System Redesign Research Articles

Return on investments in the Health Extension Program in Ethiopia.

Since 2003, the government of Ethiopia has trained and deployed more than 42,000 Health Extension Workers across the country to provide primary healthcare services. However, no research has assessed the return on investments into human resources for health in this setting. This study aims to fill this gap by analyzing the return on investment within the context of the Ethiopian Health Extension Program. We collected data on associated costs and benefits attributed to the Health Extension Program from primary and secondary sources. Primary sources included patient exit interviews, surveys with Health Extension Workers and other health professionals, key informant interviews, and focus groups conducted in the following regions: Amhara, Oromia, Tigray, and the Southern Nations Nationalities and Peoples' Region. Secondary sources consisted of financial and administrative reports gathered from the Ministry of Health and its subsidiaries, as well as data accessed through the Lives Saved Tool. A long-run return on investment analysis was conducted considering program costs (personnel, recurrent, and capital investments) in comparison to benefits gained through improved productivity, equity, empowerment, and employment. Between 2008-2017, Health Extension Workers saved 50,700 maternal and child lives. Much of the benefits were accrued by low income, less educated, and rural women who had limited access to services at higher level health centers and hospitals. Regional return ranged from $1.27 to $6.64, with an overall return on investment in the range of $1.59 to $3.71. While evidence of return on investments are limited, results from the Health Extension Program in Ethiopia show promise for similar large, sustainable system redesigns. However, this evidence needs to be contextualized and adapted in different settings to inform policy and practice. The Ethiopian Health Extension Program can serve as a model for other nations of a large-scale human resources for health program containing strong economic benefits and long-term sustainability through successful government integration.

Business Process Redesign: A Systematic Review of Evaluation Approaches

The continuous and systematic redesign of key business processes is very important for businesses and organizations that seek to achieve cost savings and efficiency enhancements. Selecting the most impactful processes and ensuring a successful redesign initiative remains an important topic that motivated the authors to conduct a Systematic Literature Review (SLR) on Business Process Redesign (BPR) Evaluation methodologies by applying an established eight-step SLR guide. The review sheds light on the current state of research and highlights the research gap by considering two dimensions of BPR artifacts: (a) the type of evaluation and (b) the generalizability of the existing approaches. The findings indicate that there is a lack of systematic methodologies in literature that properly evaluate the redesign capacity of models prior to implementation. Additionally, the existing methodologies do not cumulatively evaluate the quality characteristics that are necessary for BPR implementation or the applicability of BPR heuristics, and do not bear the generalizability to be readily used in a more general context. This paper aims to provide researchers with the necessary context and motivation to bridge this gap and further systematize BPR methodologies that can preselect the most suitable business processes for redesign.

Perancangan Sistem Pengelolaan Sampah dengan Metode Material Flow Analysis (MFA) (Studi Kasus: Kota Tasikmalaya)

This study concerns the design of a waste management system using the Material Flow Analysis (MFA) method in the city of Tasikmalaya. TPA Ciangir is the only landfill in Tasikmalaya, and its storage capacity has reached its maximum, necessitating improvements in waste management. The aim of this design is to determine an appropriate waste management system that can be implemented in Tasikmalaya. Based on observations and interviews, waste collection at TPA Ciangir in Tasikmalaya is conducted in small amounts, leading to a significant amount of household waste not being collected daily, resulting in waste accumulation and minimal transport to waste processing facilities. According to Permen PU Number 3 of 2013 and SNI 19-2454-2002, waste collection from the source should be conducted at least once every two days. Therefore, an evaluation and redesign of the waste management system based on technical aspects are needed. The best system selection will be carried out using the Analytical Hierarchy Process (AHP) method, which will then be recommended for application at TPA Ciangir in Tasikmalaya. Based on the calculations using the AHP method, scenario 3 scored the highest, at 1.676, using composting processes, RDF, and TPST-3R. From the design results, a total waste reduction of 81% was achieved, aligning with the government's target of a 70% waste reduction by 2020.

FOWLP Thermal Debonding: Easing Manufacturing Constraints

Fan-out wafer level packaging enables System-in-package (SiP) and other forms of heterogenous integration. Multi-die configuration or passives for SiP alters the warpage profile of the wafer significantly. Wafers with square-shaped dies typically have bowl or dome type deformations. Wafers with rectangular-shaped dies tend to be deformed in a parabolic shape. However, as the packaging advances to different and more sophisticated technologies, the different chip sizes in one wafer adds complexity to the base structure, which leads to an unpredictable warpage profile and a higher warpage magnitude. Downstream equipment post wafer reconstruction needs to be able to handle this change in magnitude and profile since this could otherwise cause difficulties in high volume production and result in lower yield. The process step that requires the wafer to be placed onto chucks will result in vacuum failure and, if not modified to handle high warpage, the transport mechanism can result in wafer excursion and machine downtime. However, these modifications would require a costly redesign of the machine transport system, handling system, and end effectors. A less cost-intensive solution would be to ensure that the incoming wafer post reconstruction has minimum warpage. Thermal debonding is the last process of the wafer reconstruction flow and it acts as launchpad for layer build-up. It is in this step that warpage is inevitable as the wafer is released from the carrier. Thus, it is essential to have a warpage level that is manageable by these succeeding processes. This paper addresses the issue of warpage in Fan-out Wafer Level Packaging and presents a solution that lessens the warpage in the thermal debonding stage. The efficient processing of warped wafers is critical for the development of Fan-out and the transition to high volume manufacturing of these chips.

Projecting Future Energy Production from Operating Wind Farms in North America. Part III: Variability

Abstract Daily expected wind power production from operating wind farms across North America are used to evaluate capacity factors (CF) computed using simulation output from the Weather Research and Forecasting (WRF) Model and to condition statistical models linking atmospheric conditions to electricity production. In Parts I and II of this work, we focus on making projections of annual energy production and the occurrence of electrical production drought. Here, we extend evaluation of the CF projections for sites in the Northeast, Midwest, southern Great Plains (SGP), and southwest U.S. coast (SWC) using statewide wind-generated electricity supply to the grid. We then quantify changes in the time scales of CF variability and the seasonality. Currently, wind-generated electricity is lowest in summer in each region except SWC, which causes a substantial mismatch with electricity demand. While electricity of residential heating may shift demand, research presented here suggests that summertime CF are likely to decline, potentially exacerbating the offset between seasonal peak power production and current load. The reduction in summertime CF is manifest for all regions except the SGP and appears to be linked to a reduction in synoptic-scale variability. Using fulfillment of 50% and 90% of annual energy production to quantify interannual variability, it is shown that wind power production exhibits higher (earlier fulfillment) or lower (later fulfillment) production for periods of over 10–30 years as a result of the action of internal climate modes. Significance Statement Electrical power system reassessment and redesign may be needed to aid efficient increased use of variable renewables in the generation of electricity. Currently wind-generated electricity in many regions of North America exhibits a minimum in summertime and hence is not well synchronized with electricity demand, which tends to be maximized in summer. Future projections indicate evidence of reductions in wind power during summer that would amplify this offset. However, electrification of heating may lead to increased wintertime demand, which would lead to greater synchronization.

Losing the focus on the system's purpose guarantees failure-Lesson's for health system redesign.

Losing the focus on the system's purpose guarantees failure-Lesson's for health system redesign.

Transparansi, Pengawasan, Akuntabilitas, Redesain Sistem Penganggaran dan Kinerja Badan Layanan Umum

This study aims to determine and analyze the effect of transparency, oversight, accountability and redesign of the budgeting system either partially or simultaneously on the performance of Public Service Agencies. The population was taken from PPSPM, PPK, Planning/Budget Coordinator, Finance, Academic Section along with Staff and SPI so that the population was 204 people. The sampling technique used is saturated sampling so that the entire population of 204 people is taken as a sample. The analysis technique used is multiple regression with the help of the SPSS application by testing the hypothesis using the t test and F test. The partial results show that the transparency variable has no significant effect on financial performance with a significance value of 0.552. The monitoring variable has a significant effect on financial performance with a significance value of 0.008. The accountability variable has no significant effect on financial performance with a significance value of 0.738. The redesign variable of the budgeting system has a significant effect on financial performance with a significance value of 0.024. Simultaneously the variables of transparency, supervision, accountability and redesign of the budgeting system simultaneously have a significant effect on financial performance with a significance value of 0.000. The conclusion shows that partially only the monitoring and budgeting system redesign variables have an effect on financial performance while simultaneously all independent variables including transparency, supervision, accountability and budgeting system redesign simultaneously have a significant effect on financial performance.

A conceptual model of cow-calf systems functioning on native grasslands in a subtropical region.

Cow-calf systems utilise grazing of native grasslands for beef cattle propagation and constitute the principal livestock activity in the Pampas and Campos areas. Cow-calf system sustainability is questioned because of their low production levels and negative environmental impact. Ecological intensification has been proposed as a way out that constitutes an alternative to dominant discourses based on increasing external-input use. There is, however, a considerable gap between the availability of scientific knowledge to promote the ecological intensification of cow-calf systems and farmers' practices. This gap between scientific knowledge availability and farmers' practices can be made explicit, and its consequences for systems performance can be explored through a conceptual model. Conceptual models are tools to build a systems view of the interactions among the production system's state variables, farm management, and resulting system performance. In this paper, we develop a conceptual model of cow-calf systems on native grasslands of the Pampas and Campos regions to support the diagnosis and redesign of farm systems towards ecological intensification. We apply the conceptual model to analyse cow-calf systems in Uruguay, drawing on a survey among 250 Uruguayan livestock farmers. Using the model, we show that in Uruguay, the level of implementation of strategic, tactical, and decision-supporting techniques is low. Consequently, most farms have poor control of the grazing intensity and timing of main events in the production cycle. This results in ample room to improve the productive and environmental performance of most cow-calf farms in Uruguay. We distinguished three broad types of cow-calf systems based on the degree of implementation of techniques, the evolution of state variables throughout the year, and productive indicators. These types imply different departure points and strategies for a sustainability transition process. The conceptual model designed in this paper may support the cow-calf systems sustainability transition in the context of co-innovation processes by aiding the interactive diagnosis and redesign of farm systems.

Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study

Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care. A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation. Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions. Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.

Infectious disease control: from health security strengthening to health systems improvement at global level

Since the twenty first century, the outbreaks of global infectious diseases have caused several public health emergencies of international concern, imposing an enormous impact on population health, the economy, and social development. The COVID-19 pandemic has once again exposed deficiencies in existing global health systems, emergency management, and disease surveillance, and highlighted the importance of developing effective evaluation tools. This article outlines current challenges emerging from infectious disease control from the perspective of global health, elucidated through influenza, malaria, tuberculosis, and neglected tropical diseases. The discordance among government actors and absent data sharing platforms or tools has led to unfulfilled targets in health system resilience and a capacity gap in infectious disease response. The current situation calls for urgent action to tackle these threats of global infectious diseases with joined forces through more in-depth international cooperation and breaking governance barriers from the purview of global health. Overall, a systematic redesign should be considered to enhance the resilience of health systems, which warrants a great need to sustain capacity-building efforts in emergency preparedness and response and raises an emerging concern of data integration in the concept of One Health that aims to address shared health threats at the human-animal-environment interface.

BEYOND THE HUB AND SPOKES: THE NETWORKING LOGIC AND THE OPERATIONALIZATION OF US INDO-PACIFIC STRATEGY

This article examines continuity in the transformation of the United States’ security arrangements in Asia from a Cold War “hub and spokes system” focused on East Asia into a new arrangement of “networked minilateralism” across the wider “Indo-Pacific” region. It focuses mainly on the role of the United States and the policy tools it employs to coordinate the strengthening of linkages among its partners. By employing tools of defence diplomacy, standardisation in trade and infrastructure development, revamping the rhetoric of common values and inviting extra-regional actors to play a more active role in the Indo-Pacific, Washington is mobilising a “latticework” of partners that are assisting in the redesign of the regional security system and the balancing of China. At the same time, structural changes in the region’s power balance have induced local partners to become part of this networked architecture and to maintain a clearer sense of ownership in the regional security system.

Life Analysis of TBC on an Aero Engine Combustor Based On In-Service Failures Data

TBC (Thermal Barrier Coatings) mostly find application in the combustion sections of aircraft turbine engines. With the demand for fuel economy and increased power, combustion temperatures are approaching the design limits of the metal alloys from which hot end components are made. Modern TBCs are required to not only limit heat transfer through the coating but to also protect engine components from oxidation and hot corrosion. When a TBC fails, it exposes the underlying substrate to very high gas temperatures and the life of the component gets reduce drastically. With a failed TBC, a component can even fail within its prescribed service life. This is an airworthiness issue. So it is essential to estimate the TBC life accurate possibly to ensure airworthiness of the aircraft at any given time. Premature failure are observed in the TBC applied over combustion section of a turboprop engine. The engine is 800 shp class and it powers a commuter aircraft. The objective of this paper is to find out mean life of the coating by life data analysis. The data has been fitted to Weibull distribution. The Weibull parameters have been discussed which highlights the dominating cause for TBC failure and hence suggestion for life improvement of TBC system has also been made. The need for TBC system redesign has been emphasized. In addition to this, it also presents a comparison between different users/ operators.

Driveline System Effects on Powertrain Mounting Optimization for Vibration Isolation under Actual Vehicle Conditions

<div>Vehicle vibration is the key consideration in the early stage of vehicle development. The most dynamic system in a vehicle is the powertrain system, which is a source of various frequency vibration inputs to the vehicle. Mostly for powertrain mounting system design, only the uncoupled powertrain system is considered. However, in real situations, other subsystems are also attached to the powertrain unit. Thereby, assuming only the powertrain unit ignores the dynamic interactions among the powertrain and other systems. To address this shortcoming, a coupled powertrain and driveline mounting system problem is formulated and examined. This 16 DOF problem is constructed around a case of a front engine-based powertrain unit attached to the driveline system, which as an assembly resting on other systems such as chassis, suspensions, axles, and tires. First, the effect of a driveline on torque roll axis and other rigid body modes decoupling is examined analytically in terms of eigensolutions and frequency responses. It is observed from the analysis that when the optimized uncoupled powertrain system is introduced in real vehicle conditions, the vibration isolation level of the powertrain mountings gets degraded. Then, a new improved approach of considering coupled powertrain and driveline systems in the initial design phase itself is proposed. The mounting system parameters such as mount location, mount orientation angle, and stiffness rate are optimized and redesigned for the proposed system. The results of the redesigned system show that the decoupling of the rigid body mode parameters is improved and consequently powertrain vibration performance is also improved in static and dynamic conditions of the vehicle. Overall, the findings of this study suggest that considering the driveline along with the powertrain as a coupled system at the early phase of the mounting system design itself improves the vibration performance of the vehicle during real-life situations.</div>

Breaking the mould: Developing innovative crop protection strategies with Reflexive Interactive Design

CONTEXTPests and pathogens can have great impacts on agricultural production. The use of plant protection products (PPPs) is a main preventive and curative management method in conventional farming today world-wide. However, increasing evidence shows the negative effects of PPPs on the environment and human health. New, especially preventive, approaches are needed and a promising option for developing these is the redesign of current agricultural systems, in which knowledge about the system and biological processes is integrated. Yet frameworks that can guide this process are not widely used. OBJECTIVEThis study aims to demonstrate the use of an innovative and systematic approach to the development of design concepts for pest and disease management without the use of PPPs, using Phytophthora infestans in potatoes as a case study. METHODSThe Reflexive Interactive Design method was applied to define design goals, requirements and key functions of the innovative design. These definitions were based on the needs of relevant stakeholders and the biology of the crop and disease. A range of strategies were researched that could effectively limit pathogen transmission and disease severity by interrupting the pathogen's life cycle. RESULTS AND CONCLUSIONSThe proposed design concept focuses on a combination of more traditional aspects like providing farmers with uninfected starting material and resistant varieties with novel approaches like increasing canopy porosity through intercropping with onions and preventing the spread of inoculum both into and within the field with a combination of host dilution and barriers. This research demonstrates how the Reflexive Interactive Design method can be used to develop innovative solutions for crop protection that go beyond current solution sets. SIGNIFICANCEThe systematic approach backed by literature provided the compass for the search for new and innovative solutions with strong focus on prevention. The design concept acts as a promising starting point to be further elaborated with stakeholders while effectiveness of the final design concept needs to be tested under real-life conditions.

Modern Approaches to Providing Telematics Oral Health Services in Pediatric Dentistry: A Narrative Review

A structural and organizational redesign of the dental care system is necessary today due to current trends in the demographic process and the accompanying changes in the population’s healthcare needs. The purpose of this article is to review the literature, analyzing those trends that today represent useful tools for the oral health of pediatric patients, with particular reference to teledentistry and all the supports it uses to reach remote territories or patients who, for various reasons, cannot have access to dental care. An independent literature search was conducted in three electronic databases: PubMed/MEDLINE, Google Scholar, and the COCHRANE library. Thirty-one articles were considered. Reported findings highlight that teledentistry has been used in pediatrics to educate and promote oral health and to provide remote diagnosis and monitoring through mobile health applications, smartphone cameras and apps, intraoral cameras, websites and search engines, and telephonic communications. Specifically, teledentistry has been beneficial in providing dental care in remote locations with difficult access to pediatric dentists, conducting remote diagnostic and screening programs, monitoring patients between appointments, promoting children’s oral health through dental education, and providing behavioral counseling prior to office visits. Future research should further investigate the long-term use, additional applications, and cost-effectiveness of teledentistry in children.

Reducing energy consumption without compromising food security: the imperative that could transform agriculture

Abstract The imperative of carbon neutrality requires a drastic, rapid, and sustained reduction in fossil energy consumption and greenhouse gas emissions. The Russia-Ukraine war has led to a major energy crisis, whose end does not seem imminent. The sudden and major increase in energy prices resulting from this crisis has major impacts on many sectors of the societies. This is especially true for agriculture, a direct consumer of energy that also has considerable indirect consumption through the manufacture, transport, and distribution of chemical inputs such as fertilizers and pesticides. Taking the example of France, from July 2021 to July 2022, farmers were challenged with price increases as high as 48% and 111% for energy and fertilizers, respectively (Agreste, 2022). At the global scale, in 2018, greenhouse gas emissions from fossil energy consumption in agriculture represented 0.9 Pg CO2 eq. (against 9.3 Pg CO2 eq. due to agriculture, excluding emissions due to this energy consumption) and those emissions have increased by 23% since 2000 (FAO, 2020). 
This context calls for in-depth transformation of agriculture, which is currently overly dependent on non-renewable energy in high-income economies. While research on the subject continues to grow (Box 1), this large body of work focuses more on assessing the energy consumption of current agricultural systems using multiple metrics (Box 2) than on developing supply- or demand-side alternatives that use less energy. In response to these trends, Ramankutty and Dowlatabadi (2021) suggested pathways to sustainable food systems. However, while their recommendations included energy reduction options on the food consumption side, their focus on farming practices was restricted to improving the energy efficiency of current agricultural systems and missed the necessary redesign of farming and food systems.
In this article, we look back to understand how agricultural systems came to progressively depend on non-renewable energy. We then briefly review agricultural practices and systems reducing energy consumption without compromising energy efficiency. Finally, we propose future research avenues to explore pathways for reducing energy consumption without compromising food security and sustainability challenges.

We’re Open: Caring for the Walking Well in a Rural Emergency Department

Emergency departments (EDs) are increasingly unable to cope with patient volume, leading staff to question the arrival of those seeking non-urgent care. However, these patients ideally should be afforded appropriate management and treatment. In 2014, the Carbonear General Hospital ED in Newfoundland and Labrador took decisive action, engaging front-line staff and shifting the focus of care away from why patients were visiting to prioritize how best to treat those who did. By 2019, the ED had not needed to resort to hallway medicine, despite a visit volume that increased to 30,000 patients over five years, and staff grew into a close-knit, quality improvement and community force. From this experience, it is evident that small investments in education and system redesign can shift attitudes toward ED care for patients, and provide support for primary care in the community. It has already started in one hospital — we’re open for assistance with primary and non-urgent care.

National Center for Interprofessional Practice and Education 2023: reflecting back, looking forward

ABSTRACT The United States (US) National Center for Interprofessional Practice and Education was funded at the University of Minnesota to serve as the National Coordinating Center for Interprofessional Education and Collaborative Practice (IPECP) in the US In 2012, the funders had specific expectations for operationalizing their vision that included scholarship, programs and leadership as an unbiased, neutral convener to align education with health system redesign. While US specific, the National Center benefited from and contributed to the international maturity of the field over the past decade. Through its various services and technology platforms, the National Center has a wide reach nationally and internationally. This perspective provides a unique view of the field in the US with observations and implications for the future.

Inclusive dementia care for ethnically diverse families.

With population ageing and global migration, rates of dementia are set to rapidly increase in ethnically diverse populations. This narrative review examines recent evidence on what constitutes culturally appropriate models of care. Barriers to inclusive care continue to prevail, amplifying dementia disparities in ethnically diverse communities. Cultural models that can address these include ensuring health and aged care staff are culturally competent, language supports are available, and cultural practices are integrated into daily care routines. Fundamentally, systems must be reformed to ensure they meet the needs of diverse end-users. More inclusive and widespread ethno-specific services are needed, and governments need to be mindful of demographic transitions in their populations and plan accordingly to meet future demand. Digital media and new technologies offer promising new ways to deliver culturally appropriate care to ethnically diverse groups, but its full potential is yet to be realised. Persistent dementia disparities in ethnically diverse communities can be overcome by operationalising cultural models of care, leveraging the promise of digital media, and systems redesign.

P86 Traditional knowledge about tree species for redesign of livestock systems and landscapes in Brazil

P86 Traditional knowledge about tree species for redesign of livestock systems and landscapes in Brazil