Estrategia nacional de redes integradas de servicios de salud de Guatemala, ENRISSG / National strategy of integrated health services networks of Guatemala, ENRISSG

(Acuerdo ministerial No. 246-2019) Este documento propone un marco conceptual y operativo para entender las RISS desde la perspectiva y realidad de Guatemala, brinda los lineamientos orientadores y las acciones estratégicas para que los actores y prestadores de salud de un distrito o departamento se articulen en redes, optimicen las capacidades instaladas, garanticen la continuidad de la atención y consoliden vínculos interinstitucionales e intersectoriales que permitan abordajes integrales para mejorar la calidad de vida de las personas, las familias y las comunidades. La Estrategia de RISS se promueve como uno de los mecanismos para reducir la fragmentación de los sistemas de salud y como una de las principales expresiones operativas del enfoque de la APS en el proceso de atención integral, integrada y continua a las personas; contribuyendo a hacer una realidad varios de sus elementos más esenciales, tales como la cobertura y el acceso universal; la atención integral, integrada y continua; el cuidado apropiado, y la organización y gestión de los servicios de salud. El objetivo general del acuerdo ministerial que la avala es lograr acceso y cobertura de la salud, a través de la implementación de la Estrategia de Redes integradas, basada en la atención primaria de la salud, que permita una atención de salud equitativa, integral, integrada, continua y de calidad con en el derecho de la salud. Es de aplicación obligatoria para todas las dependencias que organicen e implementen redes integradas de servicios de salud a nivel de la república y permitirá orientar a los gerentes y los equipos multidisciplinarios, interinstitucionales e intersectoriales de un territorio definido, con lineamientos y acciones para el reordenamiento, articulación, coordinación, fortalecimiento y funcionamiento de los servicios de salud en red, fomentando la planificación, implementación, monitoreo, evaluación y rendición de cuentas.

Waiting for common-law solutions for the most vulnerable populations' healthcare access.

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.

The legislative framework for salt iodization in Asia and the Pacific and its impact on programme implementation.

OBJECTIVE: Fortification of food-grade (edible) salt with iodine is recommended as a safe, cost-effective and sustainable strategy for the prevention of iodine-deficiency disorders. The present paper examines the legislative framework for salt iodization in Asian countries. DESIGN: We reviewed salt iodization legislation in thirty-six countries in Asia and the Pacific. We obtained copies of existing and draft legislation for salt iodization from UNICEF country offices and the WHO's Global Database of Implementation of Nutrition Actions. We compiled legislation details by country and report on commonalities and gaps using a standardized form. The association between type of legislation and availability of iodized salt in households was assessed. RESULTS: We identified twenty-one countries with existing salt iodization legislation, of which eighteen were mandatory. A further nine countries have draft legislation. The majority of countries with draft and existing legislation used a mandatory standard or technical regulation for iodized salt under their Food Act/Law. The remainder have developed a 'stand-alone' Law/Act. Available national surveys indicate that the proportion of households consuming adequately iodized salt was lowest in countries with no, draft or voluntary legislation, and highest in those where the legislation was based on mandatory regulations under Food Acts/Laws. CONCLUSIONS: Legislation for salt iodization, particularly mandatory legislation under the national food law, facilitates universal salt iodization. However, additional important factors for implementation of salt iodization and maintenance of achievements include the salt industry's structure and capacity to adequately fortify, and official commitment and capacity to enforce national legislation.

Implementation of National Institute for Health and Care Excellence (NICE) guidance to measure immunoglobulin A with all coeliac screens: can an affordable solution be devised?

There has been a dramatic increase in requests for coeliac disease (CD) serological screening using immunoglobulin (Ig)A tissue transglutaminase antibodies (IgA-tTG). Recently, the UK National Institute for Health and Care Excellence has revised its guidance, recommending that total IgA should also be measured in all samples. This is justified, as false-negative results may occur with IgA deficiency. However, implementation of this guidance will incur considerable expense. Tests that measure IgA-tTG antibodies can detect IgA deficiency, indicated by low background signal. This provides an opportunity to identify samples containing IgA ≤ 0·2g/l, obviating the need for unselected IgA measurement. We investigated the feasibility of this approach in two centres that use the EliA™ Celikey™ assay or QUANTA Lite® enzyme-linked immunosorbent assay to quantify IgA-tTG antibodies. In both cases, total IgA correlated strongly with background IgA-tTG assay signal. Using the Celikey™ assay, a threshold of < 17·5 response units achieved 100% sensitivity (95% confidence intervals 79·4-100%) for detection of IgA ≤ 0·2g/l, circumventing the need for IgA testing in > 99% of sera. A similar principle was demonstrated for the QUANTA Lite® assay, whereby a threshold optical density of < 0·0265 also achieved 100% sensitivity (95% confidence intervals 78·2-100%) for IgA ≤ 0·2 g/l, avoiding unnecessary IgA testing in 67% of cases. These data suggest that CD screening tests can identify samples reliably containing low IgA in a real-life setting, obviating the need for blanket testing. However, this approach requires careful individualized validation, given the divergent efficiency with which assays identify samples containing low IgA.

Getting It Right for Every Child: A National Policy Framework to Promote Children's Well-being in Scotland, United Kingdom.

POLICY POINTS: Getting It Right for Every Child (GIRFEC), a landmark policy framework for improving children's well-being in Scotland, United Kingdom, is a practice initiative signifying a distinct way of thinking, an agenda for change, and the future direction of child welfare policy. GIRFEC represents a unique case study of national transformative change within the contexts of children's well-being and universal services and is of relevance to other jurisdictions. Implementation is under way, with an understanding of well-being and the requirement for information sharing enshrined in law. Yet there is scope for interpretation within the legislation and associated guidance. Inherent tensions around intrusion, data gathering, professional roles, and balancing well-being against child protection threaten the effectiveness of the policy if not resolved. CONTEXT: Despite persistent health inequalities and intergenerational deprivation, the Scottish government aspires for Scotland to be the best country for children to grow up in. Getting It Right for Every Child (GIRFEC) is a landmark children's policy framework to improve children's well-being via early intervention, universal service provision, and multiagency coordination across organizational boundaries. Placing the child and family "at the center," this approach marks a shift from welfare to well-being, yet there is still a general lack of consensus over how well-being is defined and measured. As an umbrella policy framework with broad reach, GIRFEC represents the current and future direction of children's/family policy in Scotland, yet large-scale practice change is required for successful implementation. METHODS: This article explores the origins and emergence of GIRFEC and presents a critical analysis of its incremental design, development, and implementation. FINDINGS: There is considerable scope for interpretation within the GIRFEC legislation and guidance, most notably around assessment of well-being and the role and remit of those charged with implementation. Tensions have arisen around issues such as professional roles; intrusion, data sharing, and confidentiality; and the balance between supporting well-being and protecting children. Despite the policy's intentions for integration, the service landscape for children and families still remains relatively fragmented. CONCLUSIONS: Although the policy has groundbreaking potential, inherent tensions must be resolved and the processes of change carefully managed in order for GIRFEC to be effective. It remains to be seen whether GIRFEC can fulfil the Scottish government's aspirations to reduce inequalities and improve lifelong outcomes for Scotland's children and young people. In terms of both a national children's well-being framework within a universal public service context and a distinct style of policymaking and implementation, the Scottish experience represents a unique case study of whole-country, transformational change and is of relevance to other jurisdictions.

Assessing the legacy of a legislative Workgroup for bidirectional integration of services.

Across the USA, health care systems are recognizing the value of integrating behavioral health services and primary care. The Texas Legislature took a unique approach to integration, passing legislation creating a Workgroup to explore key issues, identify best practices, and recommend policy and practice changes. This article situates the Workgroup in a rapidly evolving policy environment, describing the passage of integrated health care legislation in Texas, the Integration of Health and Behavioral Health Services Workgroup that was created by the legislation, and the policy recommendations that emerged from the Workgroup. The article analyzes how the Workgroup process intersected with a changing policy environment in Texas and nationally, opening the door for essential collaboration and partnership. The Workgroup ultimately laid the groundwork for integration's key role in a comprehensive Medicaid transformation waiver designed to expand access, improve population health and satisfaction with treatment, while better managing costs.

In conclusion: looking to the future of comprehensive cancer control.

The articles in this monograph illustrate the progress and successes of comprehensive cancer control (CCC) since our 2005 publication. The strides made in CCC demonstrate the energy and commitment of this nationwide movement to reduce the burden of cancer for all people. The purpose of this conclusion paper is to discuss the future of CCC, which promises a new emphasis on policy, primary prevention, public health, evidence-based interventions, and global health supported by advanced communication tools.

Public policy action and CCC implementation: benefits and hurdles.

Policy change continues to be an increasingly effective means of advancing the agenda of comprehensive cancer control. Efforts have moved progressively from describing how public policy can enhance the comprehensive cancer control agenda to implementation of public policy best practices at both the state and federal levels. The current political and economic contexts bring additional challenges and opportunities to the efforts surrounding comprehensive cancer control and policy. The purpose of this paper is to highlight recent policy successes, to illustrate the importance of policy as a means of advancing the comprehensive cancer control agenda, and to discuss continued policy action as we move forward in a time of healthcare reform and continuing economic uncertainty.

[Factors of successful integrated care settings for total knee and hip arthroplasty: findings of a qualitative process analysis]. / Erfolgsfaktoren integrierter Versorgungsprozesse in der Endoprothetik: Ergebnisse einer qualitativen Prozessanalyse.

AIMS: In Germany, introduction of the law on Integrated Health Care (IC) (section sign 140a-d SGB V) opened up the possibility of cross-sectoral health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. However, cross-institutional and interdisciplinary work contexts demand new organizational structures in order to assure the coordination of different competences, resources and interests. This study aims at identifying factors of successful integrated care settings for total hip and knee arthroplasty. Using the example of an integrated care setting between an orthopaedic hospital and a rehabilitation clinic it will be examined which factors lead to successful implementation of the services and measures designed. METHOD: A qualitative research design was developed comprising different methods of data assessment (participant observation, guided expert interviews, document analyses) enabling a comprehensive exploration. Overall, data were derived from six consultations with patients, two integrated care information sessions and various documents (17 patient files, information material, patient lists, etc.). RESULTS: First of all, the different phases of development and implementation of integrated care settings were described. In this context, clearly defined aims, structures and appropriate measures seem to be crucial for an ideal long-term cooperation. Furthermore, the staff perspective on the effects of the IC programme on their daily routines proved an essential basis for process reconstruction. The staff members pointed out four main aspects regarding IC settings, i. e., improved image, increased knowledge, intensity of relationship, and less and more work effort. Against this background, factors of successful IC settings could be generated such as the need for central coordination, a regular staff information systems as well as accompanying process monitoring. CONCLUSION: Several key factors of successful integrated care settings in arthroplasty could be generated which provide important clues for shaping future interdisciplinary and cross-sectoral cooperation settings in health care services in general.

[Effect of quality assessment assurance in 2002 (before starting the German colorectal cancer screening programme by colonoscopy) on the quality of reprocessing of flexible endoscopes--a nationwide analysis]. / Effekt der Qualitätssicherungsvereinbarung von 2002 (bei Einführung der Vorsorgekoloskopie) auf die Qualität der Aufbereitung flexibler Koloskope - eine bundesweite Analyse.

BACKGROUND: International studies in the 1990 s and the HYGEA study from Germany in 2002 revealed prevalences of around 50 % of microbiological contaminations in reprocessed flexible endoscopes. Before introducing the colorectal cancer screening programme by colonoscopy in Germany in 2002, the Kassenärztliche Bundesvereinigung (KBV) and the key stakeholders of the public health insurance system agreed on a quality assessment assurance for reprocessing endoscopes where the qualification for refund for colonoscopies from the public health system was made conditional on adequate qualifications of the gastroenterologist; on a minimum number of performed procedures per year; and on adequate endoscope reprocessing documented by negative surveillance cultures two times per year. This study is an implementation and outcome evaluation of the quality assessment assurance in colonoscopy in Germany. METHODS: The following data - per year and per Kassenärztliche Vereinigung (KV) - were obtained from the KBV: the number of endoscopic units performing therapeutic and/or screening colonoscopies within each KV; the results of all microbiological surveillance tests of reprocessing quality (two per year per unit); the number of failed surveillance tests and re-tests; and the number of qualifications for refund from the public health system cancelled due to repeated failure of microbiological surveillance tests. RESULTS: The percentages of actually performed hygiene control tests (out of those prescribed by the assurance system) reached 95 % already in 2004 and remained above or close to this level thereafter. After the introduction of the quality assessment assurance, the percentage of failed microbiological surveillance tests dropped significantly and steadily from close to 17 % in 2003 to below 4 % in 2007. CONCLUSIONS: This study evidences 1. the successful implementation of the quality assessment assurance in Germany and 2. a substantial improvement in the quality of reprocessing flexible endoscopes achieved by these measures with a drop from 50 % of failed tests observed before the introduction in 2000 - 2001 to below 4 % in 2007.

[Quality assurance and total quality management in residential home care]. / Qualitätssicherung und Qualitätsmanagement in der stationären Altenpflege.

Quality, quality assurance, and quality management have been important topics in residential care homes for several years. However, only as a result of reform processes in the German legislation (long-term care insurance, care quality assurance) is a systematic discussion taking place. Furthermore, initiatives and holistic model projects, which deal with the assessment and improvement of service quality, were developed in the field of care for the elderly. The present article gives a critical overview of essential developments. Different comprehensive approaches such as the implementation of quality management systems, nationwide expert-based initiatives, and developments towards professionalizing care are discussed. Empirically based approaches, especially those emphasizing the assessment of outcome quality, are focused on in this work. Overall, the authors conclude that in the past few years comprehensive efforts have been made to improve the quality of care. However, the current situation still requires much work to establish a nationwide launch and implementation of evidence-based quality assurance and quality management.