Health System Strategies Research Articles

Piloting Implementation Design and Preliminary Readiness for Universal Suicide Risk Screening Program in Emergency Department of a Tertiary Care Centre, Nepal: A Mixed Method Study

Introduction: Nearly three quarters of the suicides occur in developing world, however few evidenced-based health systems strategies exist to detect and prevent suicide in these contexts. This pilot study evaluates the feasibility of implementing a universal suicide risk screening program in a Nepalese emergency department. Methods: This study reports the preliminary training phases of a pilot implementation trial in the emergency department to evaluate the program. The approval was obtained from the Nepal Health Research Council (Approval no. 447/2021 P), and the Kathmandu University School of Medical Sciences Institutional Ethical Review Board (Approval no. 237/2021) and Yale University IRB (Protocol ID 2000029480). Implementation assessments included suicide screening acceptability, appropriateness, confidence, system priority, and myth knowledge of staff. Implementation strategies were selected, decolonized, and preliminarily trained followed by phased supportive coaching to initiate the screening package. We designed the implementation package through co-design staff focus groups and embedded ethnography. Results: Co-design focus groups (n=8) occurred with staff and leadership. We trained 26 (76.47%) the staff on the Nepali suicide screening tool followed by supported phased initial screening over two months. Implementation assessments demonstrated increased scores on appropriateness, confidence, system priority, and myth knowledge. The implementation package included key strategies to be deployed over six months. The embedded ethnographic observations revealed barriers to effective implementation, such as anticipated stigma, reluctance to engage families, and distrust in referral processes.Conclusions: The pilot study demonstrated that training improves staff appropriateness, confidence, system priority, and myth knowledge. Despite initial barriers, co-designed strategies and phased coaching facilitates screening uptake, highlighting the program's potential for sustainable implementation.

Barriers to Personalised Prevention: Perspectives from a Multi-Stakeholder Consultation

Abstract Background The high and increasing burden of Non-Communicable Diseases (NCDs) demands a healthcare shift towards prevention. Personalised preventive interventions (PPIs) that consider biological, sociocultural, environmental, and behavioural characteristics of individuals, are not as widely adopted as other personalised medicine approaches. To identify the main barriers and gaps that are hindering the adoption of PPIs in healthcare systems, we consulted a wide range of European stakeholders, including health professionals, policy makers, citizens and patients, and researchers. Methods The consultation process included experts’ interviews and an online survey, taking place over 10 months in 2023/2024. Interviews were analysed using qualitative Thematic Analysis. The online survey development was based on the barriers identified by the interviewed experts, complemented with findings from the literature. Respondents scored their level of agreement/disagreement using a 6-point Likert scale. Descriptive statistical analysis was performed. Results A total of 26 semi-structured interviews and 270 complete surveys were obtained. Overall, the main barriers highlighted were: 1) Health systems strategies are geared towards curative care and not prevention. 2) Awareness and understanding of the concept of PPIs is low. 3) There is a lack of basic and life-long training for health professionals on PPIs; 4) There is insufficient evidence for PPIs to raise the necessary policymakers’ interest. 5) Health literacy of citizens and patients is low. 6) There is insufficient prevention research, evidence of cost-efficiency and regulation procedures for translation into health practice. Conclusions Identified barriers are interconnected and the challenges extend beyond prevention to personalized medicine interventions. Collaborative efforts are needed to elevate visibility and engage stakeholders, facilitating integration of PPIs into healthcare systems for widespread adoption. Key messages • This consultation offers valuable insights on challenges that need to be addressed to enable the integration of PPIs into healthcare and reduce the burden of NCDs. • Investments in disease prevention and PPIs should stand as a global key priority.

Assessment of the compliance with minimum quality standards by public primary healthcare facilities in Nigeria

Achieving universal health coverage (UHC) and the Sustainable Development Goals (SDG) by 2030 relies on the delivery of quality healthcare services through effective primary healthcare (PHC) systems. This necessitates robust infrastructure, adequately skilled health workers and the availability of essential medicines and commodities. Despite the critical role of minimum standards in benchmarking PHC quality, no global consensus on these standards exists. Nigeria has established minimum standards to enhance healthcare accessibility and quality, including the Revised Ward Health System Strategy (RWHSS) by the National Primary Health Care Development Agency (NPHCDA). This paper outlines the evolution of PHC minimum standards in Nigeria, evaluates compliance with RWHSS standards across all public PHC facilities, and examines the implications for ongoing PHC revitalization efforts. The study used a cross-sectional descriptive design to assess compliance across 25 736 public PHC facilities in Nigeria. Data collection involved a national survey using a standardized assessment tool focussing on infrastructure, staffing, essential medicines and service delivery. Compliance with RWHSS minimum standards was found to be below 50% across all facilities, with median compliance scores of 40.7%. Outreach posts had a median compliance of 32.6%, level 1 facilities 31.5% and level 2+ facilities 50.9%. Key findings revealed major gaps in health infrastructure, human resources and availability of essential medicines and equipment. Compliance varied regionally, with the North-west showing the highest number of facilities but varied performance across standards. The lessons learned underscore the urgent need for targeted interventions and resource allocation to address the identified deficiencies. This study highlights the critical need for regular, comprehensive compliance assessments to guide policy-makers in identifying gaps and strengthening PHC systems in Nigeria. Recommendations include enhancing monitoring mechanisms, improving resource distribution and focussing on infrastructure and human resource development to meet UHC and SDG targets. Addressing these gaps is essential for advancing Nigeria’s healthcare system and ensuring equitable, quality care for all.

Addressing unmet need for primary care in Canada.

Primary care is the key health system strategy for improving health, enhancing patient and clinician experience, saving money, and promoting equity. Once a pioneer in primary care, Canada now fails to provide access to millions of people. This crisis is widely recognized, but policy responses are varied and mostly incremental and piecemeal. The goal of providing primary care to everyone seems unrealistic and elusive in Canada, yet it has long been attained in many other countries. Without an explicit policy goal of primary care for all, most likely on a geographic basis, Canada will continue to underinvest and underperform in primary care, with ramifications that include rapidly escalating costs, emergency department and hospital overcrowding and a growing and inequitable burden of preventable suffering. A commitment to work towards this goal is needed now to ensure that Canadians have access to high-quality well-organized care for everyone.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study.

Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. Retrospective cohort study. Medicare. Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. Generalizability to other payers. Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. National Institute on Aging.

Stakeholder-informed pragmatic trial protocol of the TabCAT-BHA for the detection of cognitive impairment in primary care

BackgroundCognitive impairment and dementia are frequently under-recognized. Health system strategies anchored in primary care are essential to address gaps in timely, comprehensive diagnosis. The goal of this paper is to describe the adaptation of a tablet-based brain health assessment (TabCAT-BHA) intervention and the study protocol to test its effectiveness in improving the detection of cognitive impairment, including dementia.MethodsThis mixed-methods, pragmatic, cluster randomized, hybrid effectiveness-implementation trial is being conducted in two 18-month waves with 26 Kaiser Permanente Southern California primary care clinics, with 13 serving as intervention clinics and 13 as usual care clinics. Patients 65 years and older with memory concerns (n ~ 180,000) receiving care at the 26 clinics will be included in the analyses. Primary care clinics are provided the following practice supports as part of the TabCAT-BHA intervention: brief education and training on neurocognitive disorders and study workflows; digital tools to assess cognitive function and support clinician decision making and documentation; and registered nurse support during the work-up and post-diagnosis periods for primary care providers, patients, and families. The intervention was adapted based on engagement with multiple levels of clinical and operational leaders in the healthcare system. Effectiveness outcomes include rates of cognitive impairment diagnosis in primary care and rates of completed standardized cognitive assessments and specialist referrals with incident diagnoses. Implementation outcomes include acceptability-appropriateness-feasibility, adoption, and fidelity.ResultsWe identified seven themes organized by system-, provider-, and patient-level domains that were used to adapt the TabCAT-BHA intervention. Accordingly, changes were made to the provider education, diagnostic work-up, and post-diagnostic support. Results will be reported in fall of 2027.ConclusionsOur engagement with multiple primary and specialty care clinical and operational leaders to adapt the TabCAT-BHA intervention to these primary care clinics has informed the protocol to evaluate the intervention’s effectiveness for improving the detection of cognitive impairment, including dementia, in an integrated healthcare system.Trial RegistationClinicaltrials.gov: NCT06090578 (registered 10/24/23).

Regulation and participation of the private sector in the pursuit of universal health coverage: Challenges and strategies for health systems.

This paper focuses on the role of the private sector (including for-profit and non-profit organizations) in achieving Universal Health Coverage (UHC). It examines their involvement in the management, service delivery, resource investment and financing of primary health care (PHC) within the sustainable development goals (SDGs). The study covers a review of health systems, emphasizing the influence of private institutions on public health, and evaluates how private sector experiences contribute to system functions and progress towards UHC. The findings indicate the crucial role of the private sector in global health systems, notably expanded in several countries. Private actors are essential to improve access and coverage, particularly in countries with low health indicators. The article highlights the importance of primary care physicians understanding these dynamics since their management is vital in implementing public policies for UHC.

Multidisciplinary proactive e-consults to improve guideline-directed medical therapies for patients with diabetes and chronic kidney disease: an implementation study

IntroductionWe hypothesized that multidisciplinary, proactive electronic consultation (MPE) could overcome barriers to prescribing guideline-directed medical therapies (GDMTs) for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD).Research design...

Marburg Virus Outbreak in Equatorial Guinea: Need for Speed.

The co-existence of deadly viral pandemics can be considered a nightmare for public health authorities. The surge of a Marburg virus disease (MVD) outbreak in Africa at a time when the coronavirus-19 (COVID-19) pandemic is partially controlled with its limited resources is an urgent call for concern. Over the past decades, several bouts of MVD outbreaks have occurred in Africa with an alarming case fatality rate. Despite this, little has been done to end its recurrence, and affected countries essentially depend on preventative rather than curative measures of management. The recent outbreak of MVD declared by the health officials of Equatorial Guinea, causing several deaths in the context of the COVID-19 pandemic, signals the need for speed in the establishment and the implementation of appropriate health policies and health system strategies to contain, destroy, and prevent the spread of this deadly virus to other neighboring countries.

Impact of health system strengthening interventions on child survival in sub-Saharan Africa: a systematic review protocol

BackgroundStrengthening healthcare systems is a practical approach to enhance healthcare delivery and services. Although there has been a rise in the number of health systems strengthening (HSS) interventions in sub-Saharan Africa (SSA), there is limited evidence on the causal effect of these activities on child survival. Furthermore, the findings reported so far have been varied, and how they relate to each other remains unclear. This systematic review study aims to assess all available evidence to understand the impact of HSS activities on child survival in SSA.MethodsWe developed a search strategy to retrieve all relevant studies from electronic databases such as PubMed/MEDLINE, Web of Science, and African Journals Online. We will use a combination of search terms such as “under-five mortality,” “child mortality,” “infant mortality,” “neonatal mortality,” “child survival,” and “health systems strengthening.” The review will include studies that establish a causal relationship between HSS interventions and child survival. This will include studies with designs such as randomized controlled trials and quasi-experimental and methods like difference-in-difference. Two reviewers will independently screen all citations, abstracts, and full-text data and a third reviewer will act as a tiebreaker in case of disagreements. The primary outcome of interest is the impact of HSS activities on under-five survival. We will evaluate the quality of each study using the Bradford Hill criteria for causation.DiscussionOur systematic review will identify and evaluate all relevant evidence that establishes a causal relationship between HSS activities and the survival of children under five years in SSA. The review’s findings regarding the impact of HSS activities on child survival could be of significant interest to the donor community and policy actors in the region. We also anticipate that the review’s conclusions could serve as a valuable guide for the development of future health system interventions and strategies in SSA.Systematic review registrationPROSPERO CRD42022333913.

East Toronto Health Partners: Collaborating on Quality Improvement

Developing a shared quality agenda has led to a new focus on population health within our community in East Toronto, Ontario, Canada. Amidst pandemic recovery, community members often struggle to access care. Health care organizations are challenged to support patient flow and mental health needs, and to catch up on preventative care and chronic disease management that was delayed due to reduced in-person care. One might think that these pressures would sideline quality improvement (QI) work, however we’ve seen new energy generated by QI capacity-building and application of rapid learning cycles to address our shared challenges. 
 Ontario Health Team context
 An Ontario Health Team is “a group of collaborative partners (organizations and individuals who offer health services, social services, and other health-relevant activities) brought together under a collaborative governance framework… to work with, and be accountable for, the health and wellbeing of a well-defined Attributed Population.” This context generates motivation for organizations and stakeholders to work closely on quality initiatives. Quality improvement activities form part of a larger rapid-learning health system strategy that includes program evaluation, evidence-based best practices in frontline care, and business intelligence efforts.
 Approaches within our QI Collaboration
 -Collecting and sharing patient experience measures as part of Best Practice Guideline implementation for Person & Family-Centred Care;
 -Strengthening involvement of community members; co-creating our 2022 collaborative Quality Improvement Plan with diverse partners;
 -Accessing and reflecting on baseline data for our defined population, and building capacity for local analytics. Together with other Ontario Health Teams, we have outlined requirements for data and tools to support population health management;
 -Focusing on priority neighbourhoods to improve health equity; and building QI capacity with teams of Community Health Ambassadors within those neighbourhoods.
 Key Learnings
 Patient Experience: We grounded our work in person- and family-centred care; respecting the voices of patients and caregivers in reporting their level of involvement in care plans and treatment. Collaboration among partners uncovered examples of best practice in patient experience data collection and moved us toward data collection as an integrated system of care (beyond surveys conducted within individual organizations). 
 Patient Flow: Our collaboration led us to focus “upstream,” and to strengthen our ability to identify unmet needs for clients in community settings. A strengths-based assessment across collaborating organizations helped to increase awareness of diverse assets within our community and examples of leadership in Seniors-Friendly Care. We are launching transdisciplinary teams dedicated to responsive support for transitions in care. 
 Preventative Care: An equity approach was key. In addition to primary care practice-based improvement initiatives (e.g. cancer screening) we prioritized efforts to reach vulnerable groups, such as individuals without a family doctor, and those with barriers to navigating health services in English. Rapid-cycle improvement and evaluation plans (co-designed with community members) are helping to ensure that service offerings are addressing the needs of the community.
 RESULT: The East Toronto Health Partners’ collaborative Quality Improvement work has helped our Ontario Health Team to align and integrate work across multiple organizations – building our capabilities for proactive population health management.

Practicum to Practice Program: Improve Nurse Recruitment and Assist Schools of Nursing while Decreasing Length and Cost of Nurse Onboarding

An innovative pre-hire clinical placement program offers nursing students an opportunity to select a 1:1 senior practicum placement and accept their first job as a registered nurse on that same unit, prior to the start of the final semester practicum course of an entry-to-practice nursing program. This placement program provides a competitive recruiting strategy for a regional health system, a desired level of autonomy for nursing students, decreased orientation costs, assistance to schools of nursing by offering senior practicum sites, and increased recruitment of new graduate nurses during a critical nursing shortage in the United States.

COVID-19 outbreak control strategies and their impact on the provision of essential health services in Ghana: An exploratory-sequential study.

The COVID-19 pandemic has led to substantial interruptions in critical health services, with 90% of countries reporting interruptions in routine vaccinations, maternal health care and chronic disease management. The use of non-pharmaceutical interventions (NPIs) such as lockdowns and self-isolation had implications on the provision of essential health services (EHS). We investigated exemplary COVID-19 outbreak control strategies and explored the extent to which the adoption of these NPIs affected the provision of EHS including immunization coverage and facility-based deliveries. Finally, we document core health system strategies and practices adopted to maintain EHS during the early phase of the pandemic. This study used an explanatory sequential study design. First, we utilized data from routine health management information systems to quantify the impact of the pandemic on the provision of EHS using interrupted time series models. Second, we explored exemplary strategies and health system initiatives that were adopted to prevent the spread of COVID-19 infections while maintaining the provision of EHS using in-depth interviews with key informants including policymakers and healthcare providers. The COVID-19 pandemic and the interventions that were implemented disrupted the provision of EHS. In the first month of the COVID-19 pandemic, Oral Polio and pentavalent vaccination coverage reduced by 15.2% [95% CI = -22.61, -7.87, p<0.001] and 12.4% [95% CI = 17.68, -7.13; p<0.001] respectively. The exemplary strategies adopted in maintaining the provision of EHS while also responding to the spread of infections include the development of new policy guidelines that were disseminated with modified service delivery models, new treatment and prevention guidelines, the use of telemedicine and medical drones to provide EHS and facilitate rapid testing of suspected cases. The implementation of different NPIs during the peak phase of the pandemic disrupted the provision of EHS. However, the Ministry of Health leveraged the resilient health system and deployed efficient, all-inclusive, and integrated infectious disease management and infection prevention control strategies to maintain the provision of EHS while responding to the spread of infections.

Equity Promoting Integrated Care: Definition and Future Development.

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

Increasing prevalence of overweight and obesity among Tanzanian women of reproductive age intending to conceive: evidence from three Demographic Health Surveys, 2004-2016

Background The prevalence of people who are overweight or obese is increasing globally, especially in low- and middle-income countries. High body mass index (BMI) among women of reproductive age is a risk factor for various adverse reproductive and pregnancy outcomes. This study aims to describe trends over time in the distribution of BMI among Tanzanian women of reproductive age intending to conceive between 2004/5 and 2015/16, and identify factors associated with high BMI. Methods We used data on 20,819 women of reproductive age (15-49 years) intending to conceive who participated in the Tanzania Demographic and Health Surveys in 2004/5, 2010 and 2015/16. We estimated the prevalence of high BMI (being overweight [≥25 to &lt;30 kg/m2] and obesity [≥30kg/m2) and trends in the prevalence of high BMI across the three surveys. Using survey-weighted multivariable logistic regression, we used the most recent 2015/16 survey data to identify factors associated with high BMI. Results Median BMI increased from 21.7kg/m2 (inter-quartile range, IQR=19.9-24.1 kg/m2) in 2004/5 to 22.0 kg/m2 (IQR=20.0-24.8 kg/m2) in 2010 to 22.7 kg/m2 (IQR=20.4-26.0 kg/m2) in 2015/16. The prevalence of overweight women increased from 11.1% in 2004/5 to 15.8% in 2015 (P &lt;0.001). The prevalence of obesity increased from 3.1% in 2004/5 to 8.0% in 2015/16 (P&lt;0.001). Women in the highest wealth quintile had higher odds (adjusted odds ratio, aOR= 4.5; 95%CI 3.4-6.3, P&lt;0.001) of high BMI than women in the lowest quintile. The odds of high BMI were about four times greater (aOR=3.9; 95%CI=2.9-5.4, P&lt;0.001) for women 40-44 years compared to 20–24-year-olds. Women in the high-paying occupations had greater odds of high BMI than those working in agriculture (aOR=1.5; 95% CI=1.1-2.2, P=0.002). Women residing in the Southern zone had 1.9 (95%CI=1.5-2.5, P&lt;0.001) greater odds of high BMI than Lake zone residents. Conclusions In Tanzania, high BMI affects almost 1 in 4 women of reproductive age who intend to conceive. This contributes to the burden of poor maternal and reproductive health outcomes. We recommend developing and implementing health-system strategies for addressing high BMI, tailored to the modifiable risk factors identified among women of reproductive age.

State Laws That Require Coprescribing Opioids and Naloxone and Codispensing Practices

Coprescribing naloxone with opioids could reduce the risk of overdose. By the end of 2020, 8 U.S. states implemented coprescribing laws requiring the prescription of naloxone alongside certain opioid prescriptions. This study examined the impacts of state laws that require coprescribing opioids and naloxone on codispensing practices. Data included opioid prescriptions for commercially insured adults between 2014 and 2020. Augmented synthetic control analyses were used to examine the impacts of 8 coprescribing requirement laws implemented between 2017 and 2020 on the proportion of opioid prescription fills with a naloxone coprescription fill. Analyses were completed in spring 2023. Changes in the proportion of opioid prescription fills with a naloxone coprescription fill attributable to the laws varied across states. In 4 states (New Jersey, New Mexico, Rhodes Island, and Virginia), laws were associated with 0.8 (95% CI=0.3, 1.3) to 4.4 (95% CI=3.4, 5.4) percentage point increases in the proportion of opioid prescriptions with a naloxone coprescription fill (p<0.05). There were no statistically significant changes attributable to the other state laws (Arizona, Florida, Vermont, Washington). Laws requiring coprescribing naloxone with certain opioid prescriptions are associated with small-in-magnitude increases in codispensing in some states. Broadening the categories of opioid prescriptions covered in naloxone coprescribing requirement laws and implementing health system strategies to encourage providers to coprescribe naloxone could help to magnify the impacts of these laws.

Access to herbal medicines in Brazil: a cross-sectional study

IntroductionMedicines are essential therapeutic strategies for health systems, thus, it is essential to verify whether the use of herbal medicines is equally distributed among the Brazilian population. MethodsA cross-sectional study was conducted with the Brazilian population. Those over 18 years of age, residing in the country for at least 12 months and with regular access to the internet, were included. The information showed the profile of the individuals, health conditions and characteristics of phytotherapy use. Data were submitted to Binary Logistic Regression (P < 0.05). The research was approved by the Research Ethics Committee of the University of Pernambuco (4880,872). ResultsAmong 1 421 individuals, 727 (51.2%) used herbal medicines. The chance of this use was higher among those who did not identify as female (OR adjusted = 1.4/95% CI = 1.0–1.9; P = 0.028); white (OR adjusted = 1.4/95% CI = 1.0–1.8; P = 0.019); exclusive user of the private care sector (OR adjusted = 1.8/95% CI = 1.1–2.8; P = 0.009); with health problems (OR adjusted = 1.4/95% CI = 1.0–1.9; P = 0.010); and with product prescription (OR adjusted = 7.3/95% CI = 5.4–9.9; P < 0.001). Discussion/ConclusionsThere must be professional training, health education for users and readjustment of public policies to reduce inequalities in the use of herbal medicines.

Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries

BackgroundThere is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems.MethodsThe study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined.ResultsAbout half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans.ConclusionsThe study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving ‘health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.

A qualitative exploration of allied health providers’ perspectives on cultural humility in palliative and end-of-life care

BackgroundCultural factors, including religious or cultural beliefs, shape patients’ death and dying experiences, including palliative and end-of-life (EOL) care preferences. Allied health providers must understand their patients’ cultural preferences to support them in palliative and EOL care effectively. Cultural humility is a practice which requires allied health providers to evaluate their own values, biases, and assumptions and be open to learning from others, which may enhance cross-cultural interactions by allowing providers to understand patients’ perceptions of and preferences for their health, illness, and dying. However, there is limited knowledge of how allied health providers apply cultural humility in palliative and EOL care within a Canadian context. Thus, this study describes Canadian allied health providers’ perspectives of cultural humility practice in palliative and EOL care settings, including how they understand the concept and practice of cultural humility, and navigate relationships with patients who are palliative or at EOL and from diverse cultural backgrounds.MethodsIn this qualitative interpretive description study, remote interviews were conducted with allied health providers who currently or recently practiced in a Canadian palliative or EOL care setting. Interviews were audio-recorded, transcribed, and analyzed using interpretive descriptive analysis techniques.ResultsEleven allied health providers from the following disciplines participated: speech-language pathology, occupational therapy, physiotherapy, and dietetics. Three themes were identified: (1) Interpreting and understanding of cultural humility in palliative and EOL care (i.e., recognizing positionality, biases and preconceived notions and learning from patients); (2) Values, conflicts, and ethical uncertainties when practicing cultural humility at EOL between provider and patient and family, and within the team and constraints/biases within the system preventing culturally humble practices; (3) The ‘how to’ of cultural humility in palliative and EOL care (i.e., ethical decision-making in palliative and EOL care, complexities within the care team, and conflicts and challenges due to contextual/system-level factors).ConclusionsAllied health providers used various strategies to manage relationships with patients and practice cultural humility, including intra- and inter-personal strategies, and contextual/health systems enablers. Conflicts and challenges they encountered related to cultural humility practices may be addressed through relational or health system strategies, including professional development and decision-making support.

Integrated Management Systems (IMS) to Support and Sustain Quality One Health Services: International Lessons from the COVID-19 Pandemic by the IMIA Primary Care Working Group.

One Health considers human, animal and environment health as a continuum. The COVID-19 pandemic started with the leap of a virus from animals to humans. Integrated management systems (IMS) should provide a coherent management framework, to meet reporting requirements and support care delivery. We report IMS deployment during, and retention post the COVID-19 pandemic, and exemplar One Health use cases. Six volunteer members of the International Medical Association's (IMIA) Primary Care Working Group provided data about any IMS and One Health use to support the COVID-19 pandemic initiatives. We explored how IMS were: (1) Integrated with organisational strategy; (2) Utilised standardised processes, and (3) Met reporting requirements, including public health. Selected contributors provided Unified Modelling Language (UML) use case diagram for a One Health exemplar. There was weak evidence of synergy between IMS and health system strategy to the COVID-19 pandemic. However, there were rapid pragmatic responses to COVID-19, not citing IMS. All health systems implemented IMS to link COVID test results, vaccine uptake and outcomes, particularly mortality and to provide patients access to test results and vaccination certification. Neither proportion of gross domestic product alone, nor vaccine uptake determined outcome. One Health exemplars demonstrated that animal, human and environmental specialists could collaborate. IMS use improved the pandemic response. However, IMS use was pragmatic rather than utilising an international standard, with some of their benefits lost post-pandemic. Health systems should incorporate IMS that enables One Health approaches as part of their post COVID-19 pandemic preparedness.