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PubMed2001

A conceptual framework to measure performance of the public health system.

OBJECTIVES: This article describes a unifying conceptual framework for the public health system as a way to facilitate the measurement of public health system performance. METHODS: A conceptual framework for the public health system was developed on the basis of the work of Donabedian and a conceptual model previously developed by Bernard Turnock and Arden Handler. RESULTS: The conceptual framework consists of 5 components that can be considered in relationship to each other: macro context, mission, structural capacity, processes, and outcomes. Although the availability of measures for each of these components varies, the framework can be used to examine the performance of public health systems as well as that of agencies and programs. CONCLUSIONS: A conceptual framework that explicates the relationships among the various components of the public health system is an essential step toward providing a science base for the study of public health system performance.

Centers for Disease Control and Prevention, U.S.↗
PubMed2026

Direct and spillover hospitalisation patterns during climate hazards across regions of different health-system resilience levels in China: a nationwide retrospective analysis.

BACKGROUND: Health-system resilience serves as a key contributor in mitigating adverse health impacts during climate hazards. However, quantitative insights into resilience-associated health-care utilisation patterns and targeted adaptation policies remain scarce. We aimed to capture the spatiotemporal health impacts in disaster-exposed counties and their neighbouring counties in China during storms, floods, tropical cyclones, and blizzards or winter storms; understand the association between health-system resilience metrics and hazard-attributable hospitalisations; and develop evidence-based adaptation policies towards climate extremes. METHODS: In this retrospective, observational analysis of county-level aggregated hospitalisation data, we used a propensity score matching-difference-in-differences framework to assess the spatiotemporal changes of nine types of disease-specific hospitalisations in both disaster-exposed and neighbouring regions during storms, floods, tropical cyclones, and blizzards in China. We quantified the relative importance and health gains of health-system metrics during such hazards through random forest approach with interpretable partial dependence plots to derive evidence-based adaptation recommendations. FINDINGS: We included hospitalisation data from Jan 1, 2016 to Dec 31, 2023. In this period, 3241 county-hazard event combinations and 41 747 482 hospitalisations were recorded across 955 Chinese counties. The disaster-exposed regions experienced an initial decline in hospitalisation rates, followed by admission surges after disasters. For example, infectious disease admissions decreased by 11·92% (95% CI -10·53 to -13·31) during the flood-active period but increased by 7·68% (6·46-8·91) after 1-2 weeks of floods. Neighbouring zones were also affected through spillover effects, with infectious disease admissions increasing by 3·18% (1·76-4·61) after 1-2 weeks of the floods. Cardiovascular disease, injuries, infectious, respiratory, and mental disorders were more sensitive across all regions. Particularly for disaster-exposed counties, cardiovascular hospitalisations increased by 14·31% (7·34-21·29) during the tropical cyclone-active period. Notably, compared with low-resilience counties, high-resilience counties were associated with 19·48-30·03% smaller hazard-related relative changes in hospitalisation rates during the hazard-active period and 27·07-31·08% smaller hazard-related relative changes in hospitalisation rates in post-hazard periods. For instance, during the storm-active period, the increase in respiratory hospitalisations was 7·21% (0·67-13·75) in high-resilience counties versus 12·13% (5·20-19·05) in low-resilience counties. Health workforce (relative importance 14·58% during the hazard-active period and 13·80% during the post-hazard period) and service delivery (14·10% during the hazard-active period and 14·17% during the post-hazard period) were identified as key contributors of health-system resilience. Empirical synergistic effects were observed when combining interventions during the post-hazard period, with the combined effect of service delivery (individual contribution 8%) and workforce (individual contribution 4%) exceeding the sum of their individual contributions (16% reduction in cumulative excess admissions) by 33%. INTERPRETATION: Climate hazards are associated with substantial changes in hospitalisation rates in both disaster-exposed and neighbouring regions. Health-system resilience is essential in addressing disaster-health challenges. Targeted adaptation interventions should be context-appropriate and threshold-aware, thereby maximising the public health benefits relative to resilience-oriented investments in health systems. FUNDING: Gates Foundation and the National Natural Science Foundation of China.

Journal Article↗
PubMed2006

An instrument for assessing public health system performance: validity in rural settings.

PURPOSE: This study evaluated the validity and utility of the Local Public Health System Assessment Instrument (Local Instrument) of the National Public Health Performance Standards Program in rural settings. METHODS: The study compared the Local Instrument scores of 6 rural local public health systems to external assessments of those public health systems. The 6 public health systems represented 3 states in which 1 of the 2 local jurisdictions had scored well below and the other well above the state median in a pilot test of the Local Instrument. The study design featured a case study approach consisting of an iterative and integrated combination of semistructured individual and focus group interviews along with the collection of archival materials provided by the 6 public health systems. FINDINGS: Despite differences in Local Instrument scores, the representative public health systems in each state provided roughly the same levels of public health services. Sites varied tremendously in the percentage of survey items rated highly or less relevant. CONCLUSIONS: The National Public Health Performance Standards Program Local Instrument can provide a useful structure and process for assessing public health system performance at the local level. Key informants provided several recommendations to improve the Local Instrument, including clarification of difficult terminology and acronyms, and development of multiple instruments structured around subsets of survey items.

Health Care Surveys↗
PubMed1987

Nicaragua: a health system developing under conditions of war.

Since its inception in 1979, the Nicaraguan National Health System has dramatically improved health care in Nicaragua through the provision of universal coverage, emphasis on preventive community-based primary care, and community participation in health activities. Of major importance in the development of the health system has been the decentralization of the administration, planning, and implementation of health programs. The war in Nicaragua has had a major impact on the development of the health system. Nicaraguan health personnel and facilities have been the objects of attack by the contras and scarce resources have been diverted from the development of social programs to military activities. A large refugee population has been created which further strains existing resources. Community-based preventive health programs have been adversely affected, particularly in rural areas where military activity is the most intense. Because of the war, efforts to optimize regionalization of the health system have been retarded. Economic pressures both within Nicaragua resulting from the war and within the entire Latin American area have further hampered efforts for development. Continued major improvements in health care in Nicaragua will depend on a settlement of the present military conflict which is draining resources in all sectors of development, including health.

Economics↗
PubMed1997

The integration of two health systems: social stratification, work and health in East and West Germany.

This is an analysis of system integration, social stratification and work for health status and health care in East and West Germany. It is based on aggregate data and representative survey data of random samples of 2554 adults in both subsystems. Findings show that there were marked differences in life-expectancy prior to unification. The integration of the two systems, which occurred almost totally with regard to terms of West German health care organization, shows adjustment problems in the East for the public Health-Care-Funds and few if any for ambulatory care. The work situation has an impact on health, but there are no significant differences for East versus West. Social stratification variables show an influence on subjective health status for education (East) and for income, social status (West), while physician utilization (despite a preference of specialists by those with higher status) is not significantly determined by stratification variables in either East or West Germany. Beyond the central focus on work and stratification determinants a major finding pertains to a comparatively worse health situation for the aged and for women in what was the former East Germany. System models of Capitalism versus Socialism fit the results and recent history of the two systems to only a limited degree, as the West German corporate health system shows clear limits in following free market principles. The East German system, regardless of its centralized organization and move towards a socialist system, never fully abandoned the traditional model of German health care. Unlike the East German health system, that of West Germany, with its general expansion to 92% of the population, shows an increasing effect for social redistribution. The latter may be a reason why standard indicators of social stratification show less of an impact on health and health care than expected, while conditions at work clearly determine the health of people-the latter being the case in both the former East and West Germany.

Adult↗
PubMed1998

[Paradigm as a methodological approach to analyzing Russia's public health system].

A concept of paradigm is applied to the analysis of the national public health system. Whether it can be used as a methodological regulator in public health management is considered. Evidence is provided for the theoretical premises of constructing a paradigm of the public health system, its philosophical bases, the notional system, methodology, and the technological framework. The theoretical and practical aspects of public health paradigm, such as identification, interpretation, and rationalization are used to analyze at the conceptual and practical level, as well as search for new ways of reforming the public health system by the paradigm approach as a deeper development of the existing paradigm or its modification. This can become a foundation for the realignments of the theoretical and practical bases of the national public health system. The formation of the new paradigm of the public health system is to take place not in a revolutionary, but in a developmental mode. Priority should be given not to radical transformations and drastic changing of the key concepts, but to the fluent increasing of new knowledge and their inclusion of the theory and practice of public health. The promises of using the paradigm methodology, allowing the internal and external principles of the operation and function of the public health system to be integrated. In this context, the paradigm approach may be used as a methodological tool for analyzing person-society-state-economy-management relations within the framework of the public health system.

Humans↗
PubMed1997

An inadequate supply of qualified people will slow the pace of health system change.

Executive recruiters bring a unique perspective on changes in the health system. By knowing the hiring needs of health care organizations, recruiters understand how the organizations are reacting to changes that have already occurred and how their strategies for dealing with the changes set the direction for future trends in the health system. This Issue Brief reports on a roundtable discussion during which a group of executive recruiters considered how health system changes are reflected in recruitment efforts in health care, and what the shifts in recruitment priorities indicate for the future direction and pace of health system change. The roundtable was sponsored by the Center for Studying Health System Change.

Administrative Personnel↗
PubMed1998

Health systems for the 21st century.

Health systems for the 21st century will have to respond to many challenges. This article indicates, against the background of health for all, which factors, both from within and outside, will influence health systems and what approaches and strategies are needed to address them. A strong emphasis will be placed on the government and its ministry of health. By improving the impact of its activities and interventions, by influencing the policies of other sectors and by creating partnerships for health, governments and the ministries of health should become real leaders for health.

Delivery of Health Care↗
PubMed1998

[Changes in hospital nursing care due to the Brazilian Unified Health System].

Considering changes in the Health System, this survey analyses the view of 31 nurses from a hospital institution linked to the Brazilian Unified Health System (SUS) in order to learn how they face the changes and their actions in 1995. To better understand the content of the interviews, authors use a thematic analysis proposed by BARDIN (1977). This analysis shows that some nurses recognize a different action after the SUS inclusion and others do not. However, when their actions are analysed as a whole, they are mainly directed to be a physician complementary action. The inadequate management by the nurse has contributed for a not entire nursing care. Authors suggest the management improvement of nurses in order to redirect nursing actions.

Adaptation, Psychological↗
PubMed2004

Knowledge-based changes to health systems: the Thai experience in policy development.

Over the past two decades the government in Thailand has adopted an incremental approach to extending health-care coverage to the population. It first offered coverage to government employees and their dependents, and then introduced a scheme under which low-income people were exempt from charges for health care. This scheme was later extended to include elderly people, children younger than 12 years of age and disabled people. A voluntary public insurance scheme was implemented to cover those who could afford to pay for their own care. Private sector employees were covered by the Social Health Insurance scheme, which was implemented in 1991. Despite these efforts, 30% of the population remained uninsured in 2001. In October of that year, the new government decided to embark on a programme to provide universal health-care coverage. This paper describes how research into health systems and health policy contributed to the move towards universal coverage. Data on health systems financing and functioning had been gathered before and after the founding of the Health Systems Research Institute in early 1990. In 1991, a contract capitation model had been used to launch the Social Health Insurance scheme. The advantages of using a capitation model are that it contains costs and provides an acceptable quality of service as opposed to the cost escalation and inefficiency that occur under fee-for-service reimbursement models, such as the one used to provide medical benefits to civil servants. An analysis of the implementation of universal coverage found that politics moved universal coverage onto the policy agenda during the general election campaign in January 2001. The capacity for research on health systems and policy to generate evidence guided the development of the policy and the design of the system at a later stage. Because the reformists who sought to bring about universal coverage (who were mostly civil servants in the Ministry of Public Health and members of nongovernmental organizations) were able to bridge the gap between researchers and politicians, an evidence-based political decision was made. Additionally, the media played a part in shaping the societal consensus on universal coverage.

Cost Control↗
PubMed2005

Prevention and promotion in decentralized rural health systems: a comparative study from northeast Brazil.

Policies to reform health care provision often combine the organizational restructuring of decentralization with ideological restructuring through a new model of health care that gives greater weight to prevention and promotion. Decentralization provides a discretionary space to the local health system to define and develop its own activities. The central policy aim to shift the model of health care therefore must rely on incentives rather than directives and is likely to result in variation at local levels in the extent and mode of its implementation. The local processes affecting variation in local implementation of policies for prevention and promotion have not been studied in a developing country. This study does so by comparing two rural health systems with different levels of prevention and promotion activities in one of the poorest regions of Brazil, Ceará State in the northeast. The health system with greater activities of prevention and promotion also has a more advanced stage of decentralization, but this is in combination with many other, interacting influences that differentiate the two health systems' ability to adopt and implement new approaches. While beyond the scope of this paper to detail options for regional and national managers to encourage the adoption of a greater focus on prevention and promotion, it is clear that strategies needs to target not only the vision and actions of local health system staff, but critically also the expectations of the local population and the attitudes of local government.

Brazil↗
PubMed2004

Developing a national performance indicator framework for the Dutch health system.

OBJECTIVE: To report on the first phase of the development of a national performance indicator framework for the Dutch health system. METHODS: In January 2002, we initiated an informed interactive process with the intended users-policymakers at the Ministry of Health, Welfare and Sport-and academics to develop both the conceptual framework and its content. Decisions were based on consensus after discussing strategic goals of the health system, information needs of policy makers at the Ministry of Health, Welfare and Sport, and studying existing theory and international experiences with national performance indicator frameworks. We identified objectives and criteria for a framework at the national level, constructed a conceptual model, and selected indicator areas. RESULTS: As a starting point we chose a balanced scorecard reflecting four perspectives towards health system management information at the national level. These perspectives are consumer orientation, finances, delivery of high quality care, and the ability to learn and grow. We then linked the Lalonde model for population health to a balanced scorecard model. The constructed model makes the relationship between population health and health system management apparent, and facilitates the presentation of performance information from various perspectives. The model reflects the strategic goals of the Dutch health system, i.e. contributing to the production of health by providing necessary health care of good quality that is accessible for all Dutch citizens while simultaneously informing policy makers about the performance of the entire health system in all sectors (care, cure, prevention, and social services). The selected indicator areas for health system management information (20 in total) reflect the policy and management functions of the government and the defined public goals of the health system. The model was formally adopted by the Ministry of Health, Welfare and Sport in February 2003, and since then individual indicator areas have been operationalized by 30 representatives of various departments at the Ministry with continuous external research support. CONCLUSION: The merit of linking the balanced scorecard inspired model to public health data is that it facilitates the visualization of the contribution of the health system to the improvement of population health. The method of an intensive interactive indicator development process between policy makers and researchers has so far proven successful.

Delivery of Health Care↗
PubMed1978

The impact of the Health Professions Educational Assistance Act on state mental health systems.

One effect of the Health Professions Educational Assistance Act of 1976 is to severely limit the number of foreign medical graduates entering the United States. To examine the impact of the law in Michigan, the authors gathered data on the number of psychiatrists practicing in the state and projected future manpower needs. They conclude that it is unlikely that, given other provisions in the law, American medical graduates can numerically replace foreign medical graduates, and that alternative manpower resources will have to be developed. State mental health systems must form new relationships with universities and the private psychiatric sector, and new methods of training personnel and sharing resources must be developed. The authors emphasize the importance of giving state mental health systems sufficient time and resources to develop effective manpower plans.

Education, Medical↗
PubMedDate not supplied

[Comparative analysis of Andean and Caribbean region health systems].

OBJECTIVE: Carrying out a comparative analysis of Andean and Caribbean health systems contributing towards the general panorama of Andean and Caribbean region health care system experience. METHODS: This study was aimed at carrying out a comparative analysis of health systems in Bolivia, Colombia, Ecuador, Peru, Venezuela, the Dominican Republic and Cuba between 1990 and 2004. Documentary information from secondary sources was used. Reform and changes during the aforementioned period were compared, as well as the systems' current configurations. Described typologies were used for studying the health systems. RESULTS: Different organisational designs were found for the systems: a national health system (NHS), segmented systems and systems based on mandatory insurance. The trend of reforms introduced in the 1990s and current proposals in almost all systems are directed towards adopting mandatory insurance via a basic packet of services and strengthening competition in providing services through a public and private mix. CONCLUSIONS: The organisation and structure of most systems studied have introduced and continue to introduce changes in line with international guidelines. The generality of these structures means that efforts must still be made to adopt designs strengthening them as instruments improving populations' quality of life. Comparative analysis is a tool leading to studying health systems and producing information which can nourish debate regarding current sector reform. This work took shape during the first approach to a comparative study of Andean region and Caribbean health systems.

Bolivia↗
PubMedDate not supplied

Mental health system and services in Albania.

AIMS: To describe the mental health system in Albania. METHODS: Data were gathered in 2003 and in 2004 using a new WHO instrument, World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS), designed for collecting essential information on the mental health system of low and middle income countries. It consists of 6 domains, 28 facets and 156 items. RESULTS: The information collected through WHO AIMS covered the key aspects of mental health system in Albania: the mental health policy and the legislative framework, the network of mental health services and the characteristics of the users, the role of the primary health care, the human resources, the public education and the links with other governmental sectors, monitoring and research. CONCLUSIONS: The data collection through WHO AIMS represented a needed step for a better in-depth knowledge of the system and for implementing actions to strengthen the system. Examples of planned actions were the improvement of the mental health component in primary care, a clear shift of resources from mental hospitals to community facilities, an increase of the outpatient care and an expansion of the mental health information system.

Albania↗
PubMedDate not supplied

National Public Health Performance Standards assessment: first steps in strengthening North Dakota's public health system.

North Dakota, as a rural state with a decentralized public health system, has found the National Public Health Performance Standards Program useful in assessing performance of the state's public health system. The local instrument was used for local public health systems and on Native American reservations. A description of the process as well as aggregated results of the local performance assessment is presented. An importance ranking scale was combined with the performance scores to identify priority areas. Priority needs were specifically identified for developing community health profiles, working more closely with community partnerships, and increasing emphasis on health education activities. The process was a good opportunity for bringing partners together in local public health systems and for developing interest in using the more complete strategic planning tools in Mobilizing for Action through Planning and Partnerships.

Efficiency, Organizational↗