Indian Health System Research Articles

Trust, regulation, and stewardship of the medical profession in India

In this paper we discuss the consequences of commercialisation of medicine and the associated shift in professional values, identity, and practices for patients, doctors, and health care organisations in India. We do so within the broader frame of the widely reported fall in trust in the health system in India, and with a view to reflect on how trust may be restored to a level which sustains a different but effective type of relationship between the medical profession and society. We draw on interviews with high-level health system and social actors in India to shed light on the key influences which shape the stewardship and governance of the health care system and the medical profession in the light of mounting evidence of and concerns around the erosion of public and patient trust in these institutions in India. Analysis is presented through four interrelated thematic articulations. Two themes highlight the practices of doctors and the actions of patients which contributed to changes in their relations and particularly a decline in trust. Two further themes focus on the policy and practice implications for regulation and stewardship of the health system and the medical profession.

Applying Newly Identified Financially Focused Home Care Quality and Performance Indicators In Alberta's $23.5B/annum Health System - Preliminary Findings

Through a multi-phased mixed-method research program including an international scoping review and a modified-Delphi panel with expert policy/academic/operational representatives from across Canada, three health-system, financially focused quality and performance home care indicators were identified. This presentation will provide preliminary results of the application of the three financial indicators on overall health-system measures, system utilization and population outcomes within the province of Alberta. The time-period covered is the last five years data leading up to the start of the deceleration of the covid-19 global pandemic. Based on provincial annual financial reporting, baseline 2016/17 fiscal year home care expenditures were $585K, this rose to significantly to $716M for fiscal year 2019/20, with the most significant increase (13%) occurred between the 2017/18 and 2018/19 years. Prior to 2016/17 home care expenditures increased at a rate less than 3%. These significant home care investments increased the percent of the overall expenditures in Alberta from 3.94 to 4.6%. Furthermore, the average annual expenditures per home care client rose from $5,417 to $6,112. During this same time-period, numerous health-system indicators shifted to more favorable positions, with notable decreases in acute care days prior to death, number of those waiting in hospital for LTC, and preventing/delaying the need for LTC overall. Based on comparisons of home care investments on the overall health-system and key health-system performance indicators focused on measuring system efficiencies, preliminary examinations suggest that significant home care focused investments in Alberta significantly improved health-system performance, efficiencies, and overall outcomes for the population.

Building a digital supportive supervision system for improving health service delivery in Low- and Middle-Income countries through the collaborative requirements development methodology (CRDM): Experience from Tanzania

Background Supportive supervision is pivotal for both health service providers and managers to improve the quality of services and health outcomes. Tanzania's digital supportive supervision system is called Afya Supportive Supervision System (AfyaSS ®). The latter was designed and developed using a human-centered approach called Collaborative Requirements Development Methodology (CRDM). This paper describes the experiences of building the digital supportive supervision system through CRDM in Tanzania, a transition from the paper-based supportive supervision system. Methods In 2018, with the support of PATH, the government of Tanzania adopted a participatory human-centered design by carrying out desk reviews of existing guidelines and tools, field visits, stakeholder workshops, and user advisory groups to gather information for developing a digital supportive supervision system. The gathered information was analyzed with the lens of identifying the common challenges and system requirements. Results AfyaSS was successfully developed using CRDM and deployed in all regions across the country. It has consolidated multiple checklists for distinct health domains, and dashboard functionalities to track progress toward health system indicators, objectives, and action plans. As part of the deployment, several resources were developed to aid in the deployment process, such as a comprehensive user manual, facilitator's guide, training slides, and video tutorials. Health workers and managers can be empowered and motivated to implement comprehensive and coherent supportive supervision by using the lessons learned from this digitalization process to transform the current supervision processes to improve the quality of care by offering instruments that promote evidence-based actions. Conclusion A human-centered approach has been shown to be useful in developing digital tools for use in Tanzania’s health system. Tanzania's lessons can be applied in other low- and middle- income countries (LMICs) with similar contexts when considering implementing digital health interventions. While using the human-centered approach, it is crucial to establish a system development roadmap, conduct appropriate training, provide sustained information and communication technology, and management support for unforeseen issues, and ensure ongoing maintenance.

Crisis volunteering during COVID-19 pandemic in India: youth responds to health and human rights crisis

Purpose This study aims to explore the experiences of individuals in India who acted as informal crisis volunteers during the peak of the deadliest wave of the COVID-19 pandemic in the country. Design/methodology/approach An exploratory, qualitative design was used, and data gathered via a qualitative survey in three focus areas, namely, motivation, challenges and coping mechanisms. The sample (n = 112) comprised individuals (mean age = 21.89 years) whose volunteering efforts during the second wave of the COVID-19 pandemic were extended as part of volunteer groups or individually, online or offline, for minimum of 10 consecutive days to four months. Descriptive statistics and qualitative content analysis (Mayring, 2000) were used to analyze the data. Findings Most of the participants reported being inspired by social media activism to become crisis volunteers themselves. They also spoke of several human rights violations unfolding around them, namely, people denied right to health (availability and accessibility), rampant discrimination of various kinds and other systemic failures in crisis response by government bodies. Several reported undergoing extreme mental duress during the process, experiencing or witnessing harassment and dealing with corruption. A sense of collective identity and opportunities to engage in collective sense making and collective catharsis with fellow volunteers were reported as the most helpful coping mechanism. Originality/value Very little is known about the experience of informal crisis volunteers who assisted the public health system in India in various capacities during the pandemic. This paper explores those experiences, sheds light on various human rights violations that took place during the time and provides a glimpse into the potential of technology and social media in organized altruistic efforts.

ASSESSMENT OF TÜRKİYE'S PROVINCES WITH HEALTH INFRASTRUCTURE INDICATORS USING DESCRIPTIVE ANALYSIS AND HEALTH INDEX

Health systems assessment is critical to ensure the sustainability of health services. The interest of researchers in analysing health systems, which intensified during the pandemic, is motivated by the opportunity to identify weaknesses and propose changes. Health systems analyses provide valuable feedback for policy makers, especially in developing countries, which struggle with obstacles such as limited resources, financial constraints and deficiencies in health infrastructure. As a developing country, Türkiye has been striving to ensure equal access to health services through its health transformation programme. In the last decade, developments such as the increase in Syrian migrants and economic contraction have negatively affected this effort. This situation motivates the need to analyse the current situation in the Turkish health system and provide suggestions for improvement. The literature on the Turkish health system mostly focuses on broad health system indicators such as health service accessibility, efficiency, quality and user satisfaction. This study focuses on assessing the accessibility of health infrastructure resources. In the study, health infrastructure indicators related to the Turkish health system are evaluated on a province basis for the period from 2012 to 2021. The evaluation is based on the descriptive statistics of the dataset and the province-based health index. The findings show changing trends and gaps in access to health services with the increase in population in the period 2012-2021. Some variables (e.g. population per hospital and population per bed) show low variances, while others (e.g. population per intensive care bed) show large differences. These differences may indicate unequal development and investment in health infrastructure. For policy makers, they emphasise the need to develop policies to address these inequalities and to distribute resources equitably. Analysing the health index values shows inequalities in access to health resources in different provinces of Türkiye as a score. In particular, while some provinces such as Isparta and Bolu stand out with consistently high index scores, lower index scores in other provinces such as Şanlıurfa, Mardin, Ağrı and Şırnak indicate that inequalities in access to health services are faced. This index identifies changes and gaps in the distribution of health resources and shows policy makers priority areas for intervention.

Characteristics and contributing factors of adverse drug reactions: an analytical study of patients with tuberculosis receiving treatment under the National TB Program of India

Background Tuberculosis (TB) continues to pose a serious threat to the public health system in India. Although the National Tuberculosis Elimination Program (NTEP) is providing a wide range of interventions from early diagnosis to complete treatment to reduce morbidity and mortality from TB, adverse drug reactions (ADR) remain a challenge in treatment adherence and completion. Methods An observational cross-sectional study was conducted in selected districts of Gujarat state. A total of 593 reported TB patients were recruited with an adjusted unified distribution based on the type of cases, site of diseases, and service facility through a simple random sampling method. A semi-structured questionnaire tool was used to collect socio-demographic, clinical, and ADR-related data from the TB patients. Data was analyzed for the frequency, percentage, chi-squared, and adjusted odds ratio to find the association between the variables. Results The majority of the study participants were male (87.2%), aged 15 to 60 (57.8%), daily laborers (22.4%), and married (64.2%). Over 75% of individuals had pulmonary TB, with 87% having experienced their first episode, 83% being new cases, and 44.7% having a history of addiction. ADR with mild symptoms was reported by more than a quarter (29%) of TB patients during the intensive phase (77%). The association between ADR experience and drug susceptibility was significant (p<0.005) and drug-resistant TB patients experience two times more ADRs than drug-sensitive TB patients (OR 2.04). Binomial logistic regression was carried out to describe the association between various variables and occurrence of ADRs. Conclusion The study highlighted a need to enhance health care providers’ capacity and program structure for managing ADRs among TB patients. In order to completely eliminate TB across the country, it also emphasized the attention for a holistic and all-encompassing strategy for managing TB patients at the field level.

Implementation research for strengthening health systems in India.

Implementation research for strengthening health systems in India.

Cost-Utility Analysis of TNF-α Inhibitors, B Cell Inhibitors, and JAK Inhibitors Versus csDMARDs for Rheumatoid Arthritis Treatment.

Rheumatoid arthritis (RA) is a progressive and debilitating disease, causing persistent joint pain that limits daily activities requiring long-term treatment. Newer targeted therapies expand RA treatment options, but their high cost necessitates a focus on cost effectiveness. To address this, we aim to conduct a cost-utility analysis of these newer RA pharmacotherapies to support evidence-based policy decision-making. We analyzed the cost-utility of sequential treatment with TNF-α, B cell and JAK-inhibitors compared with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for RA treatment in methotrexate (MTX) nonresponders. We used a Markov model with lifetime horizon and 6-month cycles from an Indian health system perspective. Costs (INR 2022) and quality-adjusted life years (QALYs) were used to determine the incremental cost-effectiveness ratios (ICERs) at a cost-effectiveness threshold of India's gross domestic product (GDP) per capita (2022). We assessed uncertainty using univariate, probabilistic sensitivity, and scenario analyses. Despite additional QALYs, TNF-α, B cell, and JAK inhibitors were not cost-effective for treating moderate-to-severe patients with RA unresponsive to csDMARDs (including MTX) in India, as increased costs outweighed their clinical benefits. ICERs ranged from 10,46,206 to 31,09,207Indian Rupees in the base case analysis, exceeding three times India's GDP per-capita [approximately USD $13,287 to $39,487 and GBP £10,776 to £32,025]. Sensitivity analyses confirmed the results' robustness. Scenario analysis suggested that a cost reduction of over 75% in drug prices could make most of the interventions cost effective compared with csDMARDs. TNF-α, B cell, and JAK-inhibitors are not cost-effective compared with csDMARDs for patients with RA who have not responded to MTX in India at the current prices. Cost-effectiveness estimates were highly influenced by drug pricing variations. Therefore, reducing the prices of these interventions could enhance affordability, potentially leading to their inclusion in publicly funded health programs.

The paradox of growing technical capacities with low global governance: a review of Voluntary National Reviews’ SDG health-related indicators

BackgroundThis study delves into the States’ accountability for health-related Sustainable Development Goal (SDG) indicators from 2016 to 2020. An analysis of Voluntary National Reviews (VNR) is employed as an instrument to scrutinize the alignment of States’ indicators with the global indicator framework, shedding light on global health governance within the context of the 2030 Agenda and States’ strategic prioritization. A curation of 60 health-related indicators from 195 VNRs, produced during the aforementioned period, is organized into thematic groups.ResultsOur results highlight a concerning discrepancy in the reporting frequency of various health-related themes. The findings reveal a paradoxical coexistence characterized by the concurrent strengthening and diminution of the global health governance articulated in the Agenda’s global health governance. This manifests in the increased utilization and consistency of health-related indicators over the study years, coupled with an emphasis on infectious diseases and child and maternal health indicators. Conversely, a discernible governance decline is evidenced by the inadequate representation of health-related indicators in VNRs, notably within the domains of universal health coverage and health system indicators. Furthermore, High-Income States exhibit diminished accountability.ConclusionsThe VNRs unveil a paradox wherein burgeoning technical capacity coexists with governance deficits, a phenomenon attributable to both statistical capabilities and political preferences. The prevalent use of proxy indicators in VNRs oversimplifies the presentation of official indicators, thereby compromising the aspirational goal of pioneering statistical innovations for measuring intricate issues in the SDGs. In light of our conceptualization of the 2030 Agenda’s global health as a regime complex governance, we advocate for comprehensive investigations into each health regime cluster. This approach aims to unravel disputes, discern patterns, and elucidate States’ preferences concerning specific thematic areas. Functioning as an accountability mechanism for the Agenda’s governance, VNRs underscore States’ adaptability and short-term learning capabilities, offering valuable insights for identifying harmful goal prioritization. The discretionary nature of indicator selection by States in the VNRs, enabled by the Agenda’s proposition of a contextual adaptation of the SDGs and a blind eye to the guideline’s request to review all SDG indicators, highlights a critical flaw in the VNR as an accountability mechanism.

Data for health system comparison and assessment in the African Region: A review of 63 indicators available in international databases.

Achieving universal health coverage in the African region requires health systems strengthening. Assessing and comparing health systems contributes to this process, but requires internationally comparable data. The European Observatory on Health Systems and Policies has produced Health Systems in Transition (HiT) reviews in Europe, Asia, North America and the Caribbean with a standardised template. This study explores data availability in international databases for the quantitative health and health system indicators in the HiT template for the WHO African region. We identified ten databases which contained data for 40 of the 80 original HiT indicators and an additional 23 proxy indicators to fill some gaps. We then assessed data availability for the resulting 63 indicators by country and time, i.e. first/last year of data, years of data available overall and since 2000, and we explored for each indicator (1) against the country with the greatest availability overall and (2) against annual availability for all years since 2000. Overall data availability was greatest in South Africa (93.0% of possible total points) and least in South Sudan (59.5%). Since 2000, Uganda (60.4%) has had the highest data availability and South Sudan (37.2%) the lowest. By topic, data availability was the highest for health financing (91.4%; median start/end date 2000/2019) and background characteristics (88.5%; 1990/2020) and was considerably lower for health system performance (54.5%; 2000/2018) and physical and human resources (44.8%; 2004/2013). Data are available for different years in different countries, and at irregular intervals, complicating time series analysis. No data are available for service provision indicators. Gaps in data in international databases across time, countries, and topics undermine systematic health systems comparisons and assessments, regional health systems strengthening, and efforts to achieve universal health coverage. More efforts are needed to strengthen national data collection and management and integrate national data into international databases to support cross-country assessments, peer learning, and planning. In tandem, more research is needed to understand the specific historical, cultural, administrative, and technological determinants influencing country data availability, as well as the facilitators and barriers of data sharing between countries and international databases, and the potential of new technologies to increase timeliness of data.

Utilization of Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) Practitioners' Services Among Older Adults: Results From the Longitudinal Aging Study in India.

Ayurveda, yoga, naturopathy, Unani, Siddha, and homeopathy (AYUSH) form an alternative system of medicine in India. Understanding the utilization of AYUSH practitioners' services is crucial to substantiating the current government initiatives to mainstream AYUSH in the Indian health system. The utilization of AYUSH practitioners' services among different sub-populations, including older adults, for various health conditions is underexplored. The present study explores the utilization of AYUSH practitioners' service among older Indian adults and its correlates. During 2017-2018, the Longitudinal Aging Study in India (LASI) conducted a nationally representative study among adults aged 45 years or more and their spouses. The study leveraged this data from publicly available LASI. Descriptive analysis and cross-tabulation were performed using a subset of older adults (age ≥ 60 years, n = 31,464). The utilization of AYUSH practitioners' services was taken as the outcome variable. A logistic regression model was employed to understand the independent effect of various explorative variables on the use of AYUSH practitioners' services. One in 14 older adults utilized the services of AYUSH practitioners. The socio-demographic factors that were looked at, including religion, residence, and castewere significant independent factors for AYUSH consultation. Among chronic conditions, hypertension (use-5.6%, AOR: 1.24, CI: 1.09-1.40), diabetes (use-4.2%, AOR: 1.31, CI: 1.09-1.57), and arthritis (use-9.1%, AOR: 0.59, CI: 0.52-0.67) were independent determinants of AYUSH practitioners' service utilization. In the fully adjusted model, the effect of explanatory variables is almost similar to that in the minimally adjusted model. Only the effect of the female gender was accentuated in magnitude, whereas the effect of diabetes was partially attenuated. The preference for AYUSH practitioners' service among older adults is determined by the complex interplay between socio-demographic factors and disease conditions. Though utilization of AYUSH practitioners' service was high among certain underprivileged sections, it is assuring that education and income do not affect older populations' preference for AYUSH practitioners' service.

Morbidity pattern of communicable diseases in a tertiary care hospital in metropolitan city of western Maharashtra

Background: In India, infectious diseases continue to be predominant with emerging non-communicable diseases, imposing a double burden of diseases on health care system. Hence, the tertiary health care hospital-based study was done to compare the morbidity pattern of communicable diseases with respect to non-communicable diseases. Methods: A 2 years’ record-based data of admitted patients was collected in a tertiary health care hospital. The data was analysed using Microsoft Excel version 365. Significance of association and difference in proportions has been checked with chi-square test and Z test for SEDP respectively at significance level of 0.05. Results: During the study period of two years, 6818 patients were admitted in the hospital, of which 74.51% suffered from communicable diseases while 25.49% suffered from other types of disease including non-communicable diseases. Of the 5080, patients with communicable diseases, 57.74% were males and 42.26% were females. Communicable diseases and non-communicable diseases had male predominance (p<0.05) and was higher amongst age group 0-15 years (p<0.05). Hospital stay was prolonged in patients suffering from communicable disease (p<0.05). Significant increased difference was found in AFI, Malaria, Dengue and in Leptospirosis prevalence and significant decreased difference was found in acute gastroenteritis, IV, Covid-19, Respiratory infections and enteric fever (p<0.05). Conclusions: Communicable diseases continue to be a major threat to public health system in India. Through effective surveillance programmes, any change in trends of disease can be identified and suitable measures can be adapted to control and prevent it.

Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India

IntroductionSevere Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. AimThe primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. MethodsMarkov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. ResultsProphylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of −853,573 USD (INR -63,109,773), and negative ICUR of −211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years’ time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). ConclusionProphylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.

Comment on: The curious case of the extinction of family physicians from the Indian health system.

Comment on: The curious case of the extinction of family physicians from the Indian health system.

Has the efficiency and productivity of the health system in India improved during post-policy period? Application of the bootstrap data envelopment analysis and Malmquist productivity index

ABSTRACT The efficiency and productivity of the health system are assessed using bootstrap data envelopment analysis and the bootstrap Malmquist productivity index across 21 states of India against the backdrop of the National Health Policy (NHP-2017). We took two child outcomes and three maternal outcomes as outputs and four inputs. A technical efficiency score of 0.760 suggests that the outputs could be increased by 24% without any additional inputs in the health system. A productivity of 0.993 indicates a decline at an average rate of 0.7% per year attributable to technological regress. Deducing from the statistical tests conducted, a significant change in the efficiency of the health system over the years was observed, particularly between the pre- and post-policy periods. In contrast, no significant change in productivity was observed. Despite having relatively better outcomes, Tamil Nadu lies farther away from the frontier, which indicates the inefficient utilization of public health resources. In contrast, Bihar, which has poor health outcomes, has better efficiency and witnessed significant productivity growth, indicating the efficient utilization of limited resources.

Digital health interventions for improving access to primary care in India: A scoping review.

Access to quality healthcare remains a challenge in low-and middle-income countries. Vulnerable populations with unmet needs face the greatest challenge in accessing primary care for appropriate and timely healthcare. The use of digital technologies can not only strengthen health systems but also improve access to health care, particularly for the vulnerable. This scoping review aims to assess the various digital health technologies and interventions available for improving access to primary care for the vulnerable in India. This scoping review employed the Joanna Brigg Institute's (JBI) guidelines and Arksey and O'Malley's methodological framework. The literature search was conducted in Medline/PubMed, Embase, Web of Science-Core Collection, Scopus, AgeLine, PsycINFO, CINAHL, ERIC, Cochrane CENTRAL, and Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register databases, using the keywords, such as 'Access', 'Healthcare', 'Assistive technology', 'Digital health' 'Vulnerable', 'India' and 'Healthcare technology'. A two-staged screening of titles and abstracts, followed by full-text was conducted independently by two reviewers, using the Rayyan software. Subsequently, the data was extracted from selected studies using a pre-designed and approved extraction form. The data was then synthesised and analysed narratively. The protocol for this review has been registered with open science forum (OSF) registries (https://osf.io/63pjw/). The search yielded about 3840 records, 3544 records were eligible for screening of titles and abstracts. We included seven studies after a two-round screening and identified seven different technological innovations developed to bridge gaps in access to primary care. The commonly used digital health interventions for improving access to primary care were virtual tele-health systems and mHealth applications in-built within an android smartphone or a tablet. Digital health interventions was either used as a standalone tele-health aid or a collaborative system for community workers, primary care physicians as well as the health service users. The purpose of these innovations was to increase awareness and knowledge to access support for specific aspects of healthcare. Virtual primary health care with the specialist in the hub supporting general physicians at the primary health centres in blocks and districts was another such model used for improving access to primary care. Digital health interventions was also used for mass community screening of disabilities, such as persons with hearing disability. To re-imagine a digitally empowered health systems in India, also inclusive of the vulnerable, it is important to inclusively conceptualise, systematically develop and rigorously evaluate any public health interventions including those that are enabled by digital health interventions to bridge the gaps in access to primary care in India. Such a strategy could address the paucity of evidence in public health interventions and provide sustainable strategies to strengthen health systems in India. Trial registration: Open Science Framework-Registration Link: https://osf.io/63pjw/.

Evaluation of covid-19 mortality using machine learning regression methods based on health system indicators

Evaluation of covid-19 mortality using machine learning regression methods based on health system indicators

Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol

IntroductionAccess to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some...

Development and Implementation of a Unified Care Model Performance Framework in the Yishun Zone Regional Population Health System

Background / Objective: Governance and Leadership Subsystem (GLS) of health systems governs but also directs Service Delivery Subsystem (SDS) transformation. Performance management (PM) is a key GLS activity. Coherent PM frameworks improve SDS governance, health system performance and ultimately population health outcomes.
 Yishun Health (YH) is an integrated care organization within National Healthcare Group (NHG) caring for 320,000 residents in northern Singapore as the Yishun Zone Regional Population Health System (YZ). YH designed and deployed the Unified Care Model (UCM) as future-state SDS model to integrate and transform its care/services with care partners. A redesigned PM framework going beyond disease-condition services, specialty-departments, and institutions-partners was required.
 Method: Population segmentation was achieved using NHG River-of-Life segmentation model, dividing YZ residents into four Lifelong Care segments (LLC) and one Episodic Care segment (EC). Employing UCM, LLC and EC were further sub-segmented into a cascade of ever smaller populations of unique care needs to envision future SDS needs/demand-supply matching in the form of integrated microsystems of care/services delivery.
 UCM Performance Framework (UCMPF) was conceptualized by adapting IHI’s Quadruple Aim as annual outcomes for LLC microsystems and Dartmouth’s Clinical Value Compass as 90-day outcomes for EC microsystems. Ability to govern integrated microsystems was then modelled using clinical logic models, enabling curation of input, process, and output indicators into domains of standardized care strategies i.e. “Horizontal Logic”. “Vertical Logic” was then employed to aggregate relevant LLC or EC microsystem input, process, output or outcome indicators up the cascade of UCM population segments and higher order systems to envision future-state GLS, such as i) person and need/demand centric mesosystems e.g. LLC and EC or a community geographically, or ii) provider-centred mesosystems e.g. site-based disease condition-services or program, specialty-departments, institution-partners, culminating ultimately in whole health system or macrosystem performance indicators. UCMPF dual logic enabled stakeholders to visualize interdependencies in whole system PM indicators and more coherently co-create performance indicators at all levels of YZ.
 
 
 Results: Exceeding 1,300 existing care/services indicators across disease condition-services or program, specialty-departments, institution-partners were discovered and systemically visualized using UCMPF in LLC and EC Indicator Menus, revealing how current care/services indicators impacted input, process, output and outcome of LLC and EC at different levels of the SDS. Numerous leadership conversations were conducted to envision future GLS activities using UCMPF, spawning many working level discussions, which continue to be ongoing between senior clinicians and administrators to prioritize indicators for PM. Technical definitions for prioritized indicators was also initiated to support informatics systems and enterprise data warehouse dashboard redesign. 
 Discussion/Conclusion: UCMPF employs a systemic design and visualization approach to mitigate complexity in whole system PM. LLC and EC Menus reduce cognitive difficulty for stakeholders to relate their existing care/services measurement efforts with micro and mesosystem levels of the UCM and jumpstarts conversations whether existing care/services contribute or not towards YZ outcomes i.e. macrosystem. UCMPF therefore supports our ongoing care/services integration activity, and the co-creation of future GLS for YZ SDS is hypothesized to ultimately accelerate health system transformation towards better population health outcomes in YZ.

All talk…only a little action: a reflection on embedding equity into integrated care models in Ontario, Canada

Background: Ontario Health Teams (OHTs) are a recently introduced model of delivery intended to integrate services to deliver connected care to defined populations in Ontario, Canada. The Quadruple Aim advocates for improving patient experience, reducing cost, advancing population health, and improving the provider experience; it is meant to be a guide for OHTs for performance outcomes and as a framework for evaluation and reporting. The Quintuple Aim, incorporating an added focus on health equity, has recently been introduced to OHTs, where equity is also built into continuous quality improvement requirements. As embedded OHT research fellows, we recognize our key role in supporting equity in healthcare delivery and programs. However, we also observe the challenges to generating actionable initiatives to integrate equity into OHTs.
 Objective: The objective of this presentation is to describe equity initiatives being incorporated in four OHTs in Ontario, Canada and to identify the barriers and facilitators at the micro, meso and macro levels. This presentation is aimed at those involved in integrated care research, policy, practice, and education.
 Methods: We will use a multiple case study design to describe the contexts of four integrated care models representing large, mid, and small urban regions of the province. This work is guided by the Rainbow Model for Integrated Care, which conceptualizes different domains of integrated care. We will include multiple data sources from each OHT, including key documents, formal and informal community partnerships, the level and nature of engagement with equity-deserving groups in governance processes, the extent to which equity is emphasized in strategic plans and other documents, and the resources available, we share insights gleaned on barriers and facilitators to applying an equity lens. 
 Key Results: We identify challenges related to data availability for health equity decision making and health systems planning. Specifically, difficulties exist in accessing meaningful and linked data to understand OHT attributed populations; these difficulties are compounded when seeking data specific to equity deserving groups and when attempting to link equity relevant indicators to health system indicators. Furthermore, meaningful engagement with equity deserving groups in order to build relationships requires time and resources that are difficult to source; such engagement is particularly challenging in an environment of limited financial resources, where frequent reporting and pressure to quickly deliver outcomes is emphasized. OHTs are collaborative governance models composed of representation from member organizations, patients, and academics; this collaborative approach to governance can be a facilitator to embedding equity deserving groups into the structure of OHTs.
 Next Steps: Ontario Health Teams require support in creating comprehensive equity approaches that are specific to the needs of their communities and teams; further work is needed to better understand the needs of OHTs in this regard.