International Journal of Health Policy and Management
Volume:8 Issue: 1, Jan 2019

Significant attention has been devoted to developing intersectoral strategies to reduce health inequities; however, these strategies have largely neglected to consider how equity in health ought to be weighted and balanced with the pursuit of equity for other social goods (eg, education equity). Research in this domain is crucial, as the health sector’s pursuit of health equity may be at odds with policies in other sectors, which may consider the reduction of health inequities to be peripheral to, if not incompatible with, their own equity-related aims. It is therefore critical that intersectoral strategies to reduce health inequities be guided by a more general account of social justice that is capable of carefully balancing equity in health against the pursuit of equity in other sectors.

In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed. A realist review method was adopted involving three steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to three key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness. A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patient-purchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement. Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.

National community health worker (CHW) programmes are increasingly regarded as an integral component of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence or guidance on what this entails in practice. Based on empirical observations of South Africa’s community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale. Conceptually, the framework is based on multi-level governance thinking, that is, the distributed, negotiated and iterative nature of decision-making, and the rules, processes and relationships that support this in health systems. The specific purposes and tasks of CHW programme governance outlined in the framework draw from observations and published case study research on the formulation and early implementation of the Ward Based Outreach Team strategy in South Africa. The framework is presented as a set of principles and a matrix of five key governance purposes (or outputs). These purposes are: a negotiated fit between policy mandates and evidence, histories and strategies of community-based services; local organisational and accountability relationships that provide community-based actors with sufficient autonomy and power to act; aligned and integrated programme management systems; processes that enable system learning, adaptation and change; and sustained political support. These purposes are further elaborated into 17 specific tasks, distributed across levels of the health system (national, regional, and local). In systematising the governance functions in CHW programmes, the paper seeks to shed light on how best to support and strengthen these functions at scale.

The implications of decentralisation on human resource for health management has not received adequate research attention despite the presupposition that the concept of decentralisation leads to the transfer of management authority and discretion for human resource management from national levels to subnational levels. This study aims at investigating the extent to which decentralisation practice transfers management autonomy and discretion to subnational units, and the effect of the level of decision space on human resource management in the health sector. A mixed methods study design was adopted employing a cross-sectional survey and a document analysis. The respondents included health managers from the regional, district and hospital administrations as well as facility managers from the community-based health planning and services zones. A decision space framework was employed to measure management autonomy and discretion at various management levels of the study region. For the quantitative data, descriptive statistical analysis was used to analyse and report the data whilst the qualitative data was content-analysed. The study reported that in practice, management authority for core human resource functions such as recruitment, remuneration, personnel training and development are centralised rather than transferred to the subnational units. It further reveals that authority diminishes along the management continuum from the national to the community level. Decentralisation was however found to have led to greater autonomy in technical supervision and performance appraisal. The study also reported the existence of discrepancy between the wide decision space for performance assessment through technical supervision and performance appraisal exercised by managers at the subnational level and a rather limited discretion for providing incentives or rewards to staff. The practice of decentralisation in the Ghanaian health sector is more apparent than real. The limited autonomy and discretion in the management of human resource at the subnational units have potential adverse implications on effective recruitment, retention, development and distribution of health personnel. Therefore, further decision space is required at the subnational level to enhance effective and efficient management of human resource to attain the health sector objectives.

One of the most important steps of the health transformation program involves the application of electronic prescriptions (e-prescriptions) in health services. Information technologies are highly important in generating e-prescriptions, which can be described as a document produced by authorized personnel electronically, containing written information and instructions regarding a patient’s medication and its usage. E-prescribing has become increasingly applied in recent years as a contributing application to prescribers and patients. The aim of this study was to determine the level of satisfaction of family physicians providing primary care in Turkey regarding the application of e-prescriptions, and reveal the related positive effects and problems encountered in the first months of implementation of e-prescribing. A questionnaire with eight questions was sent to e-mails of all family physicians working in Turkey in May 2013. A total of 1564 family physicians filled in the questionnaire form and sent it back by e-mail. The responses to open-ended questions were evaluated by content analysis. It was observed that the most frequently indicated advantages of the application of e-prescriptions were speeding up the prescription process and saving time (36.6%). The most commonly reported problems regarding the application of e-prescriptions were found to be system-induced problems (26.5%) and internet problems (19.9%). In addition, the mean score of satisfaction of the family physicians who did not report problems with the application of e-prescriptions was higher than that of those who reported having problems with it. In the study, 77.8% of the family physicians were satisfied with the application of e-prescriptions. Although some problems were reported regarding the application of e-prescriptions in the first months of the application, family physicians participated in the study were found to be satisfied with the application of e-prescriptions, and identified positive effects on their work and processes.

In a rigorous systematic review, Dukhanin and colleagues categorize metrics and evaluative tools of the engagement of patient, public, consumer, and community in decision-making in healthcare institutions and systems. The review itself is ably done and the categorizations lead to a useful understanding of the necessary elements of engagement, and a suite of measures relevant to implementing engagement in systems. Nevertheless, the question remains whether the engagement of patient representatives in institutional or systemic deliberations will lead to improved clinical outcomes or increased engagement of individual patients themselves in care. Attention to the conceptual foundations of patient engagement would help make this systematic review relevant to the clinical care of patients.

Dukhanin and colleagues’ taxonomy of metrics for patient engagement at the organizational and system levels has great potential for supporting more careful and useful evaluations of this ever-growing phenomenon. This commentary highlights the central importance to the taxonomy of metrics assessing the extent of meaningful participation in decision-making by patients, consumers and community members; discusses how the purpose of an evaluation and the organizational relationships among key evaluation stakeholders is likely to influence the choice of metrics in important ways; and suggests a recasting of the metrics in the form of a logic model that supports the selection of metrics that are appropriate for a program given its stage of development and the purposes of the study.

This commentary provides an overview of the organizational readiness for change (ORC) literature over the last decade, with respect to prevailing definitions, theories, and tools to guide assessment of ORC in preparation for implementation. The development of the OR4KT by Gagnon et al is an important contribution to this body of work. This commentary highlights the strengths of the OR4KT including development based on two systematic reviews conducted by the authors to synthesize OR theory and measurement tools, and applicability to a wider range of high-income country healthcare settings through inclusion of input from a diverse group of international experts and transcultural adaptation of the tool, in the context of the literature to date. Limitations and future directions for further development of the tool are also discussed and include application of quantitative psychometric approaches and evaluation of the tool in a broader range of healthcare settings.

National level experiences, lessons learnt from the Millennium Development Goal (MDG) era coupled with the academic evidence and proposals generated by the Lancet Commission on Global Surgery (LCoGS) together with the economic arguments and recommendations from the World Bank Group’s “Essential Surgery” Disease Control Priorities (DCP3) publication, provided the impetus for political commitments to improve surgical care capacity at the primary level of the healthcare system in low- and middle-income countries (LMICs) as part of their drive towards universal health coverage (UHC) in the form of World Health Organization (WHO) Resolution A68.15. This global commitment from governments must be followed up with development of a Global Action Plan and a global coordination mechanism supported by regional implementation frameworks on the part of the WHO in order for the organisation to better coordinate all stakeholders and sustain the technical support needed to develop and implement national surgical health policy in the form of National Surgical Obstetric and Anaesthesia Plans (NSOAPs). As expounded by Gajewski et al, data and research output on surgical care is essential to informing policy development and programme implementation. This area still remains a challenge in sub-Saharan Africa (SSA) but it is envisaged that countries will include this key component in their ongoing national surgical healthcare policy development and programme implementation. In the Zambian case study, research in the area of Global Surgery investment-the surgical workforce scale-up is used to demonstrate the important role of implementation research in the development and implementation of the Zambian NSOAP as well as the need for international collaborations to this end. Scale-up reviews informed by implementation research to evaluate progress on the commitments contained in Resolution A68.15 and Decision A70.22 are essential to sustain the momentum and to help maintain focus on the gaps in all countries. There are opportunities for non-state actors especially local sub-regional academic institutions, non-governmental organizations (NGOs) and private sector to play a key role in surgical healthcare policy development and implementation research. Collection of and better information management of standardised surgical care indicators is essential for such research, for bi-annual WHO progress reporting and for demonstration of impact to justify and encourage further investments in surgical care.