Advancing Global Health Equity: The Role of the Liberal Arts in Health Professional Education.

Much innovation has taken place in the development of medical schools and licensure exam processes across the African continent. Still, little attention has been paid to education that enables the multidisciplinary, critical thinking needed to understand and help shape the larger social systems in which health care is delivered. Although more than half of medical schools in Canada, the United Kingdom, and the United States offer at least one medical humanities course, this is less common in Africa. We report on the "liberal arts approach" to medical curricula undertaken by the University of Global Health Equity beginning in 2019. The first six-month semester of the curriculum, called Foundations in Social Medicine, includes courses in critical thinking and communication, African history and global political economy, medical anthropology and social medicine, psychology and health, gender and social justice, information technology and health, and community-based training. Additionally, an inquiry-based pedagogy with relatively small classes is featured within an overall institutional culture that emphasizes health equity. We identify key competencies for physicians interested in pursuing global health equity and how such competencies relate to liberal arts integration into the African medical school curriculum and pedagogical approach. We conclude with a call for a research agenda that can better evaluate the impact of such innovations on physicians' education and subsequent practices.

Dealing with Unexpected Crises: Organizational Resilience and Its Discontents.

The chapter summarizes key literature, including emerging ideas, that is pertinent to the question of how organizations and their leadership deal with and are resilient through crises - highlighting what works in surviving unexpected crises. The chapter presents an illustration of organizational response; it concludes with an analysis of what is missing from the literature and recommends a path forward to expanding actionable knowledge in this area. Multiple, interdependent factors that foster resilience are identified including (1) being sensitive to possible threats - even seemingly small failures, (2) not relying on simple interpretations of events but rather seeking diversity to create a complete view of the environment, (3) leadership that embraces communication, transparency, and continuous learning, (4) valuing expertise and allowing expert staff to make decisions during a crisis, and (5) a cultural commitment to a resiliency mindset that accepts failures as opportunities to learn and improve. Emerging concepts that may foster resilience but require more research include managing paradox, emotional ambivalence and diversity. Additional areas for fruitful research include: the impact of short-term versus long-term, or successive, crises; external versus internal shocks and the framing of the source of shocks; how crisis affect the pace of innovation and change; the role of diversity in organizational responses to crises; and a set of methodological opportunities to leverage natural experiments or simulations in ways that allow for longitudinal data illuminating the full cycle of crises across organizations from anticipation, to response, to longer-term adaptation to the new normal.

Comparison of Cancer-Related Spending and Mortality Rates in the US vs 21 High-Income Countries.

Importance: Studies using data from before 2011 concluded that the cost of US cancer care is justified given improved outcomes compared with European countries. However, it is unclear whether contemporary US cancer care provides better value than that of other high-income countries. Objective: To assess whether cancer mortality rates in 2020 were lower in countries with higher cancer-related spending, and to estimate across countries the incremental cost per averted cancer death. Design Setting and Participants: Cross-sectional, national-level analysis of 22 high-income countries, assessing the association between cancer care expenditures and age-standardized population-level cancer mortality rates in 2020, with and without adjustment for smoking. In addition, US incremental costs per averted death compared with the other countries were calculated. This study was conducted from September 1, 2021, to March 31, 2022. Main Outcomes and Measures: Age-standardized population-level cancer mortality rates. Results: In this cross-sectional study of 22 countries, the median cancer mortality rate was 91.4 per 100 000 population (IQR, 84.2-101.6). The US cancer mortality rate was higher than that of 6 other countries (86.3 per 100 000). Median per capita spending in USD for cancer care was $296 (IQR, $222-$348), with the US spending more than any other country ($584). After adjusting for smoking, 9 countries had lower cancer care expenditures and lower mortality rates than the US. Of the remaining 12 countries, the US additionally spent more than $5 million per averted death relative to 4 countries, and between $1 and $5 million per averted death relative to 8 countries. Cancer care expenditures were not associated with cancer mortality rates, with or without adjustment for smoking (Pearson R = -0.05 [95% CI, -0.46 to 0.38]; P = .81; and R = -0.05 [95% CI, -0.46 to 0.38]; P = .82). Conclusions and Relevance: In this cross-sectional study of national cancer care expenditures and cancer mortality rates across 22 countries, although the cancer mortality rate in the US was lower than the median, the US spent twice as much on cancer care as the median country. Findings of this study suggest that the US expenditure on cancer care may not be commensurate with improved cancer outcomes.

Structural quality of labor and delivery care in government hospitals of Ethiopia: a descriptive analysis.

BACKGROUND: Ethiopia has low skilled birth attendance rates coupled with low quality of care within health facilities contributing to one of the highest maternal mortality rates in Sub-Saharan Africa, at 412 deaths per 100,000 live births. There is lack of evidence on the readiness of health facilities to deliver quality labor and delivery (L&D) care. This paper describes the structural quality of routine L&D care in government hospitals of Ethiopia. METHODS: A facility-based cross-sectional study design, involving census of all government hospitals in Southern Nations Nationalities and People's Region (SNNPR) (N = 20) was conducted in November 2016 through facility audit using a structured checklist. Data collectors verified the availability and functioning of the required items through observation and interview with the heads of labor and delivery case team. An overall mean score of structural quality was calculated considering domain scores such as general infrastructure, human resource and essential drugs, supplies, equipment and laboratory services. Summary statistics such as proportion, mean and standard deviation were computed to describe the degree of adherence of the hospitals to the standards related to structural quality of routine labor and delivery care. RESULTS: One third of hospitals had low readiness to provide quality routine L&D care, with only two approaching near fulfilment of all the standards. Hospitals had fulfilled 68.2% of the standards for the structural aspects of quality of L&D care. Of the facility audit criteria, the availability of essential equipment and supplies for infection prevention scored the highest (88.8%), followed by safety, comfort and woman friendliness of the environment (76.4%). Availability skilled health professionals and quality management practices scored 72.5% each, while availability of the required items of general infrastructure was 64.6%. The two critical domains with the lowest score were availability of essential drugs, supplies and equipment (52.2%); and laboratory services and safe blood supply (50%). CONCLUSION: Substantial capacity gaps were observed in the hospitals challenging the provision of quality routine L&D care services, with only two thirds of required resources available. The largest gaps were in laboratory services and safe blood, and essential drugs, supplies and equipment. The results suggest the need to ensure that all public hospitals in SNNPR meet the required structure to enable the provision of quality routine L&D care with emphases on the identified gaps.

Diversity, Inclusive Leadership, and Health Outcomes.

In this time of polarization and divisiveness across increasingly diverse communities, health policy and management research offers an important insight: engaging diversity meaningfully through inclusive leadership-that embraces staff across hierarchies and engages difference perspectives so that all healthcare workers of all kinds feel they can speak up and participate-can save lives. In multiple studies of quality in cardiovascular care, top performing hospitals have been shown to exhibit the capacity to embrace staff across hierarchies and engage differences so that healthcare workers of all kinds feel they can speak up and participate meaningfully in improvement efforts. Most recently, in the two-year, longitudinal Leadership Saves Lives study of 10 hospitals, the ability to adopt a culture of improvement rather than blaming was linked to significant reductions in risk-standardized mortality rates. Moreover, the guiding coalitions (ie, quality improvement teams) in six of the 10 hospitals that were most successful were distinguished in three ways that give insight about effective modes of engaging differences: (1) including staff from difference disciplines and levels in the organizational hierarchy, (2) encouraging authentic participation by the members, and (3) using constructive patterns of managing conflict (ie, having clear role definitions, working to surface minority viewpoints, and collectively revisiting the shared goal of saving lives). Based on this literature, adequately engaging a wide range of diverse viewpoints and staff roles can have a marked impact on health outcomes. Although the studies reviewed do not examine racial/ethnic diversity per se, they do lend insight into effectively navigating environments with extensive diversity of perspectives, professional identities, and experiences. Future research may assess whether these insights have application to other forms of diversity as well. In this time of extreme polarization and division globally and locally, health policy and management research has an opportunity to share evidence that could help navigate an increasingly diverse environment, at least within the field of healthcare, towards a more inclusive, humane, and life-giving approach to our collective future.

District-level health management and health system performance.

Strengthening district-level management may be an important lever for improving key public health outcomes in low-income settings; however, previous studies have not established the statistical associations between better management and primary healthcare system performance in such settings. To explore this gap, we conducted a cross-sectional study of 36 rural districts and 226 health centers in Ethiopia, a country which has made ambitious investment in expanding access to primary care over the last decade. We employed quantitative measure of management capacity at both the district health office and health center levels and used multiple regression models, accounting for clustering of health centers within districts, to estimate the statistical association between management capacity and a key performance indicator (KPI) summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. In districts with above median district management capacity, health center management capacity was strongly associated (p < 0.05) with KPI performance. In districts with below median management capacity, health center management capacity was not associated with KPI performance. Having more staff at the district health office was also associated with better KPI performance (p < 0.05) but only in districts with above median management capacity. The results suggest that district-level management may provide an opportunity for improving health system performance in low-income country settings.

Association Between Community Social Capital and Hospital Readmission Rates.

Hospital readmissions remain frequent, and are partly attributable to patients' social needs. The authors sought to examine whether local community levels of social capital are associated with hospital readmission rates. Social capital refers to the connections among members of a society that foster norms of reciprocity and trust, which may influence the availability of support for postdischarge recovery after hospitalization. Associations between hospital-wide, risk-stratified readmission rates for hospitals in the United States (n = 4298) and levels of social capital in the hospitals' service areas were examined. Social capital was measured by an index of participation in associational activities and civic affairs. A multivariate linear regression model was used to adjust for hospital and community factors such as hospital financial performance, race, income, and availability of heath care services. Results showed that higher social capital was significantly associated with lower readmission rates (P < .01), a finding that held across income-stratified analyses as well as sensitivity analyses that included hospital performance on process quality measures and hospital community engagement activities. A hospital is unlikely to be able to influence prevailing levels of social capital in its region, but in areas of low social capital, it may be possible for public or philanthropic sectors to buttress the types of institutions that address nonmedical causes of readmission.

Unit Costing of Health Extension Worker Activities in Ethiopia: A Model for Managers at the District and Health Facility Level.

BACKGROUND: Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country. METHODS: We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services. RESULTS: In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr. CONCLUSION: Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints.

Links between social environment and health care utilization and costs.

The social environment influences health outcomes for older adults and could be an important target for interventions to reduce costly medical care. We sought to understand which elements of the social environment distinguish communities that achieve lower health care utilization and costs from communities that experience higher health care utilization and costs for older adults with complex needs. We used a sequential explanatory mixed methods approach. We classified community performance based on three outcomes: rate of hospitalizations for ambulatory care sensitive conditions, all-cause risk-standardized hospital readmission rates, and Medicare spending per beneficiary. We conducted in-depth interviews with key informants (N = 245) from organizations providing health or social services. Higher performing communities were distinguished by several aspects of social environment, and these features were lacking in lower performing communities: 1) strong informal support networks; 2) partnerships between faith-based organizations and health care and social service organizations; and 3) grassroots organizing and advocacy efforts. Higher performing communities share similar social environmental features that complement the work of health care and social service organizations. Many of the supportive features and programs identified in the higher performing communities were developed locally and with limited governmental funding, providing opportunities for improvement.

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

BACKGROUND: Quality collaboratives are widely endorsed as a potentially effective method for translating and spreading best practices for acute myocardial infarction (AMI) care. Nevertheless, hospital success in improving performance through participation in collaboratives varies markedly. We sought to understand what distinguished hospitals that succeeded in shifting culture and reducing 30-day risk-standardised mortality rate (RSMR) after AMI through their participation in the Leadership Saves Lives (LSL) collaborative. PROCEDURES: We conducted a longitudinal, mixed methods intervention study of 10 hospitals over a 2-year period; data included surveys of 223 individuals (response rates 83%-94% depending on wave) and 393 in-depth interviews with clinical and management staff most engaged with the LSL intervention in the 10 hospitals. We measured change in culture and RSMR, and key aspects of working related to team membership, turnover, level of participation and approaches to conflict management. MAIN FINDINGS: The six hospitals that experienced substantial culture change and greater reductions in RSMR demonstrated distinctions in: (1) effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the 'guiding coalition' in each hospital); (2) authentic participation in the work of the guiding coalition; and (3) distinct patterns of managing conflict. Guiding coalition size and turnover were not associated with success (p values>0.05). In the six hospitals that experienced substantial positive culture change, staff indicated that the LSL learnings were already being applied to other improvement efforts. PRINCIPAL CONCLUSIONS: Hospitals that were most successful in a national quality collaborative to shift hospital culture and reduce RSMR showed distinct patterns in membership diversity, authentic participation and capacity for conflict management.

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study.

BACKGROUND: Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. METHODS: This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. RESULTS: We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015. CONCLUSIONS: Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees.

BACKGROUND: Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. OBJECTIVE: To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. DESIGN: Longitudinal, observational cohort study (2008-2010). SETTING/SUBJECTS: Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355). MEASUREMENTS: We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. RESULTS: Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. CONCLUSIONS: Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Patterns of Collaboration among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs.

OBJECTIVE: To understand how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older adults. STUDY SETTING: Sixteen Hospital Service Areas (HSAs) in the United States. STUDY DESIGN: We conducted a qualitative study of HSAs with performance in the top or bottom quartiles nationally across three key outcomes: ambulatory care sensitive hospitalizations, all-cause risk-standardized readmission rates, and average reimbursements per Medicare beneficiary. We selected 10 higher performing HSAs and six lower performing HSAs for inclusion in the study. DATA COLLECTION: To understand patterns of collaboration in each community, we conducted site visits and in-depth interviews with a total of 245 representatives of health care organizations, social service agencies, and local government bodies. PRINCIPAL FINDINGS: Organizations in higher performing communities regularly worked together to identify challenges faced by older adults in their areas and responded through collective action-in some cases, through relatively unstructured coalitions, and in other cases, through more hierarchical configurations. Further, hospitals in higher performing communities routinely matched patients with needed social services. CONCLUSIONS: The collaborative approaches used by higher performing communities, if spread, may be able to improve outcomes elsewhere.

Spending on social and public health services and its association with homicide in the USA: an ecological study.

OBJECTIVE: To examine whether state-level spending on social and public health services is associated with lower rates of homicide in the USA. DESIGN: Ecological study. SETTING: USA. PARTICIPANTS: All states in the USA and the District of Columbia for which data were available (n=42). PRIMARY OUTCOME MEASURE: Homicide rates for each state were abstracted from the US Department of Justice Federal Bureau of Investigation's Uniform Crime Reporting. RESULTS: After adjusting for potential confounding variables, we found that every $10 000 increase in spending per person living in poverty was associated with 0.87 fewer homicides per 100 000 population or approximately a 16% decrease in the average homicide rate (estimate=-0.87, SE=0.15, p<0.001). Furthermore, there was no significant effect in the quartile of states with the highest percentages of individuals living in poverty but significant effects in the quartiles of states with lower percentages of individuals living in poverty. CONCLUSIONS: Based on our findings, spending on social and public health services is associated with significantly lower homicide rates at the state level. Although we cannot infer causality from this research, such spending may provide promising avenues for homicide reduction in the USA, particularly among states with lower levels of poverty.

Professionalizing Healthcare Management: A Descriptive Case Study.

Despite international recognition of the importance of healthcare management in the development of high-performing systems, the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes in the establishment of a professional workforce of healthcare managers in low- and middle-income country (LMIC) settings using a descriptive case study approach. We draw on a historical analysis of the development of this profession in the United States and Ethiopia to identify five common themes in the professionalization of healthcare management: (1) a country context in which healthcare management is demanded; (2) a national framework that elevates a professional management role; (3) standards for healthcare management, and a monitoring function to promote adherence to standards; (4) a graduatelevel educational path to ensure a pipeline of well-prepared healthcare managers; and (5) professional associations to sustain and advance the field. These five components can to inform the creation of a long-term national strategy for the development of a professional cadre of heathcare managers in LMIC settings.