Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitative Policy Analysis.

Background Rheumatic heart disease (RHD) poses a high burden in low-income countries, as well as among indigenous and other socioeconomically disadvantaged populations in high-income countries. Despite its severity and preventability, RHD receives insufficient global attention and resources. We conducted a qualitative policy analysis to investigate the reasons for recent growth but ongoing inadequacy in global priority for addressing RHD. Methods and Results Drawing on social science scholarship, we conducted a thematic analysis, triangulating among peer-reviewed literature, organizational documents, and 20 semistructured interviews with individuals involved in RHD research, clinical practice, and advocacy. The analysis indicates that RHD proponents face 3 linked challenges, all shaped by the nature of the issue. With respect to leadership and governance, the fact that RHD affects mostly poor populations in dispersed regions complicates efforts to coordinate activities among RHD proponents and to engage international organizations and donors. With respect to solution definition, the dearth of data on aspects of clinical management in low-income settings, difficulties preventing and addressing the disease, and the fact that RHD intersects with several disease specialties have fueled proponent disagreements about how best to address the disease. With respect to positioning, a perception that RHD is largely a problem for low-income countries and the ambiguity on its status as a noncommunicable disease have complicated efforts to convince policy makers to act. Conclusions To augment RHD global priority, proponents will need to establish more effective governance mechanisms to facilitate collective action, manage differences surrounding solutions, and identify positionings that resonate with policy makers and funders.

La Gobernanza Enfermera y su impacto en la calidad en la organización sociosanitaria en Catalunya / Nursing governance and its impact on the quality of organization of health care services for older people in the Catalan region of Spain

Introducción: La Gobernanza enfermera consiste en la toma de decisiones de la líder de enfermería en la organización sanitaria y responde a las necesidades de los grupos de interés. Se estudiaron las líderes enfermeras del ámbito sociosanitario o de atención intermedia de Catalunya (España). Objetivo: Analizar las variables de Gobernanza en el ámbito sociosanitario y su relación con la calidad percibida por el paciente. Metodología: Se recogieron datos de Gobernanza mediante el Cuestionario de Gobernanza Enfermera (CGE) y Satisfacción de pacientes medidos con Plaensa(C) (Encuestas de satisfacción del paciente del CatSalut) 2013. Se obtuvieron los consentimientos y aprobación por el Comité de bioética. Se usaron los programas SPSS de IBM y Atlas- Ti para el análisis de los datos. Resultados: Respondieron 34 enfermeras (43,6%) al CGE y al Plaensa(C) 9 de ellas, edad, formación, sexo, años de experiencia y nº de camas, de septiembre 2014 a abril 2015. Los datos se analizaron con una significación del 5% y pruebas estadísticas no paramétricas. Se hallaron correlaciones con la Satisfacción del paciente (Spearman) y: "La calidad influye en las decisiones" (p=0,006), "Investigar y actualizar conocimientos" (p=0,043), y "Desarrollar comunicación estratégica" (p=0,043). Estos resultados se asemejaron a los obtenidos en estudios como el Magnet Model(R). Conclusiones: Es conveniente profundizar en la Gobernanza, la Calidad, el Conocimiento y la Comunicación mediante la investigación cualitativa. Para las enfermeras están interrelacionadas entre sí la experiencia en Tomar decisiones, Poder, Representatividad y Cuidados, a pesar de la participación (AU)

Introduction: Nursing governance consists of decisions made by nursing leaders in health organizations that respond to the needs of interest groups. Nursing leaders in the realm of social-health or intermediate care in Catalonia (Spain) were studied. Objective: Analyze the governance variables in the social-health realm and their relationship with the quality perceived by patients. Methodology: Governance data was collected through a nursing governance questionnaire and patient satisfaction measured through Plaensa(C) (CatSalut 2013 patient satisfaction surveys). The consent of participants and approval by a bioethics committee were obtained. The statistical programs SPSS (from IBM) and Atlas.ti were used for data analysis. Results: Thirty-four (43.6%) nurses responded to the nursing governance questionnaire and nine to the Plaensa(C). Information was collected about age, education, gender, years of experience and number of beds. The data collection took place between September 2014 and April 2015. The data was analyzed with a significance level of 5% and through nonparametric statistical tests. Correlations were found between patient satisfaction (Spearman) and: "Quality influences decisions" (p=0.006), "Research and update knowledge" (p=0.043), and "Develop strategic communication" (p=0.043). These results were similar to those obtained in studies such as Magnet Model(R). Conclusions: It would be worth delving deeper into the topics of governance, quality, knowledge, and communication through qualitative research. In the view of nurses, decision-making experience, power, representativeness, and care are inter-related, despite participation (AU)

Governance arrangements for health systems in low-income countries: an overview of systematic reviews.

BACKGROUND: Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems. OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview. METHODS: We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS: We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence). AUTHORS' CONCLUSIONS: Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.

Eficiencia y sostenibilidad en la gestión clínica / Efficiency and sustainability in clinical management

No disponible

Responsabilidad social vs. Responsabilidad individual en salud Social / Responsibility vs. Individual responsibility in Health Care

En el marco general de la actual 'Sociedad de la Información' y en el marco específico de la denominada 'gobernanza en salud'; reaparece el viejo problema de la atribución de responsabilidad individual en salud. Se presume que el mayor acceso al conocimiento y a la información sanitaria conlleva mayor responsabilidad individual sobre las elecciones de estilos de vida. Mi hipótesis general es que, bajo el discurso ideal de la autodeterminación informativa y la co-responsabilidad individual en salud-discurso propio de la gobernanza en salud-, se esconde la estrategia (neoliberal o libertariana) de limitación o negación de la atención de la salud pública en la responsabilidad individual ('the argument of desert'). Dicha estrategia justificaría los consiguientes recortes de poder distributivo del Estado en salud pública, reforzando las desigualdades sociales originales. Este discurso ignora que el acceso al conocimiento constituye un determinante social de la salud, y como tal, exige una estricta responsabilidad social en la prevención de la salud comunitaria (AU)

Within the general framework of present-day 'Information Society' and in the specific context of so-called 'governance in health', the old issue of individual attribution of responsibility in health comes back to the fore. It is presumed that wider access to knowledge and information on health-related matters implies greater individual responsibility on choices concerning life-styles. My overall hypothesis is that, behind the ideal discourse on informational self-determination and individual co-responsibility in health matters-a usual discourse in health governance-lies a (neo-liberal or libertarian) strategy of limitation or denial of public health care based on individual responsibility (the argument of desert). Such strategy would justify the corresponding cuts in the distributive power of the State in matters of public health, thus reinforcing original social inequalities. This discourse ignores the fact that access to knowledge is a social determinant of health and, as such, requires strict social responsibility in preventive care in matters of communitarian health (AU)

Health research and systems' governance are at risk: should the right to data protection override health?

The European Union (EU) Data Protection Regulation will have profound implications for public health, health services research and statistics in Europe. The EU Commission's Proposal was a breakthrough in balancing privacy rights and rights to health and healthcare. The European Parliament, however, has proposed extensive amendments. This paper reviews the amendments proposed by the European Parliament Committee on Civil Liberties, Justice and Home Affairs and their implications for health research and statistics. The amendments eliminate most innovations brought by the Proposal. Notably, derogation to the general prohibition of processing sensitive data shall be allowed for public interests such as the management of healthcare services,but not health research, monitoring, surveillance and governance. The processing of personal health data for historical, statistical or scientific purposes shall be allowed only with the consent of the data subject or if the processing serves an exceptionally high public interest, cannot be performed otherwise and is legally authorised. Research, be it academic, government,corporate or market research, falls under the same rule.The proposed amendments will make difficult or render impossible research and statistics involving the linkage and analysis of the wealth of data from clinical,administrative, insurance and survey sources, which have contributed to improving health outcomes and health systems performance and governance; and may illegitimise efforts that have been made in some European countries to enable privacy-respectful data use for research and statistical purposes. If the amendments stand as written, the right to privacy is likely to override the right to health and healthcare in Europe.

Radiation protection in dental X-ray surgeries--still rooms for improvement.

AIM: To illustrate the authors' experience in the provision of radiation protection adviser (RPA)/medical physics expert (MPE) services and critical examination/radiation quality assurance (QA) testing, to demonstrate any continuing variability of the compliance of X-ray sets with existing guidance and of compliance of dental practices with existing legislation. METHOD: Data was collected from a series of critical examination and routine three-yearly radiation QA tests on 915 intra-oral X-ray sets and 124 panoramic sets. Data are the result of direct measurements on the sets, made using a traceably calibrated Unfors Xi meter. The testing covered the measurement of peak kilovoltage (kVp); filtration; timer accuracy and consistency; X-ray beam size; and radiation output, measured as the entrance surface dose in milliGray (mGy) for intra-oral sets and dose-area product (DAP), measured in mGy.cm(2) for panoramic sets. Physical checks, including mechanical stability, were also included as part of the testing process. RESULTS: The Health and Safety Executive has expressed concern about the poor standards of compliance with the regulations during inspections at dental practices. Thirty-five percent of intra-oral sets exceeded the UK adult diagnostic reference level on at least one setting, as did 61% of those with child dose settings. There is a clear advantage of digital radiography and rectangular collimation in dose terms, with the mean dose from digital sets 59% that of film-based sets and a rectangular collimator 76% that of circular collimators. The data shows the unrealised potential for dose saving in many digital sets and also marked differences in dose between sets. CONCLUSION: Provision of radiation protection advice to over 150 general dental practitioners raised a number of issues on the design of surgeries with X-ray equipment and critical examination testing. There is also considerable variation in advice given on the need (or lack of need) for room shielding. Where no radiation protection adviser (RPA) or medical physics expert (MPE) appointment has been made, there is often a very low level of compliance with legislative requirements. The active involvement of an RPA/MPE and continuing education on radiation protection issues has the potential to reduce radiation doses significantly further in many dental practices.

[Petitioning for prosecution in the event of violation of the requirement to provide responsible health care]. / Påtalebegjæring ved brudd på kravet om forsvarlig helsehjelp.

BACKGROUND: The Norwegian Board of Health Supervision can petition for prosecution of health care personnel or facilities. The purpose of the survey is to find out what circumstances will prompt the Norwegian Board of Health Supervision to petition for prosecution of doctors and/or facilities for violation of the requirement of responsible conduct, how often this happens and what the outcome is. MATERIAL AND METHOD: Petitions for prosecution in the period 1 February 2002 - 31 October 2008 were reviewed. The data stem mainly from two databases containing about 11 500 cases brought before the Norwegian Board of Health Supervision. RESULTS: During the period, the Boards of Health Supervision at county level petitioned for prosecution in some 7,700 cases where doctors and/or facilities had failed to provide responsible health care. Unsound professional practice was found in about 2400 cases. The Board of Health Supervision petitioned for 19 prosecutions in 16 cases (0.7 %), in 9 of them against doctors and in 10 against facilities. Of the cases against doctors, four ended with fines, four were dismissed and in one a ruling has not yet been handed down. Eight facilities were fined, while the cases against two of them were dismissed. The number of petitions for prosecution has shown a declining tendency during the period. INTERPRETATION: The initiation of criminal proceedings against doctors and facilities is relegated by the Norwegian Board of Health Supervision to a minor position among its supervisory activities.

International obligations through collective rights: Moving from foreign health assistance to global health governance.

This article analyzes the growing chasm between international power and state responsibility in health rights, proposing an international legal framework for collective rights - rights that can reform international institutions and empower developing states to realize the determinants of health structured by global forces. With longstanding recognition that many developing state governments cannot realize the health of their peoples without international cooperation, scholars have increasingly sought to codify international obligations under the purview of an evolving human right to health, applying this rights-based approach as a foundational framework for reducing global health inequalities through foreign assistance. Yet the inherent limitations of the individual human rights framework stymie the right to health in impacting the global institutions that are most crucial for realizing underlying determinants of health through the strengthening of primary health care systems. Whereas the right to health has been advanced as an individual right to be realized by a state duty-bearer, the authors find that this limited, atomized right has proven insufficient to create accountability for international obligations in global health policy, enabling the deterioration of primary health care systems that lack the ability to address an expanding set of public health claims. For rights scholars to advance disease protection and health promotion through national primary health care systems - creating the international legal obligations necessary to spur development supportive of the public's health - the authors conclude that scholars must look beyond the individual right to health to create collective international legal obligations commensurate with a public health-centered approach to primary health care. Through the development and implementation of these collective health rights, states can address interconnected determinants of health within and across countries, obligating the international community to scale-up primary health care systems in the developing world and thereby reduce public health inequities through global health governance.

Holding the World Bank accountable for leakage of funds from Africa's health sector.

This article explores the accountability of international financial institutions (IFIs), such as the World Bank, for human rights violations related to the massive leakage of funds from sub-Saharan Africa's health sector. The article begins by summarizing the quantitative results of Public Expenditure Tracking Surveys performed in six African countries, all showing disturbingly high levels of leakage in the health sector. It then addresses the inadequacy of good governance and anticorruption programs in remedying this problem. After explaining how the World Bank's Inspection Panel may serve as an accountability mechanism for addressing the leakage of funds, discussing violations of specific Bank policies and procedures that would support a claim related to leakage and examining the relevance of human rights concerns to such as claim, the article explores some of the Panel's limitations and the positive steps taken to address these concerns.

Changing governance, governing change: medical regulation in Ireland.

The perceived need for the regulation of the medical profession is rooted in the nature and history of medicine. This paper summarizes theories of professional regulation and explores recent developments in medical regulation in Ireland, through description of background theories of professional regulation and analysis of recent developments in Ireland. Medical self-regulation is the subject of ongoing controversy owing to (1) the complex nature of medical practice; (2) informed service users; (3) identification of alleged anti-competitive practices; (4) apparent restrictions on entry to the profession; (5) the public/private mix in Irish healthcare; and (6) high-profile cases that resulted in enquiries into standards of practice. Measures being implemented to address these challenges include reforms in medical education, a new contract of employment for consultants, and enhanced schemes for continuing medical education. Broader societal trends are presenting new challenges that highlight the need for flexible regulatory frameworks in medicine.