A commentary on the Pan American Network of Nursing and Midwifery Collaborating Centres / Comentario sobre la Red Panamericana de Centros Colaboradores de Enfermería y Partería / Comentário sobre a Rede Pan-Americana de Centros Colaboradores de Enfermagem e Obstetrícia

ABSTRACT This article provides a commentary on the Pan American Network of Nursing and Midwifery Collaborating Centres (PANMCC). The objectives are to present an overview of the formation and evolution of the network, its impact on education, research, policy and communication and the benefits of membership. The advantages of international networks as a mechanism to strengthen nursing and midwifery workforces and improve health systems are also highlighted. The Pan American Health Organization (PAHO), the World Health Organization (WHO) Office in the Americas, oversees collaborating centres in the Region. Established in 1999, PANMCC consists of 17 centres situated in universities and schools of nursing. These centres provide crucial nursing and midwifery input to PAHO/WHO. The network supports global engagement and capacity building via collaboration, resource sharing and research colloquia. The linkages within the network enhance professional development, increase capacity building and heighten visibility of PANMCC and the work of its members.

RESUMEN En este artículo se presenta un comentario sobre la Red Panamericana de Centros Colaboradores de Enfermería y Partería (PANMCC, por su sigla en inglés). Los objetivos son presentar una visión general de la formación y evolución de la red, sus repercusiones en los ámbitos de la educación, la investigación, la política y las comunicaciones, así como los beneficios de pertenecer a la red. También se destacan las ventajas de las redes internacionales como mecanismo para fortalecer al personal de enfermería y partería y mejorar los sistemas de salud. La Organización Panamericana de la Salud (OPS), Oficina Regional de la Organización Mundial de la Salud (OMS) para las Américas, supervisa los centros colaboradores en la Región. Fundada en 1999, la PANMCC consta de 17 centros ubicados en universidades y facultades de enfermería, los cuales proporcionan información crucial sobre enfermería y partería a la OPS/OMS. Esta red respalda el compromiso general y el desarrollo de capacidades mediante la colaboración, el intercambio de recursos y los coloquios de investigación. Los vínculos en la red mejoran el desarrollo profesional, aumentan el desarrollo de capacidades y aumentan la visibilidad de la PANMCC y el trabajo de sus miembros.

RESUMO Este artigo traz um comentário sobre a Rede Pan-Americana de Centros Colaboradores de Enfermagem e Obstetrícia (PANMCC). Os objetivos são apresentar uma visão geral da formação e evolução da Rede, seu impacto em educação, pesquisa, políticas e comunicação e os benefícios da filiação. Também são destacadas as vantagens das redes internacionais como mecanismo para valorizar as forças de trabalho em enfermagem e obstetrícia e melhorar os sistemas de saúde. A Organização Pan-Americana da Saúde (OPAS) - o Escritório da Organização Mundial da Saúde (OMS) nas Américas - supervisiona os Centros Colaboradores na região. Criada em 1999, a PANMCC é composta por 17 centros situados em universidades e escolas de enfermagem. Esses centros fornecem informações essenciais sobre enfermagem e obstetrícia para a OPAS/OMS. A rede apoia o envolvimento global e o fortalecimento institucional por meio de colaboração, compartilhamento de recursos e colóquios de pesquisa. Os elos dentro da rede aprimoram o desenvolvimento profissional, estimulam o fortalecimento institucional e aumentam a visibilidade da PANMCC e do trabalho dos seus membros.

Unified-planning, graded-administration, and centralized-controlling: a management modality for treating acquired immune deficiency syndrome with Chinese medicine in Henan Province of China.

Henan Province in China has a major epidemic of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Chinese medicine (CM) has been used throughout the last decade, and a management modality was developed, which can be described by unified-planning, graded-administration, and centralized-controlling (UGC). The UGC modality has one primary concept (patient-centered medicine from CM theory), four basic foundations (classifying administrative region, characteristics of CM on disease treatment, health resource conditions, and distribution of patients living with HIV), six important relationships (the "three uniformities and three combinations," and the six relationships therein guide the treatment of AIDS with CM), and four key sections (management, operation, records, and evaluation). In this article, the authors introduce the UGC modality, which could be beneficial to developing countries or resource-limited areas for the management of chronic infectious disease.

Unified-planning, graded-administration, and centralized-controlling: a management modality for treating acquired immune deficiency syndrome with Chinese medicine in Henan Province of China / 中国结合医学杂志

Henan Province in China has a major epidemic of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Chinese medicine (CM) has been used throughout the last decade, and a management modality was developed, which can be described by unified-planning, graded-administration, and centralized-controlling (UGC). The UGC modality has one primary concept (patient-centered medicine from CM theory), four basic foundations (classifying administrative region, characteristics of CM on disease treatment, health resource conditions, and distribution of patients living with HIV), six important relationships (the "three uniformities and three combinations," and the six relationships therein guide the treatment of AIDS with CM), and four key sections (management, operation, records, and evaluation). In this article, the authors introduce the UGC modality, which could be beneficial to developing countries or resource-limited areas for the management of chronic infectious disease.

[UNICANCER patient expectations observatory: a new role for patients in health care institutions]. / L'observatoire des attentes des patients UNICANCER: une nouvelle place des usagers dans les établissements de santé.

UNICANCER, recognizing the role played by patients in their own management, set up a unique initiative in France in November 2011: the patient expectations observatory, which is designed to reorient and improve the quality of care provided by comprehensive cancer centers of the UNICANCER group based on a better knowledge and understanding of patient perceptions and preferences. An innovative internet-based participative consultation recorded and prioritized patient expectations. Patient management improvement actions in cancer centres were then generalized to equitably satisfy the identified patient expectations. By using patient expectations concerning organization of health care, cancer cancers therefore provide an example of the new modalities of patient participation in health care institutions, in line with the changes proposed by public authorities.

Accelerating the rate of improvement in cystic fibrosis care: contributions and insights of the learning and leadership collaborative.

INTRODUCTION: The Learning and Leadership Collaborative (LLC) supports cystic fibrosis (CF) centres' responses to the variation in CF outcomes in the USA. Between 2002 and 2013, the Cystic Fibrosis Foundation (CFF) designed, tested and modified the LLC to guide front line staff efforts in these efforts. This paper describes the CFF LLC evolution and essential elements that have facilitated increased improvement capability of CF centres and improved CF outcomes. METHODS: CF centre improvement teams across the USA have participated in 11 LLCs of 12 months' duration since 2002. Based on the Dartmouth Microsystem Improvement Curriculum, the original LLC included face to face meetings, an email listserv, conference calls and completion of between learning session task books. The LLCs evolved over time to include internet based learning, an electronic repository of improvement resources and examples, change ideas driven by evidence based clinical practice guidelines, benchmarking site visits, an applied QI measurement curriculum and team coaching. RESULTS: Over 90% of the CF centres in the USA have participated in the LLCs and have increased their improvement capabilities. Ten essential elements were identified as contributors to the successful LLCs: LLC national leadership and coordination, local leadership, people with CF and families involvement, registry data transparency, standardised improvement curriculum with evidence based change ideas, internet resources with reminders, team coaching, regular progress reporting and tracking, benchmarking site visits and applied improvement measurement. CONCLUSIONS: The LLCs have contributed to improved medical and process outcomes over the past 10 years. Ten essential elements of the LLCs may benefit improvement efforts in other chronic care populations and health systems.

Involvement of health professionals in tobacco control in the South-East Asia Region.

Tobacco use is widely entrenched in the South-East Asia (SEA) Region leading to high morbidity and mortality in this region. Several studies revealed that tobacco use is widespread among youth and school children. Exposure to second-hand smoke was reported as around 50% or more in three countries - Myanmar (59.5%), Bangladesh (51.3%), and Indonesia (49.6%). Health profession students encompassing medical, dental, nursing and pharmacy disciplines, and even qualified health professionals are no exception from tobacco use. While they are regarded as role models in tobacco cessation programs, their tobacco addiction will carry a negative impact in this endeavour. A mere inquiry about the smoking status of patients and a brief advice by doctors or dentists increases quit rates and prompts those who have not thought about quitting to consider doing so. Evidence from some randomized trials suggests that advice from motivated physicians to their smoking patients could be effective in facilitating cessation of smoking. However, the low detection rate of smokers by many physicians and the small proportion of smokers who routinely receive advice from their physicians to quit have been identified as a matter of concern. This paper describes the role and issues of involvement of health professionals in tobacco control. Data from a variety of sources is used to assess the status. Although there are some differences, tobacco use is widespread among the students and health professional students. Exposure to second hand smoke is also a matter of concern. Tobacco-related problems and tobacco control cut across a vast range of health disciplines. Building alliances among the health professional associations in a vertical way will help synergize efforts, and obtain better outcomes from use of existing resources. Health professional associations in some countries in the SEA region have already taken the initiative to form coalitions at the national level to advance the tobacco control agenda. In Thailand, a Thai Health Professional Alliance against Tobacco, with 17 allies from medical, nursing, traditional medicine, and other health professional organizations, is working in a concerted manner toward promoting tobacco control. Indian Dental Association intervention is another good example.

Política de práticas integrativas em Recife: análise da participação dos atores / Integrative practice policy in Recife, northeastern Brazil: an analysis of stakeholder involvement / Política de prácticas integradoras en Recife (Noreste de Brasil): análisis de la participación de los actores

OBJETIVO: Analisar a participação dos atores envolvidos na evolução de política municipal de práticas integrativas. PROCEDIMENTOS METODOLÓGICOS: Estudo com abordagem qualitativa em Recife, PE. A coleta dos dados foi realizada por meio de consultas às atas do conselho municipal de saúde, entre 2004 e 2009, entrevistas com informantes-chave e gestores, e grupos focais com profissionais e usuários. Os dados foram analisados segundo o modelo de condensação de significados. Para apresentação dos resultados, quatro categorias de atores foram formadas, segundo seu poder e interesse, a saber: sujeitos, população, líderes e jogadores. RESULTADOS: Após cinco anos da implantação da política em Recife, só um serviço oferecia práticas integrativas. A população ou os usuários não tiveram participação efetiva e não contribuíram com a política; os profissionais de saúde, apesar do interesse em participar do processo, não foram incluídos. Os líderes encontrados foram o Conselho Municipal de Saúde, os gestores e as entidades médicas, sendo os dois últimos também considerados jogadores, pois participaram efetivamente da elaboração da política. CONCLUSÕES: A participação de poucos atores na construção de uma política de práticas integrativas dificulta sua consolidação e amplia a distância entre formulação e implementação, prejudicando o alcance dos resultados esperados.

OBJECTIVE: To examine the involvement of stakeholders in the implementation of a local policy of integrative practices. METHODOLOGICAL PROCEDURES: Qualitative study conducted in the city of Recife, Northeastern Brazil. Data was collected from local health board records between 2004 and 2009, interviews with managers and key informants and focus groups with providers and users. The analysis was performed using the condensation of meaning model. The results were grouped into four categories of stakeholders according to their influence and interest, namely: subjects; population; leaders; and players. ANALYSIS OF RESULTS: Five years after the policy was implemented in Recife, only a single service offered integrative practices. The population, or users, did not have any effective involvement and did not make any contributions to the policy, and health providers, despite their willingness to participate in the process, were not involved. The leaders included the local health board, managers and medical organizations; the latter two were also players as they were effectively involved in the formulation of the policy. CONCLUSIONS: The involvement of few stakeholders in the formulation of an integrative practice policy makes it difficult its implementation and widens the gap between formulation and implementation, hindering the achievement of expected results.

OBJETIVO: Analizar la participación de los actores envueltos en la evolución de la política municipal de prácticas integradoras. PROCEDIMIENTOS METODOLÓGICOS: Estudio con abordaje cualitativo en Recife, Noreste de Brasil. La colecta de los datos fue realizada por medio de consultas de las actas del consejo municipal de salud, entre 2004 y 2009, entrevistas con informantes-clave y gestores, y grupos focales con profesionales y usuarios. Los datos fueron analizados según el modelo de condensación de significados. Para presentación de los resultados, cuatro categorías de actores fueron formadas, según su poder e interés, a saber: sujetos, población, líderes y jugadores. RESULTADOS: Posterior a cinco años de la implantación de la política en Recife, solo un servicio ofrecía prácticas integradoras. La población o los usuarios no tuvieron participación efectiva y no contribuyeron con la política; los profesionales de salud, a pesar del interés en participar del proceso, no fueron incluidos. Los líderes encontrados fueron el consejo municipal de salud, los gestores y las entidades médicas, siendo los dos últimos también considerados jugadores, pues participaron efectivamente de la elaboración de la política. CONCLUSIONES: La participación de pocos actores en la construcción de una política de prácticas integradoras dificulta su consolidación y amplia la distancia entre formulación e implementación, perjudicando el alcance de los resultados esperados.

Integrative practice policy in Recife, northeastern Brazil: an analysis of stakeholder involvement.

OBJECTIVE: To examine the involvement of stakeholders in the implementation of a local policy of integrative practices. METHODOLOGICAL PROCEDURES: Qualitative study conducted in the city of Recife, Northeastern Brazil. Data was collected from local health board records between 2004 and 2009, interviews with managers and key informants and focus groups with providers and users. The analysis was performed using the condensation of meaning model. The results were grouped into four categories of stakeholders according to their influence and interest, namely: subjects; population; leaders; and players. ANALYSIS OF RESULTS: Five years after the policy was implemented in Recife, only a single service offered integrative practices. The population, or users, did not have any effective involvement and did not make any contributions to the policy, and health providers, despite their willingness to participate in the process, were not involved. The leaders included the local health board, managers and medical organizations; the latter two were also players as they were effectively involved in the formulation of the policy. CONCLUSIONS: The involvement of few stakeholders in the formulation of an integrative practice policy makes it difficult its implementation and widens the gap between formulation and implementation, hindering the achievement of expected results.

Continuous medical education (CME): do we need CME for paediatric environmental medicine in Europe?

The knowledge about the influence of environmental hazards on children's health is increasing enormously. European Ministers of Health and Environment, like many other stakeholders, identified the environmental hazards in Europe for the health of children as so serious, that they called for a "Children's Environment and Health Action Plan for Europe (CEHAPE)" approved in June 2004. The knowledge of paediatricians and other health care providers on children's health and environment in Europe is insufficient, due to the lack of training in environmental medicine for medical students, clinical trainees and postgraduates. Only continuous medical education in environmental medicine can help to fill this gap of knowledge and is thereby urgently needed. The World Health Organization developed a training package for health care providers for children's health and environment, containing excellent material for paediatric training events. The International Network on Children's Health, Environment and Safety (INCHES) developed additional training material for paediatricians within the Children's Health, Environment and Safety Training (CHEST) project. The German Network Children's Health and Environment offers training for paediatric doctors' assistants in primary prevention. To improve knowledge about children's health and environment at all levels in paediatric settings, greater efforts of national institutions, paediatric associations and other institutions are necessary. It is time to strengthen existing structures and to introduce, where necessary, new structures for training in environmental medicine.

The Allegheny initiative for mental health integration for the homeless: integrating heterogeneous health services for homeless persons.

The Allegheny Initiative for Mental Health Integration for the Homeless (AIM-HIGH) was a 3-year urban initiative in Pennsylvania that sought to enhance integration and coordination of medical and behavioral services for homeless persons through system-, provider-, and client-level interventions. On a system level, AIM-HIGH established partnerships between several key medical and behavioral health agencies. On a provider level, AIM-HIGH conducted 5 county-wide conferences regarding homeless integration, attended by 637 attendees from 72 agencies. On a client level, 5 colocated medical and behavioral health care clinics provided care to 1986 homeless patients in 4084 encounters, generating 1917 referrals for care. For a modest investment, AIM-HIGH demonstrated that integration of medical and behavioral health services for homeless persons can occur in a large urban environment.

An Ontario initiative to enhance the effectiveness of AIDS Service Organizations: Community-Linked Evaluation of AIDS Resources.

This report describes the rationale, process, and early outcomes of establishing a community-based research unit. The AIDS Bureau of the Ontario Provincial Government established the Community-Linked Evaluation of AIDS Resources Unit (CLEAR), which works in partnership with the AIDS Bureau and 31 of 74 AIDS Service Organizations (ASOs) in Ontario.

The evolution of PBMA: towards a macro-level priority setting framework for health regions.

To date, relatively little work on priority setting has been carried out at a macro-level across major portfolios within integrated health care organizations. This paper describes a macro marginal analysis (MMA) process for setting priorities and allocating resources in health authorities, based on work carried out in a major urban health region in Alberta, Canada. MMA centers around an expert working group of managers and clinicians who are charged with identifying areas for resource re-allocation on an ongoing basis. Trade-offs between services are based on locally defined criteria and are informed by multiple inputs such as evidence from the literature and local expert opinion. The approach is put forth as a significant improvement on historical resource allocation patterns.

Making choices in healthcare: the reality of scarcity.

Processes are required to aid decision-makers in better managing existing resources in healthcare. To date, limited research has informed priority setting at the macro level, across broad service areas, within health organizations. As part of a participatory action research project, a macro-level resource allocation framework was developed and implemented in the Calgary Health Region (CHR). The approach relies on an expert panel of managers and clinicians who are charged with identifying, on the basis of evidence and local information, how resources might be reallocated to improve population well-being. The framework developed was seen as an improvement over historical allocation processes.

Feasibility of milk fluoridation and trends in dental caries of children in China.

The aim of the study is to investigate the feasibility of milk fluoridation as a vehicle for caries prevention, based on the current epidemiological status and its trends of dental caries in preschool children in the area of the Haidian District of Beijing, where the indications exist: Fluoride level in drinking water is low (0.2-0.3 ppm), and water fluoridation and other systemic uses of fluorides are unlikely. From 75.9 to 79.7% of 3-6-year-old children were identified as having high caries experience (dmft 4.29-4.35). It was found that 60% of the preschool children who attended kindergarten were 3-6 years old, and 40% of the 1-2-year-olds were living with their families. There is a local dairy to produce milk for the population living in this district. The amount of fresh milk produced daily is about 50,000-60,000 kg. A special kind of milk with vitamins A and D is also available for the preschool children. Data available from the Community MCH Centre indicated that the percentage of breast-feeding is 12% only. The first choice by parents for artificial feeding to the babies is fresh or powdered milk. Therefore, the breast-feeding project started in 1992. It is recommended that mothers' milk should be provided to the babies for at least four months after birth, when a specially prescribed milk for the babies, produced by the dairy, will be provided on a daily basis. The cost of milk is cheaper than others. In this connection, a five-year project on milk fluoridation as a pilot study at the community level for caries prevention of preschool children is now planned. The project is supported by BDMF, WHO, and Chinese MOPH.

Toward national health system guidelines in Canada: reflections of a comprehensive audit.

A comprehensive assessment of the Health Program Guidelines (HPG) in Canada was undertaken between January and September 1992. This review examined the strategic effectiveness and operational efficiency of the guidelines under the auspices of the Federal, Provincial and Territorial Committee on Institutional and Medical Services. To assess the perceived needs for the guidelines, over 185 structured mail questionnaires were sent to a sample of health care agencies, institutions and organizations across Canada; the response rate was over 80.5%. A key informant approach was also used to assess the perceived effectiveness and efficiency of the guidelines. Based on the results of the questionnaires, over 45 interviews and an extensive content analysis of key documents, recommendations were made that may be relevant to the Canadian health system community.

O processo de distritalizaçäo da atençäo à saúde no Estado da Bahia / Process of district formation for health care in the state of Bahia

Este trabalho trata do processo de Distritalizaçäo da atençäo à saúde no Estado da Bahia durante o período compreendido entre o início de 87 a meados de 89. Tem como eixo central a implementaçäo das propostas de reorientaçäo da gestäo e da organizaçäo dos serviços de saúde, com base nos princípios da Distritalizaçäo. Trata-se, portanto, de um "estudo de caso" no plano político institucional do setor saúde, especialmente a nível central da Secretaria de Saúde do Estado da Bahia, instituiçäo responsável pela inplantaçäo do SUDS - Sistema Unificado e Descentralizado de Saúde - contexto em que se viabilizou a proposta de Distribuiçäo. As informaçöes trabalhadas foram obtidas a partir da revisäo documental, de entrevistas a dirigentes e técnicas, bem como da observaçäo participante realizada pelo autor no período de 87/88. Os resultados, sistematizados segundo os distintos momentos do processo, de acordo com as variaçöes do quadro político-institucional no período em estudo, säo discutidos tomando-se por referência: a) os antecedentes do processo, tanto no plano Nacional (81-87) marcado pela crise e pela reorientaçäo das políticas de saúde, quanto no plano estadual, com especificidades decorrentes da situaçäo econômica, política e social mais geral e também da configuraçäo da situaçäo de saúde e do Sistema de Saúde, b) o significado estratégio da Distritalizaçäo em relaçäo ao conjunto das medidas de reorientaçäo do Sistema de Saúde contidas no SUDS, tendo em vista a construçäo do sistema único de Saúde, do qual o Distrito Sanitário constitui a base operacional e adminsitrativa. Buscando superar essa visäo "restrita" da Distritalizaçäo realizou-se uma revisäo do processo de definiçäo conceitual no âmbito da América latina, ou seja a revisäo da noçäo de SILOS - Sistemas Locais de Saúde - o que serve de referência para a discussäo mais ampla do Distrito Sanitário enquanto espaço de luta, tática de transformaçäo das práticas de saúde que adquire significado estratégico no processo de Reforma Sanitária Brasileira

Enhancing health--a new agenda for Ontario.

Recognizing that changes in demography, the social environment, economics, technology and political trends are underlying factors affecting health, Paradigm Health in Toronto examined these considerations to assess change to achieve a positive vision of health. Phase I of the study looked at opportunities and threats from the broad external environment affecting health, examined the internal strengths and weaknesses of the present Ontario health system, and analyzed the participants in the system. Phase II identified the important strategic issues gathered from the environmental study, and the strategies which could deal with these issues.

Decentralisation trends in the management of New Zealand's health services.

New Zealand is in the process of implementing major changes in the organisation and funding of its health services. Central to these changes is a largely elected area health board responsible for the funding and coordination of all services for a defined population, both public as well as non-government. Four different models of decentralisation, deconcentration (administrative), devolution (political), corporatisation (functional) and privatisation (non-government), have been used to describe and analyse these changes. There is expected to be a major devolution of powers to area health boards from central government, reversing the centralising tendencies which have occurred over the past century. Within boards a pluralistic system of service management, incorporating the above models of decentralisation, is being implemented to replace the present system of institutional administration and to give greater decision-making responsibility to health professionals, non-government agencies and community groups. These initiatives are associated with population-based funding of hospital boards complemented by service planning guidelines. Of particular importance has been the recent government decision to place the funding and management of primary health care under area health boards. However, there are serious concerns as to whether such radical changes, which could put New Zealand ahead of the rest of the world in achieving an integrated health system, can be implemented given the management expertise needed.