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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.

Dual practice in Uganda: the evolution and management of a complex phenomenon.

Author(s) Ligia Paina Bergman1, Freddie Ssengooba2, David Peters3.
Affiliation(s) 1Department of International Health, Johns Hopkins University School of Public Health, Washington, United States, 2Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 3Department of International Health, Johns Hopkins University School of Public Health, Baltimore, United States.
Country - ies of focus Uganda
Relevant to the conference tracks Health Systems
Summary Dual practice is widespread in developing countries, yet it is seldom accounted for in health workforce policies. A systems lens guided the development of a qualitative research design to describe how dual practice evolved and how it is currently managed in urban Uganda. We found that dual practice is deeply embedded in the Ugandan health system. In the absence of formal policies, the local, informal management and coping strategies provide learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of dual practice is essential for health workforce policy and planning in countries where this phenomenon occurs.
Background Dual practice, when government health providers also work in the private health sector, is widespread in developing countries, particularly in settings with rapidly developing private sectors. However, it is seldom accounted for in health workforce policy and planning. Uganda has an active private sector and a high proportion of health providers working multiple jobs, particularly in the capital region. An informal, unenforced ban on dual practice in a system where high demand for patient services is constrained by low supply of health professionals creates complexity and unanticipated dynamics over time. Informal management of dual practice, or local responses to complexity, have not been previously documented and could inform health workforce policy and planning in Uganda and similar settings.
Objectives Acknowledging that the health system is a complex adaptive system, this study applied a systems lens to describe how dual practice evolved and how this phenomenon is currently managed in urban Uganda.
Methodology A qualitative research design, supplemented by a review of historical and policy documents was used to develop five case studies of government health facilities, capturing the perspective of both health providers and health managers through semi-structured in-depth interviews. This is one of the few studies examining both doctors and nurses’ perspectives on dual practice. Additionally, interviews with policy stakeholders allowed the exploration of dual practice from multiple angles, from government to private sector. A causal loop diagram was constructed using the qualitative data in order to illustrate the influence of various health system actors, as well as interactions and feedback.
Results Dual practice in Uganda is rooted in the history surrounding the professionalization of medicine, the development of the private sector, and political and economic turmoil. Private practice, and dual practice, started as a privilege for African doctors seeking autonomy and professional status. Feedback from the economic decline and the deterioration of government infrastructure, transformed dual practice into a coping mechanism for health providers who did not migrate. Over time, the government’s skepticism and resistance to dual practice increased, although enforcing a ban has consistently been met with threats from providers leaving. Most respondents believed that the majority of health providers engaged in dual practice informally. Doctors and nurses enter dual practice through a variety of mechanisms – from direct recruitment, to informal networking. Internal labor markets have emerged around major facilities, where parallel institutions conduct well-funded research and service provision, usually related to infectious diseases. Informal management approaches at the facility level vary. In smaller facilities, nurses and doctors self-organize to ensure their shifts are covered. The facility in-charges’ emphasis is on performance and coverage during government hours, although those who had done dual practice in the past apply a personalized approach. In larger facilities, specialists organize their public and private activities depending on the type of service provided, at times in coordination with colleagues and supervisors.
Conclusion The systems lens fostered an approach to capture the perspectives of multiple health system actors, historically and across various levels of the Ugandan health system. The findings confirmed that, in the absence of formal policies, health providers adopt informal approaches to coping with and managing dual practice. Health managers emphasize the government job as a primary duty, while at the same time recognizing the reality that there are advantages to dual practice, from both the individual and the societal perspectives. Doctors and nurses have each developed unique coping mechanisms. The local management and coping strategies are learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of how dual practice evolves and how it is managed in a system is essential for health workforce policy and planning.

The ESTHER European Alliance: a decade of hospital partnerships assessed

Author(s) MEZGER Nathalie1.
Affiliation(s) 1Service de Medecine Tropicale et Humnanitaire, Hôpital Cantonal Universitaire de Genève, Genève, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Health Systems
Summary To evaluate a decade of activities, better define the current environment and its future, the ESTHER European Alliance, an initiative based on hospital/institutional partnerships with low resources countries, requested an external, qualitative assessment. Results showed that added value of these partnerships and of the EEA were well perceived. EEA seems in line with the current development cooperation landscape, helping to tackle the health human resources crisis and adapted to face the new health challenges. Nevertheless to better contribute and improve, there was a need to better demonstrate EEA's contribution to the health system strengthening and review its strategy.
Background The ESTHER Alliance (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau - EEA), a French initiative composed currently by 12 European member states (France, Italy, Luxembourg, Spain Germany, Austria, Belgium, Portugal, Greece, Norway, Switzerland, Ireland) and 1 observer (UK), was launched in 2002 to strengthen, through hospital partnerships, the capacities of low income countries to face the HIV/AIDS emergency and related diseases. Each ESTHER national entity is different from each other, but all signed a ministerial declaration of engagement to develop the initiative and are linked by a joint charter of principles.
In 2012 the Alliance members were active in 41 countries and involved in a wide range of training activities including collaboration with civil society organisations. As the last 10 years has seen a change in the worlds health needs and cooperation landscapes, ESTHER evolved and broadened its scope, scale and type of activities to include other health priorities that contribute to meet the Millennium Development Goals 4-5-6 and strengthen health systems to improve health outcomes.
In 2013, an external study was ordered by the Alliance to qualitatively assess the achievements and challenges faced by the EEA over its decade of existence.
Objectives This external qualitative evaluation of the ESTHER initiative, at European and country implementation level, aimed to capture the EEA’s achievements and challenges, draw lessons and clarify the EEA position in the current, evolving, development cooperation and health landscape in order to better define its future. This work was made on request of the EEA.
It focused on identifying the added value of the institutional partnerships for health, on identifying and analyzing the added value that the Alliance brings as a European platform for development cooperation in health, identifying commonalities and challenges for Alliance member bilateral partnership programs, evaluating contributions that partners have made to Health Systems Strengthening (HSS) and presenting future option to move forward.
Methodology Capacity Development International won the EEA international tender after each ESTHER national entity ranked the different candidate’s proposals for this qualitative evaluation.
Two investigators ran it. In all stages of the assessment they included the priority countries that have an active bilateral program (France, Germany, Spain, Italy, Norway and Ireland). Switzerland, Luxembourg, Greece and UK were involved in the first stage of this evaluation. Belgium, Portugal and Austria did not participate.
An extensive review of documents and literature provided by the EEA secretariat, the national coordinating bodies and the technical implementing partners, was performed. It was completed by an international literature review guided by key informants related to development cooperation, health partnerships, capacity development, human resources for health and health system strengthening.
The first stage of interviews focused on the ESTHER model, its achievement, its added value, the challenge and future. They reached the EEA secretariat, 10 northern governments, 13 national coordinating bodies and 2 experts working in the institutional partnerships.
Best practice demonstrating projects were selected by the interviewed national coordinating bodies to be included for the second type of interviews, which focused on the added value of hospital partnerships. Enablers, challenges, lessons learned and contribution to health system strengthening were reviewed. Nine northern implementing partners, 11 southern implementing partners and 3 southern government representatives were interviewed.
Results were analyzed at 4 different levels (added value of institutional partnerships for health, EEA level, National Secretariat level and partnership/project (case studies and lessons learned)) using the OECD/DAC framework (relevance, efficiency, effectiveness, sustainability) to draw out the main themes. Results were synthesised in the perspective of current thinking and EEA objectives and guidelines. Case studies concretely illustrated the evaluation, highlighted innovations, lessons learned and challenges in contributing to HSS.
Limitations were due to the limited time and geographical constraints. Data objective verification was beyond the scope of the study. Best practice projects were selected by the national secretariat and may be subject to bias. Descriptions were dependent on the completeness of information provided.
Results The added value of institutional partnerships (IP) for health based on capacity building and sustainable improvement was clearly perceived. Benefits were: institutional strengthening, responsiveness to needs, ownership, long term building of trust and capacity, peer to peer multidisciplinary exchanges, solidarity, innovation, ability to fund unusual interventions for development cooperation, opportunities to learn how to manage in deprived conditions and cultural sensitivity. IP was felt to go well beyond traditional assistance which is centered on short term filling of capacity gaps and was considered to be a complement to the classical development cooperation.
If hospitals, often neglected in the development, should remain central to ESTHER, inclusion of other organizations or levels was valued.
Concerns expressed the IP potential contribution to the aid fragmentation/proliferation, unintended harms, the creation of pockets of excellence and their real capacity to strengthen the health system.
Recognition, objectification, better definition of the EEA contribution to the HSS were felt to be improved, as the conceptualization of the IP added value to the gaining of knowledge, evidence and ease and the conceptualisation of costs.
The EEA added value was recognized (networking, information sharing), but much of its potential is not fully realized (joint projects, joint working, coordination).
Political mandate and release of resources not straightforward. Weight given to EEA validation and mandate varies. Political commitment was sometimes seen as a mere weight to back-up “ESTHER”, an IP quality brand. Consequently the quest for external funds becomes vital. This would be eased by a better demonstration of the EEA added value beyond members’ programs. The ESTHER diversity, a wealthy fishpond cemented by valuable charter of principles, makes knowledge generation and joint work challenging. If key, knowledge management will have to be balanced as resources are restricted.
In the changing global health agenda ESTHER seems well adapted to address issues such as the non-communicable diseases or the horizontal and integrated approaches. By building capacity, contributing to medical education and continued professional development EEA clearly addresses the human resource crisis.
There is momentum to revisit the EEA vision, strategy and objectives to better adapt to the on-going changes in economy, health and development cooperation.
Conclusion This qualitative study outlines that the EEA, which is based among others on institutional/hospital partnerships, capacity building, local ownership, is needs driven, has long term involvement, respects the Paris Declaration (enshrined in its shared charter of principles), is well aligned with the current thinking and best practices in development cooperation for health. It especially helps in tackling the health human resources crisis.
These principles and ESTHER multidisciplinary identity are clearly of value in the post MDG landscape. Initially focused on the HIV/AIDS crisis, a thematic which was already broadened to include the MDG4-5-6, the EEA has the potential to evolve and contribute to the new emergent health themes.
Added values of IP and of the EEA are well perceived by members, even if it is felt that there is still unveiled potential. The perceived addition of the work in partnerships over other forms of technical cooperation and of the EEA is nevertheless difficult to measure and demonstrate. Creation of enabling, inspiring environments by partnerships does not fully guarantee results. Approaches that address knowledge and capacity gaps through empowerment, leadership by the beneficiary and use of country systems are quite recent and lack rigorous evaluation material to assess their impact. Therefore, efforts should be made to develop material and evaluate processes and projects, but in a light and bearable manner. This could contribute to developing evidence on how to make a quality partnership that brings added value, a matter in which the Alliance could play a role.
Worldwide, little agreement exists on the effective strategy to strengthen the health system, one of the ultimate EEA goals. Operational research could help to clarify how partnership work can contribute to HSS at different levels. The EEA projects/programs diversity is a rich field to work on. This will require the Alliance members to better define and share a common understanding of the HSS.
This knowledge generation would serve EEA to better demonstrate its impact/contribution and increase donors and key stakeholders’ interest. Balance between operational research, monitoring/evaluation and service delivery will have to be found, especially when resources are scarce.
To take advantage of this momentum, clarification and re-definition of the Alliance strategy and structural improvement seem to be needed. A motivating challenge !

Administrative Integration of HIV Monitoring And Evaluation: A Case Study From South Africa.

Author(s) Mary Kawonga1, Sharon Fonn2, Duane Blaauw3.
Affiliation(s) 1Department of Community Health, Wits School of Public Health, Johannesburg, South Africa, 2School of Public Health, Wits School of Public Health, Johannesburg, South Africa, 3Centre for Health Policy, Wits School of Public Health, Johannesburg, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Health Systems
Summary With increasing global focus on the integration of vertical programmes within health systems, methods are needed to analyse whether general health service (horizontal) managers at district level exercise administrative authority over disease programmes (administrative integration). This study adapts "decision space" analysis to measure administrative integration of HIV programme monitoring and evaluation (M&E). The study shows that horizontal managers exercise high degrees of authority in producing HIV information but not in using it for decisions, while vertical managers use HIV information but in silos. The lack of M&E integration may undermine district health system strengthening aims.
Background In South Africa, integration is a health sector reform priority, while several vertical programmes exist, notably for HIV, tuberculosis (TB), and maternal and child health (MCH). Historically a national HIV/AIDS directorate and specialist HIV managers have vertically managed the HIV programme and HIV programme managers account for ear-marked HIV programme funding through dedicated parallel reporting mechanisms. This is at odds with current health sector decentralisation reforms that envisage integrated management of health services under the control of generalist (horizontal) managers at a decentralised district level. National health policy envisions health districts as the foundation of the national health system.
Objectives If health districts are to be the foundation of the health system as envisaged, then horizontal district managers would need to be allocated and to exercise authority over district health services, including disease-specific interventions (i.e. administrative integration). This study examines whether this is happening in the South African health system. We use the HIV programme as a case study given its traditionally vertical approach, and focus on the M&E (information) function as a tracer for analysing administrative integration. The research aims are to:
1. Describe the extent to which horizontal managers exercise authority over HIV M&E coordination.
2. Explore factors associated with exercised authority.
Methodology The research explores two hypotheses: a) vertical managers exercise higher degrees of authority than horizontal managers in administering HIV M&E; and higher management capacity and HIV M&E knowledge are associated with higher degrees of exercised authority. This cross-sectional study was conducted in two of South Africa’s nine provinces. Fifty one participants were interviewed including: a) managers primarily responsible for general health services or general health information (horizontal manager) and b) those responsible for vertical services or information (vertical manager). HIV M&E was defined as the production of HIV information (HIV data collection, collation, analysis) and use of HIV information for decisions.In the absence of existing methods for measuring 'exercised authority' over vertical programmes, Bossert's decision-space’ approach provided a useful frame. Since decision-space analysis has not been applied to either the M&E function or in the context of programme integration, it was adapted to measure ‘exercised (administrative) authority’ in this study. We defined exercised authority as a manager undertakes tasks to oversee HIV data collection, collation and analysis, and uses HIV data to review the programme and take action. To measure this, we first identified the M&E tasks that managers were expected to perform within each M&E domain (collection, collation, analysis, use) and then administered a semi-structured questionnaire to collect data on participants’ performance of these tasks. We developed four sub-scales to measure the degree of exercised authority for each M&E domain. Sub-scales comprised several items (M&E tasks), which we coded ‘no’ if a respondent did not perform the task (score zero) or ‘yes’ if s/he did. We computed an ordinal dependent variable for each HIV M&E domain and coded observed scores as ‘low’, ‘medium’, and ‘high’. We performed ordinal logistic regression to explore whether explanatory variables (actor type [horizontal or vertical], health system level, highest, qualification, duration of management experience, management capacity score, and M&E knowledge score) were predictive of higher degrees of exercised authority.
Results More than 75% of participants were female, with an undergraduate degree or higher, and had some management
training. Participant characteristics were similar between vertical and horizontal managers. Horizontal managers attained higher mean scores for HIV data collection.
Conclusion In light of the increasing focus on health system strengthening and integration, our research makes a contribution
by providing a method and scales for measuring and monitoring administrative integration. We anticipate that
these scales will be strengthened further by empirical testing on larger samples and varied settings. In applying this
method to South Africa’s public sector HIV programme, we find that HIV M&E coordination is generally not administratively integrated, characterised by horizontal managers exercising little authority in using HIV data, and vertical managers using HIV data in sub-programme silos. We argue that this programme model potentially undermines South Africa's policy aims of integrated management of district health services under the authority of horizontal general health service managers. The research also indicates that plans for integrating the HIV programme within the health system at decentralised district level should include investments in strategies to equip horizontal managers with the knowledge and skills to use programme data for decision-making.

Integration and Convergence in the context of National AIDS Program Planning in Resource-constrained Settings.

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India, 2, , , ,
Country - ies of focus Global,India
Relevant to the conference tracks Health Systems
Summary Using the principles of public health ethics, particularly resource allocation ethics, this paper conducts a conceptual analysis of Integration and Convergence in the light of National AIDS Program Planning in Resource-constrained Settings. Sustaining and maximizing current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that countries ought to do, without which the AIDS programs stand a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits beyond procedural ones.
Background HIV is now referred to as a chronic manageable condition – a class of conditions under which diabetes and hypertension are included. With the advent of ART and other advances in treatment, care, and support, and with the increasing number of persons newly infected with HIV, the number of people requiring prolonged care and treatment continues to grow. Thus there is a clear need to continue investments in order to consolidate and sustain the successes so far, as well as ensure that the successes of the global and national efforts are equitably distributed. Convergence and Integration have been advocated as means to achieve the above two goals. The Planning Commission of India working group on AIDS has also made remarks on similar lines that “one of the critical challenges is to move towards more effective and efficient approaches through convergence and integration of programme components such as basic HIV services, comprehensive care, support and treatment with National Rural Health Mission (NRHM) and general health systems to the extent possible” (Planning Commission Working Group on AIDS, 2011). Apart from reducing the costs of interventions, convergence and integration have the potential to strengthen overall health systems as well (Shakarishvili, G et al, 2011; 2010).
Objectives The objective of this paper is to analyse India's National AIDS Program planning through a lens of integration and a prism of resource allocation. The National AIDS Control Organization (NACO) – now a separate department under the central ministry of health and family welfare in India – conducted a series of consultations with stakeholder groups for planning the next phase of the National AIDS Control Program (NACP). Different reviews of the current phase of NACP indicate success against the set benchmarks on several fronts. The program is on track and will achieve the targets set for most of the indicators (NACO E-Consultation, 2011). The fourth phase of the program (NACP-IV) is projected as the logical next step in India’s efforts to halt and reverse the epidemic, which is also in line with the Millennium Development Goals (MDG). It is envisaged to build on the different achievements of its predecessor - NACP-III – in order to reverse the epidemic through enhanced prevention as well as reinforced care, support, and treatment. However, NACP officials themselves have stressed the need for concerted attention in future for “consolidating the gains and ensuring quality and coverage”. (NACO E-Consultation, 2011) In addition, there have been concerns regarding the availability of resources in order to continue the existing beneficial interventions and to accelerate the achievements in alignment with the national goals and the Millennium Development Goals (MDG) to halt and reverse the HIV epidemic. Quoting the Planning Commission of India’s steering committee on Health, media reports talked about a proposal to ‘merge’ NACP with the National Rural Health Mission (NRHM) (Times of India, 2012). According to some members of the steering committee, it is about training the front line health workers similar to the Auxiliary Nurse Midwives (ANMs) in the  AIDS program. However, officials from the Ministry of Health and NACO publicly expressed their unhappiness and emphasized that the NACP deals with a specialized issue and a clientele different from that of ANMs. (Times of India, 2012) It appears prima facie that this proposal for a “merger” originates with the objective to streamline the health programs. This most recent media debate does not mention the proverbial ‘elephant in the room’ which are the resource constraints faced by the AIDS program.
Methodology The analysis in this paper is based on the Modified Accountability for Reasonableness Framework. Whereas ethics can guide policy makers and program planners on “what ought to be done”, economic analysis and research evidence can substantially help in setting the priorities in a resource constrained environment. Scientific and research evidence informs us of the effectiveness of particular interventions in order to guide resource allocation decisions and economics tries to find out the efficiency of interventions from a population-health point of view. (Gibson J et al, 2005). While there has been concerted efforts to incorporate evidence and economics into the priority setting process, decision makers often feel a gap in ensuring the ethics  of decision making are addressed. (Gibson J et al, 2005). It is in this context that a framework like the Accountability for Reasonableness (A4R) becomes handy for decision makers to ensure a fair and legitimate process in priority setting (Daniels N, 2000). The A4R framework has demonstrated the potential benefits of ethical considerations to deal with the “how” part in the decision making process of allocating scarce resources. The further addition of a fifth condition of empowerment to the original four conditions further strengthens the framework (Gibson J et al, 2005). This addition is an important step in respecting autonomy by virtue of citizens and groups who are empowered to participate in the process.
Results The results of the analysis is described under the following five conditions of the A4R+E framework: Condition 1: Relevance
As per the Relevance condition, the decisions need to be made on the basis of reasons that ‘fair-minded’ stakeholders can agree upon as criteria for decision making. The reasoning must comprise evidence, principles, and values.Condition 2: PublicityThis condition stipulates that the decisions along with the rationale for decisions should be transparent and publicly accessible. Condition 3: Revision and Appeals
As per this condition, NACP-IV planning process must have built-in opportunities to revisit and revise decisions in light of further evidence or arguments and there should be a mechanism for challenge and dispute resolution.Condition 4: Enforcement
As per this condition "enforcement" is necessary to ensure that the above three process-oriented conditions are met.Condition 5: Empowerment
According to this condition, there must be “efforts to optimize effective opportunities for participation in priority setting and to minimize power differences in the decision making context”.Further, the following also needs to be kept in mind based on the results of conceptual research on Convergence and Integration. Convergence and Integration have different meanings – former being more of a programmatic high level consideration and the latter as a grass-roots level service delivery consideration. Yet, these two terms have traditionally been used synonymously to broadly refer to the concepts discussed in the above two paragraphs. However, the term ‘Merger’ is relatively new in this context and connotes a more radical approach where one entity will lose its identity once the process of merger is completed. In the context of health care organizations, mergers have raised difficult ethical issues from the perspective of clients and patients, and service providers (Shaw D, 2003). Even though mostly in the context of hospitals, there have been instances where the mergers achieved neither cost-reduction nor quality-improvement (Weil T, 2010). Thus, mergers, especially those done in haste, have the potential to harm the program and its beneficiaries. Even in the case of integration of HIV related services with general health systems, there are cautions against blanket integration as opposed to carefully planned integration of select interventions.
Conclusion The analysis in this paper reveals that issues related to resource allocation have not been acknowledged and addressed adequately in the planning process of NACP-IV. As a result, the planning process, even though participatory in nature, did not have a resource allocation framework to adhere to. Neither was it able to consult the stakeholders with possible options and rationales for decision making in the context of shrinking resources. In addition, the concepts of integration and convergence have not been dealt with in detail leaving room for speculations and misinterpretations as mergers. It does not seem to be a problem exclusive to India that resource allocation within and between sectors related to health gets inadequate if not neglected attention. Critiquing the report of the Commission on Social Determinants of Health, Bayoumi in 2009 has stated that the Commission missed an opportunity by being “largely silent” on the issue of resource allocation. However, the Commission’s report did in fact show skepticism towards the current trends of health care reform which gives a very narrow focus on economic efficiency; as opposed to a broader attention to priority measures (Bayoumi A, 2009). It is still not too late for India to adopt a framework like the modified version of the Accountability for Reasonableness framework with empowerment as an additional condition (Gibson J et al, 2005). Certainly, this framework cannot stand in isolation but must form a broader frame on which evidence and economic analysis form superimposing rubrics for decision making (Gibson J et al, 2006). For this to happen, first there should be an explicit acknowledgement of the ‘elephant in the room’, rather than silence about resource constraints. Sustaining and maximizing the current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that India ought to do, without which the AIDS program stands a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits apart from procedural ones (Gutmann A, 1997).

Equitable Access to Controlled Medicines in Nigeria: Assessment of access barriers.

Author(s) Ogori Taylor1, Olubukola Oyetunde2, Maureen Ebigbeyi3, Egbuta Okibe 4, Rui Vaz 5, Hashim Yusuf6, Iyabo Okpeseyi7, 8
Affiliation(s) 1Essential Drugs and Medicine Policy, Health Systems, World Health Organisation, Nigeria, Abuja, Nigeria, 2Clinical Pharmacy, Faculty of Pharmacy, University of Lagos, Lagos, Nigeria, 3Narcotics and Controlled Substances , National Agency for Food and Drug Administration and Control, Lagos, Nigeria, 4Food and Drugs Services Department, Federal Ministry of Health, Abuja, Nigeria, 5African Regional Office , World Health Organization, Abuja, Nigeria, 6Narcotics and Controlled Substances , National Agency for Food and Drug Administration and Control, Lagos, Nigeria, 7Food and Drug Services Department, Federal Ministry of Health, Abuja, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary Nigeria is currently undergoing a critical shortage of controlled medicines especially in the management of moderate and acute pain. National policies and regulations on controlled medicines focus mainly on preventing the diversion of the products to illicit channels without corresponding efforts to promote availability for medical use. Several strategies for control have been instituted which serve as barriers to access. Demand for narcotic analgesics was shown to be low, leading to an expiry of procured products. National policies should be reviewed to facilitate availability, accessibility and rational use of controlled substances for medical purposes while promoting adequate control.
Background WHO (2011) estimates that 83% of the world’s population who live in low and medium income countries have low to non-existent access to narcotic medicines especially for the treatment of moderate to severe pain. Thus, millions of people suffer moderate to severe pain and death due to not having access to narcotic medicines. Patients in this group include HIV/AIDS, cancer, accident/violence victims, chronic illnesses, surgery, women in labour, paediatric patients, and women in childbirth.Access to controlled medicines especially in the management of moderate and acute pain is currently acute in Nigeria. The Global Access to Pain Relief Initiative (2012) reported that Nigeria consumed only 0.1% of the minimum amount of narcotic analgesics required to manage pain in patients who died of HIV/AIDS and cancer in 2009. Consequently patients with end stage HIV/AIDS, terminal cancer, those suffering from injuries caused by accidents and violence, some chronic illnesses and those recovering from surgery undergo untold suffering due to lack of opioid analgesics which can easily control pain.
Objectives In order to provide sustainable solutions to the problem of access to narcotic analgesics and other controlled medicines, an assessment was carried out which studied the access to controlled medicines in Nigeria. Particular attention was paid to narcotic analgesics as psychotropic substances available in health facilities in public and private sector. The objective of the assessment was to locate the factors that affect access to controlled medicines in Nigeria. These factors were examined in the context of national policies and legislation, the country procurement and supply management systems, and regulatory control instituted as well as the rational use in facilities. The results will help with the formulation of adequate interventions that will ensure universal access to all patients who require them in a sustainable manner.
Methodology The relevant laws, policies, regulatory control practices, procurement and supply management relating to narcotics and controlled medicines were examined to determine their appropriateness in promoting or hindering access to controlled medicines. The procurement and supply at the Federal Central Medical Stores (FMS) and samples of secondary and tertiary health facilities throughout the country were examined. The WHO Country Assessment tool was used to analyse national policies, legislation and practices established in the country. The procurement history, quantification, pricing, storage facilities, distribution, expiry and documentation were evaluated using a tool developed at the WHO Country office.Interviews with the medicine regulatory authority were categorized and summarized. Procurement and supply management indicators from the FMS were calculated and presented as tables and graphical representations. Facility responses were summarized, categorized and presented as frequencies in tables and graphs. Prices of medicines were analysed using the WHO/HAI price and availability workbook. The median price ratios were compared with international prices.
Results Policies and Legislation.
The laws and policies on controlled medicines focus their provisions on control without any definite statement on the necessity to make them available for medical use. In addition, there is no specific national policy on controlled medicines to promote equitable access and rational use. Nigerian laws and regulations on controlled medicines are outdated and have stigmatizing words such as “dangerous drugs”, “addiction” which tend to confuse prescribers and limit their use.Procurement and Distribution.
Procurement of narcotic medicines is infrequent due to inadequate and irregular release of funds and lack of quantification of needs. The cost of procurement is high in relation to international reference prices probably due to the low quantity usually procured.There is poor geographical coverage. Distribution is centralized to Federal Medical Stores in Lagos requiring approval from several officers located at different locations. Currently, controlled medicines are limited to hospital pharmacies in the public sector. Private pharmacies and primary health care facilities are not permitted to stock controlled medicines. In addition, the heads of department of pharmacy or authorized pharmacists of institutions are required to appear in person at the FMS to collect their stocks. Most of these require travel between two to several days to collect stock thereby incurring very high costs. Sometimes controlled medicines expire at the FMS because facilities are unaware of their availability.

Although, Nigeria does not require further licensing to prescribe controlled medicines, most facilities limit prescribing to senior medical officers rather than to all trained, qualified and licensed officers. Prescriptions for narcotics in almost all facilities are limited to a duration of less than one week . Most facilities claimed not to stock narcotic medicines due to lack of prescriptions as physicians prefer combinations with analgesics for moderate and severe pain. Some combinations may cause adverse drug reactions and promote drug dependence. Inadequate capacity to prescribe may constitute a key barrier to use.

While pharmacists are not required to obtain additional licences in order to dispense narcotics, most facilities in the study permit only senior pharmacists to dispense controlled substances. The capacity to compound individual patient need is lacking in most facilities.

Conclusion Policies and legislation.
Develop/review and disseminate policies, legislation, guidelines and corresponding procedures for narcotics and controlled medicines that will promote availability and accessibility as well as adequate control of the products. Policies on the management of HIV, Family and Reproductive Health, Cancer, Mental Health, Surgery etc. need to incorporate adequate statements to require constant availability of relevant controlled products in health facilities at all times.Procurement and supply management.
Institute a Narcotics Medicines Revolving Fund in order to ensure adequate and sustainable financing for the procurement of narcotic medicines. Procure and distribute narcotics only on the basis of quantification of expressed needs by facilities. Procure annual needs in bulk to ensure affordable pricing. Evolve a decentralized distribution system based on the state structure in order to ensure equitable geographical distribution throughout the country and reduced cost of procurement by facilities.Rational use of narcotic medicines.
Build the capacity of health care professionals in prescribing and dispensing in order to ensure that patients receive narcotics appropriate to their medical needs. This can be achieved through the provision of pre and in-service training, clinical guidelines, dispensing and compounding guidelines as well as standard operating procedures.

Regulatory control.
Build adequate regulatory capacity of sufficient number of inspectors who are equipped with relevant guidelines, procedures and training and are evenly spread to ensure coverage of all facilities that procure, distribute and manufacture narcotics and controlled substances. Ensure coordination of all control agencies to improve effectiveness and promote communication.

Eldercare in Cameroon: attendance of a proximity hospital in Yaoundé.

Author(s) Jossy Eyenga-Oli1, Armelle-Lucrèce Ngougni-Kana2, Marcel Azabji-Kenfack3, Eddie-Karistan Lakoudjeu 4, Nkodo Mendimi 5
Affiliation(s) 1Direction, Hôpital de District de la Cité Verte, Yaoundé, Cameroon, 2DESSAF, DESSAF, Yaoundé, Cameroon, 3Department of Physiological Sciences, Faculty of MEdicine and Biomedical Sciences, Yaoundé, Cameroon, 4Social Affairs, DESSAF, Yaounde, Cameroon, 5Direction, Hôpital de district de la Cité Verte, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Health Systems
Summary Cameroon is entering a demographic transition era, as elsewhere in Subsaharan Africa, with more old persons in proportion to the general population. But, our hospitals are not prepared for elderly care in terms of attendance, since there are no baseline data. This study examined the attendance of a proximity district urban hospital, and gives the basic statistics of hypertension, diabetes and elderly admission in a 3-months period. We underlined the neccessity of planning a policy in terms of capacity building for elderly.
Background In recent years, several studies have reported that African countries are facing an era of demographic transition, with a marked increase in the proportion of elderly people. In Cameroon, recent statistics reported approximately 6% of older people in the general population.
Because our health services are not fully prepared specifically for the care of the elderly, it is essential to establish a statistical observatory hospital attendance by the elderly. This is in order to build better care policies for this population group. For this purpose, we have conducted this pilot study to provide baseline data in terms of attendance.
Objectives To describe the attendance and basic epidemiological patterns of elderly patients (≥60 years old) admitted to outpatient departments during a 3-months period, monitoring routine activities related to chronic health problems, hypertension and diabetes mellitus.
Methodology It was a cross sectional retrospective study conducted from June to August 2012. Data were collected from medical records, including age, sex, social status, medical history and type of treatment. Incomplete records were excluded from the study. Ageing was defined as follows: Group-A= “Younger patients”, aged 65 years. Statistical analysis was performed using MS Excel 2003.
Results At the outpatients department, we recruited consecutively from the registers a total of 1714 patients during the study period. The mean age of the whole attendance in adult consultations diabetes/hypertension unit was 39.5 years (21-87 years) and the sex ratio (male:female) of 1.08. We recorded 47,8%, 30,7% and 21,5% respectively for Group-A, Group-B and Group-C. Among them, 447 were definitely admitted for Diabetes and 171 for complicated hypertension. The diabetic patients were divided into 18,3% for Group-A, 48,3% in Group-B and 33,3% in Group-C. Hypertension patients were divided into 31,0% for Group-A, 41,5% in Group-B, and 27,5% in Group-C. The main comorbidities associated were chronic kidney disease (25.4% of the total attendance) and chronic heart disease (15,3%).
Conclusion These data show that, both in the outpatient department and admission wards, the proportion of older people varies between 20% and 45% of our health care activities, which is huge compared to the proportion of 6% the age in Cameroon. This pioneer work is an urgent plea to establish a more detailed preliminary for a plan that is dedicated to elderly care in district hospitals statistical observatory. A phase of capacity building of staff in aged care is also a conducive form of retraining.

Why Educational Interventions Fail in Changing Treatment Practices in Rural Hospitals: Evidence from Sri Lanka.

Author(s) Lalith Senarathna1, Cynthia Hunter2, Andrew Dawson3, Michael Dibley 4
Affiliation(s) 1South Asian Clinical Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka, 2Sydney School of Public Health, University of Sydney, Sydney, Australia, 3National Poisons Register & Clinical Toxicology, Royal Prince Alfred Hospital, Sydney , Sydney, Australia, 4Sydney School of Public Health, University of Sydney, Sydney, Australia.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Health Systems
Summary Non-adherence to education interventions is a barrier to improving hospital treatment. This qualitative exploration reveals that education interventions are capable of improving knowledge, but success of the intervention in rural hospitals depends on social dynamics of hospital and influences from the community. In these hospitals introducing new practices was easier than changing established practices. Treatments by clinicians were easily improved than practices with non-clinical staff involvements. Interventions for specific practices will be useful in improving adherence. Similarly, parallel community awareness programs to discuss changes of hospital practices will improve this situation.
Background Lack of continuous educational programs for health care workers has created a gap between standard patient treatment guidelines and actual practice in hospitals. This gap is a significance barrier in improving patient care in rural hospitals in low and middle income countries (LMICs) like Sri Lanka where rural primary care hospitals act as initial access point to health care for majority of the population. Although different educational strategies had been in use to promote clinical guidelines aimed at closing this gap for a range of disease in rural hospitals, non-adherence to educational interventions is a major issue. Reasons for this poor adherence to educational interventions in rural hospitals in LMIC settings have not been systematically studied. This lack of evidence has created difficulties in designing educational interventions to improve hospital treatment practices.
Objectives The objective of this study was to explore reasons for non-adherence to the recommendations from education intervention in rural hospitals in Sri Lanka.
Methodology This study was a qualitative exploration related to a completed cluster randomised controlled trial (Trail Registration Number ISRCTN73983810) conducted in 46 rural primary care hospitals in North Central Province of Sri Lanka to promote poisoning treatment guidelines using an outreach education approach. This study showed that recommended treatments which were to be initiated by clinicians were well adopted while other treatments with non-clinical staff involvement did not change. Practices that were not changed following the educational intervention were used to explore the reasons for non-adherence to recommendations from education interventions.
Focus group discussions were conducted with doctors, nurses and non-clinical staff members in selected interventional hospitals. A sampling framework developed using hospital capacity and staff numbers were used to select 8 hospitals from the intervention group for the data collection. Thematic analysis was conducted using transcribed records according to the principles of grounded theory.
Results This exploration showed that outreach education intervention was capable of improving knowledge of treatment guidelines and creating a positive attitude among hospital staff members. But this attitude and knowledge alone did not change the practices as recommended during the education interventions. There were other significant internal and external influences which played a major role in treatment decisions such as social dynamics within hospital and where the influence from the communities were more prominent. In rural hospitals where there is limited staff availability, even non-clinical staff perform assisting roles in patient treatments. Hence, changing long established practices for which both clinical and non-clinical staff contribute cannot be changed using interventions designed only for clinical staff. Introducing new practises or treatments are relatively easier than changing long established inappropriate practices.
In these rural hospitals, treatment decisions are shaped to meet community expectations which are, at times, not aligned with the recommendations from clinical guidelines or interventions. Hospital staff including doctors are reluctant to neglect requests from the community in fear of becoming unpopular. During the group discussions, doctors stated that that community awareness programs parallel to hospital education interventions are essential when promoting updated treatment practices in rural hospitals.
Conclusion In rural Sri Lankan hospitals, only education interventions do not improve treatment practices. Social dynamics of the hospital and expectations of the community influence treatment decisions. Hence, these factors should be considered in designing education interventions in rural hospitals, not only in Sri Lanka, but also similar settings in other low and middle income countries. Furthermore targeted interventions aimed at selected hospital staff categories or specific treatment practices would be more appropriate than common interventions for all staff. Similarly, awareness programs to educate community about changes in village hospitals and updates of treatment practices would facilitate improvements in the hospitals.

New Model of Formative Supervision to Improve Health Outcomes in Ukraine

Author(s) Martin Raab1, Nataliia Riabtseva2
Affiliation(s) 1Health Technology & Telemedicine Unit, Swiss Center for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Swiss Center for International Health, Swiss Tropical and Public Health Institute, Kyiv, Ukraine.
Country - ies of focus Ukraine
Relevant to the conference tracks Health Systems
Summary Swiss-Ukrainian Mother & Child Health Programmes aim to improve the quality of MCH care in Ukraine. One of the tools is formative supervision: regular structured visits to hospitals. The visits are provided by a trained team according to developed guideline. The following results are observed: improved clinical skills and practices of personnel, more comfortable, friendly & safe conditions for patients, enhanced collaboration with local authorities, etc. The approach is evaluated highly by regional management who provide logistical & financial support for the team.
What challenges does your project address and why is it of importance? The overall objective of the programme is to reform perinatal health services in the Ukraine. Historically, health services staff are hierarchically governed and directed by decrees and narrow guidelines. This human resources management scheme had been impeding continuous education based on evidence based knowledge. At the same time, health care administrations had inadequate access to information about factors leading to positive or negative health services outcomes, while the rates of maternal and infant mortality and morbidity in the country are 2-3 times higher comparing to EU averages.
How have you addressed these challenges? Do you see a solution? The special focus is on antenatal, delivery and postnatal care provision in antenatal clinics and maternity hospitals.
Key interventions are regular, structured visits to health facilities and round table discussions with managerial and service personnel. Supervisors (obstetricians, neonatologists, managerial officers) had been trained and are guided by a manual elaborated by the programme. The supervision guideline is composed of a methodology section and by assessment tools ensuring the information and data capture according to a unified format. This allows the evaluation of field information and thus allows the comparison of data across different services regions and across time. On the basis of the information obtained, gaps analysis is performed and further improvement interventions are planned and implemented.
The formative supervision is based on principles of peer support and the identification and dissemination of good practice encountered in different Ukrainian regions and facilities. Personnel of particular service regions have been assessed by supervision teams from other regions (peer exchange approach). The overall supervision approach developed for Ukraine contains key findings and elements from the WHO and leading international professional associations.
The manual for formative supervision is actively promoted throughout the country and is available under the following address:
How do you know whether you have made a difference? The development of the perinatal health services are monitored by an M&E information system which collects quantitative and qualitative information. Special interviews with personnel in the frame of the M&E scheme provide information on central changes targeted by the programme (e.g. the availability of an adequate building and devices infrastructure according to a set standard or the diagnosis and treatment according to new evidence based guidelines, etc.). Qualitative evaluation revealed an increased staff satisfaction and motivation as a result of the supervision interventions.
Concrete improvement outcomes: successful reorganization of obstetric and neonatal services according to perinatal concepts, renovations to assure thermo stability for women and newborns, improved psycho-social conditions for women and partners, the improvement of clinical skills (e.g., urgent care for woman with pre-eclampsia, correct assessment of newborn’s status, breathing support for newborn), better collaboration with local authorities for financial and policy support and improved contact with mass media to deliver health promotion messages.
Have you or the project mobilized others and if so, who, why and how? The Project mobilized:
1) Regional authorities: via regular meetings and reporting on the results – to assure their ‘political goodwill’ and support for the teams;
2) Regional team: via trainings, provision and training of manual, supervision from national consultants – so they actually perform the visits and ‘keep an eye’ on what’s going on in their regions and what is to be improved.
3) Chief / Head doctors of the partner hospitals: via special training “Why monitoring / supervision is needed? How could it be useful for managers?” – to assure their support and performance of the recommendations which occurs as a result of the visits.
When your donor funding runs out how will your idea continue to live? The regional authorities and teams will continue this activity as the positive outcome is palpable and widely promoted through national events. For this reason, authorities provide additional financial and logistical support (e.g. assuring the transportation for the team to the hospital).