health services.

Knowledge transfer for occupational health and safety: Cultivating health and safety learning culture in construction firms

Within the last decades the incidence of workspace injuries and fatalities in the UK construction industry has declined markedly following the developments in occupational health and safety (OHS) management systems. However, safety statistics have reached a plateau and actions for further improvement of OHS management systems are called for. OHS is a form of organizational expertise that has both tacit and explicit dimensions and is situated in the ongoing practices. There is a need for institutionalization and for the transfer of knowledge across and along construction supply chains to reduce OHS risks and facilitate cultural change. The focus of this article is the factors that facilitate OHS knowledge transfer in and between organizations involved in construction projects. An interpretative methodology is used in this research to embrace tacit aspects of knowledge transfer and application. Thematic analysis is supported by a cognitive mapping technique that allows understanding of interrelationships among the concepts expressed by the respondents. This paper demonstrates inconsistency in OHS practices in construction organizations and highlights the importance of cultivating a positive safety culture to encourage transfer of lessons learnt from good practices, incidents, near misses and failures between projects, from projects to programmes and across supply chains. Governmental health and safety regulations, norms and guidelines do not include all possible safety issues specific to different working environments and tied to work contexts. The OHS system should encourage employees to report near misses, incidents and failures in a ‘no-blame’ context and to take appropriate actions. This research provides foundation for construction project practitioners to adopt more socially oriented approaches towards promoting learning-rich organizational contexts to overcome variation in the OHS and move beyond the current plateau reached in safety statistics.

Assessment of dual practice among physicians in Cambodia

BackgroundDual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health.MethodsData were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals.ResultsOf 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only.ConclusionsAs policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.