Redesigning a Ministry of Health's organizational structure: exploring implementation challenges through Botswana's experiences.

INTRODUCTION: The Botswana's Ministry of Health redesigned and adopted a new organizational structure in 2005, which was poorly implemented. This article explores factors that influenced the implementation of this organizational structure. METHODS: This article draws from data collected through in-depth interviews with 54 purposively selected key informants comprising policy makers, senior managers and staff of the Ministry of Health (N = 40) and senior officers from various stakeholder organizations (N = 14). FINDINGS: Participants generally felt that the review of the Ministry of Health organizational structure was important. The previous structure was considered obsolete with fragmented functions that limited the overall performance of the health system. The new organizational structure was viewed to be aligned to current national priorities with potential to positively influence performance. Some key weaknesses identified included lack of consultation and information sharing with workers during the restructuring process, which affected the understanding of their new roles, failure to mobilize key resources to support implementation of the new structure and inadequate monitoring of the implementation process. CONCLUSION: Redesigning an organizational structure is a major change. There is a need for effective and sustained leadership to plan, direct, coordinate, monitor and evaluate the implementation phase of the reform. Copyright © 2014 John Wiley & Sons, Ltd.

Trajectories of Successful Aging Among Older Adults in Aotearoa New Zealand.

Successful aging was defined as having no multimorbidity, high functional capacity, active life engagement, and good health-related quality of life. This study analyzed data from 1433 older adults who were followed up for 12 years across seven waves from the New Zealand Health, Work and Retirement study by examining the trajectories of successful aging. Latent growth curve modeling was used to assess the growth factors of successful aging trajectories of older adults. The mean successful aging score was 3.53 (range: 0-6) in 2006 and linearly declined by 0.064 units every year. Those with higher successful aging scores at baseline had a slower decline. Successful aging scores were lower among females, Maori, and those aged 65 years and above at baseline. The findings from this study suggest that gender and ethnic inequalities play significant roles in successful aging among older adults in New Zealand.

Real-world, anti-tobacco environmental impact upon price-induced smoking reduction among urban Chinese men: Evidence from China's 2015 cigarette tax increase.

INTRODUCTION: Raising the price of cigarettes via taxation has been promoted by the World Health Organization as an important tobacco control strategy. Price elasticity of cigarettes is not uniform and is dependent upon individual and environmental determinants. Many studies have examined the determinants of price-induced smoking, taking into account sociodemographic characteristics and consumption patterns. Little research has been conducted on the association between anti-smoking environments and price-induced smoking behavior. This study addresses the deficit within the Chinese context. METHODS: Participants were 2852 male smokers identified through a multi-stage survey sampling process encompassing 6 cities in China between July and December 2016. A standardized questionnaire tapped price-induced smoking reduction and related information. Both unadjusted and adjusted logistic regression methods were applied in the analyses. RESULTS: In all, 25.5% (95% CI: 22.5-27.9) of smokers in this study decreased their smoking expenditures following the 2015 excise tax increase. The adjusted logistic regression analysis showed that increased exposures to an anti-smoking information environment (AOR=1.39; 95% CI: 1.10-1.79), restricted smoking in their home (AOR=1.67; 95% CI: 1.32-2.08) and workplace (AOR=1.43; 95% CI: 1.09-1.85) were more likely to report diminished cigarette smoking following the tax increases. CONCLUSIONS: This study adds to understanding price-induced smoking behavior among urban male Chinese smokers. Strengthening of excise tax policies needs to intensify environmental smoking restrictions and public education campaigns to increase the sensitivity of cigarette price changes among smokers.

Assessing the capacity of New Zealand health promoters to develop programs that meet the health literacy needs of both consumers and government.

ISSUES ADDRESSED: Since 2008 a conservative government in New Zealand has emphasised the importance of individual responsibility for health, with the implication that health promotion, including health literacy, would be of low priority. This paper discusses this in the context of research that aims to assess (i) the views of disadvantaged consumers on nutrition information and (ii) health promoter competence in health literacy practice, and argues that aspects of health literacy principles may indeed be of interest to conservative governments. METHODS: First, four focus groups of consumers drawn from disadvantaged neighbourhoods discussed nutrition information. Second, a self-completed questionnaire to health promoters in six non-government agencies assessed health promotion competencies and understanding of health literacy. RESULTS: Consumers confirmed the need for personal responsibility for food choices, were critical of confusing information and sought simple messages on which they could act. They also acknowledged environmental constraints on their actions. Survey respondents (n=56; 53% response rate) reported technical competence in health promotion but less competence in strategic and leadership areas. More than one-third of respondents were assessed as having a good understanding of health literacy. CONCLUSION: Consumer acceptance of individual responsibility and workforce capability in technical aspects of health literacy suggest that health promotion organisations can align themselves with government goals and seek to improve personal health literacy.

Unmet healthcare need and the significance of charity hospitals in Aotearoa New Zealand.

Nil.

Evaluation of Neighborhood Socio-Economic Status, as Measured by the Delphi Method, on Dengue Fever Distribution in Jeddah City, Saudi Arabia.

Dengue fever, a mosquito-transmitted viral disease, is present in many neighborhoods in Jeddah City, Saudi Arabia. One factor likely to affect its distribution is the socio-economic status of local neighborhoods; however, the absence of socio-economic census data in Saudi Arabia has precluded detailed investigation. This study aims to develop a proxy measure of socio-economic status in Jeddah City in order to assess its relationship with the occurrence of dengue fever. The Delphi method was used to assess the socio-economic status (high, medium or low) of local neighborhoods in Jeddah City. A Geographic Information System (GIS) was applied to understand the distribution of dengue fever according to the socio-economic status of Jeddah City neighborhoods. Low-socio-economic status neighborhoods in south Jeddah City, with poor environmental conditions and high levels of poverty and population density, reported most cases of dengue fever. Nevertheless, dengue continues to increase in high socio-economic status neighborhoods in the northern part of the city, possibly due to ideal breeding conditions caused by the presence of standing water associated with high levels of construction. Moreover, the low-socioeconomic-status neighborhoods had the highest average number of cases, being 3.95 times that of high-status neighborhoods for the period 2006-2009. The Delphi approach can produce a useful and robust measure of socio-economic status for use in the analysis of patterns of dengue fever. Results suggest that there are nuances in the relationship between socio-economic status and dengue that indicate that higher status areas are also at risk. A useful additional tool for researchers in Saudi Arabia would be the development of census data or other systematic measures that allow socio-economic status to be included in spatial analyses of dengue fever and other diseases.

Neoliberalism: what it is, how it affects health and what to do about it.

Since the 1970s, neoliberalism has been the dominant economic and political philosophy among global institutions and some Western governments. Its three main strategies are: privatisation and competitive markets; reduced public expenditure on social services and infrastructure; and deregulation to enhance economic activity and ensure freedom of 'choice'. Generally, these measures have negatively affected the health and wellbeing of communities. In New Zealand, privatisation and competition led to income inequality and an unequal distribution of the 'determinants of health', a burden borne disproportionately by children, the poor, and by Maori and Pacific people. Limiting health expenditure led to inequalities in access to services with restructuring in the 1990s, subverting the service culture of the health system. Failure to regulate for the protection of citizens has undermined health and safety systems, the security of work and collective approaches to health improvement. There has been some retreat from neoliberalism in New Zealand, but we can do more to focus on 'upstream' health initiatives, to recognise that social investment, including adequate funding of services, returns benefits far in excess of any costs, and to make sure that social and cultural equity goals are achieved.

VOICES: South Island pilot survey of bereaved people.

AIMS: To test the feasibility of surveying bereaved next-of-kin in the South Island about their perceptions of end-of-life care for people over 18 years of age; to report results; and to identify issues for future research. METHOD: The study used the VOICES (Views of Informal Carers Evaluation of Services) questionnaire from the UK, adapted for use in Aotearoa New Zealand. Identification of next-of-kin for all South Island deaths September-November 2017 was undertaken by a commercial firm specialising in such work. Addresses of next-of-kin were sought from the Electoral Roll, with 1,813 eligible people identified and 272 (15.0%) next-of-kin unable to be traced. Surveys were posted out once only, with options to complete by mail, online, by telephone or with a face-to-face interview. RESULTS: Of the 1,541 surveys distributed, 514 (33.4%) were completed. Results confirmed the suitability of the locally modified VOICES instrument and research process. The quality of care overall was rated most highly in hospice or own home, but only a minority were able to die in these settings. Nevertheless, relatives indicated that most people died 'in the best place'. CONCLUSIONS: The VOICES questionnaire is acceptable to respondents and there are viable methods for seeking a population sample. Aspects of the questionnaire require modification before wider use. The information obtained can help district health boards, hospices other healthcare providers, and consumers in planning for end-of-life care.

Hypertension and diabetes management: a policy perspective from Ghana.

PURPOSE: The purpose of this paper is to assess policy and management of hypertension and diabetes in Ghana. DESIGN/METHODOLOGY/APPROACH: The authors conducted 26 key informant interviews with policy makers, payers, providers and participants from advocacy groups associated with the management of hypertension and diabetes both at national and district levels in Ghana; conducted focus group discussions with a total of 18 hypertensive and diabetic patients; and analyzed documentation detailing activities that have been undertaken in response to the management of hypertension and diabetes in Ghana. The authors then conducted a content analysis after combining the three sources of information. FINDINGS: Using a stepwise policy process, the Ghanaian health sector has developed overarching policies and strategies on management of diabetes, hypertension, other non-communicable diseases, tobacco, alcohol and nutrition-related issues. Availability of funds and over-concentration on communicable diseases are the main barriers to the implementation of policies. Besides, response of the health sector to address the problems of hypertension and diabetes is focused more on clinical management than prevention; while the structures and processes to manage diabetes and hypertension is available at all levels of service delivery, more needs to be done on preventive aspects. ORIGINALITY/VALUE: This is the first study in Ghana to combine individual interviews, focus groups and document analysis to review policy development, implementation and response activities on the management of hypertension and diabetes. The authors believe that the evidence from this research will inform future policy initiatives on hypertension and diabetes management in Ghana.

Where there's a will, is there a way?: is New Zealand's publicly funded health sector able to steer towards population health?

Since 2000, the substantive focus of health policy in New Zealand has been closely aligned to the agendas of improving population health and reducing health inequalities. Health system restructuring, through the introduction of locally based and partially elected District Health Boards (DHBs), was the structural mechanism chosen for reorienting the health sector towards population health. Strategic planning at the DHB level was the key mechanism by which central government population health objectives would be translated into local action. This analysis of the early years of elected DHBs (2001-2005) sets out to answer the following broad questions: (i) did strategic planning by District Health Boards reflect an orientation to population health?; (ii) to what extent was strategic planning towards population health shaped by community participation and input?; (iii) to what extent did strategic planning lead to a re-prioritisation of resources? These questions were explored as part of a larger research project investigating the introduction and implementation of the DHB system. Data were collected from over 350 interviews of local and national stakeholders, and two surveys of DHB Members between 2002 and 2004-2005. Overall, DHBs demonstrated the 'will' to engage in strategic decision-making processes to enhance population health but have difficulty in finding the 'way'. The priorities and requirements of central government and the weight of institutional history were found to be the most influential factors on DHB decision-making and practice, with flexibility and innovation only exercised at the margins. This raises the key question of whether there is the governmental capacity at the local level to adequately address nationally determined population health policy priorities.

Decentralizing resource allocation: early experiences with district health boards in New Zealand.

OBJECTIVES: In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the government's stated objectives are likely to be achieved. METHODS: Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. RESULTS: The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decision-making has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. CONCLUSIONS: Decentralized decision-making is starting to make some inroads towards achieving some of the government's objectives with respect to resource allocation and purchasing.

Dispatches from the front-line: an analysis of fluoridation campaigns in southern New Zealand, 2002-2006.

OBJECTIVES: The paper aims to analyse recent campaigns for water fluoridation in the South Island and to identify lessons to be learned from the outcomes. DESIGN: The research uses a systematic case study analysis based on a public policy framework, drawing on key informants, public documents and participant observation of campaigns in five separate communities. RESULTS: Over a four-year period in five specific communities (Gore and Southland in 2004; Ashburton in 2002 and 2006; and Grey and Westland in 2005), the opportunity to introduce or retain fluoridation was rejected by local Councils. The extent of community understanding of the issues, the processes of engagement on the part of the health systems and the approaches to decision-making by Councils varied widely, but the main inputs to decisions were the rejection of expert health advice and a reliance on binding referenda or other assessments of the strength of community feeling. CONCLUSION: More evidence-based decision-making on fluoridation is required. Options at local level include tribunals and other mechanisms to support Councils, but it is likely that stronger national policy leadership and the application of robust health impact assessment may be necessary to ensure improved oral health and the reduction of inequalities.

Disclosure of treatment injury in New Zealand's no-fault compensation system.

In July 2005 New Zealand became the first country to establish comprehensive no fault coverage for all treatment injury. This paper reports on a study of disclosure policies and practices related to treatment injury within the New Zealand hospital system. All 21 district health boards (DHBs), which provide publicly funded hospital services, were asked to complete a detailed questionnaire, with 90% responding. This was followed by an extended telephone interview with the chief clinical advisers and quality managers of 11 DHBs. Most respondents reported that their boards had an established policy or were developing one. DHBs reported a high level of disclosure practice, even for preventable harm. All indicated that disclosure was now felt to be safer than non-disclosure, although this view was not shared by all grassroots clinicians. The New Zealand experience may point to ways of achieving fairer and accessible compensation for patients.

Physician advocacy in Western medicine: a 21st century challenge.

Physician advocacy occurs when doctors speak up for the health and healthcare of patients and communities. Historically, this was strong in some Western countries with doctors finding that it enhanced their authority, prestige and power. But it weakened in the 20th century when the biomedical model of heath triumphed and medicine became a dominant profession. In the second part of the 20th century, this dominance was threatened by political, technological and socioeconomic forces. These weakened medicine's state support, brought it under managerial control and undermined the social contract on which trust between doctors and the community was based. Defence of the profession was assumed by medical colleges, societies and associations. They had some success in retaining professional autonomy but did not undertake open advocacy, particularly on social justice issues, and did not therefore enhance their standing in the community. Opinion is divided on the level of advocacy that it is ethically proper for the medical profession to employ. Some contend doctors should only advise authorities when expert opinion is requested. Others contend doctors should speak out proactively on all health issues, and that collective action of this type is a hallmark of professionalism. This lack of consensus needs to be debated. Recent developments such as clinical leadership have not revitalised physician advocacy. However, continued deterioration of the UK National Health Service has led some English medical colleges to take up open advocacy in its defence. It is to be seen whether medical colleges elsewhere follow suit, as and when their healthcare systems are similarly threatened.

Reconsidering the role of a local diabetes society: patterns of membership in Christchurch, New Zealand.

OBJECTIVE: To investigate patterns of membership and barriers to service use in the Christchurch Diabetes Society. METHODS: A socio-economic profile of the Christchurch Diabetes Society's membership was constructed by examining the residential locations of society members in Christchurch City. Rates of membership by deprivation decile were calculated by comparing the membership data to the population of people diagnosed with diabetes. RESULTS: Persons living in deprived areas, in particular Maori and Pacific people, are under-represented in society membership. However, there is evidence that the relationship between ethnicity and membership rates is stronger in more deprived areas. CONCLUSIONS: This study provides further insights in understanding barriers to care and the role of NGOs. Given that groups in the community most likely to be affected by diabetes are least likely to be members of the society and to have access to the society's services, the results raise questions about the most appropriate role for local diabetes societies within a decentralised health system.

People ageing with spinal cord injury in New Zealand: a hidden population? The need for a spinal cord injury registry.

AIMS: To identify and establish a research database of ageing New Zealand people who sustained a traumatic or non-traumatic spinal cord injury (SCI) before 1990. METHODS: All living New Zealand residents incurring a SCI before 1 January 1990 were eligible. A co-ordinated consultation with apposite New Zealand organisations was undertaken to identify and access existing SCI databases, and remove duplicate or ineligible records. RESULTS: 1,400 people were identified. Using the national patient information management system to determine eligibility, 1,174 people remained after exclusions; 600 (51.1%) through the Auckland Spinal Rehabilitation Unit and 574 (48.9%) through the Burwood Spinal Unit. Common to both databases were people's National Health Index number, contact details, basic demographic data, date of injury, and neurological level of SCI. CONCLUSIONS: An unexpectedly large SCI population was uncovered; a population largely hidden due to the uncoordinated, fragmented and inconsistently collected information held within different organisations. As life expectancy rapidly increases for those with SCI, coupled with an accelerated ageing general population, this hidden SCI population can be expected to grow. A single, well-managed and coordinated national SCI registry is urgently needed in New Zealand for planning and delivery of services, especially for those developing age-related complex interwoven secondary conditions.

Understanding human resource management practices in Botswana's public health sector.

Purpose The purpose of this paper is to assess the management of the public sector health workforce in Botswana. Using institutional frameworks it aims to document and analyse human resource management (HRM) practices, and make recommendations to improve employee and health system outcomes. Design/methodology/approach The paper draws from a large study that used a mixed methods approach to assess performance of Botswana's Ministry of Health (MOH). It uses data collected through document analysis and in-depth interviews of 54 key informants comprising policy makers, senior staff of the MOH and its stakeholder organizations. Findings Public health sector HRM in Botswana has experienced inadequate planning, poor deployment and underutilization of staff. Lack of comprehensive retention strategies and poor working conditions contributed to the failure to attract and retain skilled personnel. Relationships with both formal and informal environments affected HRM performance. Research limitations/implications While document review was a major source of data for this paper, the weaknesses in the human resource information system limited availability of data. Practical implications This paper presents an argument for the need for consideration of formal and informal environments in developing effective HRM strategies. Originality/value This research provides a rare system-wide approach to health HRM in a Sub-Saharan African country. It contributes to the literature and evidence needed to guide HRM policy decisions and practices.

Analysing the Stewardship Function in Botswana's Health System: Reflecting on the Past, Looking to the Future.

BACKGROUND: In many parts of the world, ongoing deficiencies in health systems compromise the delivery of health interventions. The World Health Organization (WHO) identified four functions that health systems need to perform to achieve their goals: Efforts to strengthen health systems focus on the way these functions are carried out. While a number of studies on health systems functions have been conducted, the stewardship function has received limited attention. In this article, we evaluate the extent to which the Botswana Ministry of Health (MoH) undertook its stewardship role. METHODS: We used the WHO Health Systems Performance Assessment Frame (HSPAF) to guide analysis of the stewardship function of the Botswana's MoH focusing on formulation of national health policies, exerting influence through health regulation, and coalition building. Data were abstracted from published and unpublished documents. We interviewed 54 key informants comprising staff of the MoH (N = 40) and stakeholder organizations (N = 14). Data from documents was analyzed through content analysis. Interviews were transcribed and analyzed through thematic analysis. RESULTS: A lack of capacity for health policy development was identified. Significant policy gaps existed in some areas. Challenges were reported in policy implementation. While the MoH made efforts in developing various statutes that regulated different aspects of the health system, some gaps existed in the regulatory framework. Poor enforcement of legislation was a challenge. Although the MoH had a high number of stakeholders, the mechanisms for stakeholder engagement in the planning processes were weak. CONCLUSION: Problems in the exercise of the stewardship function posed challenges in ensuring accountability and limited the health system's ability to benefit from its stakeholders. Ongoing efforts to establish a District Health System under control of the MoH, attempts to improve service delivery at a national level and political will to strengthen public-private engagement mechanisms are some of the prospects that can improve the MoH's stewardship function.

Development of the National Health Information Systems in Botswana: Pitfalls, prospects and lessons.

BACKGROUND: Studies evaluating development of health information systems in developing countries are limited. Most of the available studies are based on pilot projects or cross-sectional studies. We took a longitudinal approach to analysing the development of Botswana's health information systems. OBJECTIVES: We aimed to: (i) trace the development of the national health information systems in Botswana (ii) identify pitfalls during development and prospects that could be maximized to strengthen the system; and (iii) draw lessons for Botswana and other countries working on establishing or improving their health information systems. METHODS: This article is based on data collected through document analysis and key informant interviews with policy makers, senior managers and staff of the Ministry of Health and senior officers from various stakeholder organizations. RESULTS: Lack of central coordination, weak leadership, weak policy and regulatory frameworks, and inadequate resources limited development of the national health information systems in Botswana. Lack of attention to issues of organizational structure is one of the major pitfalls. CONCLUSION: The ongoing reorganization of the Ministry of Health provides opportunity to reposition the health information system function. The current efforts including development of the health information management policy and plan could enhance the health information management system.