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Background: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context.Main Text: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes.Conclusions: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures. [ABSTRACT FROM AUTHOR]

Background: In the organization of health care and health care systems, there is an increasing trend towards integrated care. Policy-makers from different countries are creating policies intended to promote cooperation and collaboration between health care providers, while facilitating the integration of different health care services. Hopes are high, as such collaboration and integration of care are believed to save resources and improve quality. However, policy-makers are likely to encounter various challenges and limitations when attempting to turn these great ideas into effective policies. In this paper, we look into these challenges.Main Body: We argue that the organization of health care and integrated care is of public concern, and should thus be of crucial interest to policy-makers. We highlight three challenges or limitations likely to be encountered by policy-makers in integrated care. These are: (1) conceptual challenges; (2) empirical/methodological challenges; and (3) resource challenges. We will argue that it is still unclear what integrated care means and how we should measure it. 'Integrated care' is a single label that can refer to a great number of different processes. It can describe the integration of care for individual patients, the integration of services aimed at particular patient groups or particular conditions, or it can refer to institution-wide collaborations between different health care providers. We subsequently argue that health reform inevitably possesses a political context that should be taken into account. We also show how evidence supporting integrated care may not guarantee success in every context. Finally, we will discuss how promoting collaboration and integration might actually demand more resources. In the final section, we look at three different paradigmatic examples of integrated care policy: Norway, the UK's NHS, and Belgium.Conclusions: There seems widespread agreement that collaboration and integration are the way forward for health care and health care systems. Nevertheless, we argue that policy-makers should remain careful; they should carefully consider what they hope to achieve, the amount of resources they are willing to invest, and how they will evaluate the success of their policy. [ABSTRACT FROM AUTHOR]

Background: It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability. Methods: In NSW—the largest populational jurisdiction in Australia, and over three times the size of the UK—the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people. Conclusions: In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets—emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general. Plain English summary: This review outlines a $30 million health system reform to eating disorder treatment implemented by the NSW State Government six years ago which has seen large-scale service and workforce development across 15 geographical districts. This spans almost one million square kilometres and services 7.75 million people in Australia. The reform is very large in scale and is now in its second phase of implementation. Here outlined is the strategic process of policy and practice change of the entire reform and initial findings from an external review of phase one, which demonstrates positive effects on all three service targets—emergency departments presentations, hospital admissions and community occasions of service—including increased rates of treatment provision, improved perception of eating disorders amongst health professionals, improved pathway options and better communication within multidisciplinary teams. This type of whole-of-health system government led reform has relevance and learnings for health systems internationally. [ABSTRACT FROM AUTHOR]

Background: The healthcare financing reforms initiated by the Government of Georgia in 2007 have positively affected inpatient service utilisation and enhanced financial protection, especially for the poor, but they have failed to facilitate outpatient service use among chronic patients. Non-communicable diseases significantly affect Georgia's ageing population. Consequently, in this paper, we look at the evidence emerging from determinants analysis of outpatient service utilisation and if the finding can help identify possible policy choices in Georgia, especially regarding benefit package design for individuals with chronic conditions.Methods: We used Andersen's behavioural model of health service utilisation to identify the critical determinants that affect outpatient service use. A multinomial logistic regression was carried out with complex survey design using the data from two nationally representative cross-sectional population-based health utilisation and expenditure surveys conducted in Georgia in 2007 and 2010, which allowed us to assess the relationship between the determinants and outpatient service use.Results: The study revealed the determinants that significantly impede outpatient service use. Low income, 45- to 64-year-old Georgian males with low educational attainment and suffering from a chronic health problem have the lowest odds for service use compared to the rest of the population.Conclusions: Using Andersen's behavioural model and assessing the determinants of outpatient service use has the potential to inform possible policy responses, especially those driving services use among chronic patients. The possible policy responses include reducing financial access barriers with the help of public subsidies for sub-groups of the population with the lowest access to care; focusing/expanding state-funded benefits for the most prevalent chronic conditions, which are responsible for the greatest disease burden; or supporting chronic disease management programs for the most prevalent chronic diseases and for special age groups aimed at the timely detection, education and management of chronic patients. [ABSTRACT FROM AUTHOR]

Background: This paper discusses the way in which women's health concerns were addressed in Mexico as part of a health system reform. Discussion: The first part sets the context by examining the growing complexity that characterizes the global health field, where women's needs occupy center stage. Part two briefly describes a critical conceptual evolution, i.e. from maternal to reproductive to women's health. In the third and last section, the novel "women and health" (W&H) approach and its translation into policies and programs in the context of a structural health reform in Mexico is discussed. W&H simultaneously focuses on women's health needs and women's critical roles as both formal and informal providers of health care, and the links between these two dimensions. Summary: The most important message of this paper is that broad changes in health systems offer the opportunity to address women's health needs through innovative approaches focused on promoting gender equality and empowering women as drivers of change. [ABSTRACT FROM AUTHOR]

Background: The United Arab Emirates (UAE) government aspires to build a world class health system to improve the quality of healthcare and the health outcomes for its population. To achieve this it has implemented extensive health system reforms in the past 10 years. The nature, extent and success of these reforms has not recently been comprehensively reviewed. In this paper we review the progress and outcomes of health systems reform in the UAE.Methods: We searched relevant databases and other sources to identify published and unpublished studies and other data available between 01 January 2002 and 31 March 2016. Eligible studies were appraised and data were descriptively and narratively synthesized.Results: Seventeen studies were included covering the following themes: the UAE health system, population health, the burden of disease, healthcare financing, healthcare workforce and the impact of reforms. Few, if any, studies prospectively set out to define and measure outcomes. A central part of the reforms has been the introduction of mandatory private health insurance, the development of the private sector and the separation of planning and regulatory responsibilities from provider functions. The review confirmed the commitment of the UAE to build a world class health system but amongst researchers and commentators opinion is divided on whether the reforms have been successful although patient satisfaction with services appears high and there are some positive indications including increasing coverage of hospital accreditation. The UAE has a rapidly growing population with a unique age and sex distribution, there have been notable successes in improving child and maternal mortality and extending life expectancy but there are high levels of chronic diseases. The relevance of the reforms for public health and their impact on the determinants of chronic diseases have been questioned.Conclusions: From the existing research literature it is not possible to conclude whether UAE health system reforms are working. We recommend that research should continue in this area but that research questions should be more clearly defined, focusing whenever possible on outcomes rather than processes. [ABSTRACT FROM AUTHOR]

Background: The construction of the ordered health delivery system in China aims to enhance equity and optimize the efficient use of medical resources by rationally allocating patients to different levels of medical institutions based on the severity of their condition. However, superior hospitals have been overcrowded, and primary healthcare facilities have been underutilized in recent years. China has developed a new case-based payment method called "Diagnostic Intervention Package" (DIP). The government is trying to use this economic lever to encourage medical institutions to actively assume treatment tasks consistent with their functional positioning and service capabilities. Methods: This study takes Tai'an, a DIP pilot city, as a case study and uses an interrupted time series analysis to analyze the impact of DIP reform on the case severity and service scope of medical institutions at different levels. Results: The results show that after the DIP reform, the proportion of patients receiving complicated procedures (tertiary hospitals: β3 = 0.197, P < 0.001; secondary hospitals: β3 = 0.132, P = 0.020) and the case mix index (tertiary hospitals: β3 = 0.022, P < 0.001; secondary hospitals: β3 = 0.008, P < 0.001) in tertiary and secondary hospitals increased, and the proportion of primary-DIP-groups cases decreased (tertiary hospitals: β3 = -0.290, P < 0.001; secondary hospitals: β3 = -1.200, P < 0.001), aligning with the anticipated policy objectives. However, the proportion of patients receiving complicated procedures (β3 = 0.186, P = 0.002) and the case mix index (β3 = 0.002, P < 0.001) in primary healthcare facilities increased after the reform, while the proportion of primary-DIP-groups cases (β3 = -0.515, P = 0.005) and primary-DIP-groups coverage (β3 = -2.011, P < 0.001) decreased, which will reduce the utilization efficiency of medical resources and increase inequity. Conclusion: The DIP reform did not effectively promote the construction of the ordered health delivery system. Policymakers need to adjust economic incentives and implement restraint mechanisms to regulate the behavior of medical institutions. [ABSTRACT FROM AUTHOR]

Background: The vision of transforming health systems into learning health systems (LHSs) that rapidly and continuously transform knowledge into improved health outcomes at lower cost is generating increased interest in government agencies, health organizations, and health research communities. While existing initiatives demonstrate that different approaches can succeed in making the LHS vision a reality, they are too varied in their goals, focus, and scale to be reproduced without undue effort. Indeed, the structures necessary to effectively design and implement LHSs on a larger scale are lacking. In this paper, we propose the use of architectural frameworks to develop LHSs that adhere to a recognized vision while being adapted to their specific organizational context. Architectural frameworks are high-level descriptions of an organization as a system; they capture the structure of its main components at varied levels, the interrelationships among these components, and the principles that guide their evolution. Because these frameworks support the analysis of LHSs and allow their outcomes to be simulated, they act as pre-implementation decision-support tools that identify potential barriers and enablers of system development. They thus increase the chances of successful LHS deployment.Discussion: We present an architectural framework for LHSs that incorporates five dimensions-goals, scientific, social, technical, and ethical-commonly found in the LHS literature. The proposed architectural framework is comprised of six decision layers that model these dimensions. The performance layer models goals, the scientific layer models the scientific dimension, the organizational layer models the social dimension, the data layer and information technology layer model the technical dimension, and the ethics and security layer models the ethical dimension. We describe the types of decisions that must be made within each layer and identify methods to support decision-making.Conclusion: In this paper, we outline a high-level architectural framework grounded in conceptual and empirical LHS literature. Applying this architectural framework can guide the development and implementation of new LHSs and the evolution of existing ones, as it allows for clear and critical understanding of the types of decisions that underlie LHS operations. Further research is required to assess and refine its generalizability and methods. [ABSTRACT FROM AUTHOR]

Background: In 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called "hospital autonomy" policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals' performance, hoping to reduce government's costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings.Methods: We conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach.Results: We found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals' organization, feasibility of policy implementation, actors and stakeholders' support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure.Conclusions: Autonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result. [ABSTRACT FROM AUTHOR]

Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances. [ABSTRACT FROM AUTHOR]

The Australian health system has been the subject of multiple reviews and reorganisations over the last twenty years or more. The year 2004-2005 was no different. This paper reviews the reforms, (re)structures and governance arrangements in place at both the national and state/territory levels in the last year. At the national level some progress has been made in 2004/05 through the Australian Health Ministers' Council and there is now a national health reform agenda, albeit not a comprehensive one, endorsed by the Council of Australian Governments (COAG) in June 2005. Quality and safety was an increasing focus in 2004-2005 at both the national and jurisdictional levels, as was the need for workforce reform. Although renewed policy attention was given to the need to better integrate and coordinate health care, there is little evidence of any real progress this last year. More progress was made on a national approach to workforce reform. At the jurisdictional level, the usual rounds of reviews and restructuring occurred in several jurisdictions and, in 2005, they are organisationally very different from each other. The structure and effectiveness of jurisdictional health authorities are now more important. All health authorities are being expected to drive an ambitious set of national and local reforms. At the same time, most have now blurred the boundary between policy and service delivery and are devoting significant resources to centrally 'crisis managing' their service systems. These same reasons led to decentralisation in previous restructuring cycles. While there were many changes in 2004-2005, and a new national report to COAG on health reform is expected at the end of 2005, based on current evidence there is little room for optimism about the prospects for real progress. [ABSTRACT FROM AUTHOR]

Background: Currently, China is in the process of medical and health care reform, and the establishment of primary medical and health services covering urban and rural residents is an important aspect of this process. Studying the satisfaction of residents of underdeveloped areas with their primary medical and health services and identifying the factors that can increase the satisfaction of different groups may improve patient compliance and ultimately improve health. Moreover, such research may provide a reference for the development of medical and health undertakings in similarly underdeveloped areas.Methods: A face-to-face survey was conducted on a stratified random sample of 2200 residents in Gansu by using structured questionnaires. Demographic characteristics were collated, and questionnaires were factor-analysed and weighted using SPSS software to obtain scores for each factor, as well as total satisfaction scores. The characteristics of poorly satisfied populations were determined by a multiple linear regression analysis using SAS software. A cluster analysis was performed using SAS software for classification and a separate discussion of populations.Results: The hypertension self-awareness rate (11.29%) of the sampled population was lower than the average hypertension prevalence (23.85%), as recorded in the 2014 Health Statistical Yearbook of the region. The disease knowledge awareness factor was the lowest factor (2.857), whereas the policy awareness factor was the highest factor (4.772). The overall satisfaction was moderate (3.898). The multivariate linear regression model was significant (p <0.05). The regression coefficients were -0.041 for minors; 0.065 for unemployed people; and 0.094 for people with an elementary school educational level, a value lower than that of other population groups. A cluster analysis was used to divide the respondents into five groups. The overall satisfaction was lowest in the second population group (rural, middle-aged)(Fz = 3.64) and was highest in the fourth population group(minors) (Fz = 4.13). Different population groups showed different satisfaction rates in F1 to F6.Conclusion: Hypertensive patients had low self-awareness, and residents had a poor grasp of disease and limited health knowledge. Their overall satisfaction was moderate. Residents expressed comparatively high satisfaction with the current policy. Minors, adults with low level of education, unemployed people and other vulnerable groups expressed low overall satisfaction. The degree of satisfaction varied greatly among the different groups. Targeted medical and health practices should be implemented for different groups; additionally, the public health practice should be strengthened. [ABSTRACT FROM AUTHOR]

Background: In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies. Main body: The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly. Conclusion: Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care. [ABSTRACT FROM AUTHOR]

Background: Although some healthcare reforms such as Health Transformation Plan (HTP) were implemented in Iran to provide required healthcare services, few studies have been conducted to track the impacts of these reforms on socio-economic inequality in healthcare utilization. This study aims to track socio-economic inequalities in healthcare utilization and their changes between 2008 and 2016 in Iran.Methods: Required data were obtained from two of Iran's utilization of healthcare services survey conducted in 2008 and 2016. Erreygers concentration index (EI) was used to measure inequality in the utilization of outpatient and inpatient healthcare services (UOH and UIH). The decomposition of EI (DEI) was used to explain healthcare utilization inequality. Oaxaca decomposition (OD) was also employed to track the changes in EI in this period.Result: Inequality in UOH increased from 0.105 to 0.133 in the studied years, indicating the pro-rich distribution of UOH. Inequality in UIH decreased from 0.0558 to - 0.006. DEI showed that economic status was the main factor that contributed to inequality in the UOH and UIH. OD showed that residence in rural areas and supplementary insurance were the main contributing factors in the increased inequality of UOH. Moreover, OD also showed that economic status was the main contributing factor in the reduced inequality of UIH.Conclusion: While Iran still suffers from significant socio-economic inequalities in UOH, it seems that healthcare reforms, especially HTP, have reduced UIH inequality. Expanding healthcare reforms into the outpatient sector and also implementing effective health financing policies could be recommended as a remedy against UOH inequality. [ABSTRACT FROM AUTHOR]

Background: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.Methods: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.Results: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.Conclusions: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people's access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan. [ABSTRACT FROM AUTHOR]

Background: The knowledge exchange literature suggests that policy dialogues are intended to enhance short-, medium- and long-term capacities of individuals, organizations and health systems to use evidence to inform policy-making. Key features of effective dialogues have been suggested, but the linkages between these features and the realization of improved capacities for evidence-informed policy-making among dialogue attendees and the subsequent influence on policy-making activities are not well understood.Methods: We conducted a qualitative case study of a series of four policy dialogues that were convened in Canada among national, provincial and regional stakeholders on topics pertaining to healthcare financing and funding in 2011. Data sources included videos of participant perspectives captured during or immediately following each event and follow-up key informant interviews among dialogue participants held 4 years later in 2015. Three conceptual frameworks pertaining to (i) policy dialogues and capacities for evidence use, (ii) factors shaping policy-making across the policy cycle and (iii) factors shaping implementation of evidence guided the thematic analysis. We then synthesized the findings across the three frameworks.Results: The results suggest the potential benefits of policy dialogues described in the literature were developed among the participants at these dialogues. Informants elaborated on how dialogue features influenced their capacities to use evidence, the ideas, interests and institutions during the agenda-setting and policy formulation stages of policy-making and how implementation was affected by characteristics of policy options, individuals, organizations, the external environment and processes.Conclusions: We present a conceptual framework that furthers our understanding of the potential influence of policy dialogues on the content and mechanisms of policy development and illustrate pathways of influence on various stages of the policy cycle from agenda setting through formulation and implementation. The framework highlights important factors for consideration in designing and evaluating policy dialogues and in supporting post-dialogue knowledge exchange efforts. [ABSTRACT FROM AUTHOR]

Background: Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance coverage offers promise in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualized to many African health systems. Methods: We interviewed 37 key informants drawn from public, private and civil society organizations involved in health service delivery in Botswana. The objective was to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. We thematically synthesized their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. Results: Participants suggested that expansion of health insurance would be characterized by increased financial resources for health and catalyze an upsurge in utilization of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realizing the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. Conclusion: Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance also comes with many challenges. Decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results. [ABSTRACT FROM AUTHOR]

Background: Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Methods: Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. Results: There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists. Conclusion: PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care. [ABSTRACT FROM AUTHOR]

Background: Harmonisation is a key principle of the Paris Declaration. The Universal Health Coverage (UHC) Partnership, an initiative of the European Union, the Government of Luxembourg and the World Health Organization, supported health policy dialogues between 2012 and 2015 in identified countries in the WHO African Region. The UHC Partnership has amongst its key objectives to strengthen national health policy development. In Guinea and Chad, policy dialogue focused on elaborating the national health plan and other key documents. This study is an analytical reflection inspired by realist evaluative approaches to understand whether policy dialogue led to improved harmonisation amongst health actors in Guinea and Chad, and if so, how and why.Methods: Interviews were conducted in Guinea and Chad with key informants at the national and sub-national government levels, civil society, and development partners. A review of relevant policy documents and reports was added to data collection to construct a full picture of the policy dialogue process. Context-mechanism-outcome configurations were used as the realist framework to guide the analysis on how participants' understanding of what policy dialogue was and the way the policy dialogue process unfolded led to improved harmonisation.Results: Improved harmonisation as a result of policy dialogue was perceived to be stronger in Guinea than in Chad. While in both countries the participants held a shared view of what policy dialogue was and what it could achieve, and both policy dialogue processes were considered to be well implemented (i.e., well-facilitated, evidence-based, participatory, and consisted of recurring meetings and activities), certain contextual factors in Chad tempered the view of harmonisation as having improved. These were the pre-existence of dialogic policy processes that had exposed the actors to the potential that policy dialogue could have; a focus on elaborating provincial level strategies, which gave the sense that the process was more bottom-up; and the perception that there were acute resource constraints, which conditioned partners' interactions.Conclusions: Policy dialogue improves harmonisation in terms of fostering information exchange amongst partners; however, it does not appear to influence the operational procedures of the actors. This has implications for aid effectiveness. [ABSTRACT FROM AUTHOR]

Background: While healthcare systems vary in their structure and available resources, it is widely recognized that medical doctors play a key role in their adaptation and performance. In this article, we examine recent government and organizational policies in two different health systems that aim to develop clinical leadership among the medical profession. Clinical leadership refers to the engagement and guiding role of physicians in health system improvement. Three dimensions are defined to conduct our analysis of engaging medical doctors in healthcare leadership: the position and status of medical doctors within the system; the broader institutional context of governmental and organizational policies to engage medical doctors in clinical leadership roles; and the main factors that may facilitate or limit achievements.Methods: Our aim in this study is exploratory. We selected two contrasting cases according to their level of institutional pluralism: one national health insurance system, Canada, and one etatist social insurance system, the Netherlands. We documented the institutional dynamics of medical doctors' engagement and leadership through secondary sources, such as government websites, key policy reports, and scholarly literature on health policies in both countries.Results: Initiatives across Canadian provinces signal that the medical profession and governments search for alternatives to involve doctors in health system improvement beyond the limitations imposed by their fundamental social contract and formal labour relations. These initiatives suggest an emerging trend toward more joint collaboration between governments and medical associations. In the Dutch system, organizational and legal attempts for integration over the past decades do not yet fit well with the ideas and interests of medical doctors. The engagement of medical doctors requires additional initiatives that are closer to their professional values and interests and that depart from an overly focus on top down performance indicators and competition.Conclusions: Different institutional contexts have different policy experiences regarding the engagement and leadership of medical doctors but seem to face similar policy challenges. Achieving alignment between soft (trust, collaboration) and hard (financial incentives) levers may require facilitative conditions at the level of the health system, like clarity and stability of broad policy orientations and openness to local experimentation. [ABSTRACT FROM AUTHOR]

Background: This article examines uncomfortable realities that the European hospital sector currently faces and the potential impact of wide-spread rationalization policies such as (hospital) payment reform and privatization.Methods: Review of relevant international literature.Results: Based on the evidence we present, rationalization policies such as (hospital) payment reform and privatization will probably fall short in delivering better quality of care and lower growth in health expenses. Reasons can be sought in a mix of evidence on the effectiveness of these rationalization policies. Nevertheless, pressures for different business models will gradually continue to increase and it seems safe to assume that more value-added process business and facilitated network models will eventually emerge.Conclusions: The overall argument of this article holds important implications for future research: how can policymakers generate adequate leverage to introduce such changes without destroying necessary hospital capacity and the ability to produce quality healthcare. [ABSTRACT FROM AUTHOR]

Background: Health systems are not considered to be significantly influenced by European Union (EU) policies given the subsidiarity principle. Yet, recent developments including the patients' rights and cross-border directive (2011/24 EU), as well as measures taken following the financial crisis, appear to be increasing the EU's influence on health systems. The aim of this study is to explore how health system Europeanisation is perceived by domestic stakeholders within a small state.Methods: A qualitative study was conducted in the Maltese health system using 33 semi-structured interviews. Inductive analysis was carried out with codes and themes being generated from the data.Results: EU membership brought significant public health reforms, transformation in the regulation of medicines and development of specialised training for doctors. Health services financing and delivery were primarily unaffected. Stakeholders positively perceived improvements to the policy-making process, networking opportunities and capacity building as important benefits. However, the administrative burden and the EU's tendency to adopt a 'one size fits all' approach posed considerable challenges. The lack of power and visibility for health policy at the EU level is a major disappointment. A strong desire exists for the EU to exercise a more effective role in ensuring access to affordable medicines and preventing non-communicable diseases. However, the EU's interference with core health system values is strongly resisted.Conclusions: Overall domestic stakeholders have a positive outlook regarding their health system Europeanisation experience. Whilst welcoming further policy developments at the EU level, they believe that improved consideration must be given to the specificities of small health systems. [ABSTRACT FROM AUTHOR]

Background: Limited research exists on the process of applying knowledge translation (KT) methodology to a rural-based population health intervention.Methods: This study reports on the implementation and translational stages of a previously described Co-creating KT (Co-KT) framework in the rural town of Port Lincoln, South Australia (population: 14,000). The Co-KT framework involves five steps: (i) collecting local data; (ii) building stakeholder relationships; (iii) designing an evidence-based intervention incorporating local knowledge; (iv) implementation and evaluation of the intervention; and (v) translating the research into policy and practice. Barriers and enablers to the overall Co-KT implementation process were identified. Our intervention focused on musculoskeletal (MSK) conditions.Results: Although the Co-KT framework was valuable in engaging with the community, translating the final intervention into daily clinical practice was prevented by a lack of an accessible policy or financial framework to anchor the appropriate intervention, a lack of continued engagement with stakeholders, access problems to general practitioners (GPs) and Allied Health Professionals; and the paucity of referrals from GPs to Allied Health Professionals. Consequently, while many aspects of the intervention were successful, including the improvement of both function and pain in study participants, the full implementation of the Co-KT framework was not possible.Discussion: This study implemented and evaluated a Co-KT framework for a population with MSK conditions, linking locally generated health care system knowledge with academic input. Further policy, health system changes, and on-the-ground support are needed to overcome the identified implementation challenges in order to create sustainable and effective system change. [ABSTRACT FROM AUTHOR]

Background: In rationing decisions in health, many criteria like costs, effectiveness, equity and feasibility concerns play a role. These criteria stem from different disciplines that all aim to inform health care rationing decisions, but a single underlying concept that incorporates all criteria does not yet exist. Therefore, we aim to develop a conceptual mapping of criteria, based on the World Health Organization's Health Systems Performance and Health Systems Building Blocks frameworks. This map can be an aid to decision makers to identify the relevant criteria for priority setting in their specific context. Methods: We made an inventory of all possible criteria for priority setting on the basis of literature review. We categorized the criteria according to both health system frameworks that spell out a country's health system goals and input. We reason that the criteria that decision makers use in priority setting exercises are a direct manifestation of this. Results: Our map includes thirty-one criteria that are distributed among five categories that reflect the goals of a health system (i.e. to improve level of health, fair distribution of health, responsiveness, social & financial risk protection and efficiency) and leadership/governance one category that reflects feasibiliy based on the health system building blocks (i.e. service delivery, health care workforce , information, medical products, vaccines & technologies, financing and). Conclusions: This conceptual mapping of criteria, based on well-established health system frameworks, will further develop the field of priority setting by assisting decision makers in the identification of multiple criteria for selection of health interventions. [ABSTRACT FROM AUTHOR]

The article presents a study discussing the pursuit of divergent extensive reforms of health care systems by Brazil and Colombia, to improve access, increase efficiency and reduce health inequities. It is mentioned that reform do not seems to have had a decisive positive impact on the health outcomes. It is also mentioned that, underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints.

The article discusses the impact of the health care reforms introduced in the Netherlands to improve the health care delivery, by introducing managed competition among health care providers and hospitals. It is mentioned that the data from patients' response was obtained from 2006 to 2009 to analyze the impact of managed competition on the consumer quality index (CQI). It is observed that managed competition helped in improving the CQI thus confirming the positive impact of health care reform.

Background: The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap. Methods: Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007. Results: The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals. Conclusions: The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies. [ABSTRACT FROM AUTHOR]

Background: The United Kingdom (UK) is experiencing a general practitioner (GP) workforce retention crisis. Research has focused on investigating why GPs intend to quit, but less is known about the acceptability and effectiveness of policies and strategies to improve GP retention. Using evidence from research and key stakeholder organisations, we generated a set of potential policies and strategies aimed at maximising GP retention and tested their appropriateness for implementation by systematically consulting with GPs. Methods: 28 GP Partners and GPs working in national stakeholder organisations from South West England and London were purposively sampled, and asked to take part in a RAND/UCLA Appropriateness Method panel. Panellists were asked to read an evidence briefing summary, and then complete an online survey on two occasions. During each round, participants rated the appropriateness of policies and strategies aimed at improving GP retention using a nine point scale (1 'extremely inappropriate' to 9 'extremely appropriate'). Fifty-four potential policies and strategies (equating to 100 statements) were tested, focusing on factors influencing job satisfaction (e.g. well-being, workload, incentives and remuneration, flexible working, human resources systems). Ratings were analysed for panel consensus and categorised based on appropriateness ('appropriate', 'uncertain', 'inappropriate'). Results: 12/28 GPs approached agreed to take part, 9/28 completed two rounds of the online survey between February and June 2018. Panellists identified 24/54 policy and strategy areas (41/100 statements) as 'appropriate'. Examples included providing GP practices 'at risk' of experiencing GP shortages with a toolkit for managing recruitment and retention, and interventions to facilitate peer support to enhance health and wellbeing, or support portfolio careers. Strategies to limit GP workload, and manage patient demand were also endorsed. Conclusions: The panel of experienced GPs identified a number of practical ways to improve GP retention through interventions that might enhance job satisfaction and work-life balance. Future research should evaluate the impact of implementing these recommendations. [ABSTRACT FROM AUTHOR]

Background: All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems.Methods: The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases.Results: The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence.Conclusions: These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning. [ABSTRACT FROM AUTHOR]

Background: Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. Methods: Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. Discussion: As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor. [ABSTRACT FROM AUTHOR]

Background: Health reform has been an ongoing agenda in many countries with community pharmacy increasingly gaining attention for contributing to healthcare improvement. Likewise, multiple policy approaches have been introduced to improve community pharmacy practice in Indonesia yet no studies have evaluated their effectiveness. Therefore, this study aimed to identify and collate information on approaches intended to improve practice in Indonesian community pharmacy and subsequently examine the perceptions of key stakeholders in healthcare and community pharmacy about these approaches and the extent to which they have affected community pharmacists as a profession.Methods: This study reviewed the grey literature related to community pharmacy policies published by government and pharmacy organisations in Indonesia since 2009 and broadened the search to other relevant databases. In-depth semi structured interviews were conducted with a wide range of key stakeholders in pharmacy and healthcare between February and August 2016 to evaluate these policy approaches.Results: Seventeen policy documents were identified with the majority published by the Indonesian Pharmacists' Association (8 documents) and Ministry of Health of Indonesia (6 documents). Most documents (15 documents), either the updated version or new policy, were published since 2014 indicating the recent enthusiasm of pharmacy stakeholders to improve community pharmacy practice. Twenty-nine key stakeholders participated in the study, and highlighted three main themes regarding the policy approaches: barriers to effective policy implementation, need for policy changes and strategies to cope with policy challenges. Poor policy enforcement was commonly expressed by participants as a major challenge, with participants anticipating the need for a unified stakeholder vision to improve the current situation. Participants also mentioned several local initiatives which they claimed were improving practice but evidence was lacking.Conclusion: The introduction of policy initiatives within the past ten years has highlighted the enthusiasm of policy makers and pharmacy stakeholders to improve community pharmacy practice in Indonesia. However, some of the initiatives were conceived and enacted in a piecemeal, sometimes conflicting and uncoordinated way. Overall, fundamental and entrenched barriers to practice need to be overcome to create a more professional climate for the practice of pharmacy in Indonesia. [ABSTRACT FROM AUTHOR]