Mobilizing a Whole Community: Policy and Strategy Implications of an Integrated Local System Response to a Global Health Crisis.

The East Toronto Health Partners (ETHP) include more than 50 organizations working collaboratively to create an integrated system of care in the east end of Toronto. This existing partnership proved invaluable as a platform for a rapid, coordinated local response to the COVID-19 pandemic. Months after the first wave of the pandemic began, with the daily numbers of COVID-19 cases finally starting to decline, leaders from ETHP provided preliminary reflections on two critical questions: (1) How were existing integration efforts leveraged to mobilize a response during the COVID-19 crisis? and (2) How can the response to the initial wave of COVID-19 be leveraged to further accelerate integration and better address subsequent waves and system improvements once the pandemic abates?

A Bivariate Mapping Tutorial for Cancer Control Resource Allocation Decisions and Interventions.

Bivariate choropleth mapping is a straightforward but underused method for displaying geographic health information to use in public health decision making. Previous studies have recommended this approach for state comprehensive cancer control planning and similar efforts. In this method, 2 area-level variables of interest are mapped simultaneously, often as overlapping quantiles or by using other classification methods. Variables to be mapped may include area-level (eg, county level) measures of disease burden, health care use, access to health care services, and sociodemographic characteristics. We demonstrate how geographic information systems software, specifically ArcGIS, can be used to develop bivariate choropleth maps to inform resource allocation and public health interventions. We used 2 types of county-level public health data: South Carolina's Behavioral Risk Factor Surveillance System estimates of ever having received cervical cancer screening, and a measure of availability of cervical cancer screening providers that are part of South Carolina's Breast and Cervical Cancer Early Detection Program. Identification of counties with low screening rates and low access to care may help inform where additional resources should be allocated to improve access and subsequently improve screening rates. Similarly, identifying counties with low screening rates and high access to care may help inform where educational and behavioral interventions should be targeted to improve screening in areas of high access.

Fighting MRSA Infections in Hospital Care: How Organizational Factors Matter.

OBJECTIVE: To identify factors associated with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections at the level of the hospital organization. DATA SOURCES: Data from all 173 acute trusts in the English National Health Service (NHS). STUDY DESIGN: A longitudinal study based on trust-level panel data for the 5-year period from April 2004 to March 2009. Fixed effects negative binominal and system generalized method of moment models were used to examine the effect of (i) patient mix characteristics, (ii) resource endowments, and (iii) infection control practices on yearly MRSA counts. DATA COLLECTION: Archival and staff survey data from multiple sources, including Public Health England, the English Department of Health, and the Healthcare Commission, were merged to form a balanced panel dataset. PRINCIPAL FINDINGS: MRSA infections decrease with increases in general cleaning (-3.52 MRSA incidents per 1 standard deviation increase; 95 percent confidence interval: -6.61 to -0.44), infection control training (-3.29; -5.22 to -1.36), hand hygiene (-2.72; -4.76 to -0.68), and error reporting climate (-2.06; -4.09 to -0.04). CONCLUSIONS: Intensified general cleaning, improved hand hygiene, additional infection control training, and a climate conducive to error reporting emerged as the factors most closely associated with trust-level reductions in MRSA infections over time.

[Consolidated efforts to strengthen health promotion in living environments: The cooperation network "Equity in Health"]. / Gesundheitsförderung in den Lebenswelten gemeinsam stärken : Der Kooperationsverbund "Gesundheitliche Chancengleichheit".

BACKGROUND: In 2003, the German Federal Center for Health Education (BZgA) initiated a national Cooperation Network named "Equity in Health" to address scientific results, focusing on the association between social inequalities and health. The main goal is to support setting approaches aimed at reducing these health inequalities. RESULTS AND KEY ACTIVITIES: In the autumn of 2015 the Cooperation Network comprised a total of 65 (institutional) cooperation partners, e.g., from prevention and health promotion, from the medical profession, from the welfare associations, and from the municipal umbrella organziations. The website www.gesundheitliche-chancengleichheit.de was created to present the information available on all activities and structures. Further, Coordination Centers for Health Equity were established in all federal states of Germany to advise, coordinate and provide support for all those who are actively engaged in the key issues for each state. These Coordination Centers are sponsored by the statutory sickness funds and the Health Ministry of the respective states. They also support continuous quality improvement, based on the good practice criteria developed by the Cooperation Network. Since 2011, the local partner process "Health for All" (until November 2015 "Growing Up Healthily for All") has assisted the municipalities in developing their own integrated health strategies oriented toward the different stages in the life course ("prevention chains"). PERSPECTIVES: The results and structures that have emerged from the Cooperation Network form a good basis for the implementation of the new national Prevention Law passed by German Parliament in July 2015, to expand and develop further, on a country-wide basis and in the various states, living-space-oriented prevention and health promotion consolidating activities. The paper also discusses the present and future challenges of the Cooperation Network.

[Experience and problems of the primary health care centers' specialists in the implementation of the integrated health system based on family medicine in Ukraine].

The experience of the primary health care' centers in Lviv, Mykolaiv, Kherson regions on the basis of family medicine, integrated medical space, modern governance mechanisms, market technology, promotion trasmural' approach, intersectoral coordination and collaboration and preventative health care population allows to get the maximum effectiveness of the provision of public health in relation to a particular administrative area with limited resources.

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.

Cultural, ethical, and spiritual implications of natural disasters from the survivors' perspective.

Cultural, ethical, and spiritual implications of disaster depend on various factors. The impact of a disaster on a particular culture depends on the people in that culture and the strength and resilience of the culture. Disasters may slow cultural development; however, typically the customs, beliefs, and value systems remain the same even if the outward expressions of culture change. Critical to survivors is the implication of aid that is culturally sensitive. Ethical questions and dilemmas associated with disasters and their management are profound. Adhering to ethical principles does not solve all of the issues related to disaster management, but awareness of their utility is important. People affected by a disaster may not be capable of responding to human rights violations, so it is the first responders who must be cognizant of their responsibility to protect the victims' dignity and rights. Ethical treatment of survivors entails a crucial blend of knowledge about ethnic culture, religious beliefs, and human rights. A strong awareness of ethical principles is merely a beginning step to well-informed decision making in disaster situations. The literature also suggests that during a crisis, spirituality helps victims to cope. Important to any catastrophic event is the understanding that every disaster creates unique circumstances that require relief responses tailored to the specific situation.

Disinvestment for re-allocation: a process to identify priorities in healthcare.

Resource scarcity and increasing service demand lead health systems to cope with choices within constrained budgets. The aim of the paper is to describe the study carried out in the Tuscan Health System in Italy on how to set priorities in the disinvestment process for re-allocation. The analysis was based on 2007 data benchmarking of the Tuscan Health System with an impact on the level of resources used. For each indicator, the first step was to estimate the gap between the performance of each Health Authority (HA) and the best performance or the regional average. The second step was to measure this gap in terms of financial value. The results of the analysis demonstrated that, at the regional level, 2-7% of the healthcare budget can be re-allocated if all the institutions achieve the regional average or the best practice. The implications of this study can be useful for policy makers and the HA top management. In the context of resource scarcity, it allows managers to identify the areas where the institutions can achieve a higher level of efficiency without negative effects on quality of care and instead re-allocate resources toward services with more value for patients.

The AMPATH Nutritional Information System: designing a food distribution electronic record system in rural Kenya.

OBJECTIVE: The AMPATH program is a leading initiative in rural Kenya providing healthcare services to combat HIV. Malnutrition and food insecurity are common among AMPATH patients and the Nutritional Information System (NIS) was designed, with cross-functional collaboration between engineering and medical communities, as a comprehensive electronic system to record and assist in effective food distribution in a region with poor infrastructure. DESIGN: The NIS was designed modularly to support the urgent need of a system for the growing food distribution program. The system manages the ordering, storage, packing, shipping, and distribution of fresh produce from AMPATH farms and dry food supplements from the World Food Programme (WFP) and U.S. Agency for International Development (USAID) based on nutritionists' prescriptions for food supplements. Additionally, the system also records details of food distributed to support future studies. MEASUREMENTS: Patients fed weekly, patient visits per month. RESULTS: With inception of the NIS, the AMPATH food distribution program was able to support 30,000 persons fed weekly, up from 2,000 persons. Patient visits per month also saw a marked increase. CONCLUSION: The NIS' modular design and frequent, effective interactions between developers and users has positively affected the design, implementation, support, and modifications of the NIS. It demonstrates the success of collaboration between engineering and medical communities, and more importantly the feasibility for technology readily available in a modern country to contribute to healthcare delivery in developing countries like Kenya and other parts of sub-Saharan Africa.

[Clinical pathways in rheumatological inpatient treatment - a structured process management]. / Klinische Behandlungspfade in der akut-stationären Rheumatologie - ein strukturiertes Prozessmanagement.

Clinical pathways for three rheumatological indications have been successfully developed in the rheumatological departments of two hospitals. These diseases were selected because of the number of inpatients seen and/or the costs for diagnostics and therapy. Three quota-concepts, the coordination of treatment processes (quota-concept I), the sequence of implementing services (quota-concept II), and the economical utilization of available resources as well as the transparent definition of therapies (quota-concept III) have been established. These concepts have been tested individually as well as in complex situations.

[Concepts for a demand-oriented structuring of palliative care in the German Health Care System: the example of Lower Saxony]. / Konzepte zur bedarfsgerechten Strukturierung der Palliativversorgung im deutschen Gesundheitswesen: Das Beispiel des Bundeslandes Niedersachsen.

Palliative care can be considered a holistic care approach for patients faced with incurable and progressive diseases in their last period of life. In this context, structural, cultural and content-related deficits are increasingly taken into account in the German health care system, however, there is a lack of scientific data. Therefore, it was the objective of an expert team at Hannover Medical School to analyse the current situation of palliative care in Lower Saxony from the perspective of health system research and to give recommendations for its further development, based on empirical studies in Lower Saxony and on a systematic national and international literature review. The study revealed that the main shortcomings were an unclear structuring and an inadequate definition with respect to other areas of care, a fundamental lack of integration in regard of routine processes of care and a lack of thorough tools for needs assessments. Therefore, a concept for the integration of palliative care in the care processes of cancer patients was developed and the specific need for hospice beds in regional districts was calculated by using parameters representing provision-related and epidemiological/demographic conditions. In comparison to current structures, an assessment of over- and undersupply as well as specific recommendations how to optimize palliative care were provided for politicians, payers and providers in Lower Saxony.

An evolutionary approach to the architecture of effective healthcare delivery systems.

PURPOSE: Aims to show that material flow concepts developed and successfully applied to commercial products and services can form equally well the architectural infrastructure of effective healthcare delivery systems. DESIGN/METHODOLOGY/APPROACH: The methodology is based on the "power of analogy" which demonstrates that healthcare pipelines may be classified via the Time-Space Matrix. FINDINGS: A small number (circa 4) of substantially different healthcare delivery pipelines will cover the vast majority of patient needs and simultaneously create adequate added value from their perspective. RESEARCH LIMITATIONS/IMPLICATIONS: The emphasis is firmly placed on total process mapping and analysis via established identification techniques. Healthcare delivery pipelines must be properly engineered and matched to life cycle phase if the service is to be effective. PRACTICAL IMPLICATIONS: This small family of healthcare delivery pipelines needs to be designed via adherence to very specific-to-purpose principles. These vary from "lean production" through to "agile delivery". ORIGINALITY/VALUE: The proposition for a strategic approach to healthcare delivery pipeline design is novel and positions much currently isolated research into a comprehensive organisational framework. It therefore provides a synthesis of the needs of global healthcare.

Tackling regional health inequalities in france by resource allocation : a case for complementary instrumental and process-based approaches?

This article aims to evaluate the results of two different approaches underlying the attempts to reduce health inequalities in France. In the 'instrumental' approach, resource allocation is based on an indicator to assess the well-being or the quality of life associated with healthcare provision, the argument being that additional resources would respond to needs that could then be treated quickly and efficiently. This governs the distribution of regional hospital budgets. In the second approach, health professionals and users in a given region are involved in a consensus process to define those priorities to be included in programme formulation. This 'procedural' approach is employed in the case of the regional health programmes. In this second approach, the evaluation of the results runs parallel with an analysis of the process using Rawlsian principles, whereas the first approach is based on the classical economic model.At this stage, a pragmatic analysis based on both the comparison of regional hospital budgets during the period 1992-2003 (calculated using a 'RAWP [resource allocation working party]-like' formula) and the evolution of regional health policies through the evaluation of programmes for the prevention of suicide, alcohol-related diseases and cancers provides a partial assessment of the impact of the two types of approaches, the second having a greater effect on the reduction of regional inequalities.

The impact of decentralisation on sexual and reproductive health services in Ghana.

This paper analyses the impact of decentralisation on the political organisation, management and provision of sexual and reproductive health services in Ghana. It draws on qualitative research and interviews with key informants from the Ministry of Health, donors, NGOs, regional and district health management teams, local government and community leaders. Within a national reproductive health policy framework, previously disparate family planning, maternal and child health, STI and HIV/AIDS programmes have become more integrated, and donors have pooled or co-ordinated their funding. Some decision-making about resource allocation is meant to happen at district and regional level but in practice, this remains centrally controlled, which may be a necessary safeguard for sexual and reproductive health services. Earmarked donor funds still ensure a regular supply of contraceptives and STI drugs. However, paying for these is problematic at local level. Sexual and reproductive health staff make up a large proportion of primary health care staff, but especially in rural areas they experience poor working conditions, and there is high turnover and vacancies. District and sub-district level links are working well in this new system, but clarity is still needed on how different national sexual and reproductive health bodies relate to each other and to regional and district health authorities. The development of formal mechanisms for priority setting and advocacy at local levels could help to secure benefits for sexual and reproductive health care.

Integrating healthcare: the Counties Manukau experience.

In 1998, Counties Manukau District Health Board (CMDHB) was experiencing rapidly increasing demands on its secondary services. It was finding it increasingly difficult to meet the health needs of its relatively deprived population. There was widespread evidence of "systems failure", with poor coordination of primary and secondary services. A strategic plan was devised to meet identified priorities and this was subsequently implemented with extensive community involvement. A "disruptive change" model was utilised. Thirty separate projects were undertaken to improve coordination and integration of health services. Brief summaries of all projects are presented, and full evaluations were performed of major projects. Factors critical to project success were: dedicated and effective leadership; involvement of clinical staff; early engagement of the Maori and Pacific community; careful selection of stakeholders; reassurance for providers about privacy issues; close monitoring of project progress; realistic timeframes; and adequate initial funding. CMDHB believes that the critical factor to success in improving the performance of the health sector will be the ability of our key leaders in primary and secondary care, in both management and clinical roles, to adopt a systems view to problem analysis and solution building

Understanding the role of "the hidden curriculum" in resource allocation--the case of the UK NHS.

In this paper we want to briefly illustrate the ways in which technical, ethical and political judgements of various kinds are interwoven in the processes of healthcare decision-making in the UK. Drawing upon the research for the "Choices in Health Care" project we will borrow the notion of the hidden curriculum from education to illuminate the nature of resource allocation decision processes. In particular we will indicate some of the fundamental but largely hidden political factors in play in these processes and the importance of the inchoate and implicit notion of "NHS values" in shaping UK resource allocation policies. We suggest that these more diffuse, holistic and system level value judgements are both central to understanding priority setting and at the same time difficult to reduce or abstract out into lists of single values/principles.