Health System Development Research Articles

Assessment of patient safety culture in primary health care in Muscat, Oman: a questionnaire -based survey

BackgroundPatient safety is a universal issue which affects countries at all stages of health system development. Patient safety research in primary care reveals that globally millions of people suffer disabilities, injuries, or death due to unsafe medical practices. This study aims to explore the understanding of frontline primary health care professionals regarding patient safety culture in health care facilities in Oman.MethodsA questionnaire–based survey was conducted using a validated Hospital Survey of Patient Safety Culture tool. Invitations were sent to all 198 health professionals from each occupational category from each primary care center in Muscat, Oman.ResultsThe total number of respondents was 186 participants out of 198 (response rate: 94%). Overall, the staff had a strong sense of teamwork within the units (85%), they reported organization learning for continuous improvement (84%) and teamwork across the units (82%). However, the four dimensions which received the lowest scores were related to communication problems between the staff (23%), non-punitive response to errors (27%), frequency of event reporting (40%), and errors occurring when transferring patients to higher levels of health care during handoffs and transitions (46%).ConclusionsOverall, the participants rated patient safety in the primary health care setting as excellent or very good and the perception of patient safety was moderately positive. The core areas of strength were teamwork within the units with positivity and organization learning and continuous improvement. The weaknesses were non-punitive response to errors, inadequate staffing and hand offs and transition. The results of this study will provide policy makers and health care professionals with a detailed understanding of the current patient safety culture in primary care in Muscat, Oman. The results will be used by the Ministry of Health to inform policy and strategies to strengthen patient safety within primary health care in Oman.

Promoting health protection worldwide: The International Labour Organisation and health systems financing, 1952–2012

In recent years, universal health coverage (UHC) has returned with a vengeance to the international agenda, raising complex and highly political questions about how health systems should be organised and financed. Drawing upon an extensive analysis of archival material, this article examines the International Labour Organisation’s (ILO) approach towards health systems financing in the second half of the twentieth century, exploring its evolving strategy towards social health protection in the context of international development, and its relationship with other international agencies, notably the World Health Organisation and World Bank. It argues that while the ILO’s role in international development has come into question in recent decades, its officials have nevertheless made a meaningful contribution to the promotion of health protection worldwide. Despite the wider marginalisation of universalism in post-war international discourse, ILO officials continually shifted their strategy to ensure that mechanisms of health protection such as social health insurance were prioritised in health systems development. ILO support contributed to some notable successes, such as the achievement of UHC in Thailand in 2002.

The Challenges of Establishing Universal Health Coverage in Enugu State, South East Nigeria

This research was supported by UNN TETFUND Committee through TETFUND Institution Based Research Fund. Abstract Background: Financial risk protection for healthcare is deficient in Enugu state, Southeast Nigeria and the worst affected are the rural dwellers and the poorest, thus creating both socioeconomic and geographic inequity in access and use of services. The study aimed at eliciting the level of awareness and use of pre-payment mechanisms, and more importantly, determining the economic and political factors that facilitate or constrain achievement of Universal Health Coverage in Enugu state, Southeast Nigeria. Methods: Study was conducted in two purposively chosen urban and rural local government areas(LGA) of Enugu state with mixed method study design. Cross-sectional household questionnaire survey was conducted on 802 sample size from the two LGAs and 12 key informants participated in In-depth interviews (IDIs). The quantitative data was analysed with STATA using descriptive statistics while the qualitative IDI data was organized into nodes and sub-nodes using Nvivo: political and economic factors, corruption, communication/Awareness, capacity development / Infrastructure, policy development, leadership and referral system. Later, findings were thematically analysed. Results: The survey results showed that 84% of the study sample have secondary school education and 83% are engaged in employment or petty business. About 56% are aware of prepayment mechanism for healthcare bills but only 10% of them have used prepayment mechanisms. Out of pocket payment (85%) is the main source of payment at health facilities. Major political constraining factors to UHC revealed by the IDI include lack of political will backed with financial commitment from the political leaders, lack of legislative framework for UHC, lack of trust on the political leaders/government by the citizenry and inactive civil society organizations. Also, the poor fiscal space for health and the poverty level in the populace are big threats to sustainable UHC in Enugu state. Other economic challenges include corruption, poor health capacity development and poorly paid healthcare workers leading to poor quality of health care delivery. There is need for comprehensive health system development in the state to accommodate UHC. Conclusions: Establishment of sustainable UHC in Enugu state faces considerable political and economic challenges. There is need for increased government budgetary allocation for UHC to ensure coverage for the poor and vulnerable members. The lack of legislative framework for UHC could be resolved by legislative arm of the government. The government should invest in health system development to improve the quality of health care services to compliment the FRP component of UHC. Keywords : Universal Health Coverage, Health Insurance, Financial Risk Protection DOI : 10.7176/DCS/9-4-07 Publication date : April 30 th 2019

Rebuilding health post-conflict: case studies, reflections and a revised framework.

War and conflict negatively impact all facets of a health system; services cease to function, resources become depleted and any semblance of governance is lost. Following cessation of conflict, the rebuilding process includes a wide array of international and local actors. During this period, stakeholders must contend with various trade-offs, including balancing sustainable outcomes with immediate health needs, introducing health reform measures while also increasing local capacity, and reconciling external assistance with indigenous legitimacy. Compounding these factors are additional challenges, including co-ordination amongst stakeholders, the re-occurrence of conflict and ulterior motives from donors and governments, to name a few. Due to these complexities, the current literature on post-conflict health system development generally examines only one facet of the health system, and only at one point in time. The health system as a whole, and its development across a longer timeline, is rarely attended to. Given these considerations, the present article aims to evaluate health system development in three post-conflict environments over a 12-year timeline. Applying and adapting a framework from Waters et al. (2007, Rehabilitating Health Systems in Post-Conflict Situations. WIDER Research Paper 2007/06. United Nations University. http://hdl.handle.net/10419/63390, accessed 1 February 2018.), health policies and inputs from the post-conflict periods of Afghanistan, Cambodia and Mozambique are assessed against health outputs and other measures. From these findings, we developed a revised framework, which is presented in this article. Overall, these findings contribute post-conflict health system development by evaluating the process holistically and along a timeline, and can be of further use by healthcare managers, policy-makers and other health professionals.

Leadership in Healthcare System

Health plays a special role both for societies and economies. Regardless of the level of development of health systems and respective expenditures, they are struggling with shortage of resources. In case of Poland, this phenomenon also concerns significant deficiencies in other areas, including personnel. In the light of inevitable and necessary changes, this poses a serious risk both to the health security of Poles and successful implementation of modernization plans. Research carried out by employees of the Warsaw School of Economics highlighted the possibility of solving this problem through the use and development of leadership competences. This article is a starting point for a discussion on the role of the leadership in the process of changes in healthcare system.

Quality of data in death notification forms in the Gaza governorate: a descriptive study

BackgroundThe Cause of Death Registry data are derived from death notification forms (DNFs). These data are used to formulate mortality statistics that are used in the development of health systems and in public health planning. This study assessed the quality of registered data in DNFs in Gaza to form a basic understanding of the current situation, and with a view to providing evidence-based recommendations to improve data quality. MethodsIn 2016, the Ministry of Health issued 4861 DNFs in the Gaza governorate. A representative sample of 509 DNFs was selected using proportional systematic random sampling. A set of indicators was identified using the WHO guidelines for DNF data quality assessment. 13 data items were identified to represent administrative data plus nine items to represent medical data, and a total score for completeness was calculated. The quality of medical data was examined by a doctor trained to analyse the quality of mortality data. Administrative approval was obtained from the Ministry of Health. The assessment did not include any personal data (and all data were anonymous). FindingsThe completeness of administrative and medical data was 89·0% (5500 of 6180) and 47·3% (2168 of 4581), respectively. For the underlying cause of death, completeness was 36·5% (186 of 509). The completeness of ICD-10 coding was 46·8% (238 of 509) for the direct cause of death and 12·6% (64 of 509) for the underlying cause. Only 23·0% (three of 13) of DNFs for women of reproductive age indicated whether the woman was pregnant or not and whether her death was related to maternal health problems. The ICD-10 codes with the written cause of death were checked and the ICD-10 documentation was correct in 58·0% (138 out of 238) of DNFs for the direct cause of death and 67·2% (43 out of 64) of DNFs for the underlying cause of death. InterpretationThe completeness and accuracy of medical data in DNFs is low. There is an urgent need to train physicians and medical interns to give the correct death sequence and ICD-10 codes, particularly for the underlying cause of death. FundingNone.

Competential development of nurses in the public health system of Andalucía

The socio-demographic and epidemiological changes of our environment are characterised by an increase in ageing, chronic illness, comorbidities and with it, a progressive escalation of the demand for care. These new demands and expectations of citizenship are accompanied by an evolution of health systems (technological advances, complexity of the healthcare network, limited resources), the need to develop new roles and competence in care, together with the opportunity that full academic development implies: Nursing undergraduate and posgraduate degrees. This is why, at present, it is necessary to reorient care models in order to achieve health care for more agile, efficient and better quality care processes, adapted to the needs and expectations of citizens and to the sustainability of health systems.The Public Health System of Andalusia (SSPA) has developed, in recent decades, different nursing roles that include new competences, with the aim of responding to the needs of citizens.The objective of this article is to present how the competences development framework of nurses has been configured in the SSPA, which also integrates advanced skills in care and advanced practice profiles (Clinical Nurse Specialists and Advanced practice nurses).

3428 Adopting a learning health system architecture: a scoping review and pre-implementation framework to reduce readmissions within academic hospitals

OBJECTIVES/SPECIFIC AIMS: Of the six Centers for Medicare and Medicaid Services (CMS) monitored diagnoses targeted for readmissions reductions, reasons for readmissions within academic hospitals are poorly understood and reflect complex interactions between the patient, provider and organizational-level responses to initial hospitalization. Learning health systems (the organizational and orchestrated integration of research into evidence-based practice) can address the complexities of readmissions through an innovative approach to knowledge translation and patient-centered outcomes research. The objective of this review is to define and optimize the architecture of learning health systems to produce a dynamic pre-implementation framework of knowledge translation and patient-centered outcomes research, leveraging two engines (research and learning) within the academic and clinical settings for reducing readmissions. METHODS/STUDY POPULATION: Three databases were utilized for this scoping review (PubMed, Academic Search Premier, and Scopus) focusing on 1.) learning health systems and the methods of defining and building these systems within an academic hospital setting and 2.) the use of learning health systems in reducing readmissions within academic hospitals. Empirical articles and reviews pertaining to the architecture, development, conceptualization, definition, and translation of learning health systems were identified and compiled into a scoping review and proposed framework. RESULTS/ANTICIPATED RESULTS: The scoping review yielded 139 articles; from which 28 articles were retained. No articles were found utilizing learning health systems to address readmissions. Thus, a new architectural framework was developed incorporating common architectural themes from the literature with adaptations to fit the interests of patients, providers, and researchers in reducing readmissions within academic hospitals (Figure 1). DISCUSSION/SIGNIFICANCE OF IMPACT: Given the dearth of information applying learning health systems to readmissions, the proposed architecture for an integrative learning health system can be utilized as a dynamic foundation for adoption and pre-implementation planning for reducing readmissions within academic hospital settings. Additionally, the authors expect this model to be tested and continually refined to address historical and emerging issues for clinically-relevant and clinically-effective approaches to patient-centered practice and research.

Determinants of students’ healthy lifestyle development

The paper focuses on the importance of a healthy lifestyle development among students, which is reflected in the Concept of Health System Development in the Russian Federation until 2020. The authors identify the determinants of a healthy lifestyle development, which include: spatial-environmental, motivational-reflexive, activity-methodical, tutor-project determinants. These determinants are interrelated; it provides an increase in the efficiency of a healthy lifestyle development among students. In the field of activity-methodical determinant the authors consider problems of practice-oriented training of teachers. The results of a survey among students and teachers show that students are not ready to accept the values of a healthy lifestyle while teachers are not ready to use health-saving technologies. In this regard, the authors have developed and tested a program for improving teachers qualifications in the field of health preservation, contributing to the development of skills to apply health saving technologies. The tutor-project determinant determines a functional field of the tutor in project activities of students aimed at health preservation.

Competential development of nurses in the public health system of Andalucía.

The socio-demographic and epidemiological changes of our environment are characterized by an increase in aging, chronic illness, comorbidities and with it, a progressive escalation of the demand for care. These new demands and expectations of citizenship are accompanied by an evolution of health systems (technological advances, complexity of the healthcare network, limited resources), the need to develop new roles and competence in care, together with the opportunity that full academic development implies: Nursing undergraduate and posgraduate degrees. This is why, at present, it is necessary to reorient care models in order to achieve health care for more agile, efficient and better quality care processes, adapted to the needs and expectations of citizens and to the sustainability of health systems. The Public Health System of Andalusia (SSPA) has developed, in recent decades, different nursing roles that include new competences, with the aim of responding to the needs of citizens. The objective of this article is to present how the competences development framework of nurses has been configured in the SSPA, which also integrates advanced skills in care and advanced practice profiles (Clinical Nurse Specialists and Advanced practice nurses).

Historical roots of hospital centrism in China (1835–1949): A path dependence analysis

Stronger primary care has been associated with important contributions to health system performance, yet countries struggle to resource it adequately, given competing demands from hospitals. Although historically China has originated influential models of primary health care, it has an enduring problem with hospital dominance in health service delivery. This paper is a historical analysis of the co-evolution of hospitals and primary care providers in China from 1835 (the year when the first hospital was built in mainland China) to 1949 (the year when the People's Republic of China was founded), which aims to shed light on approaches to primary care strengthening. We develop and use a path dependence analytic framework, specifying the critical juncture, conjuncture and post-juncture development of the institutions shaping the balance between hospitals and primary care providers in China. We find that China had historically formed the hospital-centric model involving four sets of regenerating and mutually reinforcing institutions: 1) financial resources were being disproportionally distributed to hospitals; 2) high-quality medical professionals were largely concentrated in hospitals; 3) large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients; 4) hospitals answered primarily to the demand of the more privileged social group. The early institutionalization of a hospital-centric model of Western medicine in China from 1835 became resistant to change, and efforts to strengthen primary care eventually took a divergent low-cost and de-professionalized developmental path towards 1949. As China still has a hospital-centric health system seeded in the nineteenth century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, China is unlikely to achieve a primary care orientation for health system development.

Hybrid clinical-managers in Kenyan hospitals

PurposeThe purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms.Design/methodology/approachThe authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle.FindingsKenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms.Practical implicationsUnderstanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles.Originality/valueThe authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

The disciplining of self-help: Doing self-help the Norwegian way

We explore how Norwegian self-help groups are defined and managed to create a particular form of health system governmentality. Self-help groups are typically framed as therapeutic communities where participants define the agenda creating a space where open and equal interaction can produce individual learning and personal growth. In Norway, however, self-help groups are managed in a way that integrates them in to the health system but insulates them from clinical medicine; an approach that disciplines participants to act in a particular way in relation to the health system. We draw on the analysis of 1456 pages of public documents and websites from the National Nodal Point for Self-Help (NPSH), the organisation that manages self-help groups, and central government including individual testimonies from participants published between 2006 and 2014. We argue, drawing on Foucault, that self-help premised on lay-leadership and self-determination is at odds with the centrally defined regulation apparent in the model adopted in Norway and an example of disciplining that reinforces health system governmentality and serves the interests of the medical profession and the state. Further we propose that this illustrates the contestation between the pastoral power of medics, the National Nodal Point for Self-Help and the Ministry of Health. Our analysis of Norwegian self-help as a mechanism to create a particular form of health system governmentality helps explain the expansion of self-help and self-management within developed health systems and provides an explanation for why self-help within health systems, is typically situated adjacent to, rather than integrated into, clinical medicine.

Health System Developments in the Framework of Development Programs in Iran

Health System Developments in the Framework of Development Programs in Iran

Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana

ObjectiveCommunity-based initiatives have enormous potential to facilitate the attainment of universal health coverage (UHC) and health system development. Yet key gaps exist and threaten its sustainability in many low-income and...

Personalized Medicine and Medicinal Chemistry: Toward a Legal Framework in the European Union.

In the last few years, the fields of Medicinal Chemistry and especially the ones related to the so-called Personalized Medicine, have received a great attention. Significant investment and remarkable researches surround the matter; however, not all those promising advances are reaching patients as quickly as they should. The absence of an adequate regulatory framework could be of no help. The complete and/or massive sequencing of individual genomes faces many ethical-legal challenges. Some of them are access to Personalized Medicine; the treatment of a large volume of sensitive information and the use of tools produced by "big data" systems in clinical care or in predictive models. In addition, the legal protection of personal data related to health, the exercise of autonomy by patients, closely related to the regulation regarding clinical trials, are seriously involved. Our purpose of this work is to review the regulations of the European Union, in an attempt to contribute to a better understanding of the legal framework for the implementation and development of health systems based on Personalized Medicine.

Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes

BackgroundMany Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes.MethodsThis paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature.ResultsCambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives.ConclusionsSocio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.

Transformation strategies for healthy organizations.

Healthy organizations are based on dynamic relationships between productivity, health and well-being. Understanding and transforming these labor-permeating relationships through health promotion actions is necessary in the present time. To implement an intervention involving strategies likely to enable the transformation of companies into healthy organizations, based on a collective approach and seeking to boost performance and well-being at work. Participants were organizations affiliated with an occupational risk management company, selected according to their size, degree of development of workplace health and safety systems and economic activity. We designed and implemented an intervention to evaluate workplace safety and health, to finally suggest strategies to enhance occupational well-being. We detected advances in the implementation of workplace safety and health systems, and also in several other aspects, as e.g. continuous improvement and self-care programs. Additional results include the participating organizations' engagement in several problems common to all, which led to the creation of a collective network. Intervention focused on training, follow-up, consultancy and collective development of healthy organizations. Our reflections are grounded on a collective process of creation and seek to elucidate the potential and difficulties inherent to the implemented intervention, outcome expectations, resulting social cooperation networks and the process to formulate strategies to link work to health, well-being and productivity.

Scientific Measurement of The Current Role of Pharmacist in the Paradigm of Pharmaceutical Care Development

The article presents the results of systematization of data on changes in the current role of pharmacists in the context of the development of as an important scientific and practical category. The authors identify the main stages of the development of assistance in the supply system of the population. It has been determined that has undergone a difficult path of evolution. This process began with a scientific understanding of the need to introduce new forms and methods for providing services to chronic patients in hospital conditions (1967–1969, William E. Smith). More American scientists were given the definition of the term pharmaceutical care (1989–1990 years, C.D. Helper and L.D. Strand). Nowadays there are a complex process of developing scientific and practical approaches to adapting already existing WHO and FIP core documents of GPP to the realities of the development of national health systems in various developing countries. According to the results of systematization of the material, the authors of the article identified four main stages of the development of pharmaceutical care as a scientific and practical category and gave a brief description of the content of these stages of development. In addition, the authors of the article identify and characterize the modern directions of professional activity of pharmacists, which correspond to the existing international requirements and contemporary challenges of society.

Izazovi zdravstvenog zadrugarstva na teritoriji Srbije 1918-1949

Health cooperatives represented a historic turning point in the organization of the health care system in the territory of Serbia. The idea of establishing such a subsystem for the provision of healthcare services came as early as 1901 through the work of agricultural cooperatives. The concept could not be realized immediately (although there was the will of all interest groups) due to the Balkan Wars, and later the First World War. The first health care cooperatives were inaugurated in 1921, and since then until the beginning of the Second World War, they have had great success in their work. Health cooperatives were prevented from funding during the Second World War, but were re-established in that form and continued to work until 1949. Different challenges were faced by the organizers of healthcare cooperatives, both in the establishment itself, as well as within the framework of finance, legislation, resistance provided by trade guilds, resistance of the medical chamber and pharmacy wholesalers. The study of ethnomedicine was advanced during the period of work of health cooperatives and was subsequently continued. The challenge was the bad public health picture that was found after the First World War. The need for additional research in the field of ethnomedicine speaks of numerous literature, as well as of the necessity of medical enlightenment of the population. These and other challenges are discussed in the paper, and what needs to be emphasized is the success that health cooperatives have had despite all the aggravating circumstances they faced. This work is of importance to medical historians, creators of modern health policy, public health experts, educational and professional institutions. The aim of this paper is to examine how health care cooperatives work and how to respond to organizational, financial and public health challenges. Of importance is the research of this area, which is rarely mentioned in the literature of the last decades. One of the goals is also to consider the answers that health cooperatives had on these challenges and in the context of the development of the modern health system.