On the resilience of health systems: A methodological exploration across countries in the WHO African Region

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to “prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it”. There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

Moral distress and moral uncertainty in medical assistance in dying: A simultaneous evolutionary concept analysis

AIM

To develop a simultaneous, evolutionary concept analysis of moral distress and moral uncertainty in the context of medical assistance in dying (MAiD).

BACKGROUND

Moral distress is well represented in nursing literature but disagreement persists in how the concept is defined and understood. Moral uncertainty has not been investigated in-depth. Further definition and conceptual clarity is required to understand these concepts within the context of MAiD.

DESIGN

Simultaneous concept analysis.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and PubMed databases were searched for articles in English. The final sample consisted of 44 documents published from 1984 to 2019.

METHOD

An adapted combination of Rodgers's Evolutionary Model and Haase et al's Simultaneous Concept Analysis method.

RESULTS

Despite the significant overlap, moral distress and moral uncertainty have subtle distinguishing differences. Attributes of moral distress in the context of MAiD focus on knowing the right course of action but being unable to act, especially when conflict or suffering occurs. Attributes of moral uncertainty center on an inability to decide on which course of action to take or knowing what outcome is preferable.

CONCLUSION

More research is required to bring further clarity to these concepts and develop interventions to support nurses who receive requests for or participate in MAiD.

A Framework for Rigorous Qualitative Research as a Component of Mixed Method Rapid-Cycle Evaluation

As federal, state, and local governments continue to test innovative approaches to health care delivery, the ability to produce timely and reliable evidence of what works and why it works is crucial. There is limited literature on methodological approaches to rapid-cycle qualitative research. The purpose of this article is to describe the advantages and limitations of a broadly applicable framework for in-depth qualitative analysis placed within a larger rapid-cycle, multisite, mixed-method evaluation. This evaluation included multiple cycles of primary qualitative data collection and quarterly and annual reporting. Several strategies allowed us to be adaptable while remaining rigorous; these included planning for multiple waves of qualitative coding, a hybrid inductive/deductive approach informed by a cross-program evaluation framework, and use of a large team with specific program expertise. Lessons from this evaluation can inform researchers and evaluators functioning in rapid assessment or rapid-cycle evaluation contexts.

Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program

Objectives

Limited studies have investigated geographic accessibility to a nearby community pharmacy for elderly which is an essential determinant of the access to medications and pharmacy services. This research identified pharmacy deserts and investigated availability of different types of community pharmacies and their services for elderly enrolled in a State Pharmaceutical Assistance Program (SPAP).

Methods

The state of Pennsylvania in the US was used as a case to demonstrate the geographic accessibility to community pharmacy and services for elderly enrolled in SPAP. The locations of community pharmacies and households of elderly enrolled in SPAP were derived from Pharmaceutical Assistance Contract for the Elderly programs’ database. The street addresses were geocoded and the distance to a nearby community pharmacy was calculated for study sample using the haversine formula. The demographic and geographic data were aggregated to Census Tracts and pharmacy deserts were identified using the predefined criteria. Descriptive statistical analysis was used to determine whether there are statistical differences in the socio-demographic profiles and distribution of different types of community pharmacies and their services in pharmacy deserts and non-deserts. This research used hot spot analyses at county level to identify clusters of pharmacy deserts, areas with high concentration of different racial/ethnic groups and clusters of high densities of chain and independent pharmacies.

Results

The Spatial analysis revealed that 39% and 61% Census Tracts in Pennsylvania were pharmacy deserts and non-deserts respectively (p < 0.001). Pharmacy deserts were found to have significantly more females, married and white elderly and fewer blacks and Hispanics compared to pharmacy non-deserts. Pharmacy deserts had significantly fewer chain and independent pharmacies and less delivery and 24-hour services in pharmacies than pharmacy non-deserts. Hot spot analyses showed that clusters of pharmacy deserts were more concentrated in southcentral, northwest and northeast regions of the state which represent rural areas and overlapped with clusters of high concentration of white individuals.

Conclusions

The findings suggest that urban-rural inequality, racial/ethnic disparity and differences in availability of pharmacies and their services exist between pharmacy deserts and non-deserts. The methodological approach and analyses used in this study can also be applied to other public health programs to evaluate the coverage and breadth of public health services.

Preparing for section 501(r)

Steps hospitals should take to prepare for Section 501(r) requirements include the following: Prepare the board for its role in approving updated financial assistance, billing and collections, and emergency medical care policies. Revisit financial assistance policy eligibility requirements. Conduct a policy gap analysis. Review how the current financial assistance policy is publicized and make adjustments where necessary.

[Improvement of pharmaceutical benefits for military retirees in outpatient care]

For the purpose of improvement of pharmaceutical benefits for military retirees was designed the drug usage standard. This standard consists of 216 drug titles and is utilized in outpatient care in case of consistency. Monthly outpatient care costs for one military retiree are more than 900 rubles. New procedural and institutional mechanisms, ways of interdepartmental interactions, rational forms of its organization are necessary for the improvement of the effectiveness. These measures correspond to main principals of reorganization of the system of health care.

Pushing the limit. Minnesota probe of Accretive's collection practices raises new questions on hospital billing policies

The collection practices of hospitals once again grabbed the spotlight, with a report from Minnesota Attorney General Lori Swanson, left, that raises questions about aggressive techniques used by Accretive Health at Fairview Health Services in Minneapolis. While Fairview has already ended its contract with Accretive, a number of large systems still use the Chicago-based billing company.

Proactive approach identifies benefits

The University of Iowa Hospitals and Clinics in Iowa City, has developed strategies to identify uninsured patients early in the stay, and help them access ongoing care in the community. Twelve healthcare benefit assistance program social workers educate patients and families about financial options and help them apply for government-sponsored programs. Through a Revolving Fund agreement, the hospital pays the Medicaid rate to post-acute facilities while patients' Social Security Disability is pending and is paid back when the disability coverage is approved. Dedicated social workers help patients who need brand name medications and can't afford them sign up for national pharmaceutical assistance programs.

Think like a payer when patients are uninsured

Hospitals need to develop a detailed policy of when and how they'll provide post-acute financial assistance for uninsured or under-insured patients. The policy should allow staff to get real time decisions about what will be covered. Staff should apply the policy consistently to all patients in all situations. A policy frees up case managers to coordinate care for all their patients rather than spending hours at a time trying to line up post-acute care for unfunded patients.

[Experience in organization of drug supply for military personnel and military retirees in the United States]

In the U.S. troops and military retirees realize the right to obtain drugs by participating in a nationwide managed care program TRICARE under the routines TRICARE Pharmacy. Militarily, the U.S. health care holding drug based on the Basic Core Formulary and Extended Core Formulary, which are developed by US Department of Defense Pharmacy and Therapeutics Committee. Realization of subprogram TRICARE Pharmacy is performed by Express Scripts.

Monitoring duration of coverage in Medicaid and CHIP to assess program performance and quality

OBJECTIVE

To assess measures of Medicaid and Children's Health Insurance Program (CHIP) coverage duration for potential inclusion in a core set of children's health care quality measures as called for by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009.

METHODS

We reviewed published and unpublished reports and spoke to researchers, analysts, and program officials at the federal level and in selected states. Measures available in administrative data were assessed with regard to the feasibility of implementation and their validity in terms of their association with child health outcomes and state policy choices.

RESULTS

Although many measures are feasible to construct using existing administrative data, prospective measures of duration that examine a cohort of new enrollees were found to be the most valid measures based on research linking their outcomes to program policies and their consistent interpretation across states with similar enrollment and renewal structures. However, the inability of some states to link together data from their Medicaid and CHIP enrollment files affects the interpretation of these and other measures across states.

CONCLUSIONS

Prospective and retrospective measures of duration were recommended for inclusion in the core set of quality measures. Although the prospective and retrospective measures were ranked high in terms of validity and importance by the Subcommittee on Quality Measures for Children's Health Care in Medicaid and CHIP, concerns were raised about feasibility given that no state currently uses these measures to monitor program performance. Additional technical and financial resources and enhancements to administrative data systems will be needed to support state efforts in this area of quality assessment, particularly in the areas of linking Medicaid and CHIP data files, improving reason for dis-enrollment codes, and improving race and ethnicity coding. Monitoring how well states are doing at enrolling and retaining children in Medicaid and CHIP is a critical component to assessing overall program performance and quality and for interpreting many of the other proposed quality measures.

[Impact of mid-level management and support on the performance of a district health system in the Democratic Republic of the Congo]

INTRODUCTION

The aim of this study was to assess the contribution of mid-level management and support practices to the overall performance of a district healthcare system.

METHODS

This case study was carried out in the North Kivu Province of the Democratic Republic of the Congo. It was based on analysis of (i) preventive and curative healthcare services and (ii) management and support practices provided from 2000 to 2008.

RESULTS

In response to recurring sociopolitical unrest since 1992, the mid-level health system (provincial level) in North Kivu has strengthened management and support practices. The main goals have been to optimize allocation of interventions by external emergency organizations and integration of specialized program activities, to harmonize intervention techniques implemented by external partners, to standardize supervision of sanitary districts with regard to care provider skills, and to adapt strategic options defined by the Ministry of Health to the provincial level. Using this comprehensive approach, the performance of the North Kivu Province in terms of curative and preventive care has exceeded the national average since 2001. Between 2001 and 2008, use of curative services progressed from 0.36 to 0.50 new cases/capita/year. Positive results have also been recorded for infrastructure coverage, essential medicine stock, health information system, and emergency preparedness.

CONCLUSION

Stronger mid-level management and support practices have improved care activities in the health district while protecting the population from unstructured interventions by emergency organizations or specialized programs. A comprehensive management approach has also improved the resilience of the district and increased its contribution to Millennium Development Goals.

Sorry doctor, I can't afford the root canal, I have a job: Canadian dental care policy and the working poor

BACKGROUND

In Canada, most dental care is privately financed through employment-based insurance, with only a small amount of care supported by governments for groups deemed in social need. Recently, this low level of public financing has been linked to problems in accessing dental care, and one group that has received major attention are the working poor (WP), or those who maintain regular employment but remain in relative poverty. The WP highlight a significant gap in Canadian dental care policy, as they are generally not eligible for either public or private insurance.

METHODS

This is a mixed methods study, comprised of an historical review of Canadian dental care policy and a telephone interview survey of WP Canadian adults.

RESULTS

By its very definitions, Canadian dental care policy recognizes the WP as persons with employment, yet incorrectly assumes that they will have ready access to employment-based insurance. In addition, through historically developed biases, it also fails to recognize them as persons in social need. Our telephone survey suggests that this policy approach has important impacts in that oral health and dental care outcomes are significantly mitigated by the presence of dental insurance.

DISCUSSION

Canadian dental care policy should be reassessed in terms of how it determines need in order to close a gap that holds negative consequences for many Canadian families.

The primacy of politics: charting the governance of the Papua New Guinea health system since independence

To chart the course of health governance in Papua New Guinea (PNG) since Independence, this article identifies two arks of public sector administration in PNG. Each was instigated by the passing of an Organic Law. The reform periods presaged by the Organic Law on Provincial Government 1976 (OLPG) and the Organic Law on Provincial Governments and Local-level Governments 1995 (OLPGLLG) have fundamentally transformed the political and administrative structures governing the country, and in particularly those relating to health. Comparing the organization of the government-operated health system during each of these reform periods not only reveals why PNG's health services have struggled to improve since Independence, but also casts light on the key drivers of fundamental reforms in PNG. Ultimately, the exercise illustrates the 'primacy of politics', and why political concerns invariably trump service delivery concerns.

Parents’ Satisfaction with Medical and Social Assistance Provided to Children with Down Syndrome: Experience in Estonia

OBJECTIVE

Parents of children with mental or physical disabilities have been assumed to live more stressful lives than other parents, and people with Down syndrome (DS) may get second-rate care because of their diagnosis. The aim of this work is to investigate the extent of parents' satisfaction with medical and social services in Estonia provided for the DS individuals and their families.

METHODS

From 1999 to 2001, fifty-nine DS families answered questionnaires in which we inquired about their satisfaction with medical and social assistance.

RESULTS

We found that satisfaction with the quality of the information about DS is low, and most of the parents are not satisfied with the social benefits and rehabilitation options.

CONCLUSIONS

The DS families need more medical information about this syndrome. The medical staff has to learn more about how to deliver bad news and how to support parents. More work needs to be done in the area of rehabilitation options and social assistance.

Do interventions to increase income improve the health of the poor in developed economies and are such policies cost effective?

Health policy has shifted towards placing a greater emphasis on the role of lifestyle and life circumstances in improving health. The factors that are associated with poor health status are known, but the comparative effectiveness of specific policy interventions in improving health and reducing inequalities in health is unclear. For example, there is little evidence that specific policies aimed at providing income support or poverty eradication have any measurable impact on health. Two previous reviews have addressed the evidence in this area but in a fairly restrictive way. One considered only randomised trials and the other excluded non-cash benefits. This article builds on the previous reviews in three ways: a broader scope of study designs and types of intervention is considered; more recent literature is reviewed; and it considers the extent to which an economic evaluation framework has been applied. A systematic search of electronic databases was carried out for literature published since 1980 and in the English language. Each study was appraised in terms of its relevance to the question of interest, and the quality of the study design was appraised in terms of its capacity to provide robust answers. Few studies were found with health outcomes as their main focus. Most of the studies that used secondary data sources or survey data were of poor quality. Where economic evaluations were reported, these tended to be restricted to financial assessments. Different types of interventions were evaluated. In studies of cash benefits, there was limited evidence that they had a positive effect on some health domains, mainly psychosocial. Studies in welfare-to-work interventions produced mixed results in terms of impact on either income or health; there was no consistent relationship between income gains and health improvements. Five welfare-to-work studies included 'benefit-cost analysis', but these were essentially financial assessments. Studies of benefits in kind did not meet the quality criteria for inclusion in this article. Overall, we found no evidence of the potential cost effectiveness of income support or anti-poverty initiatives in improving health, nor is there a strong effectiveness literature on which to build such analysis. However, the hypothesis that increased income may improve health cannot be said to have been properly tested. Studies generally analyse the incremental effect of changes to the welfare system and do not estimate the health effects of current provisions. The production function for good health is complex. Increasing income may be a necessary, but not a sufficient, condition for the creation of better health in those with low incomes.

Barriers to forgoing nutrition and hydration in nursing homes

In the two decades since the Karen Quinlan case first brought the issues that now go under the heading of the "right to die" to the attention of the courts and the public, a well-accepted legal consensus has developed about the law governing the forgoing of life-sustaining medical treatment. Law and clinical medical practice do not always run in tandem, however, and what law prescribes does not always occur in practice. One aspect of the legal consensus-that artificial nutrition and hydration is a medical treatment and thus may be withheld or withdrawn according to the same procedures and standards as other life-sustaining medical treatments-is probably less well accepted than the remainder. For reasons that I will explain, this is understandable. But what is puzzling is that this element of the consensus seems to be even less well accepted in nursing homes than in acute-care hospitals.

[National plan for pediatric nephrology. Elaborated by the Nephrology Section of the Spanish Association of Pediatrics and by the Pediatric Nephrology Group of the Spanish Nephrology Association]

The document of the "National Program of Pediatric Nephrology" has been elaborated by Pediatric Group of Nephrologist of the Spanish Pediatric and Nephrology Associations. A methodical arrangement for the State has been included within the above mentioned document. Administrative, postgraduate training and medical care organization aspects are studied. Data concerning the distribution, profit of resources, number of the already existing and shortage of specialists, as well as those referring to accreditation of Centres and specialists, etc., have also been reviewed. A special attention has been paid to organization of end-stage renal disease treatment in children.