Lessons learned from the fight against COVID-19 in the Great Maghreb. Five lessons for a better response.

OBJECTIVE: Identify the lessons learned in the Greater Maghreb, during the first semester of the fight against the COVID-19 pandemic, in the field of response. METHODS: During the first week of May 2020, a consultation of experts was conducted, using the "Delphi" technique, through an email asking each of them, the drafting of a good practice recommendation for "Public health". The Group coordinator finalized the text of the lessons, later validated by the signatories of the manuscript. RESULTS: Five lessons of good «response¼ against epidemics have been deduced and approved by Maghreb experts, linked to the following aspects: 1. Total reservation of hospital beds for patients; 2. Clinical management of the response; 3. Discreet conflict of interest; 4. Community participation in the response; 5. Contextualization of the global fight strategy. CONCLUSION: Based on the finding of low relevance of the Maghreb response against COVID-19, this list of lessons would help support the performance of Maghreb health systems in the management of epidemics.

Taiwan renal care system: A learning health-care system.

Taiwan renal care system is an evolving learning health-care system. There are four facets of this system. From the early history of dialysis and Taiwan Renal Registry Data System, it facilitates the generation of data to knowledge. National multidisciplinary pre-end-stage renal disease care project and outcome enhances knowledge to practice. Early chronic kidney disease (CKD) programs and 2015 Taiwan CKD clinical guidelines implicate the practice to customer, and then explore the causes of CKD help to resume customer to data. A learning health-care system allows better and safer care at lower cost, enhancement of public health and patient empowerment. The successful development of a learning health-care system was to collect, accumulate and analyze data, interpret results, deliver tailored message and take action to change practice. Through the established database and data analysis, an integrated care system would be able to improve clinical outcomes and achieve the most cost-effectiveness care. Acute kidney injury, CKD with unknown origin, palliative care and kidney transplant are our new focuses to struggle.

Tunisian documentation of «Public Health¼ in post revolution, with a taste of freedom. For a fair, participatory and efficient National Health System.

CONTEXT: Following the Tunisian revolution of 2010/2011, a new Public Health literature emerged, by the ministerial departments as well as the civil society, which was marked by the transparency and the comprehensiveness of the approach. OBJECTIVE: To identify the key ideas of the new Tunisian Public Health discourse, reconciling the principles of a globalizing paradigm with the health problems of a country in transition. METHODS: During this qualitative research, a selected series of three Tunisian reports of Public Health, published in the first quinquennium of the revolution, was read by an independent team of experts in Public Health, not having contributed to their elaboration, to identify the consensual foundations of the new Public Health discourse. These documents were: the "2011 Health Map" of the Department of Studies and Planning of the Ministry of Health, the "Societal Dialogue Report on Health Policies, Strategies and Plans" (2014), and the "Report on the right to health in Tunisia" (2016). RESULTS: The reading of this sample of the Tunisian Public Health literature of the post-revolution brought out three consensual ideas: 1. The constitutional principle of the "right to health" (article 38 of the constitution) with its corollary the State's obligation to ensure access to comprehensive, quality and secure care; 2. The challenge of social "inequalities" of access to care, reinforced by a regional disparity in the distribution of resources, particularly high-tech (specialist doctors, university structures); 3. Advocacy for a National Health System, based on a universal health coverage for its funding and citizen participation in its governance. CONCLUSION: The new Tunisian Public Health literature, in post-revolution, calls on all stakeholders in Preventive and Community Medicine to replace their segmental, technical and hospital practices with a new approach, centered on the implementation of a National Health System that is based on a socialized financing of care and citizen participation in its management.

Outcome evaluation of a state comprehensive cancer control plan: laying the foundation.

CONTEXT: Rigorous outcome evaluation is essential to monitor progress toward achieving goals and objectives in comprehensive cancer control plans (CCCPs). OBJECTIVE: This report describes a systematic approach for an initial outcome evaluation of a CCCP. DESIGN: Using the Centers for Disease Control and Prevention evaluation framework, the evaluation focused on (1) organizing cancer plan objectives by anatomic site and risk factors, (2) rating each according to clarity and data availability, (3) the subsequent evaluation of clearly stated objectives with available outcome data, and (4) mapping allocation of implementation grants for local cancer control back to the CCCP objectives. SETTING: South Carolina. MAIN OUTCOME MEASURES: Evaluation outcomes included (1) a detailed account of CCCP objectives by topic area, (2) a systematic rating of level of clarity and availability of data to measure CCCP objectives, (3) a systematic assessment of attainment of measurable objectives, and (4) a summary of how cancer control grant funds were allocated and mapped to CCCP objectives. RESULTS: A system was developed to evaluate the extent to which cancer plan objectives were measurable as written with data available for monitoring. Twenty-one of 64 objectives (33%) in the South Carolina's CCCP were measurable as written with data available. Of the 21 clear and measurable objectives, 38% were not met, 38% were partially met, and 24% were met. Grant allocations were summarized across CCCP chapters, revealing that prevention and early detection were the most heavily funded CCCP areas. CONCLUSIONS: This evaluation highlights a practical, rigorous approach for generating evidence required to monitor progress, enhance planning efforts, and recommend improvements to a CCCP.

Governability framework for the evaluation and implementation of complex public health functions.

BACKGROUND: The dominant theoretical basis of our public health practice originates from a positivist or reductionist paradigm. It fails to take into account the complexity emerging out of public health's multiple influences originating from biological and social worlds. A deeper understanding of the interaction of elements that characterize the implementation of public health functions will enhance our ability to generate evidence and learn further. OBJECTIVE: The "interactive governance theory" by Jan Kooiman introduced here offers an analytical framework that uses the concept of "governability." It is a measure of how governable a particular social system is that takes care of a public function. Assessment is facilitated by breaking down and describing the social system into constituent parts and by exploring the properties, qualities, and the way in which they interact with each other. Further, by deliberating a complex public health function such as immunization services in the context of developing countries, we explore the application of the interactive governance theory and governability. CONCLUSION: The theory offers new insights into how interactive and holistic approaches can be integrated into public health practice. The advantage of the concept of "governability" is that it enables us to explore why some governance systems deliver what they are expected to, while others do not. This might help us to identify areas where governance can be improved.

[The use of management contracts and professional incentives in the public health sector]. / O uso de contratos de gestão e incentivos profissionais no setor público de saúde.

Results-based management is a cornerstone of reform in public administration, including the health field, and has become the basis for other innovations such as the institutionalization of management contracts and the use of professional incentives. This review article aims to introduce and discuss the use of such management contracts in the public health sector. Management by results has developed means and tools that highlight the importance of shared responsibility and mutual commitment between workers and management-level directors. Thus, preset goals are negotiated among all the stakeholders and are evaluated periodically in order to grant professional incentives. It is necessary to improve the mechanisms for control and observation, to more precisely determine the healthcare and management indicators and their patterns, to train stakeholders in designing the plan, and to improve the use of professional incentives in order to effectively increase accountability vis-à-vis the desired results.

O uso de contratos de gestão e incentivos profissionais no setor público de saúde / The use of management contracts and professional incentives in the public health sector

A gestão por resultados constitui um dos pilares da reforma na gestão pública, inclusive na área da saúde, tendo como principais inovações: a institucionalização de contratos de gestão e a utilização de incentivos profissionais. O objetivo deste artigo de revisão de literatura é apresentar e discutir a utilidade e aplicabilidade de contratos de gestão e incentivos profissionais na gestão por resultados no setor público de saúde. A gestão por resultados só será possível quando existir corresponsabilidade e compromisso mútuo entre os trabalhadores e o nível diretivo. Por isso, as metas preestabelecidas devem ser pactuadas entre todos os atores envolvidos e avaliadas de forma periódica para que os incentivos profissionais sejam garantidos. Para efetivamente aumentar a responsabilização sobre os resultados desejados é preciso aprimorar os mecanismos de controle e monitoramento, definir de forma mais precisa indicadores e seus padrões no campo da assistência e da gestão, capacitar as partes envolvidas na elaboração do plano e aperfeiçoar o uso de incentivos profissionais.

Results-based management is a cornerstone of reform in public administration, including the health field, and has become the basis for other innovations such as the institutionalization of management contracts and the use of professional incentives. This review article aims to introduce and discuss the use of such management contracts in the public health sector. Management by results has developed means and tools that highlight the importance of shared responsibility and mutual commitment between workers and management-level directors. Thus, preset goals are negotiated among all the stakeholders and are evaluated periodically in order to grant professional incentives. It is necessary to improve the mechanisms for control and observation, to more precisely determine the healthcare and management indicators and their patterns, to train stakeholders in designing the plan, and to improve the use of professional incentives in order to effectively increase accountability vis-à-vis the desired results.

Developing and implementing the Massachusetts Comprehensive Cancer Control Coalition Survivorship Summit.

Cancer survivors face numerous medical and psychosocial challenges, which the medical and public health systems are ill-equipped to deal with. In May 2008, the Massachusetts Comprehensive Cancer Control Coalition conducted a Survivorship Summit to elicit input from cancer survivors and professionals on developing system-level action plans for cancer survivorship issues. We describe how health care and public health professionals can implement similar events. Our results suggest that a cancer survivorship summit can be a valuable tool for cancer coalitions and advocacy organizations in determining survivorship agendas and action plans.

A new paradigm for quarantine and public health activities at land borders: opportunities and challenges.

The Institute of Medicine (IOM) report Quarantine Stations at Ports of Entry: Protecting the Public's Health focused almost exclusively on U.S. airports and seaports, which served 106 million entries in 2005. IOM concluded that the primary function of these quarantine stations (QSs) should shift from providing inspection to providing strategic national public health leadership. The large expanse of our national borders, large number of crossings, sparse federal resources, and decreased regulation regarding conveyances crossing these borders make land borders more permeable to a variety of threats. To address the health challenges related to land borders, the QSs serving such borders must assume unique roles and partnerships to achieve the strategic leadership and public health research roles envisioned by the IOM. In this article, we examine how the IOM recommendations apply to the QSs that serve the land borders through which more than 319 million travelers, immigrants, and refugees entered the U.S. in 2005.

The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys.

BACKGROUND: The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment. METHODS: In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program. RESULTS: Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt. CONCLUSION: Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well.

Mental health emergency preparedness: the need for training and coordination at the state level.

INTRODUCTION: The coordination and integration of mental health agencies' plans into disaster responses is a critical step for ensuring effective response to all-hazard emergencies. PROBLEM: In order to remedy the current lack of integration of mental health into emergency preparedness training, researchers must assess mental health emergency preparedness training needs. To date, no recognized assessment exists. The current study addresses this need by qualitatively surveying public health and allied health professionals regarding mental health preparedness in Kansas. METHODS: Participants included 144 professionals from public health and allied fields, all of whom attended one of seven training presentations on mental health preparedness. Following each presentation, participants provided written responses to nine qualitative questions about preparedness and mental health preparedness needs, as well as demographic information, and a program evaluation. Survey questions addressed perceptions of bioterrorism and mental health preparedness, perceptions about resource and training needs, as well as coordination of preparedness efforts. RESULTS: Overall, few respondents indicated that they felt their county or community was prepared to respond to an attack. Respondents felt less prepared for mental health issues than they did for preparedness issues in general. The largest proportion of respondents reported that they would look to a community mental health center or the state health department for mental health preparedness information. Most respondents recognized the helpfulness of interagency coordination for mental health preparedness, and reported a willingness to take an active role in coordination. CONCLUSIONS: The current study provides important data about the gaps regarding mental health preparedness in Kansas. This study demonstrates the present lack of preparedness and the need for coordination to reach an appropriate level of mental health preparedness for the state. These findings are the first step to implementing effective distribution of information and training.

Facilitating effective health promotion practice in a public health unit: lessons from the field.

OBJECTIVES: Health promotion is a core function of public health services and improving the effectiveness of health promotion services is an essential part of public health service development. This report describes the rationale, the process and the outcomes of a realignment designed to improve the effectiveness of health promotion activities in a public health unit (PHU) in New Zealand. METHODS: A practice environment analysis revealed several factors that were hindering the effectiveness of the health promotion unit's (HPU) activities. Two primary change mechanisms were implemented. The first was an outcomes-focused model of planning and service delivery (to support evidenced-based practice), the second was the reorganisation of the HPU from a topics-based structure to an integrated one based on a multi-risk factor paradigm of population health. RESULTS: During the realignment barriers were encountered on multiple levels. At the individual level, unfavourable attitudes to changes occurred because of a lack of information and knowledge about the benefits of evidence and research. At higher levels, barriers included resourcing concerns, a lack of organisational commitment and understanding, and tensions between the political need for expedient change and research and development need for timely consideration of the impact of different models of practice. CONCLUSIONS AND IMPLICATIONS: This realignment took place within the context of a changing public health environment, which is significantly altering the delivery of public health and health promotion. Realignments designed to facilitate more effective health promotion and public health practice will continue, but need to do so in the light of others' experience and debate.

Effect of the Integrated Management of Childhood Illness strategy on health care quality in Morocco.

OBJECTIVE: To evaluate an intervention to promote health workers' use of the World Health Organization's Integrated Management of Childhood Illness clinical guidelines and to identify other factors influencing quality of care received by Moroccan children. SETTING: Public outpatient health facilities. DESIGN: Cross-sectional survey of consultations with sick children under 5 years old at facilities in two intervention and two comparison provinces in April 2000 (6-12 months after intervention). Consultations were observed, children's caretakers and health workers were interviewed, and children were re-examined by a 'gold standard' study clinician. STUDY PARTICIPANTS: Probability sample of 467 consultations (97.9% participation) performed by 101 health workers in 62 facilities. INTERVENTION: Health workers received in-service training with job aids and a follow-up visit with feedback 4-6 weeks after training. MAIN OUTCOME MEASURES: Index of overall guideline adherence (mean percentage of recommended tasks that were done per child) and the percentage of children requiring antibiotics correctly prescribed antibiotics. RESULTS: Quality of care was better in intervention provinces, according to the adherence index (79.7 versus 19.5%, P < 0.0001), correct prescription of antibiotics (60.8 versus 31.3%, P = 0.0013), and other indicators. Multivariate modeling revealed a variety of factors significantly associated with quality, including health worker attributes (pre-service training, residence in government-subsidized housing, sex, and opinions) and child/consultation attributes (child's age and temperature, number of chief complaints, and caretaker type). CONCLUSIONS: Exposure to the intervention was strongly associated with adherence to the guidelines and correct prescribing of antibiotics 6-12 months after exposure. Many other factors may influence health worker performance.

What factors induce health care decision-makers to use clinical guidelines? Evidence from provincial health ministries, regional health authorities and hospitals in Canada.

This paper addresses three questions: What is the extent of clinical guideline utilization by decision-makers in provincial health ministries, regional health authorities and hospitals in Canada? Are there differences between these work settings in regard to the extent of clinical guideline utilization? What are the determinants of clinical guidelines utilization in health ministries, regional health authorities and hospitals? Based on a survey of 899 decision-makers from Canadian provincial health ministries, regional health authorities and hospitals, the results indicate that there are large differences between work settings in regard to clinical guideline utilization. Not surprisingly, work settings like hospitals rely more intensively on clinical guidelines than the other work settings (health ministries or agencies and regional health authorities). The results of the regression models indicate that cognitive factors, social factors, technological factors, organizational factors and individual attributes significantly predict the utilization of clinical practice guidelines by decision-makers. However, the results of the regression models also indicate that some factors that predict clinical guideline utilization by decision-makers in hospitals do not predict clinical guidelines utilization by decision-makers working in ministries or in regional health authorities. Therefore, these results suggest that customized interventions would be appropriate in order to efficiently increase the utilization of clinical practice guidelines in different work settings. The paper concludes with suggestions for future research.

Safer injections following a new national medicine policy in the public sector, Burkina Faso 1995-2000.

BACKGROUND: The common failure of health systems to ensure adequate and sufficient supplies of injection devices may have a negative impact on injection safety. We conducted an assessment in April 2001 to determine to which extent an increase in safe injection practices between 1995 and 2000 was related to the increased access to injection devices because of a new essential medicine policy in Burkina Faso. METHODS: We reviewed outcomes of the new medicine policy implemented in 1995. In April 2001, a retrospective programme review assessed the situation between 1995 and 2000. We visited 52 health care facilities where injections had been observed during a 2000 injection safety assessment and their adjacent operational public pharmaceutical depots. Data collection included structured observations of available injection devices and an estimation of the proportion of prescriptions including at least one injection. We interviewed wholesaler managers at national and regional levels on supply of injection devices to public health facilities. RESULTS: Fifty of 52 (96%) health care facilities were equipped with a pharmaceutical depot selling syringes and needles, 37 (74%) of which had been established between 1995 and 2000. Of 50 pharmaceutical depots, 96% had single-use 5 ml syringes available. At all facilities, patients were buying syringes and needles out of the depot for their injections prescribed at the dispensary. While injection devices were available in greater quantities, the proportion of prescriptions including at least one injection remained stable between 1995 (26.5%) and 2000 (23.8%). CONCLUSION: The implementation of pharmaceutical depots next to public health care facilities increased geographical access to essential medicines and basic supplies, among which syringes and needles, contributing substantially to safer injection practices in the absence of increased use of therapeutic injections.

Strategic planning and public mental health services.

OBJECTIVES: To provide an overview of approaches to strategic planning and to examine issues in relation to their applicability to public mental health services. CONCLUSIONS: Strategic planning is important for optimal functioning of mental health services in an increasingly complex environment. Although each approach will have advantages depending on context, the overall principles of the learning organization developed by Senge have particular relevance for mental health services.

Healthcare in Ontario: what has the system learned?

In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos.

SARS: a health system's perspective.

Effective communications with different stakeholders was critical for health systems everywhere during the worldwide SARS outbreak earlier this year. For Capital Health in Edmonton, Alberta, the health system was able to build on its past experiences in dealing with meningococcal outbreaks and its planning for a pandemic flu.

Commentary: developing and retaining a public health workforce for the 21st century: readiness for a paradigm shift to community-based public health.

The Partnership for the Public's Health work in supporting partnerships between local health departments and community-based organizations has offered important insights into the difficulties of changing public health practice to a more community-based model. Keys to these difficulties are workforce issues: availability, appropriateness of initial training, recruitment, retention, and issues of continuing education. These challenges and some positive examples are discussed.