Health System Performance Measurement Research Articles

Health system inequities in Lao People's Democratic Republic: Evidence from a nationally representative phone survey.

Despite substantial economic growth in Lao People's Democratic Republic (PDR) over the past 20 years, high levels of income inequality and poverty persist and have likely been exacerbated by the COVID-19 pandemic. In this article, we use novel survey data to assess the extent to which socioeconomic status is associated with access to quality care in Lao PDR. We utilised data from the Lao People's Voice Survey (PVS), which was designed to measure health system performance from the perspective of the population. The survey was conducted between May and August 2022. Primary outcomes of interest were having a usual source of healthcare, using a government health centre (rather than a hospital or private clinic) as the usual source for care, receiving preventive health services, experiencing unmet healthcare needs, the quality of recent healthcare visit, and confidence in accessing and affording healthcare when needed. Poverty was measured using household asset ownership. We used logit models to assess the associations between poverty and health system performance measures, and additionally assessed differences between these associations in urban vs. rural areas by interacting urban residence with poverty. Poverty was negatively associated with having a regular provider for care (adjusted odds ratio (aOR) 0.45, 95% CI 0.26-0.78), receiving preventive health services (aOR 0.54, 95% CI 0.37-0.80), and confidence in the ability to receive care (aOR 0.50, 95% CI 0.34-0.72) and afford care (aOR 0.50, 95% CI 0.34-0.73) when needed. Poverty was positively associated with using government managed health centres as a usual source or for care (aOR 2.16, 95% CI 1.35-3.48). Poverty was not significantly associated with user experience or perceived quality of care in the last visit to the health facility. No differences in the associations between poverty and access to quality care were found between rural and urban settings. The results presented in this article suggest socioeconomic disparities in health care access in Lao PDR despite major national efforts to provide universal access to care. Universal health care policies may not be reaching the poor and additional targeted efforts may be needed to meet their healthcare needs.

The impact of devolution on local health systems: Evidence from Greater Manchester, England

Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach.We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents.Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (−110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed.Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study.

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery. The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Mortality-based indicators for measuring health system performance and population health in high-income countries: a systematic review

Abstract Objectives Mortality-based indicators are commonly used as measures of population health but less frequently applied to measuring health system performance. This systematic review aimed to identify and describe mortality indicators relevant to the measurement of population health and health system performance in high-income countries. Methods We searched peer-reviewed databases (MEDLINE, Embase, CINAHL, Health Business Elite, Health Policy Reference Center, and POPLINE) and grey literature (government agencies, professional associations, and international/non-governmental health organizations). The search was limited to indicators identified for use in high-income countries. We extracted information on indicator characteristics and alignment with dimensions of effectiveness, efficiency, and equity. We assessed the applicability of the indicator to the context of population health, health system, or both settings, alignment with SMART criteria (specific, measurable, actionable, relevant, and timely), and potential for analyses of population subgroups. Health system was defined as encompassing both medical care and public health services and activities. Results We extracted 385 mortality-based indicators from 240 sources. Indicators were organized into six major domains: all-cause mortality (n = 12), premature mortality (n = 92), life expectancy (n = 23), cause-specific mortality (n = 127), infant, child, and adolescent mortality (n = 50), and hospital-related mortality (n = 81). The majority of indicators (86%) could be applied to measuring health system performance. Premature mortality indicators showed the most potential to measuring both population health and health system performance. Conclusions This review compiled a wide range of mortality indicators relevant to measuring health system performance in high-income countries. Indicators of premature mortality were most relevant to measuring both population health and health system performance.

The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990–2019: a systematic analysis of the Global Burden of Disease Study 2019

Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence. In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance. In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings. Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world. The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation.

Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction

Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown. To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018. Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019). Enrollment in Medicare Advantage vs traditional Medicare. The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions). The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]). Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Validation and endorsement of health system performance measures for opioid use disorder in British Columbia, Canada: A Delphi panel study

BackgroundLimited data exists on the performance of the healthcare system in opioid use disorder (OUD). We evaluated the face validity and potential risks of a set of health system performance measures for OUD collaboratively with clinicians, policymakers and people with lived experience of opioid use (PWLE) in the interest of establishing an endorsed set of measures for public reporting. MethodsThrough a two-stage Delphi-panel approach, a panel of clinical and policy experts validated and considered 102 previously constructed OUD performance measures for endorsement using information on measurement construction, sensitivity analyses, quality of evidence, predictive validity, and feedback from local PWLE. We collected quantitative and qualitative survey responses from 49 clinicians and policymakers, and 11 PWLE. We conducted inductive and deductive thematic analysis to present qualitative responses. ResultsA total of 37 measures of 102 were strongly endorsed (9/13 cascade of care, 2/27 clinical guideline compliance, 17/44 healthcare integration, and 9/18 healthcare utilization measures). Thematic analysis of responses revealed several themes regarding measurement validity, unintended consequences, and key contextual considerations. Overall, measures related to the cascade of care (excluding opioid agonist treatment dose tapering) received strong endorsements. PWLE highlighted barriers to accessing treatment, undignified aspects of treatment, and lack of a full continuum of care as their concerns. ConclusionWe defined 37 endorsed health system performance measures for OUD and presented a range of perspectives on their validity and use. These measures provide critical considerations for health system improvement in the care of people with OUD.

Explaining regional variations in colon cancer survival in Ontario, Canada: a population-based retrospective cohort study

ObjectivesRegional variation in cancer survival is an important health system performance measurement. We evaluated if regional variation in colon cancer survival may be driven by differences in the patient population,...

Current PROM and PREM use in health system performance measurement: Still a way to go

There is a growing impetus to “measure what matters” to enable health systems to optimise value-based, person-centred healthcare. This paper describes the critical importance of patient-reported outcome and experience measures (PROMs and PREMs) in this pursuit and provides an in-depth overview of how PROM and PREM programs differ between England, the United States, and Australia. A comprehensive timeline of PROM, PREM, legislation/policy, and value-based purchasing (pay-for-performance) program implementation accompanies this discussion. Importantly, this paper highlights disparities between these nations’ PROMs and PREMs programs, evidencing that we still have a way to go towards equal health system performance measurement globally. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework. (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens.

Evaluations of effective coverage of maternal and child health services: A systematic review.

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Variation in the COVID-19 infection–fatality ratio by age, time, and geography during the pre-vaccine era: a systematic analysis

SummaryBackgroundThe infection–fatality ratio (IFR) is a metric that quantifies the likelihood of an individual dying once infected with a pathogen. Understanding the determinants of IFR variation for COVID-19, the disease caused by the SARS-CoV-2 virus, has direct implications for mitigation efforts with respect to clinical practice, non-pharmaceutical interventions, and the prioritisation of risk groups for targeted vaccine delivery. The IFR is also a crucial parameter in COVID-19 dynamic transmission models, providing a way to convert a population's mortality rate into an estimate of infections.MethodsWe estimated age-specific and all-age IFR by matching seroprevalence surveys to total COVID-19 mortality rates in a population. The term total COVID-19 mortality refers to an estimate of the total number of deaths directly attributable to COVID-19. After applying exclusion criteria to 5131 seroprevalence surveys, the IFR analyses were informed by 2073 all-age surveys and 718 age-specific surveys (3012 age-specific observations). When seroprevalence was reported by age group, we split total COVID-19 mortality into corresponding age groups using a Bayesian hierarchical model to characterise the non-linear age pattern of reported deaths for a given location. To remove the impact of vaccines on the estimated IFR age pattern, we excluded age-specific observations of seroprevalence and deaths that occurred after vaccines were introduced in a location. We estimated age-specific IFR with a non-linear meta-regression and used the resulting age pattern to standardise all-age IFR observations to the global age distribution. All IFR observations were adjusted for baseline and waning antibody-test sensitivity. We then modelled age-standardised IFR as a function of time, geography, and an ensemble of 100 of the top-performing covariate sets. The covariates included seven clinical predictors (eg, age-standardised obesity prevalence) and two measures of health system performance. Final estimates for 190 countries and territories, as well as subnational locations in 11 countries and territories, were obtained by predicting age-standardised IFR conditional on covariates and reversing the age standardisation.FindingsWe report IFR estimates for April 15, 2020, to January 1, 2021, the period before the introduction of vaccines and widespread evolution of variants. We found substantial heterogeneity in the IFR by age, location, and time. Age-specific IFR estimates form a J shape, with the lowest IFR occurring at age 7 years (0·0023%, 95% uncertainty interval [UI] 0·0015–0·0039) and increasing exponentially through ages 30 years (0·0573%, 0·0418–0·0870), 60 years (1·0035%, 0·7002–1·5727), and 90 years (20·3292%, 14·6888–28·9754). The countries with the highest IFR on July 15, 2020, were Portugal (2·085%, 0·946–4·395), Monaco (1·778%, 1·265–2·915), Japan (1·750%, 1·302–2·690), Spain (1·710%, 0·991–2·718), and Greece (1·637%, 1·155–2·678). All-age IFR varied by a factor of more than 30 among 190 countries and territories. After age standardisation, the countries with the highest IFR on July 15, 2020, were Peru (0·911%, 0·636–1·538), Portugal (0·850%, 0·386–1·793), Oman (0·762%, 0·381–1·399), Spain (0·751%, 0·435–1·193), and Mexico (0·717%, 0·426–1·404). Subnational locations with high IFRs also included hotspots in the UK and southern and eastern states of the USA. Sub-Saharan African countries and Asian countries generally had the lowest all-age and age-standardised IFRs. Population age structure accounted for 74% of logit-scale variation in IFRs estimated for 39 in-sample countries on July 15, 2020. A post-hoc analysis showed that high rates of transmission in the care home population might account for higher IFRs in some locations. Among all countries and territories, we found that the median IFR decreased from 0·466% (interquartile range 0·223–0·840) to 0·314% (0·143–0·551) between April 15, 2020, and Jan 1, 2021.InterpretationEstimating the IFR for global populations helps to identify relative vulnerabilities to COVID-19. Information about how IFR varies by age, time, and location informs clinical practice and non-pharmaceutical interventions like physical distancing measures, and underpins vaccine risk stratification. IFR and mortality risk form a J shape with respect to age, which previous research, such as that by Glynn and Moss in 2020, has identified to be a common pattern among infectious diseases. Understanding the experience of a population with COVID-19 mortality requires consideration for local factors; IFRs varied by a factor of more than 30 among 190 countries and territories in this analysis. In particular, the presence of elevated age-standardised IFRs in countries with well resourced health-care systems indicates that factors beyond health-care capacity are important. Potential extenuating circumstances include outbreaks among care home residents, variable burdens of severe cases, and the population prevalence of comorbid conditions that increase the severity of COVID-19 disease. During the pre-vaccine period, the estimated 33% decrease in median IFR over 8 months suggests that treatment for COVID-19 has improved over time. Estimating IFR for the pre-vaccine era provides an important baseline for describing the progression of COVID-19 mortality patterns.FundingBill & Melinda Gates Foundation, J Stanton, T Gillespie, and J and E Nordstrom

Development and validation of health system performance measures for opioid use disorder in British Columbia, Canada

BackgroundPerformance measurement provides an evidence-based means to inform development of interventions to improve the quality of care for people who use opioids. We aimed to develop and assess the predictive validity of health system performance measures for opioid use disorder (OUD) in British Columbia (BC), Canada. MethodsPerformance measures were generated using retrospective population-level administrative datasets (both provincial and regional) and publicly-reported retrospective data according to four domains (care engagement, clinical guideline compliance, integration, and healthcare utilization). The adjusted odds ratio was estimated via generalized linear mixed models to determine predictive validity for all-cause hospitalization or mortality within 6 months of measurement. FindingsA total of 102 performance measures were constructed. We identified 55,470 diagnosed PWOUD, and 39,456 ever engaged in opioid agonist treatment (OAT). We found divergent rates of treatment for concurrent conditions (7.4% for alcohol use disorder to 80.1% for HIV/AIDS), low levels of linkage to OAT and other outpatient care following acute care, and increasing levels of service provision, including increases in OAT prescribers and pharmacies, naloxone kit distribution and overdose prevention site visitation. Our analyses on the predictive validity measures largely supported a priori hypotheses on the direction of effect on the outcome. ConclusionsWe identified a range of priorities to improve the quality of care for PWOUD, with critical gaps in linkage to care through acute care settings and long-term engagement in OAT. The proposed measures can be derived for geographic and clinical subgroups and updated over time, providing a basis to monitor and evaluate efforts to address the public health burden of OUD.

Equity in healthcare utilization in Canada's publicly funded health system: 2000-2014.

Equity in healthcare utilization is a globally accepted measurement of health system performance. In Canada, equity is included as a policy goal in the Federal health legislation that governs healthcare systems. This study used ten cycles of the Statistics Canada Canadian Community Health Survey (CCHS, n = 664,548) to examine the trends in income-related inequities in healthcare utilization in Canada from 2000 to 2014. The horizontal inequity (HI) index was used to quantify inequity in healthcare utilization for general practitioner (GP) visits, specialist physician (SP) visits and hospital admissions (HA) nationally, in urban and rural areas, and for all provinces. Nationally, GP and SP visits show pro-rich inequity, while HA demonstrates pro-poor inequity. This pattern is consistent in the provincial and urban and rural areas results. Trend analysis suggested that inequity in GP visits became more pro-poor in New Brunswick, but more pro-rich in Prince Edward Island and Quebec. Despite the inclusion of equity as a main policy goal, this study demonstrated that inequity in healthcare utilization remains a persistent issue in the Canadian healthcare system.

Strategic Health Purchasing and Health System Performance in Nigeria

Purchasing has been adopted by many countries as a mechanism to achieve greater efficiency and improved responsiveness of services to patient demands. This study examined the effects of strategic health purchasing on health system performance in Nigeria. The data for the study was collected using a purposive sampling survey in the Akure metropolis. The results indicated a positive relationship between health system performance and purchasing strategy, payment mechanism and service utilisers with the regression coefficients of 0.30, 0.16 and 0.33. This implied that purchasing strategy, payment mechanism and service utilisers are likely to improve health system performance. The results also revealed a positive relationship between each of the health system performance measurement dimensions (life expectancy, the performance of different areas of health services, distribution of access to health facilities, fairness of health financing, prompt attention to medical needs and purchasing strategy, providers payment mechanism and service utilisers. It was concluded that health system performance can be improved by the implementation of strategic health purchasing. Therefore, paying for health care services should be made strategic and rules relating to auditing and accountability should be made more effective.

Refined avoidable mortality for comparative health systems performance assessment: an impact study

Abstract Background Avoidable mortality is headline indicator of relative health system performance in European Union policy processes. However, the reliability of this indicator for cross-national comparisons of health system performance is limited by the lack of control for cross-country differences in population health status, and the challenges in selecting causes of death and age limits. This study examined the feasibility and impact of several refinements of avoidable mortality addressing these concerns. Methods Using a sample of 30 European countries, including EU Member States, United Kingdom, Norway, and Iceland, we examined the feasibility and impact of adjusting avoidable mortality for cross-country differences in disease prevalence and disease stage, using extended age thresholds, and calculating the avoidable burden of disease. We measured the impact of the feasible adjustments by calculating the average absolute change in country ranks compared to the 2014 country ranking based on the standard avoidable mortality. Results Given publicly available data, only the calculation of years of life lost due to avoidable causes of death and using different age thresholds to calculate avoidable mortality are currently feasible. The impact of the feasible adjustments varied between countries with no visible geographic pattern. Including deaths due to avoidable causes at all ages changed the country ranks by an average of 1.9 places in men and 2.8 in women. Using years of life lost due to avoidable causes of death changed the rank by an average of 8.1 places in men and 8.7 in women. Conclusions Country rankings are highly sensitive to the type of refinement. However, a full assessment of refinements was not possible due to missing data. To ease the implementation of morbidity-based refinements of avoidable mortality, we recommend that a shorter list of avoidable causes of death is developed. Key messages A continuous refinement of relative health system performance measures and improving the availability of internationally comparable health data are critical to effectively support policy making. Updating the age thresholds used to calculate avoidable mortality and using years of life lost due to avoidable causes of death are currently feasible and have a sizeable impact on country rankings.

Health systems and global progress towards malaria elimination, 2000\u20132016

BackgroundAs more countries progress towards malaria elimination, a better understanding of the most critical health system features for enabling and supporting malaria control and elimination is needed.MethodsAll available health systems data relevant for malaria control were collated from 23 online data repositories. Principal component analysis was used to create domain specific health system performance measures. Multiple regression model selection approaches were used to identify key health systems predictors of progress in malaria control in the 2000–2016 period among 105 countries. Additional analysis was performed within malaria burden groups.ResultsThere was large heterogeneity in progress in malaria control in the 2000–2016 period. In univariate analysis, several health systems factors displayed a strong positive correlation with reductions in malaria burden between 2000 and 2016. In multivariable models, delivery of routine services and hospital capacity were strongly predictive of reductions in malaria cases, especially in high burden countries. In low-burden countries approaching elimination, primary health center density appeared negatively associated with progress while hospital capacity was positively correlated with eliminating malaria.ConclusionsThe findings presented in this manuscript suggest that strengthening health systems can be an effective strategy for reducing malaria cases, especially in countries with high malaria burden. Potential returns appear particularly high in the area of service delivery.

Analiza merenja performansi sistema bezbednosti i zdravlja na radu u rudarsko energetskom kompleksu

In modern mining complexes, the amount of available information on the performance of occupational health and safety systems is constantly increasing. Measurement and evaluation of system performance, as well as the need to develop a better measurement model, arises primarily due to necessity of the improvement of occupational health and safety. The scope of the model aiming to maturity analysis of safety performance measurement, which was applied in the research whose results are presented in this paper, included the performance measurement practice, the commitment and culture of performance measurement and the use of measurement results. In addition to the three basic topics mentioned, an assessment related to the state of the occupational health and safety system was added. As a result of the application of the proposed model, an overall maturity score was obtained. This paper presents the results of the maturity analysis of occupational health and safety system performance measurement in the company TE-KO "Kostolac", which identifies areas that will be given special attention in the future in terms of improving the management of occupational health and safety.

Frameworks of Performance Measurement in Public Health and Primary Care System: A Scoping Review and Meta-Synthesis.

Background:This study was conducted to synthesize the evidence on the dimensions of performance appraisal of the public health and primary care system through a scoping review and meta-synthesis.Methods:The review conducted systematically in 2018 with a scoping review approach. To identify pertinent studies, the following electronic databases were systematically searched until December 20, 2017: Cochrane, ISI Web of Science, PubMed, Scopus, Science Direct, and Embase. Reviewing the studies found on the search bases was carried out in three stages by two persons individually. According to refined studies, the data were extracted to meet the objectives and respond to the research questions. The thematic analysis was used to identify and categorize the dimensions of performance measurement.Results:Using this process, 20 studies were eligible for our research. The critical points in measuring the performance of the public health field were classified into eight main domains including leadership and stewardship, funding, resource generation, service delivery, quality, accessibility, efficiency/productivity, and community health status. The differences in measurement frameworks are inevitable. One reason for the differences in the health system performance measurement framework is the differences in the data or data collection, analysis, and reporting. Performance measurement in the field of health, especially primary care, was a multidimensional issue.Conclusions:Each of the main dimensions had several sub-criteria, indicating the broadness and complexity of the performance of first-level care providers. Single-dimensional performance measurement could underpin incorrect policies and decisions.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index.

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Evaluate the Implementation of Occupational Health and Safety (OHS) Management System Performance Measurement at PT. XYZ Medan to minimize Extreme Risks

OHS is an activities to ensure and protect the safety and health of the workforce through prevention of occupational injuries and occupational diseases. One way of prevention of work accident is through to implement OHS System. The OHS process should begin with a good planning process to ensure that its implementation complies with the desired policies and objectives. PT. XYZ Medan has implemented OHS System which is regulated in the procedures and manuals of the company’s management system. The purpose of this study was to assess and evaluate the Occupational Safety and Health Management System and also to evaluate Hazard Identification in the company. This research uses checklist method of all assessment criteria of OHS management system based on Indonesian Government Regulation, and for application of OHS in company use qualitative data through spreading of quisioner to managers, supervisors and workers. Based on the result of observation, it is found that the implementation of OHS in the company is not fully complied with the Indonesian Government Regulation. There are still 24 unfulfilled criteria that is concerning policy, plan of OHS, document control, product control, work security, hazard inspection, material management, skills and abilities. This study resulted in the acquisition of the results of analysis in the achievement level of OHS is 92.2% and has been included in the satisfactory category so worthy to be certified and ranked the golden flag. And analysis of the implementation and implementation of OHS to the established principles has been above 50% and can be interpreted that OHS is considered important to be applied in the company.