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PubMed2006

The CMIO--a new leader for health systems.

Physician leadership is a critical success factor for health information technology initiatives, but best practices for structuring the role and skills required for such leadership remain undefined. The authors conducted structured interviews with five physician information technology leaders, or Chief Medical Information Officers (CMIOs), at health systems that broadly used health information technology. The study aimed to identify the individual skills and organizational structure necessary for a CMIO to be effective. The interviews found that the CMIOs had significant management experience prior to serving as a CMIO and were positioned and supported within each health system similar to other executive leaders; only one of the five CMIOs had formal informatics training. A review of the findings advocates for the CMIO to have a strong background and role as a physician executive supported by knowledge in informatics, as opposed to being a highly trained informaticist with secondary management expertise or support.

Health Facility Administration↗

PubMed1992

Health systems education yesterday, today, and tomorrow.

This paper traces the history of the application of industrial management engineering techniques to health systems problems. The educational background of early practitioners and the development of specialized health systems educational programs are described. Projections are made about the future of health systems engineering and health systems education.

Delivery of Health Care↗

PubMedDate not supplied

Regional health systems address many audiences. Baptist uses language of the bard.

Regional health systems address many audiences. The winners in this category are: Baptist Health Systems of South Florida, Coral Gables, Fla., first place; Memorial Hospital & Health System of South Bend, South Bend, Ind., second place; and Orlando Regional Healthcare, Orlando, Fla., third place.

Annual Reports as Topic↗

PubMed2002

Building the legal foundation for an effective public health system.

Work has been underway nationally since the mid-1990s to equip state and community public health systems with the infrastructure needed to perform essential public health services. Key components of that infrastructure are a competent workforce, information and communication systems, health department and laboratory capacity, and legal authorities. As part of this transformative work, standards and assessment tools have been developed to measure the capacity and actual performance of public health systems. In addition, a number of states have examined the legal foundation for public health services and have revised and updated those authorities to improve their system's capacity in the context of evolving health challenges. Among those states are Nebraska, New Jersey, and Texas, all of which, beginning in 1999, have adopted dynamic new approaches to aligning public health's legal authorities with new missions and expectations for performance and accountability. This article describes the approaches that these three states have taken to strengthen their legal foundation for public health practice, to illuminate the perspectives legislators and health officials bring to the process, and to give decision makers in other states practical insight into the potential benefits of reviewing and restructuring public health's legal authorities. The underlying stimuli for the states' initiatives differed significantly, yet shared an important, common core. What they held in common was concern that outdated elements of the public health system and infrastructure hindrered delivery of essential public health services at the community level. Where they differed was in the type of tools they found most suitable for the job of rejuvenating those structures. The approaches taken, and the policy tools selected, reflect the unique health needs of each state, establish relationships among state and community health authorities and agencies, and provide guidance by elected and appointed policy makers. Each state continues to refine its approach as it gains experience with the new authorities.

Community Health Services↗

PubMed2006

The impact of contracting-out on health system performance: a conceptual framework.

Despite the increased popularity of contracting-out of health services in developing countries, its effectiveness on overall health system performance is not yet conclusive. Except for substantial evidence of contracting-out's positive effect on access to health services and some evidence on improved equity in access, there is little evidence of contracting-out's impact on quality and efficiency. Most studies on the subject evaluate specific contracting-out projects against narrowly specified project objectives, not against more broadly defined health system goals. For this reason, conclusions of positive effects pertaining to project level may not hold at system level. This paper presents a conceptual framework that is expected to facilitate comprehensive, rigorous, and standardized evaluation of contracting-out at health system level. Specifically, this framework supports: full and standardized description of contracting-out interventions, study of the determinants of effectiveness, examination of provider and purchaser responses, assessment of the impact of contracting-out on all dimensions of health system performance, and cross-project analyses.

Delivery of Health Care↗

PubMed2001

Comparative efficiency of national health systems: cross national econometric analysis.

OBJECTIVE: To improve the evidence base for health policy by devising a method to measure and monitor the performance of health systems. DESIGN: Estimation of the relation between levels of population health and the inputs used to produce health. SETTING: 191 countries. MAIN OUTCOME MEASURE: Health system efficiency (performance). RESULTS: Estimated efficiency varied from nearly fully efficient to nearly fully inefficient. Countries with a history of civil conflict or high prevalence of HIV and AIDS were less efficient. Performance increased with health expenditure per capita. CONCLUSIONS: Increasing the resources for health systems is critical to improving health in poor countries, but important gains can be made in most countries by using existing resources more efficiently.

Delivery of Health Care↗

PubMedDate not supplied

Nonprofit health systems: a promising new class of corporate citizen.

Leading nonprofit health systems are demonstrating that communities can benefit from the emergence of this new class of corporate citizens. Just as the business sector has produced many good corporate citizens to the great advantage of American society, health systems with sufficient financial and organizational gravitas increasingly are assuming these roles, and in so doing, are making positive differences in their communities. More system leaders, however, must find compelling reasons to assume these demanding roles. They also must learn how to play citizenship roles more fully and effectively if the potential social good available through health systems' corporate citizenship is to be realized.

Community-Institutional Relations↗

PubMed1998

Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.

Decision Making, Organizational↗

PubMed2003

Dissemination of heart health promotion in the Ontario Public Health System: 1989-1999.

This paper reports the results of an analysis of the dissemination of community-based heart health promotion strategies. The research draws on diffusion and socio-ecological theories to study the first 10 years of heart health promotion in the public health system in Ontario, Canada. Using case description and interpretive analysis, the study describes developments in five stages of dissemination, and examines the interplay of factors operating in the internal organizational setting and the external environment in order to explain these developments. Findings demonstrate that dissemination of health promotion is a long-term, iterative process involving multiple stages. Dissemination is influenced by a complex interplay of factors operating within the public health system (especially traditional public health practice and champions) and factors in the environment in which the public health system operates (especially research, practice information and health policies). Implications are that policy makers should take a long-term view of dissemination, identify intermediate and long-term goals consistent with dissemination stages, and capitalize on internal and external forces supporting dissemination goals. Similar case-study research in other public health systems and time periods, and in more advanced stages of dissemination, will add further insight into the dissemination process.

Health Promotion↗

PubMed2001

Health system goals: life, death and ... football.

OBJECTIVES: Both the World Health Organization (WHO) and the Fédération Internationale de Football Association (FIFA) have developed sophisticated ways of defining and aggregating performance to produce overall, single-number indices. These are used to illustrate some of the problems of measuring, comparing and improving health system performance. METHODS: Possible associations between FIFA football rankings for international 'A' sides for 176 countries and rankings on the WHO overall health system performance index were explored using econometric techniques. RESULTS: There is a significant relationship between a country's FIFA ranking and its ranking by the WHO. Taken at face value, the statistical analysis suggests that, if the national football team does well, the WHO score improves. CONCLUSIONS: The relationship between FIFA and WHO ranks is entirely spurious. However, comparison of the two indices illustrates problems with the WHO exercise, including measurement difficulties, how policy-makers may use the information to improve health system performance, what the public are to make of the data and how different dimensions of overall performance may be subject to trade-offs.

Delivery of Health Care↗

PubMedDate not supplied

[Local health systems. Moral rationality of community decisions].

The author examines the points of convergence between local health systems and bioethics in three basic areas: structural or institutional, methodological or justificatory, and regulatory or normative. Comparisons are drawn between the decentralization of the health system posed by local health systems and deconcentration of the power vested in multidisciplinary ethics committees; the strategy of social participation and the movement in the United States of community decision-making in the area of health; and the basic concepts of primary health care and the principle of justice. The theories of Pellegrino and Thomasma on the philosophic bases for medical practice provide the framework of this comparative analysis. The article concludes with a call for a local health systems-bioethical nexus in which this discipline can provide the basis for infusing an ethical component into participatory planning and community decision-making.

Delivery of Health Care↗

PubMedDate not supplied

Overcoming health-systems constraints to achieve the Millennium Development Goals.

Effective interventions exist for many priority health problems in low income countries; prices are falling, and funds are increasing. However, progress towards agreed health goals remains slow. There is increasing consensus that stronger health systems are key to achieving improved health outcomes. There is much less agreement on quite how to strengthen them. Part of the challenge is to get existing and emerging knowledge about more (and less) effective strategies into practice. The evidence base also remains remarkably weak, partly because health-systems research has an image problem. The forthcoming Ministerial Summit on Health Research seeks to help define a learning agenda for health systems, so that by 2015, substantial progress will have been made to reducing the system constraints to achieving the MDGs.

Delivery of Health Care↗

PubMed1986

The place of primary health care in a comprehensive health system.

UNLABELLED: In considering the place of Primary Health Care in a comprehensive health system, we must first consider what is meant by the term 'comprehensive'. Comprehensive systems take into account all phases of life from infancy to old age, and integrate all aspects of being, including physical, psychological, mental, social, environmental, political and so on. It is the task of those who deliver the primary health care system to evaluate and prioritize health needs in specific populations, and to implement programs which honor the community's unique priorities, taking into account all phases and aspects of life. Drawing upon data collected from a comprehensive field survey of community health activities in Hiketa, in Kagawa Prefecture in Shikoku, and other similar surveys carried out in Japan, as well as references such as the Report of the International Conference on Primary Health Care (Alma Ata), and the World Health Organization Global Strategy for Health for All by the Year 2000, this background paper will outline the critical aspects to be considered in implementation of primary health care in comprehensive health systems, as a context for further discussion. Aspects to be considered are as follows: Community representation and participation Evaluation of health needs Prioritization of health needs IMPLEMENTATION: consultation with specialists IMPLEMENTATION: utilization of local resources IMPLEMENTATION: health education IMPLEMENTATION: support of local government IMPLEMENTATION: co-ordination of laymen, specialists, officials and others Evaluation Follow through. Illustrative examples will be used to highlight problems and solutions as each aspects is considered.

Community Health Services↗

PubMed2000

Health system reform and the role of field sites based upon demographic and health surveillance.

Field sites for demographic and health surveillance have made well-recognized contributions to the evaluation of new or untested interventions, largely through efficacy trials involving new technologies or the delivery of selected services, e.g. vaccines, oral rehydration therapy and alternative contraceptive methods. Their role in health system reform, whether national or international, has, however, proved considerably more limited. The present article explores the characteristics and defining features of such field sites in low-income and middle-income countries and argues that many currently active sites have a largely untapped potential for contributing substantially to national and subnational health development. Since the populations covered by these sites often correspond with the boundaries of districts or subdistricts, the strategic use of information generated by demographic surveillance can inform the decentralization efforts of national and provincial health authorities. Among the areas of particular importance are the following: making population-based information available and providing an information resource; evaluating programmes and interventions; and developing applications to policy and practice. The question is posed as to whether their potential contribution to health system reform justifies arguing for adaptations to these field sites and expanded investment in them.

Developing Countries↗

PubMed2004

Ethics and health systems research in 'post'-conflict situations.

Although considerable attention has been given to ethical issues related to clinical research in developing countries, in particular related to HIV therapy, there has been limited focus on health systems research, despite its increasing importance in the light of current trends in development assistance. This paper examines ethical issues related to health systems research in 'post'-conflict situations, addressing both generic issues for developing countries and those issues specific to 'post'-conflict societies, citing examples from the author's Cambodian experience. It argues that the destruction of health infrastructure results in a loss of structures and processes that would otherwise protect prospective research subjects who are part of vulnerable populations. It identifies the growth of health systems research as part of a trend towards sectoral and programmatic development assistance, the emergence of 'knowledge generation' as a form of research linked to development, and the potential for conflict where multilateral and bilateral donors are both primary funders and users of health systems research. It also examines the position of the health system researcher in relation to the sponsors of this research, and the health system being analysed.

Cambodia↗

PubMed2003

What works for mental health system change: evolution or revolution?

The mental health system has realized significant metamorphoses in the standards and practices of quality care for people with psychiatric disability during the past decade. Now change agents are wrestling with effective strategies that help real-world systems to adopt programs reflecting these metamorphoses. Two fundamental approaches to systems change are compared and contrasted here: evolution and revolution. First, the authors compare the different ways in which evolution and revolution might approach change in the mental health system. They do this by showing how they might influence the transformation of day treatment into supported employment programs. Then, the authors present the two approaches as naturally occurring change processes that work in tandem to affect real-world adaptations. Finally, they summarize practical strategies that change agents might adopt to realize evolution and revolution. Clearly, all stakeholder groups need to become strategic about system change so that real-world practices keep up with the ideals emerging in practice guidelines and evidence-based practice reviews.

Employment, Supported↗

PubMed1993

Developing district health systems in the rural Transvaal. Issues arising from the Tintswalo/Bushbuckridge experience.

District health systems are increasingly acknowledged as a foundation for national health services based on primary health care. Initial efforts to institute a demonstration district health system in the Bushbuckridge area of the eastern Transvaal are described. These include efforts to overcome the organisational and administrative fragmentation caused by homeland and provincial boundaries. Close attention needs to be given to district-level health management, the complementary roles of district and regional health authorities, working relationships and accountability among professional staff from different disciplines, involvement of the community in a district health authority and the district health system as an element of local government.

Community Health Services↗

PubMed2003

European health systems and cancer care.

INTRODUCTION: Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s. OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS: The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal. CONCLUSIONS: Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.

Community Health Planning↗