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Introduction: The System Level Framework (SLMF) is a policy introduced by New Zealand’s Ministry of Health in 2016 with the aim of improving health outcomes by stimulating inter-organisational integration at the local level. We sought to understand which conditions that vary at the local level are most important in shaping successful implementation of this novel and internationally significant policy initiative relevant to integrated care. Strategy and Methods: We conducted 50 interviews with managers and clinicians who were directly involved in SLM implementation during 2018. Interview data was supplemented with the SLM Improvement Plans of all districts over the first three years of implementation. We used Qualitative Comparative Analysis (QCA) to identify the combinations and configurations of necessary and sufficient conditions of successful implementation. Results: We found that the strength of formal and informal organisational relationships at the local level were critical conditions for implementation success, and that while fidelity to the policy programme was necessary, it was not sufficient. Broader contextual features such as population size and complexity of the organisational environment were less important. The SLMF was able to deepen and widen inter-organisational collaboration where it already existed but could not mitigate the legacies of weaker relationships. Discussion: The two dimensions of implementation success, ‘Maturity of SLM Improvement Plan Processes’ and ‘Data Sophistication and Use’ were closely related. Broadly, our findings support the contention that integrated approaches to health system improvement at the local level require collaborative, trust-based approaches with an emphasis on iterative learning, including the willingness to share data between organisations. Conclusion: In the context of integrated care, our findings support the need to focus on establishing the conditions that build collaborative governance in addition to strengthening it when it already exists.

Background : Recent New Zealand policy documents aim for pharmacists to be retained , and promote the provision of extended clinical pharmacy services. However, younger pharmacists have expressed dissatisfaction with the profession on informal s ocial for a. Objectives : To explore the characteristics, and perspectives of pharmacy as a career, of recent Bachelor of Pharmacy (BPharm, four - year degree) graduates who have left, or are seriously considering leaving the New Zealand pharmacy profession i n the near future and where they have gone, or plan to go. Methods : We conducted a cross - sectional study with a mixed - method explanatory sequential design. An anonymous online survey among those who completed their pharmacy undergraduate degree (BPharm or equivalent) in 2003 or later and who had left or who were seriously considering leaving the New Zealand pharmacy profession in the next five years, was open from 1 st December 2018 to 1 st February 2019. Recruitment occurred via University alumni databases, pharmacy professional organisations, pharmaceutical print media, social media and word - of - mouth. Ten semi - structured interviews were then conducted with a purposive sample of survey respondents. Descriptive statistics were generated from the quantitative d ata and qualitative data were analysed using manifest content analysis. Results : We received 32 7 analysable surveys of which 40. 4 % (n=132) were from those who had already left the New Zealand pharmacy sector at the time of the data collection and the rest ( 59.6% n=19 5 ) were those working within the sector, but seriously considering leaving the profession. Reasons most commonly reported for studying pharmacy were having an interest in health and wanting to work with people. The most common reasons for leavin g, or wanting to leave, were dissatisfaction with the professional environment, including inadequate remuneration, and a perceived lack of career pathways or promotion opportunities. A wide range of career destinations were declared, with medicine being mo st frequently reported. Conclusions : Most of the reasons for leaving/considering leaving the profession reported relate to the values and features of the pharmacy profession such as the professional environment, remuneration and career pathways. These find ings are consistent with other studies and may represent a barrier to achieving the aims of recent health policy docum

ABSTRACT INTRODUCTIONIn 2016, the New Zealand Ministry of Health introduced the System Level Measures (SLM) framework as a new approach to health system improvement that emphasised quality improvement and integration. A funding stream that was a legacy of past primary care performance management was repurposed as ‘capacity and capability’ funding to support the implementation of the SLM framework. AIMThis study explored how the capacity and capability funding has been used and the issues and challenges that have arisen from the funding implementation. METHODSSemi-structured interviews with 50 key informants from 18 of New Zealand’s 20 health districts were conducted. Interview transcripts were coded using thematic analysis. RESULTSThe capacity and capability funding was used in three different ways. Approximately one-third of districts used it to actively support quality improvement and integration initiatives. Another one-third tweaked existing performance incentive schemes and in the remaining one-third, the funding was passed directly on to general practices without strings attached. Three key issues were identified related to implementation of the capacity and capability funding: lack of clear guidance regarding the use of the funding; funding perceived as a barrier to integration; and funding seen as insufficient for intended purposes. DISCUSSIONThe capacity and capability funding was intended to support collaborative integration and quality improvement between health sector organisations at the district level. However, there is a mismatch between the purpose of the capacity and capability funding and its use in practice, which is primarily a product of incremental and inconsistent policy development regarding primary care improvement.

Objectives Public hospitals in Nepal account for a major share of the total health budget. Therefore, questions are often asked about the performance of these hospitals. Existing measures of performance are limited to historical ratio analyses without any benchmarks. The objective of this study is to explore the trends in inputs, outputs and productivity changes in Nepalese public hospitals from 2011–2012 to 2013–2014. Setting and participants The study was conducted among 32 Nepalese public hospitals (23 district level and 9 higher level) for the three fiscal years from 2011–2012 to 2013–2014. Outcome measures First, basic ratio analyses were conducted for the input and output measures over the study years. Then, Malmquist productivity change scores were obtained using data envelopment analysis. Aggregated as well as separate analyses were conducted for district level and higher level hospitals. Results Real expenditures of the sampled hospitals declined over the 3-year period from an average of US$ 371 000 in year 1 to US$ 368 730 in year 2 and US$ 328680 in year 3. The average aggregated hospital outputs increased marginally from 8276 in 2011–2012 to 8613 in 2013–2014. The total factor productivity of the study hospitals declined by 6.9% annually from 2011–2012 to 2013–2014. Of the total 32 hospitals, productivity increased in only 12 (37.5%) hospitals and declined in the remaining 20 hospitals. The total factor productivity loss was influenced by a decline in technology change, despite an increase in efficiency. Conclusions In general, productivity of the study hospitals declined over the study period. Availability and accessibility of accurate, detailed and consistent measures of hospital inputs and outputs is a major challenge for this type of analysis.