Making effective referrals happen: a theory-informed policy analysis.

Effective referral is a critical element of a well-functioning health system. While having a good referral policy in place is important, equally important is its effective implementation. Using the implementation of a policy on referral of obstetric emergencies in Shanghai as a case, we illustrate the application of the 'Inhabited Institutions' analytical approach for studying policy implementation. In doing so, our study highlights how 'referral' is a quintessential systems process embedded in institutional, social and historical contexts. We show that multiple institutional logics, in the form of explicit and tacit organizing principles and assumptions, intersect to influence and shape actors' actions, sometimes with good outcomes and sometimes with poor outcomes. We reveal the embedded agency of frontline healthcare managers and providers across different levels of care. We show how frontline managers and providers, operating under conditions of uncertainties and ambiguities in organizational processes, actively draw upon their experience and network capital to creatively adapt to get referrals done in a timely manner to save lives of critically ill pregnant women. From our findings, two sets of linked implications emerge for strengthening referral systems. Given that referral often involves ill and complicated cases, getting referrals right depends on the exercise of discretion and judgement by those at the frontline to arrive at timely and workable solutions-health systems need to recognize this. We also conclude that to get referrals right, while one needs clearly defined policies and implementation processes that are locally appropriate, well understood by all concerned and easy to follow, this is not enough. In addition, explicit measures that enable the exercise of discretion and judgement at the frontline need to be locally identified and adopted.

Shaping the Health Policy Agenda: The Case of Safe Motherhood Policy in Vietnam.

BACKGROUND: Maternal health remains a central policy concern in Vietnam. With a commitment to achieving the Millennium Development Goal (MDG) 5 target of maternal mortality rate (MMR) of 70/100 000 by 2015, the Ministry of Health (MoH) issued the National Plan for Safe Motherhood (NPSM) 2003-2010. In 2008, reproductive health, including safe motherhood (SM) became a national health target program with annual government funding. METHODS: A case study of how SM emerged as a political priority in Vietnam over the period 2001-2008, drawing on Kingdon's theory of agenda-setting was conducted. A mixed method was adopted for this study of the NPSM. RESULTS: Three related streams contributed to SM priority in Vietnam: (1) the problem of high MMR was officially recognized from high-quality research, (2) the strong roles of policy champion from MoH in advocating for the needs to reducing MMR as well as support from government and donors, and (3) the national and international events, providing favorable context for this issue to emerge on policy agenda. CONCLUSION: This paper draws on the theory of agenda-setting to analyze the Vietnam experience and to develop guidance for SM a political priority in other high maternal mortality communities.

Managing patient complaints in China: a qualitative study in Shanghai.

OBJECTIVES: To examine the handling system for patient complaints and to identify existing barriers that are associated with effective management of patient complaints in China. SETTING: Key stakeholders of the handling system for patient complaints at the national, Shanghai municipal and hospital levels in China. PARTICIPANTS: 35 key informants including policymakers, hospital managers, healthcare providers, users and other stakeholders in Shanghai. PRIMARY AND SECONDARY OUTCOME MEASURES: Semistructured interviews were conducted to understand the process of handling patient complaints and factors affecting the process and outcomes of patient complaint management. RESULTS: The Chinese handling system for patient complaints was established in the past decade. Hospitals shoulder the most responsibility of patient complaint handling. Barriers to effective management of patient complaints included service users' low awareness of the systems in the initial stage of the process; poor capacity and skills of healthcare providers, incompetence and powerlessness of complaint handlers and non-transparent exchange of information during the process of complaint handling; conflicts between relevant actors and regulations and unjustifiable complaints by patients during solution settlements; and weak enforcement of regulations, deficient information for managing patient complaints and unwillingness of the hospitals to effectively handle complaints in the postcomplaint stage. CONCLUSIONS: Barriers to the effective management of patient complaints vary at the different stages of complaint handling and perspectives on these barriers differ between the service users and providers. Information, procedure design, human resources, system arrangement, unified legal system and regulations and factors shaping the social context all play important roles in effective patient complaint management.

Health policy processes in maternal health: a comparison of Vietnam, India and China.

This article reports on a comparative analysis to assess and explain the strengths and weaknesses of policy processes based on 9 case-studies of maternal health in Vietnam, India and China. Policy processes are often slow, inadequately coordinated and opaque to outsiders. Use of evidence is variable and, in particular, could be more actively used to assess different policy options. Whilst an increasing range of actors are involved, there is scope for further opening up of the policy processes. This is likely, if appropriately managed with due regard to issues such as accountability of advocacy organisations, to lead to stronger policy development and greater subsequent ownership; it may however be a more messy process to co-ordinate. Coordination is critical where policy issues span conventional sectoral boundaries, but is also essential to ensure development of policy considers critical health system and resource issues. This, and other features related to the nature of a specific policy issue, suggests the need both to adapt processes for each particular policy issue and to monitor the progress of the policy processes themselves. The article concludes with specific questions to be considered by actors keen to enhance policy processes.