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Background: Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation., Methods: This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis., Results: The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes., Conclusions: Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed., (© 2024. The Author(s).)

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]

The health of any nation, and the Bulgarian one in particular, is extremely important for the economy, security and development of the country. Unlike other European countries, due to defects in the structure and functioning, the Bulgarian health system could not achieve satisfactory final results in a number of important aspects of public health. One part of the essential problems includes high rates of morbidity, mortality, wide spread of health risk factors, and on the other - insufficient satisfaction of medical professionals (doctors, nurses, support staff) and patients. This, combined with the changes in the political administration of Bulgaria, led to a decision for a radical reform in the health care system. Conditionally, the changes can be divided, according to their nature, into 6 large groups: 1) Reforms leading to democratization of the system; 2) Reforms related to liberalization; 3) Reforms in the status of primary care practices; 4) Reforms in the organization, construction and structure of the system; 5) Reforms in financing and payment methods; 6) Reforms in the management of the primary care system and practices. The purpose of this review article is to present the theoretical framework, grounds and goals for the reform of the health care system in Bulgaria carried out in the past, with a focus on primary care and the current state. [ABSTRACT FROM AUTHOR]

Since 1999, performance-based financing or pay-for-performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration., (Copyright © 2018 John Wiley & Sons, Ltd.)

Background: Ensuring equal access to medicines and their appropriate and safe use at reasonable costs are core functions of health systems. Despite that, few descriptions of national medicines policies' development processes and implementation strategies have been published. This study aimed to describe the government program-based development of the Rational Pharmacotherapy Action Plan in Finland as a part of the undergoing major health and social service system reform, also covering the implementation of rational pharmacotherapy in the reformed system and processes. Methods: The data of this qualitative study consisted of public reports and Steering Group meeting memos related to the development of the national Rational Pharmacotherapy Action Plan that the Ministry of Social Affairs and Health coordinated. Qualitative content analysis applying systems theory and the conceptual framework of integrated services as theoretical frameworks was used as an analysis method. Results: The national Rational Pharmacotherapy Action Plan covering 2018–2022 was created in a bottom-up development process involving a wide range of stakeholders. Rational pharmacotherapy was redefined by adding equality as the fifth pillar to complement the previously defined pillars of being effective, safe, high-quality, and cost-effective. The Action Plan formed a normative framework for long-term development, with a vision and principles focusing on people-centeredness, better coordination and management of the medication use processes, the continuity of treatment paths and the flow of patient and medicines information through partnerships, and evidence-informed policies and practices. Conclusion: Through intensive stakeholder participation, the bottom-up approach created a national vision and principles of rational pharmacotherapy along with strong commitment to implementing the goals and measures. The concern lies in ensuring the continuity of the Action Plan implementation and achieving a balanced long-term development aligned with the integrated and reformed national social and health services system. The development of the pharmaceutical system has several national and EU-level dependencies requiring political long-term commitment. While the Action Plan differs from the national medicines policy, it forms a good basis for long-term development covering important parts of medicine policy at the micro, meso, and macro levels of the service system. [ABSTRACT FROM AUTHOR]

Following the UK Academy of Medical Royal Colleges Report on seven day consultant present care, the Royal College of Physicians and Surgeons of Glasgow held a symposium to explore clinicians' views on the ways in which clinical care should best be enhanced outside 'normal' working hours. In addition, a survey of members and fellows was undertaken to identify the tests which would make the greatest impact on care out of hours. Key messages were: (a) that seven-day consultant delivered care would not achieve the desired benefit to patient care if introduced in isolation from other inter-relating factors. These include alternatives to hospital admission, enhanced nursing support, increased junior medical, pharmacy, social care and ambulance availability and greater access to selected diagnostic services; (b) that the care of hospital inpatients is a service which is one part of the totality of secondary care provision. Any significant change in the deployment of staff for inpatient care must be carefully managed so as not to result in a reduced quality of care provided by the rest of the system., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

The author reviews the history of calls for reform of graduate medical education (GME), beginning with the Rappleye report of 1940, the first report on GME. Several continuities emerge. First, the reports have regularly called for GME to serve the "health needs of society." However, these perceived "needs" have continually been shifting as medicine and society evolve, thereby presenting GME a moving target. Second, the reports have regularly called for GME to focus more on education and less on service in order to avoid exploiting residents and compromising their training. Third, GME is a multifaceted subject. Reports on GME have typically addressed one part or another but not the subject as a whole. In their selectivity, the reports have reflected the particular perspective of the sponsoring groups. What the reports have generally not discussed, but what is underscored by calls for reform, is that GME is expensive, and any effort to improve its quality will be costly in terms of money, faculty time, or both. Thus, the profession has become complicit in maintaining the status quo. Any successful effort toward reform must acknowledge that GME functions as part of the larger health care delivery system, whose fate will ultimately determine the quality and robustness of GME in America.

This editorial reviews two landmark contributions to disability reform in Australia, both published in 2023 - the 12 volume report of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability and the important Commonwealth Government of Australia report on the operation of the 10-year-old National Disability Insurance Scheme. It contends that each leaves Australia with major steps that need to be taken to enable persons with disability to live in a fairer, safer and more inclusive environment in which their human rights are genuinely respected. The reports contain many challenges where a balance needs to be orchestrated between implementation of principled reform and what is financially feasible. If Australia's governments are to adopt the recommendations in the reports, politics will need to be set aside and collaboration between Federal and State governments will be essential. Attitudes and practices will have to change in government and the general community, laws, protocols and even institutions will need to be reformed, accountability mechanisms will need to be tightened, and considerable sums of money will have to be spent. [ABSTRACT FROM AUTHOR]

Purpose: In the mid 1990s the NHS "did" competition, in the mid 2000s the NHS is "doing" choice. This paper aims to cut through the rhetoric, highlight the differences and parallels between then and now and identify if these differences will have a different or the same impact on local services., Design/methodology/approach: Following a review of literature from the 1990s, a qualitative research study is used to examine the impact of competition and markets in the 1990s. The discussion examines the implications of this study for current system reform., Findings: Patient choice recreates many of the features of the internal market, but despite concerns at the time, the internal market did not have a significant impact on services. It is likely that patient choice will similarly have a limited impact., Research Limitations/implications: The research is a case study confined to Day Surgery in one part of the North of England., Originality/value: The paper reminds academics and practitioners what happened last time the NHS attempted to introduce a market-based system.

Recent changes to US reimbursement policies are increasingly holding providers financially accountable for patients' health. Providing nonmedical services in conjunction with primary care--known as wraparound services--is one strategy to improve patient outcomes and reduce overall health care spending. These services leverage additional providers to address patients' social determinants of health. Eskenazi Health--an Indianapolis, Indiana, safety-net provider--introduced wraparound services at its federally qualified health center sites. Behavioral health, social work, dietetics, patient navigation, and other services that address patients' social and behavioral needs are co-located with primary care services. In an eleven-year panel of primary care patients, receipt of any wraparound service was negatively associated with subsequent hospitalizations and emergency department visits. The estimated cost savings from potentially avoided hospitalizations alone was $1.4 million annually. Under value-based payment, wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs. [ABSTRACT FROM AUTHOR]

Many countries are under pressure to reform health care financing and delivery. Hospital care is one part of the health system that is under scrutiny. Private management initiatives are a possible way to increase efficiency in health care delivery. This motivates the interest in developing methodologies to assess hospital performance, recognizing hospitals as a different sort of firm. We present a simple way to describe hospital production: hospital output as a change in the distribution of survival probabilities. This output definition allows us to separate hospital production from patients' characteristics. The notion of "better performance" has a precise meaning: (first-order) stochastic dominance of a distribution of survival probabilities over another distribution. As an illustration, we compare, for an important DRG, private and public management and find that private management performs better, mainly in the range of high-survival probabilities. The measured performance difference cannot be attributed to input prices or to economies of scale and/or scope. It reflects pure technological and organisational differences. [ABSTRACT FROM AUTHOR]

During the last decades of the nineteenth century, public health policy in Japan transformed from a stricter focus on anti-disease measures to a more discursive and long-term strategy, one that attempted to train local and prefectural administrators to implement top-down directives regarding hygiene (eisei 衛生). This paper uses the early speeches and articles published by The Sanitary Society of Japan (Dai Nippon Shiritsu Eiseikai 大日本私立衛生会, lit. "Great Japan Private Hygiene Association"), the nation's largest forum for the discussion and dissemination of knowledge related to hygiene, to analyze how and why this change took place. Founded in 1883 by leading figures in medicine and the medical social sciences, the Society attempted to reformulate popular understandings of hygiene and health after widespread manipulation of the government's early public health programs. I argue that the Society repurposed and reformulated supposedly native Japanese healing practices in order to ground unfamiliar medical concepts, including the term "hygiene" (eisei) itself, within the familiar vocabulary of supposedly shared medical traditions. In recuperating and mobilizing these ideas, the organization broadened the discourse of hygiene while also immuring the concept within a circle of medical elites. [ABSTRACT FROM AUTHOR]

Health system reforms across Africa, Asia and Latin America in recent decades demonstrate the value of health policy and systems research (HPSR) in moving towards the goals of universal health coverage in different circumstances and by various means. The role of evidence in policy making is widely accepted; less well understood is the influence of the concrete conditions under which HPSR is carried out within the national context and which often determine policy outcomes. We investigated the varied experiences of HPSR in Mexico, Cambodia and Ghana (each selected purposively as a strong example reflecting important lessons under varying conditions) to illustrate the ways in which HPSR is used to influence health policy. We reviewed the academic and grey literature and policy documents, constructed three country case studies and interviewed two leading experts from each of Mexico and Cambodia and three from Ghana (using semi-structured interviews, anonymized to ensure objectivity). For the design of the study, design of the semi-structured topic guide and the analysis of results, we used a modified version of the context-based analytical framework developed by Dobrow et al. (Evidence-based health policy: context and utilisation. Social Science & Medicine 2004; 58 :207–17). The results demonstrate that HPSR plays a varied but essential role in effective health policy making and that the use, implementation and outcomes of research and research-based evidence occurs inevitably within a national context that is characterized by political circumstances, the infrastructure and capacity for research and the longer-term experience with HPSR processes. This analysis of national experiences demonstrates that embedding HPSR in the policy process is both possible and productive under varying economic and political circumstances. Supporting research structures with social development legislation, establishing relationships based on trust between researchers and policy makers and building a strong domestic capacity for health systems research all demonstrate means by which the value of HPSR can be materialized in strengthening health systems. [ABSTRACT FROM AUTHOR]

The study of health systems (HSs) is an important but confusing field. Its unclear boundaries, overlap, and multiple interpretations of terms require conceptual clarification. In light of the available evidence, Firstly, it is very important to realize that the current HSs thinking addresses individual parts rather than the whole HS. Secondly, it fails to recognize that concentrating on the performance of one part of the HS may have damaging effects on the whole HS. Thirdly, current HSs thinking fails to address the views, interests and influence of human resources for health involved in the implementation of reform, and how people and communities are expected to benefit from it. Fourthly, it does not take into account the different meanings, perceptions, cultural values and beliefs that may influence the very different institutions and structures belonging to a HS and working towards the same goals. Fifthly, the structural parts of HSs are designed to work in a stable environment, rather than addressing the ever changing context. Finally, HSs thinking does not provide a structural response to cope with the variety of healthcare stakeholders. The way HSs are currently understood may contribute to their weak performance. The current understanding is fundamentally functionalist, because the practice has focused on the definition of the structure, units and functions at different levels of recursion. The analysis of the literature demonstrates that most existing HSs are underpinned by functionalist approaches. This review provides a conceptual framework for many of the studies that focuses on specific situations and localities and explores what other approaches and methodologies can offer, in order to develop a framework for a given HS, which is more relevant in theory and practice than the other functionalist frameworks that may have been adopted previously. This framework will hopefully also narrow the gap between HSs goals and performance. [ABSTRACT FROM AUTHOR]

While applied sociology can take on many forms, it has been argued that public sociology is very much connected to the work of social movements. In this paper, I discuss my own scholar activism within the Movement for Single Payer Health Care Reform and its implications for the grassroots mobilization of this movement. This paper is, in part, a response to the call to develop discussions about the applied sociological process to better understand the “specific kinds of engagement” that make up radical public and social change–oriented applied sociology. The role of scholar activist is another avenue through which applied sociologists can better understand the social world and promote positive social change. Scholar activists can work within social movements to build theory about social movement mobilization through an interactive and empowering process that highlights the epistemological authority of movement participants. Scholar activists also act as a medium through which the collective experiences and narratives of social movement actors can be understood and shared with a wider audience. In this paper, I unpack one part of this process by engaging in the practice of reflexivity through which I analyze my role as a scholar activist within the Movement for Single Payer Health Care Reform. [ABSTRACT FROM AUTHOR]

Purpose: Sustainability and transformation partnerships (STPs) were introduced to England, asking 44 local areas to submit their health and social care plans for the period from October 2016 to March 2021. This study aims to offer a deeper understanding of the complex structure in the local practice, and to discuss the associated challenges and chances. Design/methodology/approach: Documentary analysis, qualitative interviews and questionnaire survey are used for this study. Findings have been compared and analysed thematically. Findings: The study participants reported that apart from pooled budgets, past collaborative experience and local leadership are crucial elements for transforming health and social care integration in Greater Manchester (GM). Also, this study provides policy recommendations to promote effective collaborative partnerships in local practices and mitigate local inequity of funding progress. Research limitations/implications: The findings of this paper cannot be extrapolated to all stakeholders due to the limited samples. Meanwhile, some of the discussions about the case of GM may not be transferrable to other STPs. Originality/value: This study argues that the success of pooled budgets is the result, rather than the cause, of effective negotiations between various stakeholders; and therefore, there is no evidence suggesting that pooled budgets can resolve the discoordination of health and social care. Moreover, due to the bottom-up approach adopted by STPs, more effective boroughs tend to receive additional funding, resulting in an increasing gap of development between effective and ineffective boroughs. [ABSTRACT FROM AUTHOR]

Purpose: This paper examines how "quality" was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of "quality" and (2) To explore how frames of quality and the framing process may have influenced policy implementation. Design/methodology/approach: The authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis. Findings: The authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers. Originality/value: As health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how "quality" is framed in the context of these policies and with what effect. This is the first framing analysis of "quality" in health policy. [ABSTRACT FROM AUTHOR]

There have been numerous initiatives for a long period of time to enhance integration in healthcare in many countries, but these processes still prove to be challenging. More research is needed to understand the interplay between different factors and different collaboration contexts, and this paper makes a contribution in this respect. We explore how collaboration can be established and sustained across organizational boundaries. Theory and methods: We draw on the concept of sense-making (Weick) as we investigate the complex interplay between structure and agency in facilitating or constraining collaboration across organizational boundaries. The empirical material consists of 35 interviews with health personnel participating in three different collaboration initiatives between primary and secondary care regarding obesity and diabetes in Norway. The health care providers involved are all public. The aim of the collaboration is to enhance knowledge sharing and to improve prevention and treatment across primary and secondary care providers tailored to the needs of the patient. The study is part of The Research Council of Norway's evaluation program of The Coordination Reform, a reform addressing coordination and collaboration in healthcare. Results: We find that structure, competence, equality and commitment are important elements to establish and sustain collaboration across organizational boundaries. Discussion: Organizational, technological and financial structures can both facilitate and constrain collaboration. When participants determine their scope of action, they do so by interpreting the latitude provided by structural frames, but also by how they interpret the interaction with others. When participants in primary and secondary care each interpret each other as competent professionals, this enhances collaboration. Furthermore, when participants in both organizations experience the relationship between them as equal, this also enhances collaboration. Likewise, if one part interprets the other part as regarding them as less competent or superior in the relationship, this represents a barrier for collaboration. Many collaboration initiatives have one or several dedicated persons who are highly committed to the collaboration and who drive the work forward in spite of many challenges. However, if not other participants in the collaboration initiatives, as well as in their local community, interpret the collaboration as meaningful and commit themselves to the work, this represents a barrier for collaboration over time. Conclusions: Collaboration depends on participants finding collaboration meaningful. Development of integrated care in our study is neither a result of structural adaptation alone, nor of strategic action alone, but a result of the interactions between concerned actors and their interpretations of structural frames and the actions of others. Implications for policy makers and practitioners are to pay attention to both agency and structure when planning for integration of healthcare services. Limitations: The majority of the informants come from primary care. This could possibly imply a bias towards perspectives from primary care. On the other hand, informants from secondary care are included, and the collaboration initiatives are originally initiated by secondary care. Suggestions for future research: Possible future research includes focusing on how different groups of patients and their carers experience these and other collaboration initiatives. [ABSTRACT FROM AUTHOR]

The author comments on the problems facing state health care reform and coverage in the U.S. He says health insurance in the country is generally accessed through employer-provided benefits and 82 percent of Americans without health insurance are in families with at least one part time worker. He discusses the Employee Retirement Income Security Act (ERISA) of 1974, which was enacted to regulate the increasing size and complexity of private pension plans provided by employers to their employees. Alternatives to mandated health insurance are explored.

Background: Diagnosis-related groups (DRGs) are a payment system that could effectively solve the problem of excessive increases in healthcare costs which are applied as a principal measure in the healthcare reform in China. However, expert-oriented DRG grouping is a black box with the drawbacks of upcoding and high cost.Methods: This study proposes a method of data-based grouping, designed and updated by machine learning algorithms, which could be trained by real cases, or even simulated cases. It inherits the decision-making rules from the expert-oriented grouping and improves performance by incorporating continuous updates at low cost. Five typical classification algorithms were assessed and some suggestions were made for algorithm choice. The kappa coefficients were reported to evaluate the performance of grouping.Results: Based on tenfold cross-validation, experiments showed that data-based grouping had a similar classification performance to the expert-oriented grouping when choosing suitable algorithms. The groupings trained by simulated cases had less accuracy when they were tested by the real cases rather than simulated cases, but the kappa coefficients of the best model were still higher than 0.6. When the grouping was tested in a new DRGs system, the average kappa coefficients were significantly improved from 0.1534 to 0.6435 by the update; and with enough computation resources, the update process could be completed in a very short time.Conclusions: As a new potential option, the data-based grouping meets the requirements of the DRGs system and has the advantages of high transparency and low cost in the design and update process. [ABSTRACT FROM AUTHOR]

Introduction: Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat.Study Description: This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map.Results: The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care.Conclusion: The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration. [ABSTRACT FROM AUTHOR]

Purpose: The Health Service Executive in Ireland seeks to further develop healthcare in the community. It has identified that this reform requires developing leadership amongst the staff. This study aims to identify what kind of leadership staff in community healthcare observe in practice and their leadership preferences. The core objective has been to identify the readiness of the organisation to implement the adopted national policy of integrated community care reform in terms of leadership development. Design/methodology/approach: An online cross-sectional survey was conducted using the Organisational Cultural Assessment Instrument, based on the Competing Values Framework. This tool identifies four overarching leadership types: Clan (Collaborative), Adhocracy (Creative), Market (Competitive) and Hierarchy (Controlling). Participants (n = 445) were a representative sample of regional community health care employees. They were asked to identify presently observed leadership and preferred leadership in practice. The statistical analysis emphasised a comparison of observed and preferred leadership types. Findings: Participants reported the current prevailing leadership type as Market (M = 34.38, SD = 6.22) and Hierarchical (M = 34.38, SD = 22.62), whilst the preferred or future style was overwhelmingly Clan (M = 40.38, SD = 18.08). Differences were significant (all p's < 0.001). The overall outcome indicates a predominance of controlling and competitive leadership and a lack of collaborative leadership to implement the planned reform. Originality/value: During reform in healthcare, leadership in practice must be aligned to the reform strategy, demonstrating collaboration, flexibility and support for innovation. This unique study demonstrates the importance of examining leadership type and competencies to indicate readiness to deliver national community health care reform. [ABSTRACT FROM AUTHOR]

This article elaborates on Robert Kastenbaum's death system analysis by explaining social change efforts among Ecological Death Advocates (EDAs), a diverse group of designers, scientists, spiritualists, and entrepreneurs who seek to develop more environmentally sensitive and humanistic alternatives to contemporary death management practices. Drawing from online and documentary data, we highlight EDAs claims about problems with conventional death management and the solutions they propose. Specifically, EDAs challenge hyperrationalized and professionalized death management practices by advocating for more ecologically benign approaches that link past traditions with new technological innovations to better align death practices with personal and community needs. We theorize EDA reform efforts as an aspect of "death-system" politics to carve out cultural, economic, and political space for alternative end-of-life decisions that better reflect broad ecological sensibilities and changing attitudes toward death. [ABSTRACT FROM AUTHOR]

Between 1826 and 1843, the medical practitioners of Jamaica engaged in a long and fraught campaign to create a College of Physicians and Surgeons. This campaign linked the island with global processes of medical and political reform, especially in Britain, and numerous studies have revealed the political barriers that faced efforts to reshape medical practices in this period. Yet, the metropole was also in a continuous dialogue with its colonial periphery. Existing work has looked at what this dialogue meant for the circulation of medical theories and practices, but equally important was the transmission of medical institutions, which provided structures for their development and application. The campaign in Jamaica offers an important case study of the complex process by which medical institutions spread in this period and reveals both the imperial aspects of medical and social reform in Jamaica and the colonial aspects of medical reform in Britain. [ABSTRACT FROM AUTHOR]

Background Many countries have committed to achieving Universal Health Coverage. This paper summarizes selected health financing themes from five middle-income country case studies with incomplete progress towards UHC. Methods The paper focuses on key flagship UHC programs in these countries, which exist along other publicly financed health delivery systems, reviewed through the lens of key health financing functions such as revenue raising, pooling and purchasing as well as governance and institutional arrangements. Results There is variable progress across countries. Indonesia's Jaminan Kesehatan Nasional (JKN) reforms have made substantial progress in health services coverage and health financing indicators though challenges remain in its implementation. In contrast, Ghana has seen reduced funding levels for health and achieved less than 50% in the UHC service coverage index. In India, despite Ayushman Bharat (PM-JAY) reforms having provided important innovations in purchasing and public-private mix, out of pocket spending remains high and the public health financing level low. Kenya still has a challenge to use public financing to enhance coverage for the informal sector, while South Africa has made little progress in strategic purchasing. Conclusions Despite variations across countries, therefore, important challenges include inadequate financing, sub-optimal pooling, and unmet expectations in strategic purchasing. While complex federal systems may complicate the path forward for most of these countries, evidence of strong political commitment in some of these countries bodes well for further progress. [ABSTRACT FROM AUTHOR]

Background: Globally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012-2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners. Methods: A qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011--2012 (contextual mapping), 2013--2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018. Results: Six broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public--private partnerships, transform systems and processes and adopt a systems lens. Conclusion: A third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening? [ABSTRACT FROM AUTHOR]

In the late nineteenth century, British anthropometrists attempted to normalize the practice of measuring bodies as they sought to collate data about the health and racial makeup of their fellow citizens. As the country's leading anthropometrists, Francis Galton and Charles Roberts worked to overcome suspicion about their motives and tried to establish the value of recording physical dimensions from their subjects' perspective. For Galton, the father of the eugenics movement, the attainment of objective self-knowledge figured alongside the ranking of one's physique and faculties against established norms. The competitive tests at Galton's anthropometric laboratory were meant to help subjects identify their strengths and weaknesses, ultimately revealing their level of eugenic fitness. Roberts, on the other hand, saw the particular value of anthropometric data in informing economic and social policy, but capitalized on parents' interest in their children's growth rates to encourage regular monitoring of their physical development. While both Galton and Roberts hoped that individuals would ultimately furnish experts with their anthropometric data to analyze, they both understood that the public would need to have explained the practical purposes of such studies and to familiarize themselves with their methods. This article argues that while anthropometry did not become a fully domestic practice in this period, it became a more visible one, paving the way for individuals to take an interest in metrical evaluations of their bodies in the coming years. [ABSTRACT FROM AUTHOR]

Healthcare affordability is a worry for many Americans. We examine whether the relationship between having problems paying medical bills and mental health problems changed as the Affordable Care Act (ACA) was implemented, which increased health insurance coverage. Data from the 2013–2016 Health Reform Monitoring Survey, a survey of Americans aged 18–64, were used. Using zero-inflated negative binomial regression, adjusted for predisposing, enabling, and need factors, we examined differences in days of mental health symptoms by problems paying medical bills (n = 85,430). From 2013 to 2016, the rates of uninsured and problems paying medical bills decreased from 15.1% to 9.0% and 22.0% to 18.6%, respectively. Having one or more days of mental health symptoms increased from 39.3% to 42.9%. Individuals who reported problems paying medical bills had more days of mental health symptoms (Beta = 0.133, p < 0.001) than those who did not have this problem. Insurance was not significantly associated with days of mental health symptoms. Over the 4-year period, there were not significant differences in days of mental health symptoms by problems paying medical bills or insurance status. Despite improvements in coverage, the relationship between problems paying medical bills and mental health symptoms was not modified. [ABSTRACT FROM AUTHOR]

Patient organizations such as those in Sweden face individualization processes on two fronts, both in their own voluntary sector and in the healthcare sector. The aim of this study is to investigate how the patient organizations are handling the two-front individualization process internally in their organizations, as well as externally towards a more patient-centred healthcare system. With more diverse stakeholders and individual patients given increased influence, we would expect a corresponding adjustment in the strategies of the patient organizations. The article's focus is on the organizations' representative role, and theories on advocacy strategies are used to identify the nature of the patient organizations' advocacy work. To find out how adjustments are made, 17 semi-structured interviews were conducted with representatives from local branches of three large Swedish patient organizations. The interviews show a low tendency to adjust as a response to this two-front individualization and illustrate a paralyzed rather than modified behaviour in these organizations. Individualization being a global trend, we believe these results are of interest to scholars of collective participation in all parts of the world. [ABSTRACT FROM AUTHOR]

7 But, the ACA also ratcheted up health care complexity by expanding disparate features of private and public insurance, exacerbated by the crazy quilt of 4 Samantha Smith, Many lower-income Republicans see ensuring health coverage for all as a government responsibility, PEW (Mar. 23, 2017), https://www.pewresearch.org/facttank/2017/03/23/many-lower-income-republicans-see-ensuring-health-coverage-for-all-as-agovernment-responsibility/ ("Lower-income Republicans are both more likely to say they approve of the Affordable Care Act and to say the government is responsible for ensuring health care coverage than higher-income Republicans. 113 But, states that have resisted exercising the options in Medicaid historically, or that have opted out of ACA Medicaid expansion (often the same states), are unlikely to take up a new public option even though it is the most federalism-centric, or state-inclusive, of the current bills. 199 But, if Medicare for America offers money to states for administering new enrollment (much in the way that HHS currently pays for states' Medicaid administrative costs), and states can opt out with a federal backstop (like the ACA's exchanges), then this structure could be constitutionally permissible. This federalism structure was a contradiction in the new federal law, which was designed with core statutory protections for poor people on one hand but allowed states to continue policy control over medical care for their poor populations through state flexibilities (exercised through "options" in Medicaid) and other policymaking tools left to states. The CHOICE Act allows (but does not require) states to advise the Secretary on cost control measures 105 Currently this is the only bill to give states a formal role in the public option (aside from possibly running the exchange on which the public option is sold, a role offered to states under the ACA). [Extracted from the article]

Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service ethos. However, the extent to which efficiency gains are realized and public purpose is maintained depends on policy choices about governance and payment systems. We present a case study of Malaysia's National Heart Institute (IJN), which was created in 1992 by corporatization of one department in a large public hospital. The aim of the paper is to examine whether IJN has achieved the goals for which it was created, and if so, whether it provides a potential model for further reforms in Malaysia and other similar health systems. Using a combination of document analysis and key informant interviews, we examine key governance, health financing and payment, and equity issues. For governance, we highlight the choice to have IJN owned by and answerable to a Ministry of Finance (MOF) holding company and MOF-appointed board, rather than the Ministry of Health (MOH). On financing and payment, we analyze the implications of IJN's combined role as fee-for-service provider to MOH as well as provider of care to private patients. For equity, we analyze the targeting of IJN care across publicly-referred and private patients. These issues demonstrate unresolved tensions between IJN's objectives and public service goals. As an institutional innovation that has endured for 28 years and grown dramatically in size and revenue, IJN's trajectory offers critical insights on the relevance of the hybrid public-private models for hospitals in Malaysia as well as in other middle-income countries. While IJN appears to have achieved its goal of establishing itself as a commercially viable, publicly owned center of clinical excellence in Malaysia, the value for money and equity of the services it provides to the Ministry of Health remain unclear. IJN is accountable to a small Ministry of Finance holding company, which means that detailed information required to evaluate these critical questions is not published. The case of IJN highlights that corporatization cannot achieve its stated goals of efficiency, innovation, and equity in isolation; rather it must be supported by broader reforms, including of health financing, payment, governance, and transparency, in order to ensure that autonomous hospitals improve quality and provide efficient care in an equitable way. [ABSTRACT FROM AUTHOR]

Background and Aims: Federal, state and local US governments have sought interventions to reduce deaths due to opioid overdoses by increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low‐income, childless adults, potentially giving this group financial access to naloxone. The aims of this paper are: (1) to describe the changes in the amount of Medicaid‐covered naloxone used between 2009 and 2016 and (2) to quantify the differential change in the amount of dispensed naloxone between states that expanded their Medicaid programs and states that did not. Design A quasi‐experimental approach based on states' ongoing choice to expand their Medicaid program to all adults with incomes between 100 and 138% of the federal poverty line (FPL), starting in 2014. As of 2018, 37 states had expanded and 14 states had not. Estimation of the policy impact relies on a difference‐in‐difference method. Setting: US state Medicaid programs. Participants and measurements: Data are from the Medicaid Drug Rebate Program and include all dispensed prescriptions of naloxone through the Medicaid program. State/quarters with fewer than 10 prescriptions are suppressed; n = 1632. Findings Prior to Medicaid expansion, the number of Medicaid‐covered naloxone prescriptions was very similar in expansion and non‐expansion states. On average, states that expanded Medicaid had 78.2 (95% confidence interval = 16.0–140.3, P = 0.02) more prescriptions per year for naloxone compared with states that did not expand Medicaid coverage, a nearly 10 increase over the pre‐expansion years. Medicaid expansion contributed to this growth in Medicaid‐covered naloxone more than other state‐level naloxone policies. Conclusions: Medicaid accounts for approximately a quarter of naloxone sales. Medicaid expansion generated 8.3% of the growth in naloxone units from 2009 to 2016, holding other factors constant. [ABSTRACT FROM AUTHOR]

The article discusses strategies to understand and resolve the complex health care system issues in the U.S. and to introduce reform in the sector as of June 2019. Topics include such theories as Systems Thinking, the book "General Systems Theory" published by Ludwig von Bertalanffy, and the field of complexity science that covers such areas as health care and management science.

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes. [ABSTRACT FROM AUTHOR]

Compatibility measure is a very well-known method to deal with decision making problems with uncertain preference relations. In this paper, on the basis of generalized distance measure of hesitant fuzzy linguistic elements, we define the compatibility measures for hesitant fuzzy linguistic preference relations (HFLPRs), including compatibility degree, compatibility index, and acceptable compatibility, and some important special properties are also discussed. Furthermore, based on the compatibility measures of HFLPRs, we propose a method for determining the experts' weights in group decision making (GDM), as well as establish an algorithm for solving the GDM problem with HFLPRs. A case study is set up to utilize the compatibility measures of HFLPRs for dealing with a practical GDM problem, which is to determine which aspect is optimal in the process of medical and health system reform. Finally, some comparisons and analyses are also discussed in detail. [ABSTRACT FROM AUTHOR]

The demanding and giving of reasons for their actions are core business for public policy makers in a democracy. But there are many different reasons for asking why questions, and correspondingly many different responses that might count as adequate answers. Seven different reasons for reason-giving are here distinguished and categorized along two dimensions: political moralism versus political realism, and high versus low politics. All of those were in play in the enactment and adjudication of the Affordable Care Act, The attempts at repealing it were characterized by low-politics and political-realist modes of reason-giving more exclusively. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The specialty of emergency medicine is experiencing the convergence of a number of transformational forces in the United States, including health care reform, technological advancements, and societal shifts. These bring both opportunity and uncertainty. 21st Century Challenges: Persistent challenges such as the opioid epidemic, rising health care costs, misaligned incentives, patients with multiple chronic diseases, and emergency department crowding continue to plague the acute, unscheduled care system. Reductionism and Complex Systems Thinking: The traditional approach to health care practice and improvement–reductionism–is not adequate for the complexity of the twenty‐first century. Reductionist thinking will likely continue to produce unintended consequences and suboptimal outcomes. Complex systems thinking provides a perspective and set of tools better suited for the challenges and opportunities facing public health in general, and emergency medicine more specifically. Implications for Emergency Medicine: This article introduces complex systems thinking and argues for its application in the context of emergency medicine by drawing on the history of the circumstances surrounding the formation of the specialty and by providing examples of its application to several practice challenges. [ABSTRACT FROM AUTHOR]

This article considers British efforts to pacify Caribbean subjects through improvements in health and sanitation during the interwar period. When Barbadians mobilized against poor working and living conditions in the 1920s, the Colonial Office, under a renewed commitment to "trusteeship," urged the Barbadian government to improve health and sanitary conditions to prevent further unrest. However, the White creole elites who controlled the local state used eugenic arguments to challenge reforms that would benefit poor Black subjects. Rather than improve colonial relations, metropolitan efforts to reform public health in Barbados instead revealed the limitations at the heart of imperial rule. [ABSTRACT FROM AUTHOR]