Effect Heterogeneity in Responding to Performance-Based Incentives: A Quasi-Experimental Comparison of Impacts on Health Service Indicators Between Hospitals and Health Centers in Malawi.

Heterogeneity of effects produced by performance-based incentives (PBIs) at different levels of care provision is not well understood. This study analyzes effect heterogeneities between different facility types resulting from a PBI program in Malawi. Identical PBIs were applied to both district hospitals and health centers to improve the performance of essential health services provision. We conducted two complementary quasi-experiments comparing all 17 interventions with 17 matched independent control facilities (each 12 health centers, five hospitals). A pre- and post-test design with difference-in-differences analysis was used to estimate effects on 14 binary quality indicators; interrupted time series analysis of monthly routine data was used to estimate effects on 11 continuous quantity indicators. Effects were estimated separately for health centers and hospitals. Most quality indicators performed high at baseline, producing ceiling effects on further measurable improvements. Significant positive effects were observed for stocks of iron supplements (hospitals) and partographs (health centers). Four quantity indicators showed similar positive trend improvements across facility types (first-trimester antenatal visits, voluntary HIV-testing of couples, iron supplementation in pregnancy, vitamin A supplementation of children); two showed no change for either type of facility (skilled birth attendance, fully immunized one-year-olds); five indicators revealed different effect patterns for health centers and hospitals. In both health centers and hospitals, the largely positive PBI effects on antenatal care included resilience against interrupted supply chains and improvements in attendance rates. Observed heterogeneity might have been influenced by the availability of specific resources or the redistribution of service use.

Is folate deficiency a common cause of distal symmetric polyneuropathy in Zambian clinics?

OBJECTIVES: To evaluate the odds of vitamin B12 and folate deficiencies among Zambian clinic attendees with distal symmetric polyneuropathy (DSP) and age, sex, and HIV matched controls. METHODS: Cases were adults from clinics in urban/peri-urban Zambia. Controls were enrolled among persons not seeking personal medical care, such as a caregiver or person collecting antiretrovirals without a medical complaint. Participants underwent structured interviews, physician examination, and assessments of complete blood count, renal and liver profiles, serum vitamin B12 and folate, erythrocyte folate, plasma total homocysteine and methylmalonic acid. HIV testing and CD4 counts were performed when appropriate. RESULTS: Among 107 consenting matched case-control pairs, 65% were female, 52% HIV positive, with mean age of 47.6 (SD 13.5) years. Among HIV positive participants, mean CD4 count was 484 (SD 221) and 482 (SD 236) for cases and controls, respectively (p = .93). DSP symptoms and severity did not differ by HIV status (p's > 0.05). Height, history of tuberculosis treatment, alcohol use, education, asset index, dietary diversity, and nutritional supplement use did not differ between cases and controls (p's > 0.05). DSP cases had at least 3:1 odds of having low serum folate (p = .0001), severely low erythrocyte folate (p = .014), and elevated total homocysteine (p = .001) levels compared to controls. Markers of vitamin B12 deficiency were not associated with case status (p's > 0.05). CONCLUSION: Markers of folate deficiency are highly associated with DSP among Zambian clinic attendees. Future studies should consider a broader range of comorbid nutritional deficiencies, and strategies for interventions.

[The Pharmacy Combining Convenience Store with Care Consulting Services].

The primary pharmacy system and health support pharmacy system were established in 2016. However, local pharmacies need to get closer to the community. To this end, each pharmacy is making efforts to contribute locally. Here, we introduce various initiatives in our region. Akakabe Pharmacy has 66 stores in Osaka Prefecture, mainly in the northeastern part of Osaka, where the elderly population is growing. We are implementing a dominant strategy: cooperation with the city and administration is strong, and we hold many related events directed towards the public. For example, two thousand participants gathered in an event sponsored by the city aimed at the improvement of beauty and health. At such events, participants can easily consult with pharmacists. Dispensing pharmacy stores-pharmacies that combine the features of a convenience store with care consulting services-were established in 2016. Care consultations are potentially highly advantageous to the users. In the consultation space of a pharmacy, a care worker conducts various events every month, such as on dementia prevention, body composition measurement, and more. We believe that this type of combined pharmacy and convenience store has the potential to become a regional comprehensive care center. We intend to share the possibility of a new pharmacy system, centered on this pharmacy/store/consultation model, as a basis to revamp the pharmacy industry.

[Emergency care in the autonomous regions of Spain. Improvement in pre-hospital emergency care and welfare coordination. SESPAS Report 2012]. / La atención a la urgencia en las comunidades autónomas. Mejoras en las urgencias prehospitalarias y la coordinación asistencial. Informe SESPAS 2012.

The present article describes the general organization of pre-hospital emergency care in the autonomous regions and provides data on activity corresponding to 2010, drawn from the information available in the Primary Care Information System of the Ministry of Health, Social Policy and Equality. Emergency care is provided through various organizational structures covering 24-hour periods. Family medicine attended 17.8 million emergency consultations and nursing attended 10.2 million (year 2010, 14 autonomous communities, 79.7% of the National Health System population). Emergency department utilization ranged between 0.11 and 0.83 urgent family physician consultations per inhabitant/year and between 0.05 and 0.57 nursing consultations per inhabitant/year. Any reform in the management of pre-hospital emergency care will involve organizational changes and aims to produce measurable improvements in healthcare coordination. In the new organizational designs, most of the responsibility lies with human resources in order to achieve the new goals for the future aims to be presented in an operational teamwork structure. Undoubtedly, the main challenge is to achieve optimal coordination with other welfare levels, including the police, social services, nursing homes, etc. If optimal care of the population needs to count on the efforts of all these groups, mobility, individual differences, consistent achievement of high standards, and -most of all- the use of these services by citizens will determine the final result. The results can be quantified in various ways, but evaluation should concentrate on the resources used, the degree of satisfaction among all the parties involved and optimal management of demand, which will help to disseminate the need for a rational resource use.

The future of community-centred health services in Australia: lessons from the mental health sector.

It is apparent that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy. Community-centred health care has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions. Nevertheless, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. The reasons for these trends are explored. The future of community health services in Australia is uncertain, and in some states under serious threat. We consider lessons from the partial dismantling of Australian community mental health services, despite a growing body of Australian and international studies finding in their favour. Community-centred health services should be reconceptualised and resourced as the centre of gravity of local, effective and affordable health care services for Australia. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services

[Service Centers for elderly people in the city of Dortmund--a future oriented model for integrative and local support and care Article for the discussion "Community Care Access Centers"]. / Seniorenbüros in Dortmund - Zukunftsorientiertes Modell für eine integrative und wohnortnahe Versorgung und Betreuung : Ein Beitrag zur Diskussion zu den Pflegestützpunkten.

It is an indisputable fact in the political and specialist discussion concerning the reform of the German public long-term care insurance to give better advice and support for constant nursing care. In order to reach this goal "Community Care Access Centers", in which competent advisors work to assess and to coordinate the necessary assistance, are proposed. Nevertheless the draft of the new act is disputed with questions with respect to implementation and finance. The already existing "Service Centers for elderly people" in the city of Dortmund is a good example of how to set up the desirable structures.

Women's health care centers: multiple definitions.

Feminist health and holistic health movements predate and contribute to the current changes in women's health care. Recently, there has been a rivitalization of women's health centers reflecting three approaches to women's health: (1) centers with an exclusive focus on one health problem, e.g., breast cancer, chemical dependency (2) centers with a predominantly reproductive focus, and (3) centers with a holistic/feminist health care focus. Based on an exploratory survey of women's centers in a large city, this paper identifies differences among them and discusses the potential for misguidance that may occur with the current increase in women's health centers. It also discusses the implications of this growth for social work education and clinical practice.