Service Delivery Structure Research Articles

Outcomes-based contracts and the hidden turn to public value management

Despite long-standing criticisms of the paradigm, New Public Management (NPM) retains a strong influence over organizations in public administration. Social Impact Bonds (SIB) are an outcomes-oriented investment entity which has emerged from NPM with grand promises of social change. Building on a longitudinal case study of a health-based SIB, this paper identifies how key actors move away from NPM by resisting such management principles and shift toward Public Value Management (PVM). The paper finds that this is possible when the public interest and performance objectives are designed with a public value orientation whilst other NPM principles shift over time through resistance and negotiation. The paper provides insight into how key actors re-organize to embed public value in a financing and public service delivery structure that is often regarded as flawed and inefficient. The paper offers several contributions to public value literature, including the role of the state, as well as the emerging literature on SIBs and outcomes-based contracts.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BackgroundResponsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.MethodsWe completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2–4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.ResultsAll stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.ConclusionsUsing a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Pandemic fueled a major expansion of home‐based treatment provider

Leaders of a home‐based substance use treatment company that experienced substantial growth during the COVID‐19 pandemic said they are establishing important models in both service delivery and payment structure. Most of the media attention to Aware Recovery Care's work has focused on counteracting the notion that addiction care must take place in a facility, but the company's CEO also pointed out that its pioneering managed care contract brings the field closer to value‐based payment for services.

Health workforce policy in the Russian Federation: How to overcome a shortage of physicians?

Russia looks for ways to overcome a shortage of physicians. Health workforce policy is focused on training an additional number of physicians. The current efforts have reduced some areas of the shortage but failed to solve the problem due to many factors that reproduce the deficit. A distorted structure of service delivery with weak primary care generates demand for outpatient specialists and hospital doctors and requires a perpetual increase in their number. The lack of long-term labor planning results in the oversupply of some specialties and the shortage of others. The regulation of post-graduate training is not enough to improve the allocation of physicians across specialties and health system sectors. We argue that an extensive increase in the number of physicians without changing their composition will hardly change the situation. A more active structural policy is required with a focus on strengthening primary care and improving planning and regulation of health workforce structure.

Staff turnover and knowledge loss: a case study of the University of Nairobi Library

Rationale of Study – Staff turnover affects an organisation’s ability to maintain knowledge continuity. This paper investigates staff turnover as a potential threat to knowledge loss at the University of Nairobi Library.Methodology – Questionnaires were used to collect data which identified the factors within the University of Nairobi Library that determine staff exit. Correlation and regression were used to examine the verifiability of these parameters.Findings – From the study, it was found out that the main determinants of staff turnover are inadequate training and development programmes for staff; job satisfaction depending on the favourability of the job; poor pay and lack of benefit conditions; as well as work climate or environment and leadership style. Staff turnover leads to reduced organisational output and productivity; loss of organisational or institutional memory; creation of gaps in service delivery and organisational structure; high cost of training and recruitment of new staff; low level of commitment since the teams are shaken by the loss of a team member; low organisational integration resulting from broken team; loss of library users; and increased work load amongst the remaining staff.Implications – The authors recommend that the University of Nairobi Library should carefully look into the factors making the staff to migrate to other organisations. The library should also institute the necessary measures to reduce the staff turnover and enhance staff retention in order to reduce the knowledge loss.Originality – The study is original to the University of Nairobi Library. The findings, however, may be applied to other academic libraries in Kenya and beyond.

Structural changes in the Russian health care system: do they match European trends?

ВackgroundIn the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS.MethodsWe address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system.ResultsThe main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery.ConclusionThe structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.

Rekonstruksi Pencatatan Perkawinan Berdasarkan Relevansi Antara Hukum Administrasi Negara dengan Hukum Administrasi Sipil

This study aimed to analyze the problems of enforcing civil administrative law in marriage registration and the concept of reconstructing marriage registration based on the relevance of state administrative law to civil administrative law. The method used in this study was normative juridical with a statutory approach and a conceptual approach. The problems of enforcing civil administration law in marriage registration include general problems related to administration, such as errors in identity writing and the organization of administrative institutions, which were full of personnel management problems. The reconstruction of marriage registration was based on the relevance between state administrative law and civil administrative law relating to the interests of public service delivery and institutional structure structuring in civil service law. The arrangement of personnel in the office of religious affairs need to pay attention to the employment law to create services based on professionalism in serving the community.

Adherence to malaria management guidelines by health care workers in the Busoga sub-region, eastern Uganda

BackgroundAppropriate malaria management is a key malaria control strategy. The objective of this study was to determine health care worker adherence levels to malaria case management guidelines in the Busoga sub-region, Uganda.MethodsHealth facility assessments, health care worker (HCW), and patient exit interview (PEI) surveys were conducted at government and private health facilities in the sub-region. All health centres (HC) IVs, IIIs, and a sample of HC IIs, representative of the tiered structure of outpatient service delivery at the district level were targeted. HCWs at these facilities were eligible for participation in the study. For PEIs, 210 patients of all ages presenting with a history of fever for outpatient care at selected facilities in each district were targeted. Patient outcome measures included testing rates, adherence to treatment, dispensing and counselling services as per national guidelines. The primary outcome was appropriate malaria case management, defined as the proportion of patients tested and only prescribed artemether-lumefantrine (AL) if positive. HCW readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and anti-malarials) to provide malaria case management were also assessed. Data were weighted to cater for the disproportionate representation of HC IIs in the study sample.ResultsA total of 3936 patients and 1718 HCW from 392 facilities were considered in the analysis. The median age of patients was 14 years; majority (63.4%) females. Most (70.1%) facilities were HCIIs and 72.7% were owned by the government. Malaria testing services were available at > 85% of facilities. AL was in stock at 300 (76.5%) facilities. Of those with a positive result, nearly all were prescribed an anti-malarial, with AL (95.1%) accounting for most prescriptions. Among those prescribed AL, 81.0% were given AL at the facility, lowest at HC IV (60.0%) and government owned (80.1%) facilities, corresponding to AL stock levels. Overall, 86.9% (95%CI 79.7, 90.7) of all enrolled patients received appropriate malaria case management. However, only 50.7% (21.2, 79.7) of patients seen at PFPs received appropriate malaria management.ConclusionAdherence levels to malaria case management guidelines were good, but with gaps noted mainly in the private sector. The supply chain for AL needs to be strengthened. Interventions to improve practise at PFP facilities should be intensified.

Last Place of Care and End-of-Life Quality of Life in the United States: Evidence From a National Representative Data Set

Background: Quality of life (QoL) during last stage of life has raised expanded interests as an important aspect of person-centered care. Last place of care (LPC), refer to the last place decedents received their formal end-of-life care (EOLC), has been identified as a key indicator of older adults’ end-of-life QoL, but the relationship was understudied. This study explores the association between LPC and end-of-life QoL among American older adults. Methods: Data used seven waves of Last Month of Life data with a total sample of 3068 Medicare decedents in NHATS. Outcome is end-of-life QoL assessed by eleven measures on four domains: pain and symptoms management (SP), quality of healthcare encounter (HE), person-centered care (PC), and overall quality of care (QC). LPC was categorized into home, hospital, nursing home, and residential hospice. Multivariate logistic regression analyses were used to examine the relationship with covariates. Results: LPC varied by most demographic characteristics, except immigration status and education. Older adults whose LPC is hospital, compared to those who had home-care, were less likely to have great experiences on HE, PC, and QC. People dying at nursing homes are more likely to receive care meeting their dyspnea and spiritual needs. Residential hospice is negatively related to respected care, clear coordination, and keeping family informed, but are more likely to provide PS and spiritual care. Discussion: Home-based end-of-life care has certain advantages but still has room to improve on SP and religious concerns. Hospitals should keep reforming their service delivery structure to improve patients’ QoL.

Evidence of integrated primary-secondary health care in low-and middle-income countries: protocol for a scoping review

BackgroundIntegrated care is a people-centered health delivery approach that ensures the comprehensiveness, quality, and continuity of service across the settings and levels of health systems. The World Health Organization (WHO) recommends integration across levels and building-blocks of health systems as a prerequisite of Universal Health Coverage (UHC). While health systems of low- and middle-income countries (LMICs) are often fragmented and led by siloed service delivery structure, several LMICs—including India—have attempted health system integration. Several systematic reviews of evidence on healthcare integration from developed countries exist, but no synthesis from LMICs was reported to date. This review will overview the existing evidence of primary-secondary care integration (PSI) in the context of LMICs, aiming to support policy decisions for the effective integration of health delivery systems in India.MethodsThe review will be conducted following the six steps recommend by Arksey and O'Malley. Scientific and grey literature will be systematically selected from PubMed, Embase, Scopus, Web of Science, Global Index Medicus, and electronic repositories (such as WHO, World Bank, Health Policy Plus, and OpenGrey). Using a comprehensive search strategy, literature written in English and published between 2000 and 2020 will be selected, and two independent authors will screen their titles and abstracts. The result will be charted using a data extraction form and reported using tables, figures, and narrative forms.DiscussionNo ethical approval is necessary for the review. The final report will be developed with the consultation of other stakeholders and disseminated through workshops, conference papers, and peer review articles. The review will serve as a guiding tool to approach, implement, and test the PSI models in India and other LMICs.Scoping review registrationhttps://osf.io/kjhzt.

Does it matter who delivers? The case of early childhood education and care in Korea

ABSTRACT This paper takes the case of early childhood education and care in Korea to explore how the service delivery structure that utilises non-traditional welfare institutions creates tensions between private and public interests. It highlights that the state’s primary concern is to ensure citizens’ access to services provided in the market, the providers of which are entrusted with social responsibilities at the same time. Yet because social goals are pursued through the use of economically efficient tools, the economic logic is introduced where it should not, in ways that are detrimental to social goals.

Contextual determinants of IT governance mechanism formulation for senior care services in local governments

Recognizing the critical role that information technology (IT) can play for the aging population, local governments tend to take responsibilities for IT-enabled senior care service delivery. Formulating IT governance mechanisms is important for governments to perform their responsibilities and maximize public value. As service arrangers, governments’ actions are affected by complex external environments for legitimacy, which has been largely ignored in the existing studies. By incorporating the strategic and institutional perspectives of legitimacy into Savas’s service delivery structure, this study developed a triadic framework that accounts for different contextual determinants related to the external market environment and the institutional environment to investigate the formulation of IT governance mechanisms. A survey involving 329 town-level governments in Beijing, China, was done to validate our research model. The results illustrate that the demand-supply market forces have direct impacts on IT governance mechanism formulation in local governments. Institutional pressures exert a mediating effect by transiting the supply market force into governments’ actions. Our triadic framework reveals a dynamic service delivery structure, contributing to Savas’s service delivery structure and IT governance research.

A One Health framework for integrated service delivery in Turkana County, Kenya

Pastoralists in sub-Saharan Africa have limited access to public services due to their mobile lifestyle, economic and political marginalization, and the limited health infrastructure that is common to arid and semi-arid lands (ASALs) where they primarily reside. This often results in poor health outcomes, including increased rates of maternal, neonatal, and under-5 mortality. One Health approaches that integrate human and animal health service delivery can help to improve pastoralists’ health through increased vaccine coverage and improved access to services.Kenya has institutionalized One Health at the national level; however, progress at the subnational level has been limited due to sustainability concerns, competing priorities, and insufficient coordination platforms. To address this gap, this paper presents a One Health framework (OHF) to aid in the implementation of integrated human and animal health policies in Turkana County, which can act as a model for other ASALs. Utilizing a grounded theory design, we conducted semi-structured interviews and focus group discussions with human health, animal health, and pastoralist stakeholders. Inadequate engagement with the public sector was identified as a major limitation by community members. Factors that contributed to this include distance to health facilities and restricted department capacities such as availability of vehicles, personnel, and cold chain maintenance.Our proposed OHF harnesses the existing structure of service delivery in Turkana and establishes an official coordination mechanism to implement One Health activities, through the form of mobile “One Health Huduma Centres”, offering a range of public services. This innovative framework is supported by stakeholders in Turkana and can improve service delivery constraints thereby improving the health of Turkana pastoralists.

Bidirectional Screening of Diabetes Mellitus and Tuberculosis in Cambodia

Background: Cambodia has a high burden of Tuberculosis (TB) with an incidence rate of 326 per 100,000 population in 2018 and rapidly increasing rates of Diabetes Mellitus (DM) with prevalence rate 9.6% in 2016. The introduction of the first national guidelines for the management of TB/DM co-morbidity in 2014 has resulted in the introduction of coordinated service delivery. Objective: This study aimed to assess the performance and the results of bidirectional TB/DM screening, diagnosis of co-morbidity, and enrollment in treatment in 7 health operational districts in 5 provinces in Cambodia. Methods: The retrospective study reviewed patient records of 6,463 DM patients and 8,403 TB patients who received treatment between July 2016 and February 2019 in 7 referral hospitals and 113 health centers. Results: Forty percent of DM patients were screened for TB, and 55% of TB patients were screened for DM. Of the screened DM patients, 4.6% were diagnosed with TB. Of screened TB patients, 3.7% were diagnosed with DM. All DM patients diagnosed with TB were enrolled in TB treatment and 95% of TB patients diagnosed with DM began receiving treatment for DM. Conclusion: This is the first study examining TB/DM co-morbidity and coordinated service delivery in Cambodia. The gaps in the performance of bidirectional screening suggest areas for further intervention. To increase the rate of bidirectional screening, provider compliance with standards needs to be improved by strengthening providers competencies. Strengthened data collection and reporting systems will also contribute to increasing provider accountability. Secondly, the current structure of TB and DM service delivery with TB services only available from the public sector and public DM services only available at the referral level creates a challenging environment for effective referrals and coordinated care and should be reconsidered. In addition to improved coordination between the public and private sectors, expansion of public DM services to health centers and to the community level warrants exploration. Finally, the increased focus needs to be given to addressing the high levels of pre-diabetes. Cambodia has a limited window of opportunity to build capacity and develop systems to effectively manage TB/DM co-morbidity.

Building an integrated system of urological care: the case of Russian regions

Background: Integrated pathways are commonly seen as the way to strengthen service delivery in many countries. Russia has traditionally had a multilevel system of care that consists of facilities varying in terms of complexity of cases treated. The recent innovation is to establish a new intermediate level of inter district specialty centers IDSC that serve the population of a few local areas and provide additional services, including preventive care and early disease identification. Integrated pathways between levels of service delivery are developed and implemented. Voronezh region is a pilot cite for this innovation in the area of urological care with the focus on the cases of benign prostate hyperplasia BPH. The objective of the research is to evaluate: 1 the scale of new BPH cases identification, 2 the change in the structure of service delivery in multilevel system, 3 the trends in total and unit cost of BPH treatment. Methods and data: The indicators of BPH cases structure, utilization and expenditure trends in Voronezh oblast for each level of service delivery are analyzed. The data relates to men older than 50 year in 2009-2013 before and after the reorganization in 2010. Results: 1- The number of identified new cases increased, while the share of surgical cases decreased. 2- The IDSCs treat the bulk of cases now, while the share of tertiary care hospitals regional and federal decreased substantially. 3- The first impact of the innovation was the growth of BPH expenditure due to early revealing the cases, but the new institutional structure together with a constant surveillance of cases has afterwards slowed down this growth. 4- The unit cost per one BPH case has a strong downward tendency – due to a decrease in tertiary care utilization. Conclusion: Multilevel system of care, based on early identification of cases and integrated pathways between the levels, can contribute to decreasing the share of complex cases requiring surgical interventions. It can also lead to decreasing the share of tertiary care utilization and lower unit cost.

Preventable infant deaths, lone births and lack of registration in Mexican indigenous communities: health care services and the afterlife of colonialism

ABSTRACT Mexico’s indigenous communities continue to experience higher levels of mortality and poorer access to health care services than non-indigenous regions, a pattern that is repeated across the globe. We conducted a two-year ethnographic study of pregnancies and childbirth in an indigenous Wixárika community to explore the structural causes of this excess mortality. In the process we also identified major differences between official infant mortality rates, and the numbers of infants born to women in our sample who did not survive. We interviewed 67 women during pregnancy and followed-up after the birth of their child. At baseline, socio-demographic data was collected as well as information regarding birthing intentions. In depth-interviews and semi-structured interviews were conducted with 62 of these women after the birth of their child, using a checklist of questions. Women were asked about choices regarding, and experiences of childbirth. Of the 62 women we interviewed at follow-up 33 gave birth at home without skilled attendance and five gave birth completely alone in their homes. Five neonates died during labour or the perinatal period. Concerns about human resources, the structure of service delivery and unwanted interventions during childbirth all appear to contribute to the low institutional childbirth rate. Our data also suggests a low rate of death registration, with the custom of burying infants where they die. This excess mortality, occurring in the context of unnecessary lone and unassisted childbirth are structurally generated forms of violence.

Spiegeln Onlinebewertungen Strukturunterschiede in der Versorgung wider? Eine Analyse am Beispiel von Arztbewertungsportalen

BackgroundPrevious surveys have shown that patient satisfaction varies with the regional supply of physicians. Online ratings on physician-rating websites represent a relatively new instrument to display patient satisfaction results. The aim of this study was (1) to assess the current state of online ratings for two medical disciplines (dermatologists and ear, nose and throat (ENT) specialists), and (2) to analyze online derived patient satisfaction results according to the physician density in Germany. MethodsWe collected online ratings for 420 dermatologists and 450 ear, nose, and throat (ENT) specialists on twelve German physician-rating websites. We analyzed the online ratings according to the physician density (low, medium, high physician density). For this purpose, we collected secondary data from both physician-rating websites and the regional associations of statutory health insurance physicians. Data analysis was performed using Median tests and Chi-square tests. ResultsIn total, 10,239 online ratings for dermatologists and 8,168 online ratings for ENT specialists were analyzed. Almost all dermatologists (99.3 %) and ENT specialists (98.9 %) were listed on one of the physician-rating websites. A total of 93.5 % of all listed dermatologists and 96.9 % of ENT-specialists were rated on at least one of the physician-rating websites. Significant differences were found in the distribution (i.e., percentage of listed or rated physicians) of the ratings according to the regional physician density on only one physician-rating website (p<0.001). Furthermore, online ratings were shown to be better in regions with a higher physician density on two physician-rating website. On jameda.de, for example, dermatologist ratings were better in regions with a higher physician density compared to regions with a lower number of physicians (average rating: 2.16 vs. 2.67; p<0.001). ConclusionsOnline ratings of dermatologists and ENT specialists hardly differ in terms of regional physician density. Physician-rating websites thus do not appear to be appropriate to mirror differences in the health service delivery structure. Our findings thus do not confirm the results from previously published studies.

Feasibility of mHealth intervention to improve uptake of antenatal and postnatal care services in peri-urban areas of Karachi: a qualitative exploratory study

Background: In Pakistan, poor antenatal and postnatal coverage, has accounted for nearly 70% of preventable maternal deaths. Interventions implemented to improve uptake of antenatal and postnatal care (PNC) services have not shown significant improvements. Recent increase in cellphone penetration has brought forward mHealth as a potential strategy to enhance antenatal care (ANC) and PNC uptake. The objective of this study was to explore if mHealth technology is a feasible strategy to improve uptake of preventive maternal healthcare services in peri-urban areas of Karachi. Methods: The study employed an exploratory qualitative research design using focus group discussions (FGDs) and key-informant interviews. FGDs were conducted with pregnant women, women in the postnatal period and lady health workers (LHWs) whereas key-informant interviews were conducted with maternal neonatal and child health experts and mHealth experts. The study data was analyzed using NVivo version 11. Results: This research found that women, healthcare providers and technology experts consider mHealth strategy has high potential to address barriers related to provision and utilization of ANC and PNC services. Healthcare providers and women understand the term mHealth and knew the benefits of mHealth services. Few of the women and healthcare providers are currently using mHealth for providing and receiving ANC and PNC services. Women and healthcare provider seemed ready for mHealth use however expressed challenges such as, illiteracy, cultural restrictions, lack of trustworthiness and misuse of technology. Conclusions: This study informs that mHealth is operationally feasible, culturally acceptable and technologically appropriate strategy. For successful integration of mHealth technology in to existing maternal neonatal and child health service delivery structure, it is considered imperative to build a sustainable model of mHealth by involving government, local communities, telecommunication personnel, health care providers and mHealth and maternal neonatal and child health experts and through tailoring the design of the mHealth solutions in such a way that it benefits majority of women.

P133 Using a cross sectional survey to establish a national picture of the activity, governance and delivery of condom distribution schemes in england, in the financial year 2015/16

IntroductionCondoms remain a key intervention to prevent sexually transmitted infections (STI), pregnancy and HIV. C-Card is a type of condom distribution scheme (CDS) with condom demonstration and risk assessment at...

Military veteran cancer survivors’ preferences for a program to address lifestyle change and psychosocial wellness following treatment

ABSTRACTThis study aimed to understand military veteran cancer survivors’ preferences regarding the delivery of post-treatment wellness services. Thirty-three military veteran cancer survivors were interviewed about their perceptions of three models of health service delivery (home-, primary care-, and oncology-based services). Conventional qualitative content analysis revealed strengths and weaknesses of each service delivery model's content and structure (e.g., program location, inclusion of emotional support, access to clinical experts). All service delivery programs had strengths, with clinic-based programs offering the greatest breadth of services deemed important for wellness by cancer survivors.