Search

Background: Even now the further training in surgery faces considerable challenges. The planned hospital structural reform will result in new bureaucratic and organizational hurdles, which could lead to a considerable loss of quality in advanced surgical training across all disciplines., Objective: The aim of this position paper is to describe the current and future challenges for advanced surgical training and to identify possible approaches and opportunities for the further development against the background of the planned hospital structural reform., Material and Methods: For the development of this position paper a committee of representatives of the Young Forums of the German surgical societies identified and critically discussed current problems and challenges of the present residency training system and formulated a list of demands for a sustainable residency training concept., Results: The planned shift to outpatient treatment and centralization were identified as central challenges for surgical residency training. Surgical training must be considered consistently and from the outset in all political reform efforts. In addition to a transparent and cost-appropriate financing of residency training, we call for the involvement of all German surgical societies in the reform process. Furthermore, the social framework conditions for junior surgeons should be considered., Conclusion: The structural change in the hospital landscape in Germany, which is being forced by politicians, harbors the risk of a further loss of quality and experience in surgical treatment and training. At the same time, the planned hospital reform offers a unique opportunity to address existing problems and challenges in surgical training and to consider them as a starting point for structural changes which are fit for the future., (© 2024. The Author(s).)

The Bündnis Junger Ärztinnen und Ärzte (BJÄ, Alliance of Young Physicians in Germany) has presented a position paper (PP) on Postgraduate Medical Education (PGME) against the background of an unfolding hospital reform in Germany, and they describe existing deficits of PGME in Germany. Based on this, demands were made of legislators, employers and medical associations which could result in a sweeping reformation of PGME. Hospital reforms can only be accomplished with well trained and motivated physicians. In this respect the BJÄ regards the reform of hospitals and the health-care system as a chance for a reform of PGME, which is long overdue. Legislative competence for PGME lies with the States of the Federal Republic of Germany and this warrants an adjustment of state medical association laws to accommodate the demands of the BJÄ. Generally PGME must be taken into consideration in all health-care legislation, in analogy to the meanwhile globally adopted principle of "Health in all Politics (HiAP)". The BJÄ has made every endeavour to produce this PP. The responsible stakeholders and actors in the health-care system would be well-advised to take the position paper seriously with a dwindling physician work force in hospitals and serious quality deficits in PGME. Hence, the BJÄ must be comprehensively supported. They need congenial partners to define the scientific foundation of all their demands, to test their application under real life conditions in hospital and outpatient care, to pursue research on the impact on patient care and on the intended transformation of the health-care system. This might best be accomplished by partnering with a scientific Association for Postgraduate Medical Education as has been the case in many countries for decades., Competing Interests: The author declares that he has no competing interests., (Copyright © 2024 Hahn.)

The coverage reforms of the Patient Protection and Affordable Care Act have fundamentally changed the U.S. health care system. The law's health insurance regulations, which include protections for persons with preexisting conditions, have made health insurance more accessible. The premium tax credit and cost-sharing subsidies have made nongroup coverage more affordable. The essential health benefit package and coverage for preventive services without cost sharing have made insurance more comprehensive. Perhaps most important, the Medicaid expansion extended coverage to millions of low-income adults. Despite these gains, more needs to be done to bring the United States closer to achieving universal coverage. In this position paper, the American College of Physicians recommends action to enhance and expand eligibility for health insurance financial subsidies; stabilize health insurance marketplaces; provide sustained funding for outreach, education, and enrollment assistance activities; test and implement a mechanism to encourage enrollment; expand Medicaid in all states; and establish a public insurance option to increase competition.

The concept of "participation" and the use of "participatory methods" in human, healthcare, nursing, and gerontological research, as well as the corresponding fields of practice, represent an expanding field of interest. However, the objectives and organization of "participation" are not always sufficiently explicated. The Critical Gerontology Working Group of the German Society of Gerontology and Geriatrics presents a statement on this phenomenon, and proposes a catalogue of criteria for reflection upon and assessment of participation by older people in research and practice, which can also be considered a stimulus for further discussions.

Health inequities, within and across countries, stand as a critical global challenge of our time. Over 1 billion people face preventable diseases and premature deaths due to limited access to [...]

Food and nutrition services, along with the health care organizations they serve, are becoming increasingly complex. These complexities are driven by sometimes conflicting (if not polarizing) human, department, organization, and environment factors and will require that managers shift how they think about and approach productivity in the context of the greater good of the organization and, perhaps, even society. Traditional, single-factor approaches to productivity measurements, while still valuable in the context of departmental trend analysis, are of limited value when assessing departmental performance in the context of an organization's goals and values. As health care continues to change and new models of care are introduced, food and nutrition services managers will need to consider innovative approaches to improve productivity that are consistent with their individual health care organization's vision and mission. Use of process improvement tools such as Lean and Six Sigma as strategies for evaluating and improving food and nutrition services efficiency should be considered., (Copyright © 2015 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.

Accountable care organizations have received considerable attention as a component of health care reform and have been specifically addressed in recent national legislation and demonstration projects by CMS. The role or roles of radiologists in such organizations are currently unclear, as are changes to the ways in which imaging services will be delivered. The authors review concepts fundamental to accountable care organizations and describe roles for radiologists that may facilitate their success in such health care delivery systems., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

From the American Recovery and Reinvestment Act (ARRA) and the newly passed healthcare reform legislation to emerging reimbursement models and shifting consumer health trends, a confluence of events are driving radical change in the nation's healthcare system and bringing about the convergence of telehealth, electronic health records (EHRs) and health information exchange (HIE). That is the focus of "The Crossroads of Telehealth, Electronic Health Records & Health Information Exchange: Planning for Rural Communities," a new white paper from the Northwest Regional Telehealth Resource Center (NRTRC). "Accelerating adoption and utilization of telehealth technologies, telemedicine in particular, will be critical to a successful stakeholder response to the disruptive changes that are underway in healthcare," said NRTRC Executive Director Christina B. Thielst, FACHE. "By leveraging telehealth networks and their existing infrastructures, Regional Extension Centers, HIEs and other data-sharing initiatives will be better-positioned to fulfill their commitments to the healthcare delivery system of the future--a system in which even the most rural and remote populations have timely access to care and their health records." The white paper explores emerging trends and recent disruptors impacting the healthcare delivery system and examines the opportunities they present for the advancement of telecommunications-based health solutions and the broadband infrastructure available through telehealth networks. It also takes an in-depth look at the various uses of telehealth and the most common delivery models of telemedicine, as well as the role of the telehealth network and Telehealth Resource Centers (TRCs) in expanding the reach of these vital initiatives. Finally, the white paper highlights the evolution of the REACH Montana Telehealth Network from facilitating teleradiology at three remote sites into a consortium of healthcare providers at 18 sites linked by high-bandwidth telecommunications in the north central region of Montana. REACH, which considers HIE to be a primary function, is currently working to leverage its existing T1 infrastructure to create the "railroad tracks" that will carry medical data and information within the region and beyond. "This white paper is an excellent analysis of the intersection of telehealth and health information technology, and the opportunities and challenges this electronic technology will bring to rural America," said Terry J. Hill, Executive Director of the Rural Health Resource Center, the Duluth, Minn.-based national knowledge center for rural hospitals providing technical assistance, information, education and other resources to rural health care providers and their communities. Adds Thielst: "Crossroads is a valuable planning tool for any healthcare stakeholder, but it is especially important for rural communities wanting to address health information exchange. It is just one of many resources available through the NRTRC to help advance the involvement of teleheatlh networks in HIE initiatives and to help transform the telehealth infrastructure into the 'superhighway' across which remote and rural areas will finally be able to participate in the widespread exchange of electronic health information." One of five TRCs in the nation, the NRTRC leverages the collective expertise of 33 telehealth networks across Alaska, Hawaii, Idaho, Montana, Oregon, Utah, Washington, Wyoming, and United States-affiliated Pacific Islands to share information and resources which assist in the development of new telehealth programs. The NRTRC is focused on further growth and new provider adoption of telehealth technologies to enhance delivery systems and reduce organizational and patient costs.

The contemporary models and trends of European organisational developments in primary care, identified in part 1 of this article, are the subject of analysis and discussion. Four main issues are identified in relation to the future protection and progress of primary care, and a series of policy interventions specified. These are directed at international agencies and action. Two new case study summaries are supplied as illustrations of the dilemmas now being encountered by primary care organisations across the extended Europe. With some supplementary material, the article is an edited version of the 2008 European Forum for Primary Care (EFPC) position paper on the organisation of primary care in Europe.

Addressing workforce issues has increasingly become a central feature of the organisation and management of public sector services internationally. The introduction of new work roles to public services is one approach advocated in response to recruitment and retention difficulties with professional staff and to increasingly complex services. This paper aims to critically examine UK's new roles policy in a health care context and explore its wider relevance by drawing on findings from an action research Ph.D. study aimed at exploring one such new role. This deliberately flexible role was held by individuals without a recognised qualification but study findings illustrate that, over the time, the role came to include the complex discharge planning work with patients previously carried out by registered nurses (RNs). The analysis presented highlights shortcomings in current new roles policy including the unacknowledged influence of competing policy goals; the erroneous assumption that defining who does what is clear-cut in practice; the lack of longer-term review of new roles; and the incompatibility between role flexibility and needs for role clarity. Policy makers, managers and practitioners are urged to acknowledge the subtleties and complexities of new work roles in the public sector highlighted by this study.

Health reforms must be firmly grounded in evidence, which in turn, should be utilized for appropriate modifications as the reforms get on their way to being implemented. It must be appreciated that the generation of evidence and its utilization must proceed in tandem with the reforms process - an approach which allows action accompanied by rigorous evaluation and up-gradation of programs and policies. The individual components of health reforms being proposed in the Gateway Paper, which presents a viewpoint on the configuration of health reform in Pakistan also mandate robust evaluation. This can allow the evaluation of competing concepts and can, therefore, guide the up-scaling of appropriate initiatives for broader systems-wide adoption. With this as a context, the Gateway Paper stresses on the need to: develop a comprehensive policy on research, bridge gaps in technical capacity within institutions, particularly those with research as a core mandate, broaden the base of budgetary and extra-budgetary research funding sources, foster appropriate incentives and rewards for research and mainstream an institutional mechanism for ethical oversight of research within the country. The Gateway Paper also underscores the need to develop a comprehensive, sustainable public health surveillance system and flags the legal requirements in this regard. It lays emphasis on the need to define priorities for epidemiological research in specific domains, particularly with reference to defining targets for preventive initiatives. In addition, strong recommendations have been made to institutionalize health policy and systems and operational research and to invest in capacity building of decision-makers in order to enable them to recognize the benefits of evidence based decision-making.

Pakistan has an extensive public sector service delivery infrastructure consisting of a three tiered healthcare delivery system which includes Basic Health Units and Rural Health Centers forming the core of the primary health model, secondary care including first and second referral facilities providing acute, ambulatory and inpatient care through Tehsil Headquarter and District Headquarter hospitals and Tertiary Care comprising teaching hospitals. Notwithstanding, most people receive healthcare through private out-of-pocket payments made directly to the providers at the point of care. Recently, many attempts have been made to mainstream alternative arrangements of service delivery at various levels in order to bridge gaps in the present system of service delivery, albeit with limited success. As one of the core areas of reform-related interventions, the Gateway Paper makes a strong case for introducing change at two levels in order to obviate these issues. Firstly, at the level of hospitals the hospital sustainability reform process calls for major structural and financing adjustments, the development of appropriate policy frameworks, decentralizing hospital management to autonomous hospital boards and providing legal, managerial and fiscal autonomy to hospitals with appropriate community representation. At the primary healthcare level, a system for restructuring BHUs and RHCs has been supported--one that makes a case for appropriate checks and balances in order to ensure sustained improvements by redefining the roles of management, quality assurance, regulation and community oversight the latter through linkages with the devolution initiative. The Gateway Paper dovetails these alternative service delivery arrangements with parallel financing models.

As an opening of a dialogue on health reforms in Pakistan, the Gateway Paper presents a viewpoint on its proposed directions making a strong case for systems reforms, which need to scope beyond the healthcare system. Positioning the reform process to strengthen Pakistan's health policy cycle, the paper articulates a roadmap for a paradigm shift to achieve health outcomes in Pakistan with major structural reorganization within the health system. The proposed reform points in the four areas namely, reforms within the health sector, overarching measures, reconfiguration of health within an inter-sectoral scope and generating evidence for reforms. Reforms within the health sector focus on developing new models of service delivery and health financing which can enable the state to leverage the private sector outreach to deliver health-related public goods on the one hand and maximize the outreach of the State's health care delivery mechanisms through mainstreaming the role of the private sector on the other, albeit with safeguards. In addition, these call for strengthening the stewardship role to regulate these arrangements. The second area of reform focuses on overarching measures; these include developing frameworks for public-private partnerships which will enable the bringing together of organizations with the mandate to offer public goods and those that could facilitate this goal through the provision of resources, technical expertise or outreach; mainstreaming health into the country's social protection strategy in order to address issues of access and affordability for the poor and introducing civil service and public service reform focused on good governance, accountability, breakdown of institutional corruption which are critical to improving health outcomes. The third area of reform involves broadening health to its inter-sectoral scope, redefinition of objectives and targets within the health sector and garnering support from across the sectors to forester inter-sectoral action particularly with reference to the social determinant of health. The fourth area of reform focuses on generation of evidence around which several priority areas for health systems and policy research have been flagged. The Gateway Paper also underscores the need to develop norms and standards and points to institution mechanisms which need to be created to support the reform process.

As opposed to preventive healthcare where State mandated healthcare agencies play a pre-dominant role, a number of actors within the healthcare system other than the State play a role in providing personalized curative healthcare within the country. The sector constitutes a set of diverse group of doctors, nurses, pharmacists, traditional healers, drug venders as well as laboratory technicians, shopkeepers and unqualified practitioners. The services they produce include hospitals, nursing homes, maternity clinics, clinics run by a range of healthcare providers, diagnostic facilities and the sale of drugs from pharmacies and unqualified sellers. However, in some cases the distinction between public and private sector is not very clear as many public sector practitioners practice privately, legally and illegally. The sector is fragmented and characterized by a mixed ownership patterns, many types of providers and different systems of medicines. As a viewpoint on the configuration of a proposed health reform within Pakistan, the Gateway Paper flags key issues in relation to this sector. This encompasses lack of a formal regulatory mechanism for private sector providers and their delivery mechanisms, absence of a formal mechanism for building capacity and ensuring quality and absence accreditation arrangements for private hospitals and nursing homes. With this as a context recommendations focus on the nature of regulatory mechanisms and the institutional arrangements necessary support them with particular reference to quality and continuing medical. In regard to traditional medicines directions focus on exploring ways to harnessing the potential within the system in order to leverage its outreach and integrate it with the formal healthcare system. The Paper also stresses on the need to fully exploit the potential within behavioral change interventions in order improve health systems performance in Pakistan and to broaden its scope from lifestyle and prevention behaviors in a health education paradigm to impact the performance of all the actors in the health care system.

The existence of appropriate institutional and human resource capacity underpins the viability and sustainability of a health reform process within a country. Building human resource capacity within the health sector involves building the capacity of health service providers, health managers and administers as well as the stewards of health. Although capacity building is linked to a generic process closely linked to the broader economic, social and developmental context, it has specific health system connotations which should be the focus of a concerted effort. These include quantitative issues, in-effective deployment and brain-drain, qualitative considerations which stem from gaps in the quality of undergraduate as well as discrepancies in the content and format of training and absence of this in service of training health professionals and gaps in regulation. As one of the fundamental corner stones of health reform the Gateway Paper calls attention to the need to avert these issues with the development of a well-defined policy in human resource development as an entry point. This should be based on an analysis of the human resource need and should clearly define career structures for all categories of healthcare providers, and articulate the mechanisms of their effective deployment. Creating a conducive an rewarding environment, institutionalizing personnel management reform which go beyond personnel actions and set standards of performance, and develop appropriate incentives around this, would be critical. It would also be important to pay due attention to the content and format of training at an undergraduate level, at a postgraduate level and with reference to ongoing education and the allied roles of continuing medical education programs and accreditation of health systems educational institutions. The Gateway Paper also lays stress on effective regulation to curb the practice of quackery.

Pakistan's public health interventions include a range of programs lead by the federal government with implementation arms at the provincial and district levels. Some of the programs are disease specific such as the respective programs on HIV/AIDS, Malaria, Tuberculosis, non-communicable diseases and Hepatitis; others are specific to life cycle domains such as in the case of maternal and child health whereas still others such as the National Program for Family Planning and Primary Healthcare and the National Expanded Program for Immunization are cross-cutting. Although these programs have contributed to improving health outcomes at intermediate outcomes level, a number of critical impediments to maximizing their impact have been noted. These include lack of integration, institutional impediments to the implementation of programs with particular reference to problems at the federal/provincial level and unrealized implications of federal programs at the provincial level are amongst the foremost. These have been further compounded by the addition of another service delivery tier in Pakistan's health system through the introduction of the devolution initiative. Furthermore, the unsustainable and under-utilized BHUs which serve as the service delivery base of these programs add to the problems. The Gateway Paper makes a number of recommendations to obviate these issues such as recommendations to integrate programs, strengthen surveillance systems, and with reference to obviating issues to implementation, emphasis is laid on decentralizing decision-making and central control, institutionalizing managerial audit, and prioritizing specific governance and management reforms. The Paper also stresses on the need for establishing a national coordination mechanism for fostering federal/provincial harmony and ensuring the creation of appropriate counterpart institutional arrangements in the provinces and districts. Recommendations on restructuring BHUs at a management, oversight, quality related and community participation level will play a vital role in determining the manner in which the efficiency of these public health programs can be enhanced.

The Gateway Paper recognizes three system interfaces as being critical to the delivery of healthcare within Pakistan. These include the federal/provincial interface, the provincial-district interface and the public-private interface. A number of gaps in each area have been highlighted. At the federal-provincial interface lack of provincial ownership of federal initiatives, gaps in provincial counterpart arrangements, ambiguities about federal and provincial roles and responsibilities, conflicts over sharing of resources and gaps in understanding provincial requirements and poor coordination have been articulated as core issues. It is envisaged that the development of a broad based mechanism to develop a consensus on national policy positions, incorporation of appropriate guidance from the provinces, giving provinces an active participatory role in decision-making, garnering their support and clearly demarcating roles and responsibilities will obviate some of these issues as would the institutionalization of a federal-provincial coordinating mechanism to review actions at both levels with regards to progress on meeting stipulating goals. At a district level poor governance, limited capacity within the system, lag in granting full district level financial and administrative autonomy, and lack of operational clarity in the rules of business have contributed to the challenge. This is compounded by inadvertent centralization of some functions within the district, which political and administrative decentralization has paradoxically created and impediments to harnessing the role of communities. The clear delineation of these issues provides a substrate, which need to be at the heart of strategic reform within the context of the recent devolution initiative. At the public-private interface the absence of locally established principles, legislative frameworks, policies and operational strategies have been contributing to the adhoc nature of public-private engagement within the country, which leads to skewed powered relationships and lack of clarity in combined models of governance. Within this context the Gateway Paper makes a strong case for developing a set of norms and ethical principles, developing legislative and policy frameworks, and specific guidelines to steer such relationships with careful attention to accountability and sustainability related parameters.

Pakistan currently principally uses three modes of financing health--taxation, out of pocket payments and donor contributions of which the latter is the least significant in terms of size. Less than 3.6% of the employees are covered under the social security scheme and there is a limited social protection mechanism, which collectively serves the health needs of 3.4% of the population. The main issues in health financing include low spending, lack of attention to alternate sources of financing and issues with fund mobilization and utilization. With respect to the first, health reforms proposed as part of the Gateway Paper make a strong case for promoting the reallocation of tax-based revenues and developing sustainable alternatives to low levels of public spending on health. With respect to alternative sources of health financing, the Gateway Paper lays stress on exploring policy options for private health insurance, broadening the base of Employees Social Security, creating a Federal Employees Social Security Programme, developing social health insurance within the framework of a broad-based social protection strategy, which scopes beyond the formally employed sector, establishing a widely inclusive safety net for the poor; mainstreaming philanthropic grants as a major source of health financing; developing a conducive tax configuration; generating greater corporate support for social sector causes within the framework of the concept of Corporate Social Responsibility and developing cost-sharing programmes, albeit with safeguards. The Gateway Paper regards efficient fund utilization a priority and lays stress on striking a balance between minimizing costs, controlling costs and using resources more efficiently and equitably--in other words, getting the best value for the money, on the one hand, and increasing the pool of available resources, on the other. Specific interventions such as the promotion of transparent financial administration, budgeting and cost controls and enhancing the capacity to overcome onerous financial management procedures and decentralizing decision-making are underscored as a priority as is the need for ensuring greater financial procedural clarity at the federal-provincial-district interface.

As an opening for a dialogue on health reforms in the country, the Gateway Paper places emphasis on strengthening the stewardship function of mandated State agencies in Pakistan with particular attention to two key areas. Firstly, greater emphasis on a stewardship role for the Ministry and departments of health in the context of inter-sectoral scope of health and secondly, a stronger role for the State agencies as regulators of healthcare within the country. The Gateway Paper envisages that the role of State agencies will become more critical as new models of financing health and delivering services are structured given that these entail regulation of private sector providers, providing oversight for ensuring a system for ongoing education and implementation of frameworks for public-private partnerships. The Gateway Paper refers to stewardship with reference to analysis and overview of health policies within the country, their relationship with evidence, their follow-up into planning and finally their implementation. The Paper also provides an insight into policies from a process-related as well as content and program related perspectives. In doing so a number of questions relating to the evidence and policy disconnect; issues at strategic and operational levels of planning, and governance-related impediments to program implementation have been discussed and a viewpoint articulated on an approach to addressing these challenges.