Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection

High performing primary health care organizations from patient perspective: a qualitative study in China

BACKGROUND

There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited. This study aimed to generate a profile of high performing PHC organizations from the perspective of patients.

METHODS

We conducted semi-structured interviews with 58 PHC users from six provinces (Shandong, Zhejiang, Shaanxi, Henan, Shanxi, Heilongjiang) in China using purposive and snowball sampling techniques. Transcription was completed by trained research assistants through listening to the recordings of the interviews and summarizing them in English by 30-s segments to generate the narrative summary. Informed by the Classification System of PHC Organizational Attributes, thematic analysis aimed to identify domains and attributes of high performing PHC organizations.

RESULTS

A profile of a high performing PHC organization with five domains and 14 attributes was generated. The five domains included: (1) organizational resources including medical equipment, human and information resource; (2) service provision and clinical practice including practice scope, internal integration and external integration; (3) general features including location, environment and ownership; (4) quality and cost; and (5) organizational structure including continuous learning mechanism, administrative structure and governance.

CONCLUSIONS

A five-domain profile of high performing PHC organizations from the perspective of Chinese PHC users was generated. Organizational resources, service delivery and clinical practices were most valued by the participants. Meanwhile, the participants also had strong expectation of geographical accessibility, high quality of care as well as efficient organizational structure. These organizational elements should be reflected in further reform efforts in order to build high performing PHC organizations.

Frameworks of Performance Measurement in Public Health and Primary Care System: A Scoping Review and Meta-Synthesis

Background:

This study was conducted to synthesize the evidence on the dimensions of performance appraisal of the public health and primary care system through a scoping review and meta-synthesis.

Methods:

The review conducted systematically in 2018 with a scoping review approach. To identify pertinent studies, the following electronic databases were systematically searched until December 20, 2017: Cochrane, ISI Web of Science, PubMed, Scopus, Science Direct, and Embase. Reviewing the studies found on the search bases was carried out in three stages by two persons individually. According to refined studies, the data were extracted to meet the objectives and respond to the research questions. The thematic analysis was used to identify and categorize the dimensions of performance measurement.

Results:

Using this process, 20 studies were eligible for our research. The critical points in measuring the performance of the public health field were classified into eight main domains including leadership and stewardship, funding, resource generation, service delivery, quality, accessibility, efficiency/productivity, and community health status. The differences in measurement frameworks are inevitable. One reason for the differences in the health system performance measurement framework is the differences in the data or data collection, analysis, and reporting. Performance measurement in the field of health, especially primary care, was a multidimensional issue.

Conclusions:

Each of the main dimensions had several sub-criteria, indicating the broadness and complexity of the performance of first-level care providers. Single-dimensional performance measurement could underpin incorrect policies and decisions.

Factors affecting the performance of public out-patient services

Objective The delivery of public out-patient services is an essential part of complex healthcare systems, but the contribution of public out-patient services is often ill defined and poorly evaluated. The aim of this study was to identify and better understand those factors that may affect the performance of out-patient services to provide health service managers, clinicians and executives with a conceptual framework for future decision-making processes. Methods The present qualitative research involved five exploratory case studies. These case studies were conducted across two specialties at hospitals in the Metro North Hospital and Health Service in Queensland. Data were obtained from 38 interviews and 15 focus groups, and were analysed to identify common themes. Further analysis helped identify the most significant factors and build a conceptual framework for understanding the relationships between those factors and their effect on performance. Results Across both specialties there were 10 factors (scheduling, performance, service framework, categorisation or prioritisation of patients, internal and external stakeholders, resources, service demand, culture, system challenges and medical stakeholders) identified that may affect the performance of out-patient services. These factors were condensed into five core domains: culture, stakeholders, resources, demand and system reform. Conclusion Strategies to address the five core domains identified may provide a framework for sustainable improvement in the delivery of out-patient services. What is known about the topic? The provision of specialist out-patient services is an essential element of health service delivery. Access to specialist services in the public sector is challenging because of the escalating demand associated with an increasing and aging demographic. The factors that may affect the delivery of out-patient services need to be addressed for long-term sustainable improvement. What does this paper add? This paper provides a conceptual framework grounded in rigorous qualitative data analysis for understanding the internal and external factors that affect waiting times for specialist out-patient services. The results of this qualitative research indicate that there are five core domains that may influence waiting times in the public out-patient setting. When these domains are addressed at the strategic, tactical and operational levels, they have the potential to provide significant improvement in the delivery of out-patient services. What are the implications for practitioners? This paper guides the attention of relevant stakeholders towards the five core domains identified (culture, stakeholders, resources, demand and system reform) that influence the performance of waiting times at the operational, tactical and strategic levels within the public hospital setting.

"Three Nooses on Our Head": The Influence of District Health Reforms on Maternal Health Service Delivery in Vietnam

BACKGROUND

The impact of reorganisation on health services delivery is a recurring issue in every healthcare system. In 2005 Vietnam reorganised the delivery of health services at the district level by splitting preventive, curative, and administrative roles. This qualitative study explored how these reforms impacted on the organisation of maternal health service delivery at district and commune levels.

METHODS

Forty-three semi-structured interviews were conducted with health staff and managers involved in the provision of maternal health services from the commune to the central level within five districts of two Northern provinces in Vietnam. The data were analysed thematically.

RESULTS

The results showed that 10 years after the reforms created three district-level entities, participants reported difficulties in management of health services at the district and commune levels in Vietnam. The reforms were largely perceived to negatively affect the efficient and effective use of clinical and other resources. At the commune level, the reforms are said to have affected the quality of supervision of the communes and their staff and increased the workload in community health centres.

CONCLUSION

The findings from this study suggest that the current organisation of district health services in Vietnam may have had unintended negative consequences. It also indicates that countries which decide to reform their systems in a manner similar to Vietnam need to pay attention to coordination between a multiplicity of agencies at the district level.

Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding

BACKGROUND

This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS

Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS

Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS

Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.

Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala

INTRODUCTION

Mid-level health workers are on the front-lines in underserved areas in many LMICs, and their performance is critical for improving the health of vulnerable populations. However, improving performance in low-resource settings is complex and highly dependent on the organizational context of local health systems. This study aims to examine the views of actors from different levels of a regional health system in Guatemala on actions to support the performance of auxiliary nurses, a cadre of mid-level health workers with a prominent role in public sector service delivery. A concept mapping study was carried out to develop an integrated view on organizational support and identify locally relevant strategies for strengthening performance.

METHODS

A total of 93 regional and district managers, and primary and secondary care health workers participated in generating ideas on actions needed to support auxiliary nurses' performance. Ideas were consolidated into 30 action items, which were structured through sorting and rating exercises, involving a total of 135 of managers and health workers. Maps depicting participants' integrated views on domains of action and dynamics in sub-groups' interests were generated using a sequence of multivariate statistical analyses, and interpreted by regional managers.

RESULTS

The combined input of health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a cross-cutting theme. Pattern matching and go-zone maps indicated directions for action based on areas of consensus and difference across sub-groups of actors.

CONCLUSIONS

This study indicates that auxiliary nurses' performance is interconnected with the performance of other health system actors who require support, including managers and community-level collaborators. Organizational climate is critical for making auxiliary nurses feel supported, and greater attention to improving the quality of hierarchical relationships is needed in LMIC settings. The participatory nature of the concept-mapping process enabled health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance in a vulnerable region.