'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya.

BACKGROUND: Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. METHODS: We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. RESULTS: Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. CONCLUSION: We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Health Education Programs Challenges in Rural Communities: Experiences of Health Educators and Healthcare Authorities.

BACKGROUND: Health education is one of the main areas of primary health care and it is improbable that health promotion will succeed without it. However, studies show that there are some problems when implementing health education programs in rural communities. This study was carried out to illuminate the barriers to health education using Ardabil's health center manager's and health educators' experiences. METHODS: This was a qualitative study using the content analysis approach. Twenty-seven health educators and managers were selected to participate in the study considering the maximum variation. Purposive sampling technique was used to select study participants. Data were collected through semi-structured interviews and focus group discussions. Data analysis was done using a six-stage thematic analysis framework. RESULTS: During the data analysis, four themes were apparent as barriers to health education in rural communities included: inefficient management skills, lack of responsibility among health personnel, inadequate policies, and poor inter-sectoral cooperation. CONCLUSIONS: It seems that changing job descriptions of health workers, reviewing health priorities, increasing lobbying activities are mechanisms that can help overcome barriers to health education in the rural communities.

How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states.

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.

Burnout Syndrome in Family Health Strategy Managers. / Síndrome de Burnout em gerentes da Estratégia de Saúde da Família.

This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.

Este artigo analisou a Síndrome de Burnout (SB) entre os gerentes da Estratégia de Saúde da Família (ESF) no Município do Rio de Janeiro e suas associações entre os fatores que influenciam a presença/ausência da SB nesses profissionais. Com natureza descritiva, ele utilizou um questionário, composto de duas partes: 1) perfil do gerente e fatores que possam influenciar a presença de Burnout; 2) Inventário Maslach Burnout Inventory. A taxa percentual de retorno foi de 63,5% (143) dos 225 enviados. Os gerentes da ESF são em geral, enfermeiros (68,6%), jovens (74,5% até 39 anos), do sexo feminino (76,9%) e que atuam na gerência há menos de 5 anos (85,2%). A presença da SB foi identificada em 11,2% dos gerentes. Os fatores de natureza organizacional foram os que obtiveram maior número de variáveis com associação. Esses dados apontam para necessidade de realização de mudanças nas práticas organizativas de serviços e de mudanças nos processos de trabalho. A realização de outros estudos, que aprofundem estas questões, pode contribuir neste sentido.

Síndrome de Burnout em gerentes da Estratégia de Saúde da Família / Burnout Syndrome in Family Health Strategy Managers

Resumo Este artigo analisou a Síndrome de Burnout (SB) entre os gerentes da Estratégia de Saúde da Família (ESF) no Município do Rio de Janeiro e suas associações entre os fatores que influenciam a presença/ausência da SB nesses profissionais. Com natureza descritiva, ele utilizou um questionário, composto de duas partes: 1) perfil do gerente e fatores que possam influenciar a presença de Burnout; 2) Inventário Maslach Burnout Inventory. A taxa percentual de retorno foi de 63,5% (143) dos 225 enviados. Os gerentes da ESF são em geral, enfermeiros (68,6%), jovens (74,5% até 39 anos), do sexo feminino (76,9%) e que atuam na gerência há menos de 5 anos (85,2%). A presença da SB foi identificada em 11,2% dos gerentes. Os fatores de natureza organizacional foram os que obtiveram maior número de variáveis com associação. Esses dados apontam para necessidade de realização de mudanças nas práticas organizativas de serviços e de mudanças nos processos de trabalho. A realização de outros estudos, que aprofundem estas questões, pode contribuir neste sentido.

Abstract This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.

Defining a New Leadership Model to Stay Relevant in Healthcare.

Because the healthcare landscape is in a state of extreme disruption, the ability to adapt is essential for organizations and their leadership teams. Players outside the sector, changing workforce and patient demographics, new technologies, cost pressures, and other influences are challenging hospital and health systems' abilities to perform as expected.Amid this ambiguity, a lack of urgency is preventing organizations from adjusting to a business environment in flux. Never has it been more important for leaders to show courage, learn, and guide their organizations to the front lines of innovation. In today's world, being a learning organization-one in which leaders and team members lean together into change, rather than back away-is crucial to remaining relevant. To quote philosopher Eric Hoffer, "In times of change, learners inherit the earth while the learned find themselves beautifully equipped to deal with a world that no longer exists."At Virginia Mason, a health system based in Seattle, Washington, our management methodology-the Virginia Mason Production System-allows the organization to be a nimble responder to change. It also empowers individuals across the enterprise, regardless of job or title, to assume hands-on roles in accomplishing our collective vision to transform healthcare. This "we culture" shines a bright light on improvement opportunities and provides the framework needed for collaborative, interdisciplinary efforts to develop solutions.

Quality, Costs, and Policy: Factors Influencing Choice of Anesthesia Staffing Models.

EXECUTIVE SUMMARY: Certified registered nurse anesthetists (CRNAs) can practice independently or with varying degrees of supervision by physicians or anesthesiologists. Before 2001, the Centers for Medicare & Medicaid Services (CMS) conditions of participation required CRNAs to be supervised by a physician. Starting in November 2001, CMS implemented an opt-out policy to give states greater autonomy in determining how anesthesia services are delivered. The policy also provided a mechanism to increase access to anesthesia services.We sought to understand and describe surgical facility leaders' perceptions of CRNA quality, safety, and cost-effectiveness; the motivation and rationale for using different anesthesia staffing models; and facilitators and barriers to using CRNAs. We applied a mixed-methods approach to understand surgical facility leadership decision-making for staffing arrangements.The use of anesthesia staffing models differed by location and surgical facility type. For example, the predominantly CRNA model was used in only 10% of large urban hospitals but in 61% of rural ambulatory surgical centers. Interviews with surgical facility leaders revealed that geographic location, surgeon preference, and organizational inertia were powerful contributors to a facility's choice of staffing model. Other factors included the Medicare opt-out provision, facility experience, and cost considerations. Differences in quality and safety between models were not contributing factors for most facilities.

Testing the Integrative Quality Care Assessment Tool (INQUAT).

PURPOSE: Identifying the factors that contribute or hinder the provision of good quality care within healthcare institutions, from the managers' perspective, is important for the success of quality improvement initiatives. The purpose of this paper is to test the Integrative Quality Care Assessment Tool (INQUAT) that was previously developed with a sample of healthcare managers in the USA. DESIGN/METHODOLOGY/APPROACH: Written narratives of 69 good and poor quality care episodes were collected from 37 managers in Italy. A quantitative content analysis was conducted using the INQUAT coding scheme, to compare the results of the US-based study to the new Italian sample. FINDINGS: The core frame of the INQUAT was replicated and the meta-categories showed similar distributions compared to the US data. Structure (i.e. organizational, staff and facility resources) covered 8 percent of all the coded units related to quality aspects; context (i.e. clinical factors and patient factors) 10 percent; process (i.e. communication, professional diligence, timeliness, errors and continuity of care) 49 percent; and outcome (i.e. process- and short-term outcomes) 32 percent. However, compared to the US results, Italian managers attributed more importance to different categories' subcomponents, possibly due to the specificity of each sample. For example, professional diligence, errors and continuity of care acquired more weight, to the detriment of communication. Furthermore, the data showed that process subcomponents were associated to perceived quality more than outcomes. RESEARCH LIMITATIONS/IMPLICATIONS: The major limitation of this investigation was the small sample size. Further studies are needed to test the reliability and validity of the INQUAT. ORIGINALITY/VALUE: The INQUAT is proposed as a tool to systematically conduct in depth analyses of successful and unsuccessful healthcare events, allowing to better understand the factors that contribute to good quality and to identify specific areas that may need to be targeted in quality improvement initiatives.

Challenges of implementation: Strategic purchasing in Iran Health Insurance Organization.

BACKGROUND: Strategic purchasing has been introduced as a key strategy for solving the problems faced by insurance companies. In Iran, the government has mandated the Iran Health Insurance Organization (IHIO) to implement this strategy. However, there are serious challenges to achieving that. The present study aims to identify these challenges. METHODS: In this qualitative study, a semi-structured interview was conducted on 27 health managers and experts at the national level. The dimensions of the A. Preker model were used to analyze the data. RESULTS: Challenges of strategic purchasing in the IHIO were categorized into five concepts-political economy, policy design, organizational structure, organizational environment, and management capacity; within these concepts, 22 challenges were identified. CONCLUSIONS: Improving strategic purchasing in Iran requires adopting a coherent approach and taking into account all the affecting factors. By revising some policies, and modifying and defining the rules needed to solve the infrastructural problems, the success of strategic purchasing can be obtained.

The ethnographer as health service leader: An insider's view of organisational change.

PURPOSE: The conceptual presentation of a detailed case study of structural reorganisation in the English NHS illustrates what factors lead to productive or unproductive organisational change. FINDINGS: This autoethnography of a NHS Trust chair provides an account of two reorganisations over an 8-year period. The paper is based on diaries that allow for the presentation of examples that highlight different processes and outcomes. The various actors in the two reorganisations gave complex and multilayered meanings to structural changes and their impact. Two theoretical frameworks helped to analyse the dynamics of productive and unproductive changes. CONCLUSION: It is argued that structural change rarely delivers and that working through people and paying due attention to their motivations and moral imperatives will more likely produce benefits to organisations, staff, and patients.

Examining the Healthcare Administrator's Perspective on "Teamness" in Primary Care.

EXECUTIVE SUMMARY: Team-based care has been identified as an important element of effective primary care practice. While there is a growing body of literature supporting the value of team-based care, research on best practices in team-based care has suffered from the lack of a widely accepted framework with common definitions. We used qualitative interviews to explore healthcare administrators' perspectives regarding team-based care descriptions, their decisions regarding composition of a team, and how they identify characteristics of a well-functioning team. Interviewees discussed six broad themes: (1) definitions of team-based care, (2) team structure and roles, (3) team goals, (4) monitoring team effectiveness, (5) challenges to implementing team-based care, and (6) the influence of healthcare policy on team-based care. The study findings can be used to identify further ways to assess the notion of "teamness."

Paired learning - improving collaboration between clinicians and managers.

Purpose Close collaboration between NHS clinicians and managers is essential in providing effective healthcare, but relationships between the two groups are often poor. Paired learning is a peer-peer buddying tool that can break down barriers, increase knowledge and change attitudes. Paired learning has been used with doctors and managers but not for multi-professional clinicians. The purpose of this paper is to assess whether a paired learning programme (PLP) can improve knowledge and attitudes between multi-professional NHS clinicians and managers. Design/methodology/approach A PLP pairing clinicians and managers over a four-month period to participate in four buddy meetings and three group meetings was delivered. A mixed methods study was completed which collected quantitative and qualitative data in the form of pre- and post-course questionnaires and focus group discussions. Findings Participants reported increased understanding, changed attitudes and better communication between clinicians and managers following the PLP. Self-rated knowledge increased across all domains but was only statistically significant for ability to engage, ability to establish shared goals and knowledge of decision-making processes. Research limitations/implications This paper highlights the value of paired learning in encouraging collaboration between clinicians and managers but is of a small size. The PLP did not provide enough data to examine relationships and interaction between clinicians and managers, this should be considered in any future work. Originality/value To the authors' knowledge, this is the only published paper showing data from a PLP involving multi-disciplinary health professionals.

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers' use of information in decision-making: experience from Cape Town, South Africa.

BACKGROUND: Governance, which includes decision-making at all levels of the health system, and information have been identified as key, interacting levers of health system strengthening. However there is an extensive literature detailing the challenges of supporting health managers to use formal information from health information systems (HISs) in their decision-making. While health information needs differ across levels of the health system there has been surprisingly little empirical work considering what information is actually used by primary healthcare facility managers in managing, and making decisions about, service delivery. This paper, therefore, specifically examines experience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers' use of information for decision-making influenced by governance across levels of the health system? The research is novel in that it both explores what information these facility managers actually use in decision-making, and considers how wider governance processes influence this information use. METHODS: An academic researcher and four facility managers worked as co-researchers in a multi-case study in which three areas of management were served as the cases. There were iterative cycles of data collection and collaborative analysis with individual and peer reflective learning over a period of three years. RESULTS: Central governance shaped what information and knowledge was valued - and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based HIS which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the subdistrict level had influence over what information was valued, generated and used locally. CONCLUSIONS: Strengthening local level managers' ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

"We are toothless and hanging, but optimistic": sub county managers' experiences of rapid devolution in coastal Kenya.

BACKGROUND: In March 2013, Kenya transitioned from a centralized to a devolved system of governance. Within the health sector, this entailed the transfer of service provision functions to 47 newly formed semi-autonomous counties, while policy and regulatory functions were retained at the national level. The devolution process was rapid rather than progressive. METHODS: We conducted qualitative research within one county to examine the early experiences of devolution in the health sector. We specifically focused on the experience of change from the perspective of sub-county managers, who form the link between county level managers and health facility managers. We collected data by observing a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, conducting informal interviews wherever we could. Informal observations and interviews were supplemented by fifteen tape recorded in depth interviews with purposively selected sub-county managers from three sub-counties. RESULTS: We found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources in addition to confused lines of accountability within the health system. However, they harnessed individual, team and stakeholder resources to maintain their jobs, and continued to play a central role in supporting peripheral facility managers to cope with change. CONCLUSIONS: Our study illustrates the importance in accelerated devolution contexts for: 1) mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; 2) clear lines of communication during reforms to these actors and 3) anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, we show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained software capacity building within the health system.

Cognitive bias in health leaders.

Cognitive bias can be a serious impediment to rational decision-making by health leaders. We use a hypothetical case study to introduce some basic concepts of bias with examples of mitigation strategies. We argue that the effect of biases should be considered when making every significant administrative decision.

Healthcare @ The Speed of Thought: A digital world needs successful transformative leaders.

In the wake of transformational change powered by the digital era, resultant leadership challenges and strategies essential for successful change, both tactical and cultural, are linked to defined capabilities within the Systems Transformation domain of the LEADS in a Caring Environment framework. Honed from experience, specific softer leadership behaviours supporting system transformation are both described and reinforced. Further, a matrix combining the LEADS framework capabilities with these more specific behaviours is offered as a planning tool that leaders may reflect upon and map out key activities associated with their sponsorship of significant change.

Mental health care network: the views of coordinators of the Family Health Strategy (FHS). / Rede de cuidado em saúde mental: visão dos coordenadores da estratégia saúde da família.

OBJECTIVE: This study aimed to analyze the opinions of the coordinators of the Family Health Strategy (FHS) on the mental health care network in the city of Pelotas/RS. METHOD: Descriptive and exploratory study with a qualitative approach, carried out with six FHS coordinators, in 2012. Semi-structured interview was used in data collection, and the results were evaluated using the thematic analysis. RESULTS: The network designed by the coordinators consists of few formal services and is focused on the Psychosocial Care Centers (CAPS). The informal network has a greater number of care units. Exchange of information related to joint responsibilities in the care is scarce, with lack of dialogue. CONCLUSION: The coordinators have scarce knowledge on the formal care network and on care focused on the ESF and CAPS. They also recognize the importance public policies that value and expand the informal care spaces in the territory.

Monitoring practices in municipal healthcare management and their interface with nursing. / Práticas de monitoramento na gestão municipal em saúde e sua interface com a enfermagem.

OBJECTIVE: To analyse the healthcare monitoring practices of the local government and its interfaces with nursing. METHODS: This is a descriptive, exploratory, and qualitative study conducted in six municipalities in the 10th health region of the state of Rio Grande do Sul. Data were collected through semi-structured interviews with six healthcare managers and one adviser, and subjected to content analysis. RESULTS: The results led to the final categories, "Monitoring practices in municipal healthcare management" and "Difficulties of managers in implementing monitoring". CONCLUSION: The managers pointed out potentialities and weaknesses in the monitoring practices of municipal healthcare. This process is critical for the practice of healthcare workers, especially nurses, since it encourages the use of new tools and innovations that support decision making.

Meeting Basic Needs: Social Supports and Services Provided by Hospice.

OBJECTIVE: Describe social goods and services for which hospices assist patients and families and the resources hospices use to do so. BACKGROUND: Basic social supports and services not routinely covered by insurers may be needed by terminally ill patients and their families. Little is known about hospices' provision of such social supports and services. METHODS: A 2014-2015 cross-sectional survey of hospices nationwide. Participating hospices had been in operation for at least 3 years and were located in any of the 50 states or District of Columbia. Hospices were surveyed about availability and sources of internal funds and referral to obtain basic social supports for patients. Descriptive statistics, bivariate analysis, and categorization were used to describe hospice practices. Measures included frequency and nature of goods and services provision in the prior year; and extent to which hospices used internal funds or community referral for goods and services. RESULTS: Over 80% (n = 203) reported internal funds covered services not reimbursed by insurers; 78% used funds in last year. Hospices used internal funds for food (81.7%), shelter (57.8%), utility bills (73.5%), and funeral costs (50%). Hospices referred patients/families to community organizations to obtain a similar range of services, including transportation, clothing, linens/towels, furniture/appliances, home repairs, and caregiver support. DISCUSSION: Hospices are using internal resources and accessing community resources to provide patients with basic social needs not routinely covered by insurance.

Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective.

BACKGROUND: Health services that operate 7 days per week are under pressure to show the increased cost of providing weekend services can be measured in improved patient outcomes. The evidence for weekend allied health services in acute medical and surgical wards is weak and there is wide variation between the services offered at different hospitals. METHODS: This qualitative study was undertaken during a multi-site stepped wedge randomised controlled trial involving twelve acute medical and surgical wards from two Australian hospitals, in which weekend allied health services were removed before being reinstated with a stakeholder driven model. In-depth interviews were conducted with twenty-two staff responsible for managing weekend services at the involved hospitals. Participants were asked about their perceptions of the advantages and disadvantages of providing a weekend allied health service. RESULTS: Managers perceive the services improve patient flow and quality of care and reduce adverse incidents, such as falls and intensive care admissions. They also highlighted the challenges involved in planning, staffing and managing these services and the uncertainties about how to provide it most effectively. CONCLUSIONS: Rising healthcare costs provide opportunity for public and professional debate about the most effective way of providing weekend allied health care services, particularly when health services provide limited other weekend services. Some managers perceived weekend allied health services to improve patient quality of care, but without studies which show these services on acute medical and surgical wards clearly change patient outcomes or provide health economic gains, these resources may need to be redirected. The resources may be better spent in areas with clear evidence to show the addition of weekend allied health services improves patient outcomes, such as on acute assess units and rehabilitation wards.