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Learning from evidence: Advice-seeking behaviour among Primary Health Care physicians in Pakistan.

Author(s) Asmat Malik1, Cameron Willis2, Saima Hamid3, Anar Ulikpan 4, Peter Hill 5.
Affiliation(s) 1Department of Research and Development, Integrated Health Services, Islamabad, Pakistan, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Maternal and Reproductive Health, Health Services Academy, Islamabad, Pakistan, 4School of Population Health, The University of Queensland, Brisbane, Australia, 5School of Population Health, The University of Queensland, Brisbane, Australia.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Systems
Summary Access to information is critical for creating and maintaining high performing Primary Health Care (PHC) systems. Among multiple sources of information, advice-seeking from humans possesses significant importance for the physicians in their clinical settings because they are looking for readily available answers to their questions. We used Tuberculosis and measles as a lens for analyzing the advice-seeking behavior of PHC physicians in Pakistan. The study concludes that the heath care providers are falling prey to stagnant system behaviour. There is a need to better understand system behaviors and to identify system principles such as information flows and feedback loops.
Background The available studies provide some insights into how physicians seek information while working in PHC settings. However, as this literature is largely confined to developed countries, there is relatively little known about how physicians in low-middle income countries access or use information when faced with difficult to diagnose conditions. In these settings, where access to electronic information sources is often scarce, understanding advice seeking behaviors from human sources becomes particularly important. Using methods grounded in systems science, this study examines the advice seeking behaviour of PHC physicians in a rural district of Pakistan, analyzes the degree to which the existing PHC system supports their access to advice, and explores ways this system might be strengthened to better meet provider needs.
Objectives Tuberculosis (TB) and measles are currently providing major challenges to PHC physicians in Pakistan. We used these two conditions as a lens for analyzing the advice-seeking behavior of PHC physicans in Pakistan. The specific research questions of this study were:
• To what degree does the existing structure of the PHC system in Pakistan support physicians in accessing advice on difficult to diagnose cases of tuberculosis and measles?
• To what degree are physicians satisfied with their current access to advice on difficult to diagnose cases of tuberculosis and measles?
• What changes, if any, do physicians recommend to improve their access to advice on difficult to diagnose cases of tuberculosis and measles?
In order to answer these research questions, this study has the following specific research objectives:
• To document the flow of information on diagnosing TB and measles cases in the PHC system of Pakistan;
• To describe the advice seeking behaviour of physicians in situations of difficult to diagnose cases of TB and measles;
• To explore physicians’ satisfaction with their access to advice in difficult to diagnose cases of TB and measles;
• To identify and describe possible changes, if any, that physicians recommend to improve their access to advice in difficult to diagnose cases of TB and measles.
Methodology This study was conducted at the district level in Pakistan from January 2013 to August 2013. The organization of health services at a district level is similar across Pakistan. With a cross-sectional study design we employed three research methods comprising:
1. Mapping of formal system of flow of information for diagnosing TB and measles.
Through documentary review and targeted key informant interviews with five district health administrators and line-managers of vertical health programs, we mapped the existing system of the flow of information for assisting physicians in diagnosing TB and measles cases. Illustrations of formal information dissemination systems were developed in the form of flow charts showing the direction of flow of information and roles and responsibilities for providing information/feedback at various hierarchical levels.
2. Survey for social network analysis of physician advice seeking behaviour.
A semi-structured questionnaire was used to conduct a survey for mapping professional networks. The key questions were structured to identify whom each physician had contacted for advice whenever faced a difficult to diagnose cases of TB and measles. Out of the 61 BHUs in district Attock, only those with an appointed physician (n=49) were invited to participate. The compiled data was imported in UCINET software for generating sociograms.
3. Key stakeholder interviews.
Based on the analysis of the findings from Sociograms, the BHU physicians were divided into three groups:
• Physicians who sought advice from a designated person (formally notified by the health department)
• Physicians who sought advice from someone other than a designated person
• Physicians who did not seek advice from any other person
This grouping provided the basis for selecting 11 study respondents for in-depth interviews. All study participants agreed to one-on-one interviews and consented to audio recording. Three separate interview guides were used during these semi-structured in-depth interviews among the three groups of study respondents. The average interview time was 20 minutes. The researchers using an inductive process identified categories, sub-themes and themes. The research team then compared their findings to optimize the data conformity. The final themes were presented after the research team’s consensus on the analysis process.
Results The present configuration of the primary health care system in Pakistan is largely a result of the push for universal health coverage and Health for All under the declaration of Alma Ata Conference on PHC in 1978. Under the influence of this global movement, an extensive network of PHC clinics (5449 Basic Health Units and 579 Rural Health Centers) has been established as the first point of contact for those seeking healthcare across all districts in Pakistan.
Early detection of both TB and measles is critical to decrease morbidity and mortality rates. There are multiple sources of information available to assist physicians in diagnosing cases of TB and measles including clinical guidelines, case definitions and case detection protocols. While these information sources are largely provided through government agencies, the precise channels used for their distribution and the ways in which physicians make use of these channels have not been made explicit. Mostly they use their personal social networks in order to seek guidance in clinical care from their friends, peers, and other disease-specific experts.
With a systems approach, the thematic analysis has been categorized under four key areas. Firstly, the health leadership designs health programs and interventions without placing competent experts and a pathway to seek information on difficult cases (system organizing). Referral systems are not functional and there is no feedback on the patients’ from whom advice is being taken. As a consequence, patients are lost to the private sector. Secondly, PHC clinics do not have functional linkages with tertiary care hospitals (system network). In addition, no needs assessment for refresher trainings is conducted by the health department. Thirdly, the PHC physicians are not provided any feedback on patients sent to higher level centers (system dynamics). There exists no formal system of communication and dissemination through which the latest research or related materials are shared. In addition, there exist no opportunities where PHC physicians can be placed at secondary or tertiary care hospital on a rotation basis. Lastly, the focus of the health managers and administrators is more on administrative running of programs and meeting targets (system knowledge). Consequently, capacity building in clinical management has become a neglected priority.
Conclusion The analysis of the PHC system in Pakistan clearly demonstrates that the problems in the health sector are deeply rooted and complex in nature. The evidence from this study demonstrates that in situations where PHC physicians require further advice in diagnosing potential cases of TB or measles, it is unclear from whom this advice is being sought, or the degree to which the current PHC system enables physicians to seek this advice.
PHC level acts as a driver for healthcare delivery system whereas human resources are the main driving force behind a functional health system because they provide a human link that connects the system building blocks. However, in Pakistan, the heath care providers are falling prey to  stagnant system behaviour. The solutions require a systems’ thinking that views public health problems as a part of a wider and dynamic system, with a focus on in-depth understanding of the linkages, relationships, interactions and behaviors among the sub-system components that characterize the entire system. It is imperative to better understand system behaviors and to identify system principles such as information flows and feedback loops.

Exploring Primary Care: System Dynamics in USA and Romania.

Author(s) Andrada Tomoaia-Cotisel1, Karl Blanchet2, Zaid Chalabi3, Samuel Allen 4, Victor Olsavsky 5, Cassandra Butu6, Michael Magill7, Bernd Rechel8
Affiliation(s) 1Health Services Research & Policy, London School of Hygiene and Tropical Medicine, Cluj-Napoca, United States, 2Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom, 3Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Utah Medical Education Council, Utah Medical Education Council, Salt Lake City, United States, 5WHO Country Office Romania, WHO Country Office Romania, Bucharest, Romania, 6WHO Country Office Romania, WHO Country Office Romania, Bucharest, Romania, 7Department of Family & Preventive Medicine, University of Utah, Salt Lake City, United States, 8Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
Country - ies of focus Romania, United States
Relevant to the conference tracks Health Systems
Summary Policy-makers are better able to identify and implement effective health system strengthening (HSS) efforts when they have an accurate understanding of the dynamic, emergent behavior of the system they are attempting to strengthen. Achieving such an understanding is difficult. Yet, without it, decisions can easily result in unintended consequences or policy resistance. This paper describes system dynamics methodologies employed in the context of a HSS effort in Utah, USA and explores ways of applying them in LMICs, based on a case study in Romania. We present differences in data needs, availability and quality; and discuss how methods can be modified in view of these constraints.
Background Policy-makers are better able to identify and implement effective health system strengthening (HSS) efforts when they have an accurate understanding of the dynamic, emergent behavior of the system they are attempting to strengthen. Achieving such an understanding is difficult. Yet, without it, decisions can easily result in unintended consequences or policy resistance. In high-income countries, such understanding is increasingly obtained through the use of complex system modeling and detailed statistical analysis using large datasets. However, in low- and middle-income countries (LMICs) the data available are more limited, introducing higher levels of uncertainty in health system parameters. Despite this uncertainty, systems thinking and system dynamics supplies decision-makers with information needed in HSS efforts.“Systems thinking” provides a comprehensive framework for capturing, from diverse perspectives, how health systems function and how complex changes occur. System dynamics takes this approach to the next level by developing quantitative computer-based simulation models that can analyze system behavior and simulate how systems respond to policy measures and other changes over time.
Objectives To describe system dynamics methodologies employed in the context of a HSS effort in Utah, USA. Methodologies used are explained and ways of applying them in low and middle income countries are explored, based on a case study in Romania. The World Health Organization projects the burden of non-communicable diseases (NCDs) in LMICs to grow from half of total disability-adjusted life years in 2004 to three quarters by 2030. As LMIC health systems are already strained, this awareness necessitates that LMIC policy-makers anticipate and prepare for the consequences of this shift. As many NCDs are best managed in primary care settings, many HSS efforts aim to enhance primary care. System dynamics provides methods for creating custom-tailored tools to do this.HSS efforts in Romania, as in other former communist countries, focus on overcoming a previous neglect of primary health care, while redesigning the provision and financing of primary care at the same time. The goal being to facilitate patient centered care with a whole person orientation, providing all key elements of primary care.
Methodology System dynamics methodology will be presented as used in a high-income country setting and as modified for implementation in a middle-income country setting. In both contexts, the core methodology progresses as follows: 1) develop a conceptual model of the health system, 2) transpose the conceptual model to a dynamic quantitative model of the system, 3) develop and run scenarios simulating the policies and interventions under consideration. This methodology is couched within a participatory action research approach. Methodological tools employed included: Causal Loop Diagrams (CLDs) identifying key system structures such as feedback loops and time delays; statistical analyses and literature review identifying relationships among system variables; model validation techniques and key informant discussions with a diverse set of stakeholders. Decision-makers are involved throughout the project, participating in model development and critique, providing key informant expertise, designing scenarios to be tested, and discussing scenario results.We present differences in high and middle income country data needs, availability and quality. We also discuss how methods can be modified in view of these data constraints. These modifications impact the model produced and the lessons obtained from it. Strengths and limitations of these modifications are discussed.
Results We found that applying a SD methodology in LMICs is possible, but that the level of uncertainty in the model developed depends on the type and amount of available data. CLDs can be developed on the basis of interviews with key stakeholders, as well as using information in the literature. Quantifying the relationship between the identified system variables should ideally use context-specific data to increase model validity. However, model validation techniques can be performed using less data, for example via key informant discussions to elucidate a relationship’s potential behaviour. A health system model can be operationalized using less than ideal datasets. Existing data sources include qualitative and quantitative data on primary care in Romania and nationwide hospital diagnosis-related groups (DRGs) data. Additional low-cost resources would be required to conduct key stakeholder interviews to verify model structure and to design policy scenarios.
Conclusion Applying system dynamics in HSS requires the creative use of mixed methods within the constraints of data availability, transdisciplinary research teams and multi-level stakeholder involvement (of patients, providers, administrators and policy-makers). In particular, in LMICs’ HSS efforts, policy-makers need to know how to adapt innovations to their specific context and health system. System dynamics methodology promises to allow for this kind of tailoring; it also provides a framework for conceptualizing and simulating system behavior. Its design, tools and required parameterization can draw on experiences from elsewhere, while at the same time be adapted to local contexts.

Immunization status of young people attending a youth clinic in Geneva, Switzerland

Author(s) Anne Meynard1, Emilien Jeannot2, Lydia Markham3, Claire-Anne Lazarevic 4, Bernard Cerutti 5, Francoise Narring6
Affiliation(s) 1Department of Pediatrics, Geneca University Hospitals, Geneva, Switzerland, 2Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland, 3Private general practice, Private general practice and school health service, Nyon, Switzerland, 4School Health Service , Department of Public instruction Geneva, Geneva, Switzerland, 5Faculty of medicine University of Geneva, Faculty of medicine University of Geneva, Geneva, Switzerland, 6Department of Pediatrics, University hospitals Geneva, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Advocacy and Communication
Summary This study aims to describe immunization status at first visit in a collective of young people coming to an academic youth clinic. Results confirm our hypothesis that many young immigrants have had adequate childhood vaccination especially for tetanus but  are missing Hepatitis B and HPV. Collaboration between nurses in the youth clinic and school health services allows, not only detection of under-vaccinated youth, but quick and effective vaccination .
Background Adolescents are under-vaccinated and have limited access to effective care or preventive services in many regions of the world. Data on immunization status of adolescents or young adults in Switzerland are scarce and little is known about barriers to adequate coverage. Swiss vaccination coverage data shows that children of foreign origin are usually better immunized, but that this difference is lost in adolescence, where the most important factor of adequate vaccination is the presence of a school health vaccination program.
Objectives The objective is to describe the immunization status at first visit and differences in immunization status according to duration of stay in Switzerland and nationality of young people coming to a mulitdisicplinary youth clinic in Geneva
Methodology Immunization status at first visit (medical file, immunization booklets or school health database) was collected retrospectively between January 2010 and June 2011 in all patients coming for a first visit at Geneva University hospital’s multidisicplinary youth clinic. The main outcomes were Tetanus antibody titers one month after a booster of tetanus containing regimen and immunization status at first visit and the comparing of rates between young people of Swiss or foreign origin and for foreigners according to duration of stay in Switzerland.
Results 89% of patients tested for tetanus antibodies had values above 1000 U/l indicating adequate childhood immunization with 29% above 10’000 U/l putting them at risk of hyperimmunization if given usual adult catch up regimens (3 dosis). On the contrary Hepatitis B serology was often negative among the same population in our sample. Finding written information about immunization is significantely higher in youth born in Switzerland regardless of sex and nationality for all vaccines studied (tetanus, measles, hepatitis B and HPV) but is inferior to Swiss vaccination coverage data. Collection of information was highly facilitated by collaboration between academic youth clinic and school health services.
Conclusion In the absence of data, many young people immunized against tetanus or measles might in fact already be well immunized for childhood vaccinations. Effective collaboration between school-health services, primary health care facilities and youth clinics is highly effective in improving adolescent vaccine coverage especially with the help of public heath policies. School health services are usually very well informed about vaccination strategies in countries of immigration and the WHO database can also help to adapt recommendations to migratory flows.  However, they might miss young people at higher risk of being under or over immunized for example those with no booklet, absent from school on the day of immunization campaign, or with no permanent address. In Switzerland, parental consent is required for Hepatitis B or HPV immunization for young people under 16 years of age.Individually adapted catch-up immunization plans for adolescents and young adults regardless of origin or gender can avoid unnecessary and unsafe vaccination, and bring attention to barriers to adolescent vaccination as well as other adolescent health issues. Individual counseling allows targeted screening for silent infectious diseases (STI’s, Hepatitis, Chagas disease or common parasitic infections) but should mainly focus on assessment of protective and risk factors for healthy development of young people.

Case Management in Mental Health Settings in Bosnia and Herzegovina.

Author(s) Darko Paranos1, Biljana Lakić2, Tatjana Popović3, Dženita Hrelja Hasečić 4.
Affiliation(s) 1Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina, 2Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 3Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 4Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Chronic Diseases
Summary Within scope of the Mental Health Project in Bosnia and Herzegovina (BIH) the Case Management in Mental Health was introduced across the country with the aim of improving the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs. In order to achieve planned objectives an integrated set of activities was conducted compromising of teaching materials development, continuous education activities targeting Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives and (Peer) Support to Mental Health institutions in applying Case Management. Initial findings indicate the significant increase in the number of CMHCs which successfully started with the application of the Case Management in their institutions.
Background Activities were conducted within the scope of the Mental Health Project (MHP) in Bosnia and Herzegovina (BIH). The Mental Health Project in BIH is a result of continuous commitment of the health ministries to continue the mental health reform in BIH. The mental health reform was launched in 1996 focusing on community-based care as a contrast to the traditional model that was mainly oriented towards hospital treatment of persons with mental disorders. The overall goal of the Mental Health Project in BIH, in the period June 2010 - December 2013, was to improve the general mental health of the population and enhance the capacities of policy makers and competent institutions for complying with European standards in mental health care in BIH. Since 2011 the Mental Health Project in Bosnia and Herzegovina was involved in trainings of Community Mental Health Centres staff in the field of Case Management with the aim to improve the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs.
Objectives The objectives of the Mental Health in BiH Project in the period June 2010 to December 2013 were as follows: 1. Improved administrative and legislative frameworks to enable efficient operations and processes in mental health care in both BiH entities, Federation of Bosnia and Herzegovina and Republika Srpska.
2. Persons with mental problems to have access to improved and better quality services of mental health care at the community level.
3. Provision of high-quality mental health services at the community level is supported as a priority of the reform process by the management structures in Community Health Centres.
4. Capacities to fight against stigmatisation and discrimination related to mental disorders are strengthened. Within the objective 2, the specific objectives include: a) Competencies and skills of the multidisciplinary teams of the Community Centres for Mental Health to be enhanced, b) Independence and responsibility of the nurses in provision of the mental health services and direct work with clients to be enhanced.In order to achieve planned objectives the integrated set of activities were conducted:
• Teaching materials development -
o The Case Management continuing education Curriculum and Manual development
• The continuous education -
o A Training of Trainers (ToT) course in Case Management
o The health professionals continuous education of Community Mental Health Centres multidisciplinary teams and
psychiatric hospitals/clinics/departments representatives
• (Peer) Support to Mental Health institutions in applying Case Management -
o Mentoring and support to Community Mental Health Centres and psychiatric
hospitals/clinics/departments in applying Case Management.
Methodology The case management is a collaborative process which connects users with services and available resources aimed at ensuring provision of optimal care. The approach involves the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders, and often reluctant to come into contact with mental health services. It is activated by establishing contact with customers in the community, a comprehensive needs assessment, developing individual "tailored" packages of care and effective coordination of services and treatments in a variety of services which increases the user's potential for recovery. The process of introducing the Case Management principles across Mental Health Settings in Bosnia and Herzegovina is based on a set of integrated activities. The Development of Teaching materials sets the fundamentals for the continuous education of multidisciplinary teams employed by Community Mental Health Centres and psychiatric hospitals/clinics/departments representatives. The core materials are the Case Management in Mental Health Curriculum and Manual which are organised into seven modules: I - Introduction to Case Management - concepts, principles, practices and theories; II – User Involvement and needs assessment; III - Assessment and Risk Management; IV - Planning of care, implementation of treatment and use of resources in the community; V - The Case Management at the first psychotic episode, early intervention and prevention of relapse; VI - Team Approach to Mental Health; VII - Gender and Mental Health. The Mental Health Professional continuous education was organised in two phases. The first step was to identify, recruit and train group of mental health professionals as a part of Case Management Training of Trainers course. The next step was to deploy trainers in training of Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives.Applying the Care Coordination model across the country began after the completion of the trainings. The Peer support to Mental Health Institutions across the country is organised Systematic (peer) support to application principles in Mental Health Settings will be conducted in between September- December 2013 with aim of ensuring increased access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs is secured.
Results The Mental Health Case Management Curriculum and Manual were developed setting the basis for continuous education of Mental Health Professionals in Bosnia and Herzegovina. Training for trainers was completed in 4 training cycles with total duration of 9 days. As an education result, 21 mental health professionals have been certificated and formally appointed as future trainers by entity MoHs. Training of CMHC multidisciplinary teams was organised involving 625 mental health professionals from 67 CMHCs and 15 psychiatric hospitals/clinics/departments. 565 professionals (or 90%) passed the final exam, and successfully completed the training. After completion of the trainings the application of Case Management across the Mental Health care institutions started. Initial findings indicate that the 54% CMHCs (37 out of 69) successfully started the application of the Case Management in their institutions. As such this data indicates the significant increase in number of institutions applying the Case Management compared with 4 CMHCs from the baseline conducted in 2008. (Peer) Support to Mental Health institutions will provide not only support to the institutions in applying Case Management in standardised manner, but will provide insight in terms of effectiveness in changing the practice of those institutions. The key indicators to measure success of the process (in the short term) are the percentage of CMHCs appointing the Case Managers, number of appointed Case managers per CMHC (segregated by profession, particular focus on nurses) and percentage of service users involved in care plan development. A particular focus will be on measuring the service users involved in Case Management satisfaction.
Conclusion CMHCs capacities to involve the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders are improved when compared to the initial survey. The significant increase in the number of CMHCs applying Case Management in their institutions is observed. The Case Management is recognised by the revised service nomenclature, an organised and officially recognised classification/ registry of the health services endorsed by entity/cantonal Health Insurance Funds. As only those services officially recognised in the nomenclature can be performed by health institutions and charged to HIFs, a long term sustainability of Case Management is supported. Initial findings emphasise the issues of a large number of patients covered by the coordinated care, lack of staff and other resources required for adequate Case Management application in their institutions. In addition, another obstacle in the implementation of the Case Management observed is weak cooperation among agencies and institutions involved in the Case Management process.