Health System Dynamics Research Articles

"I won't ever feel normal": experience reported through photovoice by children with chronic kidney disease.

Much of the global chronic kidney disease burden is experienced in low- and middle-income countries. Children living with chronic kidney disease (CKD) face medical and social challenges, and they need support at the individual and family levels. This study aimed to explore children's experiences living with kidney replacement therapy (KRT) who attend the largest pediatric nephrology department in Guatemala. This qualitative study used photovoice and asked children to take pictures that represented what is like to live with CKD. Each child and their caregiver underwent an interview where the photos were used to elicit and facilitate discussion. The interviews were recorded, transcribed, and then analyzed using thematic analysis. Eight children and their mothers participated in the study. Three themes were identified: interactions with the health system, changing and difficult family dynamics, and strains on social interactions. Children face social challenges including self-isolation and alienation. The family dynamics and familial structures often are forced to change, inducing stress. This is all exacerbated by the difficulties that arise in navigating the Guatemalan health system. Photovoice techniques are a feasible way to understand the experiences of children and their families who face CKD. The disease affects all aspects of life and recognizing this while advising and administering care can help provide a comprehensive level of care. Health systems need to make efforts aimed at improving the quality of care as well as the multidisciplinary support available to children and their families.

IJCM_214A: Digital interventions for childhood malnutrition in a tribal area of Andhra Pradesh: Understanding the problem through a health system perspective

Background: Childhood malnutrition is a major public health concern in the tribal areas of Andhra Pradesh, India, particularly in the region of ITDA Rampachodavaram. The integration and effectiveness of digital health interventions in these underserved regions are vital for addressing this endemic issue. However, the unique challenges posed by the remote and resource- limited settings of tribal areas make the implementation of such interventions particularly complex. Moreover, the varying complexity of the digital health ecosystem in these areas adds another layer of concern to deploying digital health solutions. Objectives: 1. To explore digital health interventions related to childhood malnutrition in the Integrated Tribal Development Agency (ITDA) of Rampachodavaram. 2. To understand the dynamics of the local health system and the digital health ecosystem in the implementation of these interventions. 3. To examine the role of street-level bureaucrats in implementing digital interventions and identify the barriers and facilitators affecting this process Methodology: The research was conducted in ITDA Rampachodavaram, involving interviews with health system officials and Focus Group Discussions (FGDs) with frontline health workers. The Health System Dynamics (HSD) framework and Lipsky’s theory on street-level bureaucrats were utilized, and enriched with insights into the digital health ecosystem. Results: The study reveals significant systemic, contextual, and human factors influencing the implementation of digital health interventions. Challenges include the complex role of street-level bureaucrats and systemic barriers like inadequate training, technological limitations, and disparities in digital access and literacy. Conclusion: This study highlights the potential of digital health interventions in improving childhood malnutrition outcomes in tribal areas. It stresses the importance of adaptive, inclusive strategies and advocates for digital health equity. Empowering frontline health workers and tailoring interventions to the specific health system dynamics and digital ecosystem of tribal regions are key for effective implementation.

Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States.

In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries. Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US. We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality. Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.

Socioecological factors linked with pharmaceutical incentive-driven prescribing in Pakistan

Pharmaceutical marketing through financial incentivisation to general practitioners (GPs) is a poorly studied health system problem in Pakistan. Pharmaceutical incentivisation is seen to be distorting GPs prescribing behaviour that can...

Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: A qualitative study.

The weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh. Using a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data. Organization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities. Despite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.

Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in Situations of Dual Agency at the Hospital Level Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations".

The article by Waitzberg et al on dual agency in hospitals reports on three strategies to mitigate dilemmas arising from conflicting clinical and economic considerations. This could be further explored by using systems science methods that allow in-depth analyses of (health) system dynamics, networks, and agent-based modelling, and that take into account local context, incentives and how institutions work. Future studies may also draw on the literature of multi-criteria decision-making and evidence-informed deliberative processes (EDPs) that are increasingly being used to optimise legitimate health benefit package design. Toolkits to assist hospital professionals in improving their decision-making need to be practical, with ample attention for the process of decision-making, including transparency, use of evidence, and opportunities for health professionals (and possibly others stakeholders) to contest or formally appeal against certain decisions.

Health system readiness for non-communicable diseases at the primary care level: a systematic review

ObjectiveTo synthesise evidence on the primary healthcare system’s readiness for preventing and managing non-communicable diseases (NCDs).DesignSystematic review.Data sourcesOvid MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus were searched from 1 January 1984...

Governance in Primary Care Systems: Experiences and Lessons from Urban, Rural, and Remote Settings in the Philippines

Objectives. Workforce shortages, policy fragmentation, and administrative fragmentation have broadened health inequities in the absence of an effective primary care system in the Philippines. While a central component within the health system, the role of governance in strengthening primary care systems remains underexplored. Therefore, this study aims to: 1) examine governance challenges encountered upon strengthening primary care systems; and 2) provide experience-based recommendations for improving primary care services in the Philippines. Methods. Data on governance issues were obtained from participant observation and regular meetings facilitated over one year. Conducted across urban, rural, and remote settings, the present study outlines experience-near insights throughout a hierarchy of system implementers—from those in positions of authority to frontline workers. These insights were thematically analyzed and organized following the Health System Dynamics Framework. Results. This study identified six governance challenges: 1) establishing a health information system; 2) engaging leaders, healthcare staff, and communities; 3) assuring efficient financing; 4) assuring health workforce sufficiency; 5) addressing legal challenges; and 6) planning evaluation and monitoring. To address these challenges, this study forwards systemic solutions to advance effective governance and improve healthcare performance. Conclusion. A renewed approach to strengthening primary care systems is fundamental to achieving universal healthcare. This entails good governance that develops strategies, equips people with tools for proper implementation, and provides data for evidence-based policies. The experiences outlined in the present study envisions guiding policymakers toward improving health outcomes in a devolved setting.

Determinants of access to childhood cancer medicines: a comparative, mixed-methods analysis of four Caribbean countries

Equitable access to essential medicines is a key facet of childhood cancer care, recognised by WHO as vital to improved childhood cancer outcomes globally. In the Caribbean, childhood cancer outcomes are poorer than those in most high-income countries. We aimed to generate in-depth comparative evidence of the current challenges and opportunities related to access to childhood cancer medicines in the Caribbean to identify context-sensitive health systems strategies to improve drug access and inform evidence-based paediatric cancer policies in the region. In this convergent, parallel, mixed-methods study, we mapped and analysed the determinants of access to childhood cancer medicines in four Caribbean countries (The Bahamas, Barbados, Jamaica, and Trinidad and Tobago). We analysed contextual determinants of access to medicines within and across study site jurisdictions, alignment of childhood cancer medicine inclusion between each country's national essential medicines list (NEML) and WHO's 2017 Essential Medicines List for Children, and availability and cost of chemotherapeutic agents at five tertiary care hospitals. We used a mixed-effects logistic regression model to analyse the association of medicine price, procurement efficiency (via median price ratio [MPR]), and site with drug availability. The fixed effect evaluated the effect of site and MPR on the probability of stockout in a given month. We assessed determinants of medicine access via thematic analysis of semi-structured qualitative interviews, literature, and policy documents. We collected and analysed data for 28 childhood cancer medicines from Barbados, 32 from The Bahamas, 30 from Trinidad and Tobago, and 31 from Jamaica. Despite stepwise inclusion of childhood cancer medicines in NEMLs, all four countries had frequent and recurrent stockouts for many cytotoxic medicines, showing no consistent relationship between NEML inclusion and availability. A mean MPR of greater than 3·0 in Trinidad and Tobago, The Bahamas, and Barbados suggests uniformly high procurement inefficiency, resulting in significant effects on drug stockout days. For each one unit increase in MPR the adjusted odds ratio (OR) of stockout increased by 10% (adjusted OR 1·10, 95% CI 1·04-1·16; p<0·01). These challenges in access to childhood cancer medicines stem from health system and policy dynamics at institutional, national, and supranational levels that cause price volatility and erratic medicine availability. Key challenges include disparate policy commitments (eg, among sites), inefficient procurement and supply chain management practices, and local effects of international market pressures. The Caribbean region exemplifies deficiencies in access to childhood cancer medicines that might be overcome by improved regional harmonisation of drug registration, pharmacovigilance, and procurement alongside national forecasting to strengthen global pharmaceutical planning and prioritisation. Focused political attention to address these challenges is required to ensure efficient, reliable, and sustained availability of cancer mediciness. The SickKids-Caribbean Initiative.

Failure to Thrive: The Perfect Storm

In this case, a 93-year-old woman declines rapidly following glossectomy surgery and experiences rapid weight loss. She becomes withdrawn and uncommunicative and is diagnosed as failure to thrive and potentially cognitively impaired. The eventual explanation for her decline is unexpected, surprising-and counterintuitive. This case illustrates the importance of investigating every aspect of medication use related to outcomes including medication administration, therapeutics, and health system dynamics.

Health system, socio-cultural, economic, environmental and individual factors influencing bed net use in the prevention of malaria in pregnancy in two Ghanaian regions

BackgroundImproving maternal health remains a priority to the Ghanaian government. Consequently, it has implemented the World Health Organization recommendation of distributing free long-lasting insecticidal nets (LLINs) to pregnant women—one of the effective strategies to combating malaria in pregnancy. However, the burden of negative outcomes of malaria in pregnancy such as low birth weight and miscarriages is still high. This may be related to the health system, socio-cultural and economic dynamics that influence LLIN use, but their role is not well understood. This ethnographic study sought to understand health system, socio-cultural, economic and environmental dynamics in utilization of LLINs among pregnant women in two Ghanaian regions.MethodsAn ethnographic study design was used. In-depth interviews and conversations were conducted among health workers, pregnant women and opinion leaders. Observations were conducted in 12 communities and eight health facilities. Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee. Nvivo 11 was used to support data coding. Data were triangulated and analysed using a thematic approach.ResultsFindings suggest health system, socio-cultural, economic, environmental and individual factors influenced LLIN use. Health facility readiness in stocking LLINs influenced ownership and use. Receiving appropriate information from health providers and encouragement from public officials improved LLIN use. Women with a history of LLIN use prior to becoming pregnant and women who had young children remained consistent users. Experiencing irritating effects of LLINs and preference for traditional methods to wade off mosquitoes, reduced LLIN use. Pregnant women whose household and family members used LLINs were influenced positively to use them. Gender power relations between husbands and wives influenced women’s use of LLINs. The type of housing and weather conditions contributed to inconsistent use. Staying out late for business purposes and to converse, exposed pregnant women to mosquito bites.ConclusionGiving out LLINs at facility level should be accompanied with comprehensive information, which is relevant to the socio-cultural context that women live in. Mass distribution should factor in individual and public information to promote community acceptance and proper use of ITNs. Facilities should be encouraged to constantly maintain LLINs stock in order to ensure that ANC registrants receive LLINs for use.

What will it take for the Global Plan priority countries in Sub-Saharan Africa to eliminate mother-to-child transmission of HIV?

BackgroundThe 2016 ‘Start Free, Stay Free, AIDS Free’ global agenda, builds on the 2011-2015 ‘Global Plan’. It prioritises 22 countries where 90% of the world’s HIV-positive pregnant women live and aims to eliminate vertical transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries.MethodsA literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation’s building blocks to strengthen health systems, van Olmen’s Health System Dynamics framework and Baral’s socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate).ResultsEMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (p<0.001); in simple linear regression it is 53% protective against percent MTCT. In contrast, SEM demonstrated that the case rate was driven by the number of HIV exposed infants (HEI) i.e. maternal HIV prevalence (p<0.001). In linear regression models, ART access alone explains only 17% of the case rate while HEI alone explains 81% of the case rate. In multiple regression, HEI and ART access accounts for 83% of the case rate, with HEI making the most contribution (coef. infant HIV exposure=82.8, 95% CI: 64.6, 101.1, p<0.001 vs coef. ART access=-3.0, 95% CI: -6.2, 0.3, p=0.074).ConclusionReducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.

Exploring the health system for sustainable and integrated acute malnutrition services applying a systems lens: the case of Afghanistan

Introduction: Afghanistan has an estimated annual burden of severe acute malnutrition in children under five of over 600,000, with less then 30% accessing care. Since 2009, acute malnutrition has been part of the country’s Basic Package of Health Services, which is outsourced for implementation to local partners and regulated by the Ministry of Public Health. A gradual transition to government implementation is expected to change the dynamics of health system functions and actors, with unpredictable outcomes. Building competencies in applying systems thinking by taking into account tacit knowledge may strengthen adaptive management and leadership for improving sustainable and integrated acute malnutrition interventions. We explored the dynamics of the health system with a systems lens to identify opportunities for improving sustainable and integrated acute malnutrition services to inform policies. Methods: A mixed method design involved over 70 health actors to explore the health system capacity through participatory system dynamics mapping based on rapid observation, key informant interviews, group discussions and document review. The policy analysis investigated acute malnutrition coverage. A network analysis explored involvement and influences of health actors. A framework approach appraised key health system functions and explored the level of integration of acute malnutrition. System changes over time and causal loop analyses explored system dynamics to identify leverages for improving and sustaining health outcome. Results: Key policies and strategies were in place but did not consistently recognise severe acute malnutrition as a major childhood illness. Narrow involvement of health actors missed opportunities for ‘learning together’ and developing sustainable and broad-based technical leadership. The health actors network showed two scale free hubs of the Public Nutrition Directorate and health workers of health facilities making the link between government and partners at and between the national/provincial and community levels. The Basic Package of Health Services left community-based nutrition underdeveloped and 40% of the hard-to-reach population uncovered. Most funding remained emergency based, and quality and ownership were limited despite major training efforts. The extent of integration was stronger at implementation level than at policy and organisational level. Behaviour-over-time, mapping the effects of financial and technical support on effective coverage, showed late but fast expansion of coverage. Causal loop analysis, building on tacit knowledge to describe the complexity of interactions and influences, found reinforcing effects from policy, competency and community involvement and dumping effects from financial and technical support on improving quality. Based on the learning from the change mechanisms, an initial theory of change identified assumptions that should be tested and refined in evaluations. Conclusion: The exploration of health system capacity and dynamics uncovered strengths and missed opportunities for sustaining integrated acute malnutrition services in Afghanistan. This study is an initial step in applying systems thinking using tacit knowledge through participative approaches to explain unpredictable behaviour and foster dialogue and ‘learning together’ for improving sustainable and integrated acute malnutrition services. Further research should encourage applying systems thinking to further understand dynamic complexity by opening the black box to understand why change happens, how and under what circumstances, and design effective interventions.

Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda

BackgroundDespite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda.MethodsThis study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13).ResultsFive dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage.ConclusionThe sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation

BackgroundMuch of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes.MethodsThis is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation.DiscussionThis study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.

Health system factors affecting implementation of integrated management of childhood illness (IMCI): qualitative insights from a South African province.

The Integrated Management of Childhood Illness (IMCI) strategy has been adopted by 102 countries including South Africa, as the preferred primary health care (PHC) delivery strategy for sick children under 5 years. Despite substantial investment to support IMCI in South Africa, its delivery remains sub-optimal, with varied implementation in different settings. There is scarce research globally, and in the local context, examining the effects of health system characteristics on IMCI implementation. This study explored key determinants of IMCI delivery in a South African province, with a specific focus on health system building blocks using a health system dynamics framework. In-depth interviews were conducted with 38 districts, provincial and national respondents involved with IMCI co-ordination and delivery, exploring their involvement in, and perceptions of, IMCI strategy implementation. Identified barriers included poor definition of elements of a service package for children and how IMCI aligned with this, incompetence of trained nurses exacerbated by inappropriate rotation practices, use of inappropriate indicators to track progress, multiple cadres coordinating similar activities with poor role delineation, and fragmented, vertical governance of programmes included within IMCI, such as immunization. Enabling practices in one district included the use of standardized child health records incorporating IMCI activities and stringent practice monitoring through record audits. Using IMCI as a case study, our work highlights critical health system deficiencies affecting service delivery for young children which need to be resolved to reposition IMCI within the broader child 'survive, thrive and transform' agenda. Recommendations for appropriate health system strengthening include the need for redefining IMCI within a broader PHC service package for children, prioritizing post-training supervision and mentoring of practitioners through appropriate duty allocation and rotation policies, strengthening IMCI monitoring with a specific focus on quality of care and building stronger clinical governance through workforce allocation, role delineation and improved accountability.

Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals.

Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.

\u201cIf donors woke up tomorrow and said we can't fund you, what would we do?\u201d A health system dynamics analysis of implementation of PMTCT option B+ in Uganda

BackgroundIn October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes and adoptions of new PMTCT policies have not been accompanied by health systems research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems.MethodsThis qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. A total of 82 individual interviews and 16 focus group discussions were completed. We conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes.ResultsOf the ten elements in the health system dynamics framework, context and resources (finances, infrastructure & supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability.ConclusionsThe health system dynamics framework offers a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.

Effects of operational decisions on the diffusion of epidemic disease: A system dynamics modeling of the MERS-CoV outbreak in South Korea

We evaluated the nosocomial outbreak of Middle East Respiratory Syndrome (MERS) Coronavirus (CoV) in the Republic of Korea, 2015, from a healthcare operations management perspective. Establishment of healthcare policy in South Korea provides patients’ freedom to select and visit multiple hospitals. Current policy enforces hospitals preference for multi-patient rooms to single-patient rooms, to lower financial burden. Existing healthcare systems tragically contributed to 186 MERS outbreak cases, starting from single “index patient” into three generations of secondary infections. By developing a macro-level health system dynamics model, we provide empirical knowledge to examining the case from both operational and financial perspectives. In our simulation, under base infectivity scenario, high emergency room occupancy circumstance contributed to an estimated average of 101 (917%) more infected patients, compared to when in low occupancy circumstance. Economic patient room design showed an estimated 702% increase in the number of infected patients, despite the overall 98% savings in total expected costs compared to optimal room design. This study provides first time, system dynamics model, performance measurements from an operational perspective. Importantly, the intent of this study was to provide evidence to motivate public, private, and government healthcare administrators’ recognition of current shortcomings, to optimize performance as a whole system, rather than mere individual aspects.

Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: investment needs, population health gains, and cost-effectiveness.

We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART). We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints. Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved. Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.