[Characteristics of compulsory service programs for medical professionals in the Andean states]. / Características del servicio social para profesionales médicos en los estados andinos.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programsincluding remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

Características del servicio social para profesionales médicos en los estados andinos / Characteristics of compulsory service programs for medical professionals in the Andean states

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programs­including remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

Rural Work and Specialty Choices of International Students Graduating from Australian Medical Schools: Implications for Policy.

Almost 500 international students graduate from Australian medical schools annually, with around 70% commencing medical work in Australia. If these Foreign Graduates of Accredited Medical Schools (FGAMS) wish to access Medicare benefits, they must initially work in Distribution Priority Areas (mainly rural). This study describes and compares the geographic and specialty distribution of FGAMS. Participants were 18,093 doctors responding to Medicine in Australia: Balancing Employment and Life national annual surveys, 2012-2017. Multiple logistic regression models explored location and specialty outcomes for three training groups (FGAMS; other Australian-trained (domestic) medical graduates (DMGs); and overseas-trained doctors (OTDs)). Only 19% of FGAMS worked rurally, whereas 29% of Australia's population lives rurally. FGAMS had similar odds of working rurally as DMGs (OR 0.93, 0.77-1.13) and about half the odds of OTDs (OR 0.48, 0.39-0.59). FGAMS were more likely than DMGs to work as general practitioners (GPs) (OR 1.27, 1.03-1.57), but less likely than OTDs (OR 0.74, 0.59-0.92). The distribution of FGAMS, particularly geographically, is sub-optimal for improving Australia's national medical workforce goals of adequate rural and generalist distribution. Opportunities remain for policy makers to expand current policies and develop a more comprehensive set of levers to promote rural and GP distribution from this group.

Current status and job satisfaction of village doctors in western China.

To strengthen rural health services, the Chinese government has launched a series of policies to promote health workforce development. This study aims to understand the current status of village doctors and to explore the factors associated with village doctors' job satisfaction in western China. It also attempts to provide references for further building capacities of village doctors and promoting the development of rural health service policy.A multistage stratified sampling method was used to obtain data from a cross-sectional survey on village doctors across 2 provinces of western China during 2012 to 2013. Quantitative data were collected from village doctors face-to-face, through a self-administered questionnaire.Among the 370 respondents, 225 (60.8%) aged 25 to 44 years, and 268 (72.4%) were covered by health insurance. Their income and working time calculated by workloads were higher than their self-report results. Being healthy, working fewer years, and having government funding and facilities were the positive factors toward their job satisfaction. Village doctors working with government-funded village clinics or facilities were more likely to feel satisfied.Problems identified previously such as low income and lack of insurance, heavy workload and aging were not detected in our study. Instead, village doctors were better-paid and better-covered by social insurance than other local rural residents, with increased job satisfaction. Government policies should pay more attention to improving the quality of rural health services and the income and security system of village doctors, to maintain and increase their job satisfaction and work enthusiasm. Further experimental study could evaluate effects of government input to improve rural health human resources and system development.

Guía de acercamiento y negociación / Approach and negotiation guide

El presente documento, es una actualización del que se elaborara en el 2016. Bajo la premisa aportada por el Convenio 169, en el artículo 25 que establece que: "Los servicios de salud…deberán planearse y administrarse en cooperación con los pueblos interesados y tener en cuenta sus condiciones económicas, geográficas, sociales y culturales, así como sus métodos de prevención, prácticas curativas y medicamentos tradicionales." Por ello, el modelo presentado, establece que "toda acción que se planifica desde fuera de la comunidad, altera su camino normal y se constituyen en intervenciones que reconfigura su cultura, formas de vida y cosmopercepción. Es necesario reconsiderar que las comunidades saben vivir y desarrollarse desde sus realidades, y que las intervenciones constituirán acciones para apoyar sus procesos históricos, incluyendo las de salud. Y agrega que: "debe tomar en cuenta las condiciones económicas, geográficas sociales y culturales de los pueblos; este párrafo justifica plenamente del porqué la planeación y administración de los servicios deben darse en conjunto; por cuanto ellos son los que conocen sus propias necesidades, sus realidades, su cultura, su organización local y todo lo referente a la comunidad."

Best Practices and Innovative Solutions to Overcome Barriers to Delivering Policy, Systems and Environmental Changes in Rural Communities.

To better understand the barriers to implementing policy; systems; and environmental (PSE) change initiatives within Supplemental Nutrition Assistance Program-Education (SNAP-Ed) programming in U.S. rural communities; as well as strategies to overcome these barriers, this study identifies: (1) the types of nutrition-related PSE SNAP-Ed programming currently being implemented in rural communities; (2) barriers to implementing PSE in rural communities; and (3) common best practices and innovative solutions to overcoming SNAP-Ed PSE implementation barriers. This mixed-methods study included online surveys and interviews across fifteen states. Participants were eligible if they: (1) were SNAP-Ed staff that were intimately aware of facilitators and barriers to implementing programs, (2) implemented at least 50% of their programming in rural communities, and (3) worked in their role for at least 12 months. Sixty-five staff completed the online survey and 27 participated in interviews. Barriers to PSE included obtaining community buy-in, the need for relationship building, and PSE education. Facilitators included finding community champions; identifying early "wins" so that community members could easily see PSE benefits. Partnerships between SNAP-Ed programs and non-SNAP-Ed organizations are essential to implementing PSE. SNAP-Ed staff should get buy-in from local leaders before implementing PSE. Technical assistance for rural SNAP-Ed programs would be helpful in promoting PSE.

Challenges in conducting a community-based influenza vaccine trial in a rural community in northern India.

Evidence on influenza vaccine effectiveness from low and middle countries (LMICs) is limited due to limited institutional capacities; lack of adequate resources; and lack of interest by ministries of health for influenza vaccine introduction. There are concerns that the highest ethical standards will be compromised during trials in LMICs leading to mistrust of clinical trials. These factors pose regulatory and operational challenges to researchers in these countries. We conducted a community-based vaccine trial to assess the efficacy of live attenuated influenza vaccine and inactivated influenza vaccine in rural north India. Key regulatory challenges included obtaining regulatory approvals, reporting of adverse events, and compensating subjects for trial-related injuries; all of which were required to be completed in a timely fashion. Key operational challenges included obtaining audio-visual consent; maintaining a low attrition rate; and administering vaccines during a narrow time period before the influenza season, and under extreme heat. We overcame these challenges through advanced planning, and sustaining community engagement. We adapted the trial procedures to cope with field conditions by conducting mock vaccine camps; and planned for early morning vaccination to mitigate threats to the cold chain. These lessons may help investigators to confront similar challenges in other LMICs.

Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision.

OBJECTIVE AND THE CONTEXT: This paper examines the beliefs and experiences of women and their families in remote mountain villages of Nepal about perinatal sickness and death and considers the implications of these beliefs for future healthcare provision. METHODS: Two mountain villages were chosen for this qualitative study to provide diversity of context within a highly disadvantaged region. Individual in-depth interviews were conducted with 42 women of childbearing age and their family members, 15 health service providers, and 5 stakeholders. The data were analysed using a thematic analysis technique with a comprehensive coding process. FINDINGS: Three key themes emerged from the study: (1) 'Everyone has gone through it': perinatal death as a natural occurrence; (2) Dewata (God) as a factor in health and sickness: a cause and means to overcome sickness in mother and baby; and (3) Karma (Past deeds), Bhagya (Fate) or Lekhanta (Destiny): ways of rationalising perinatal deaths. CONCLUSION: Religio-cultural interpretations underlie a fatalistic view among villagers in Nepal's mountain communities about any possibility of preventing perinatal deaths. This perpetuates a silence around the issue, and results in severe under-reporting of ongoing high perinatal death rates and almost no reporting of stillbirths. The study identified a strong belief in religio-cultural determinants of perinatal death, which demonstrates that medical interventions alone are not sufficient to prevent these deaths and that broader social determinants which are highly significant in local life must be considered in policy making and programming.

The Intersection of National Immigration and Healthcare Policy.

Immigration policy and health care policy remain principal undertakings of the federal government. The two have recently been pursued independently in the judicial and legislative arenas. Unbeknownst to many policymakers, however, national immigration policy and health care policy are linked in ways that, if unattended, could undermine the well-being of a significant portion of the US population, specifically medically underserved rural and urban populations. Using current data from a workforce report of the Association of American Colleges and the published literature, we demonstrate the significant impact that contemporary immigration policy directives may have on the number and distribution of international medical graduates who currently provide-and by the year 2025 will provide-a significant portion of primary health care in the United States, especially in underserved small urban and rural communities.

Doing implementation research on health governance: a frontline researcher's reflexive account of field-level challenges and their management.

BACKGROUND: Implementation Research (IR) in and around health systems comes with unique challenges for researchers including implementation, multi-layer governance, and ethical issues. Partnerships between researchers, implementers, policy makers and community members are central to IR and come with additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers, drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs). METHODS: The IR on VHSNC took place in one state/province in India over an 18-month research period. The IR study had twin components; intervention and in-depth research. The intervention sought to strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data collection and a research assistant was living in the study sites. The frontline research assistant experienced a range of challenges, while collecting data from the study sites, which were documented as field memos and analysed using inductive content analysis approach. RESULTS: Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a) between the community and frontline researchers and (b) between implementers and frontline researchers. In the community, the frontline researcher was viewed as the supervisor of the intervention and was perceived by the community to have power to bring about beneficial changes with public services and facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and feedback on community mobilization to improve their approaches. A concerted effort was undertaken by the whole research team to clarify and dispel concerns among the community and implementers through careful and constant communication. The strategies employed were both managerial, relational and reflexive in nature. CONCLUSION: Frontline researchers through their experiences shape the research process and its outcome and they play a central role in the research. It demonstrates that frontline researcher resilience is very crucial when conducting health policy and systems research.

Oral Health Care in Rural America.

(1) Rural Americans are twice as likely to lose their adult teeth as their urban counterparts. (2) Seventy-two percent of the country is classified as rural, but is home to only 15 percent of the population (46.2 million people). (3) According to the Pew Center on the States, rural residents are more likely to use emergency departments for their oral health needs because of a lack of dental insurance and a shortage of dental providers.

Barriers to safe abortion access: uterine rupture as complication of unsafe abortion in a Ugandan girl.

A 15-year-old girl at 18 weeks gestation by the last menstrual period presented to a rural Ugandan healthcare facility for termination of her pregnancy as a result of rape by her uncle. Skilled healthcare workers at the facility refused to provide the abortion due to fear of legal repercussions. The patient subsequently obtained an unsafe abortion by vaginal insertion of local herbs and sharp objects. She developed profuse vaginal bleeding and haemorrhagic shock. She was found to have uterine rupture and emergent hysterectomy was performed. Young and poor women are at high risk of unplanned pregnancy and subsequent mortality during pregnancy and childbirth. Unsafe abortion is a leading and entirely preventable cause of maternal mortality worldwide. Multiple barriers restrict access to safe abortions including social and moral stigma, gender-based power imbalances, inadequate contraceptive use and sexual education, high cost and poor availability, and restrictive abortion laws.

Drones in medicine-The rise of the machines.

This is a medical kitty hawk moment. Drones are pilotless aircrafts that were initially used exclusively by the military but are now also used for various scientific purposes, public safety, and in commercial industries. The healthcare industry in particular can benefit from their technical capabilities and ease of use. Common drone applications in medicine include the provision disaster assessments when other means of access are severely restricted; delivering aid packages, medicines, vaccines, blood and other medical supplies to remote areas; providing safe transport of disease test samples and test kits in areas with high contagion; and potential for providing rapid access to automated external defibrillators for patients in cardiac arrest. Drones are also showing early potential to benefit geriatric medicine by providing mobility assistance to elderly populations using robot-like technology. Looking further to the future, drones with diagnostic imaging capabilities may have a role in assessing health in remote communities using telemedicine technology. The Federal Aviation Administration (FAA) in the United States and the European Aviation Safety Agency (EASA) in the European Union are some examples of legislative bodies with regulatory authority over drone usage. These agencies oversee all technical, safety, security and administrative issues related to drones. It is important that drones continue to meet or exceed the requirements specified in each of these regulatory areas. The FAA is challenged with keeping pace legislatively with the rapid advances in drone technology. This relative lag has been perceived as slowing the proliferation of drone use. Despite these regulatory limitations, drones are showing significant potential for transforming healthcare and medicine in the 21st century.

LOCAL GOVERNMENT AND COMMUNITY LEADERS' PERSPECTIVES ON CHILD HEALTH AND MORTALITY AND INEQUITY ISSUES IN RURAL EASTERN INDONESIA.

Since 2001 a decentralization policy has increased the responsibility placed on local government for improving child health in Indonesia. This paper explores local government and community leaders' perspectives on child health in a rural district in Indonesia, using a qualitative approach. Focus group discussions were held in May 2013. The issues probed relate to health personnel skills and motivation, service availability, the influence of traditional beliefs, and health care and gender inequity. The participants identify weak leadership, inefficient health management and inadequate child health budgets as important issues. The lack of health staff in rural areas is seen as the reason for promoting the use of traditional birth attendants. Midwifery graduates and village midwives are perceived as lacking motivation to work in rural areas. Some local traditions are seen as detrimental to child health. Husbands provide little support to their wives. These results highlight the need for a harmonization and alignment of the efforts of local government agencies and local community leaders to address child health care and gender inequity issues.