Local health systems in 21st century: who cares?-An exploratory study on health system governance in Amsterdam

'One Health' Actors in Multifaceted Health Systems: An Operational Case for India

The surging trend of (re)emerging diseases urges for the early detection, prevention, and control of zoonotic infections through the One Health (OH) approach. The operationalization of the OH approach depends on the contextual setting, the presence of the actors across the domains of OH, and the extent of their involvement. In the absence of national operational guidelines for OH in India, this study aims to identify potential actors with an attempt to understand the current health system network strength (during an outbreak and non-outbreak situations) at the local health system of Ahmedabad, India. This case study adopted a sequential mixed methods design conducted in two phases. First, potential actors who have been involved directly or indirectly in zoonoses prevention and control were identified through in-depth interviews. A network study was conducted as part of the second phase through a structured network questionnaire. Interest and influence matrix, average degree, network density, and degree of centralization were calculated through Atlas.Ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), UCINET (Analytic Technologies, Lexington, KY, USA) software. The identified actors were categorized based on power, administrative level (either at the city or district level), and their level of action: administrative (policy planners, managers), providers (physicians, veterinarians), and community (health workers, community leaders). The matrix indicated that administrative actors from the district level were ‘context setters’ and the actors from the city level were either ‘players’ or ‘subjects’. The network density showed a strength of 0.328 during the last outbreak of H5N1, which decreased to 0.163 during the non-outbreak situation. Overall, there was low collaboration observed in this study, which ranged from communication (during non-outbreaks) to coordination (during outbreaks). The private and non-governmental actors were not integrated into collaborative activities. This study concludes that not only collaboration is needed for OH among the sectors pertaining to the human and the animal health system but also better structured (‘inter-level’) collaboration across the governance levels for effective implementation.

From Urban Projects to Healthy City Policies

A definition of projectitis (also known as ‘projectism’) is proposed to describe a key barrier to full deployment of a Healthy City vision and values. This chapter argues that to put health high on local social and political agendas necessarily means to transcend project-based work, and move into lasting programme and policy development. The conditions for such approaches are favourable in Healthy Cities, as a number of glocal (global and local) developments invest and sustain longer term perspectives. These conditions include emphases on policy diffusion, social justice, a better understanding of complex systems, and global commitments to the development and implementation of Health in All Policies. These efforts, in turn, are grounded in renewed and tangible support from Universal Health Coverage and Primary Health Care, asset-based community health development, and better insights into what drives (health) equity and economic development. In describing these elements of policy development for value-based Healthy Cities the chapter also gives a firm argument for a broad range of stakeholders to engage successfully in longer term policy change.

European Healthy Cities come to terms with health network governance

A focus on good governance in the WHO European network of Healthy Cities mirrors the WHO Region's strategic emphasis-its member states in the Health 2020 strategy espouse governance for health as key. Healthy Cities adopted governance as a key value and approach to delivering specific health programmes and policies. This article reviews the extent to which they actually introduce and align governance concepts and approaches with their local government commitments. Healthy Cities show that better participation, policy-making and intersectoral action result from an emphasis on governance. This happens across the designated cities and is not limited to a certain class (in terms of population or geographical location) or the time they have been designated. The support of WHO in driving the governance agenda seems important, but no data are available to show that European Healthy Cities are different from other urban environments.

Generic versus specific competencies of entry-level public health graduates: employers' perceptions in Poland, the UK, and the Netherlands

Constant changes in society and the public health domain force public health professionals into new roles and the development of new competencies. Public health professionals will need to be trained to respond to this challenge. The aim of this comparative study among Poland, the UK and the Netherlands is to identify competence needs for Master of Public Health graduates entering the labour market from a European perspective. A self-administered questionnaire was sent to employers in the three countries, rating the importance of competency in public health on a master's level. In all three countries, interpersonal competencies, like team working and communication skills, are rated as highly important. However, employers in the UK and Poland generally rate public health specific competencies as much more important than their Dutch colleagues. It is concluded that while public health specific knowledge is providing a useful starting point for entry-level public health professionals, employers increasingly recognise the value of generic competencies such as communication and team working skills. The results suggest a stronger emphasis on teaching methods that encourage active learning and the integration of skills, which is crucial for enhancing graduates' employability, and foster an open attitude to multidisciplinary working, which is essential in modern health care.

Preventive home visitation programmes for older people: the role of municipality organisation

The organisational influence on benefits of preventive home visitation programmes for older people has escaped scientific evaluation. This study aims to investigate organisational structures and processes in relation to preventive home visits. As part of a randomised controlled trial investigating whether educational intervention towards municipality health care professionals could enhance active life expectancy, information of municipality leadership, home visit approach, strengths and limitations of communication within the organisation were obtained using individual and focus group interviews. Thirty-four municipalities in four counties participated. Data was systematically condensed using a phenomenological approach upon which general patterns were categorised into a theory-based formal typology of the preventive home visitation management in the municipalities. Three distinct strategies for preventive home visitation programmes were identified. Eighteen municipalities were categorised as "Framework Management", 15 as "Management by Rules" and one as "Project Management". Small municipality size was associated with the "Framework Management" type. "Management by Rules" municipalities had higher population densities and their overall expenses for older people were higher. "Framework Management" municipalities used more resources on preventive home visits, communicated better, experienced less staff changing and had higher social capital than "Management by Rules" municipalities. Municipality structures and management processes of preventive home visitation programmes varied considerably in 34 Danish municipalities, but the majority could be categorised as using either a "Framework Management" or a "Management by Rules" strategy. Each strategy is associated with particular advantages and disadvantages, which may explain differences in the overall benefit of the programme between municipalities.

Urban as a determinant of health

Cities are the predominant mode of living, and the growth in cities is related to the expansion of areas that have concentrated disadvantage. The foreseeable trend is for rising inequities across a wide range of social and health dimensions. Although qualitatively different, this trend exists in both the developed and developing worlds. Improving the health of people in slums will require new analytic frameworks. The social-determinants approach emphasizes the role of factors that operate at multiple levels, including global, national, municipal, and neighborhood levels, in shaping health. This approach suggests that improving living conditions in such arenas as housing, employment, education, equality, quality of living environment, social support, and health services is central to improving the health of urban populations. While social determinant and multilevel perspectives are not uniquely urban, they are transformed when viewed through the characteristics of cities such as size, density, diversity, and complexity. Ameliorating the immediate living conditions in the cities in which people live offers the greatest promise for reducing morbidity, mortality, and disparities in health and for improving quality of life and well being.

Comparing health system performance assessment and management approaches in the Netherlands and Ontario, Canada

Background

Given the proliferation and the growing complexity of performance measurement initiatives in many health systems, the Netherlands and Ontario, Canada expressed interests in cross-national comparisons in an effort to promote knowledge transfer and best practise. To support this cross-national learning, a study was undertaken to compare health system performance approaches in The Netherlands with Ontario, Canada.

Methods

We explored the performance assessment framework and system of each constituency, the embeddedness of performance data in management and policy processes, and the interrelationships between the frameworks. Methods used included analysing governmental strategic planning and policy documents, literature and internet searches, comparative descriptive tables, and schematics. Data collection and analysis took place in Ontario and The Netherlands. A workshop to validate and discuss the findings was conducted in Toronto, adding important insights to the study.

Results

Both Ontario and The Netherlands conceive health system performance within supportive frameworks. However they differ in their assessment approaches. Ontario's Scorecard links performance measurement with strategy, aimed at health system integration. The Dutch Health Care Performance Report (Zorgbalans) does not explicitly link performance with strategy, and focuses on the technical quality of healthcare by measuring dimensions of quality, access, and cost against healthcare needs. A backbone 'five diamond' framework maps both frameworks and articulates the interrelations and overlap between their goals, themes, dimensions and indicators. The workshop yielded more contextual insights and further validated the comparative values of each constituency's performance assessment system.

Conclusion

To compare the health system performance approaches between The Netherlands and Ontario, Canada, several important conceptual and contextual issues must be addressed, before even attempting any future content comparisons and benchmarking. Such issues would lend relevant interpretational credibility to international comparative assessments of the two health systems.