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Knowledge for better health: a conceptual framework and foundation for health research systems.

Health research generates knowledge that can be utilized to improve health system performance and, ultimately, health and health equity. We propose a conceptual framework for health research systems (HRSs) that defines their boundaries, components, goals, and functions. The framework adopts a systems perspective towards HRSs and serves as a foundation for constructing a practical approach to describe and analyse HRSs. The analysis of HRSs should, in turn, provide a better understanding of how research contributes to gains in health and health equity. In this framework, the intrinsic goals of the HRS are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Its four principal functions are stewardship, financing, creating and sustaining resources, and producing and using research. The framework, as it is applied in consultation with countries, will provide countries and donor agencies with relevant inputs to policies and strategies for strengthening HRSs and using knowledge for better health.

Artificial Intelligence↗

Hospitals in a changing health care system.

Health system change is happening locally, and hospitals are at the center of this change. This paper, which presents data from a 1995 study of fifteen diverse communities, sketches the broad economic and organizational forces affecting hospitals in these communities and the hospitals' responses. Within these larger trends, local flavors and differences emerge. These appear to reflect variations in each community's employment base and health care purchasing experience, in the history and political strength of health system stakeholders, and in regional issues of culture or religious affiliation for some hospitals.

Delivery of Health Care↗

Impact of targeted programs on health systems: a case study of the polio eradication initiative.

The results of 2 large field studies on the impact of the polio eradication initiative on health systems and 3 supplementary reports were presented at a December 1999 meeting convened by the World Health Organization. All of these studies concluded that positive synergies exist between polio eradication and health systems but that these synergies have not been vigorously exploited. The eradication of polio has probably improved health systems worldwide by broadening distribution of vitamin A supplements, improving cooperation among enterovirus laboratories, and facilitating linkages between health workers and their communities. The results of these studies also show that eliminating polio did not cause a diminution of funding for immunization against other illnesses. Relatively little is known about the opportunity costs of polio eradication. Improved planning in disease eradication initiatives can minimize disruptions in the delivery of other services. Future initiatives should include indicators and baseline data for monitoring effects on health systems development.

Adult↗

An update on the community tracking study: a focus on the changing health system.

A major research project of the Center for Studying Health System Change (HSC) analyzes how the health system is evolving in 60 communities across the United States and the effects of those changes on people. Underway since 1996, the Community Tracking Study, which is funded exclusively by the The Robert Wood Johnson Foundation, is a longitudinal project that relies on periodic site visits and surveys of households, physicians and employers. The study is intended to provide a sound information base for decisions made by health care leaders. This Issue Brief provides an update of the study's design and research agenda.

Community Health Services↗

Patient and health system delays in the diagnosis and treatment of tuberculosis in Southern Taiwan.

SETTING: Tainan city, Tainan county and 13 townships of Kaohsiung county, Southern Taiwan. OBJECTIVE: To measure delays in the diagnosis and treatment of sputum-positive tuberculosis (TB) and to determine factors associated with delays in seeking health care (patient delay) and in starting anti-tuberculosis treatment (health system delay). DESIGN: A population-based patient interview study. RESULTS: Median patient delay was 7 days (range 0-730). Median health system delay was 23 days (range 0-489), 13 for smear-positive patients and 37 for smear-negative patients (P < 0.005). Median total delay was 44 days (range 0-730). Age <65 years was associated with longer patient delay. Negative smear, absence of haemoptysis, not having a chest radiograph at the first medical consultation and visiting clinics for first consultation were associated with a longer health system delay. Age <65 years, negative smear and cough as the only presenting symptom were associated with longer total delay. CONCLUSION: Patient delay was substantially shorter than health system delay. To reduce health system delay, clinics need to be involved and the referral mechanism must be strengthened. Physicians should maintain high alert for TB and perform prompt sputum smear examinations.

Adolescent↗

[Measures developed by the public health system to prevent accidents and violence in children and adolescents in Fortaleza, Ceará, Brazil].

This article deals with measures developed by the public health system to prevent accidents and violence in children in Fortaleza, Ceará State, Brazil. The program resulted from the need perceived by the authors in light of statistics on mortality from external causes in childhood and adolescence and the fact that there was apparently no preventive action being taken by the public health system. We conducted a questionnaire-based survey of health administrators in the six Regional Executive Secretariats (SERs) corresponding to the geographic districts in which the health system is divided in Fortaleza. According to the survey, existing preventive measures are limited in time and space, and there is no overall policy in this direction; the current measures are organized as health education campaigns focused on prevention of alcohol and drug abuse, violence, household accidents, and juvenile delinquency. SER-I was the only health district that had established partnerships with other sectors in developing such activities. We conclude that the public health system's agenda in Fortaleza needs to incorporate the prevention of childhood and adolescent accidents and violence, taking an inter-sectoral approach and joining efforts in order for the knowledge accumulated on such health problems to be transformed into effective action

Accident Prevention↗

Consumer participation and influence in a Health Systems Agency.

Consumer participation and influence were studied in one Health Systems Agency in the southeastern United States over a 20-month period (July 1976--February 1978). Consumer board members were found to be significantly less influential in agency decision making than were provider board members. This difference in influence existed even though virtually no difference existed between consumers' and providers' levels of participation. Consumer board members, while representing minority and nonminority, and both rural and nonrural groups, tended nevertheless also to be middle-class, middle-income individuals. Low-income and working-class groups were underrepresented on the board of the Health Systems Agency. Furthermore, consumer representatives tended to be satisfied with and have access to health care.

Adolescent↗

[Responsiveness of the Mexican health system].

OBJECTIVE: To present and discuss findings on the responsiveness of the Mexican health system. MATERIAL AND METHODS: The data source was the 2002-2003 National Performance Assessment Survey. A descriptive analysis was performed and results were adjusted for user's expectations using vignette information. Final results were disaggregated by sex, provider, age, and education level. RESULTS: Responsiveness scores given by women and senior individuals were higher than those provided by men and young adults. Major differences were observed when provider comparisons were made. In ambulatory care, the Ministry of Health and private providers were better rated than major social security institutions. For in-patient care, private providers were better rated than public health institutions. CONCLUSIONS: Responsiveness of the Mexican health system requires improvements in certain areas in order to meet one of the basic goals of all health systems.

Adolescent↗

Strategic positioning for nursing excellence in health systems: insights from chief nursing executives.

The emergence of health systems as a dominant structure for organizing healthcare has stimulated the development of health system chief nursing executive (CNE) positions. These positions have large spans of control, requiring CNEs to balance a wide range of responsibilities, making them accountable for fiscal management, quality of care, compliance, and contributing to organizational growth. As such the CNE is required to use principles of distributive justice to guide priority setting and decision making. This review addresses important questions about CNE system integration strategies, strategic priorities, and organizational positioning as they attempt to fulfill their ethical responsibilities to patients and the nurses they serve.

Benchmarking↗

Patient choice and patient empowerment in northern European health systems: a conceptual framework.

The issue of patient choice presents a complicated challenge to publicly operated health systems. Increased patient choice can strengthen the citizen's commitment to traditional welfare state objectives, or alternatively, it can severely damage that commitment, depending upon the design of the choice mechanism and the structural context within which patient choice occurs. For patient choice to be linked to true empowerment, choice must reinforce rather than undercut the accountability of health care providers to the population they serve. This article explores the basic issues involved in empowering patients within publicly operated health systems. The author first reviews the conceptual components that could or should be incorporated within the notion of empowered patients, then examines what would be required to actually empower patients within health systems, defined in terms of expanding not only logistical choice but also clinical influence and decision-making participation. The article concludes with a wide-ranging analysis of the impact of potential policies and mechanisms on the long-term objectives in achieving democratically accountable health care systems.

Cross-Cultural Comparison↗

Inova Health System, Falls Church, Virginia.

Inova Health System found a change strategy that supported redesign of our patient care delivery to improve the patient experience while changing the culture of the organizations, ensuring system integration and reducing costs. Using the large group intervention of the Conference Model we involved staff and physicians from the entire system to create a model of care to meet the needs of the future. This methodology allowed us the opportunity to tap the intellectual capital of the organization's and build capacity among a wide range of our staff. The adventure is outlined in our On the Scene.

Benchmarking↗

Changing the infection control paradigm from off-line to real time: the experience at Millard Fillmore Health System.

In 1993, several departments at Millard Fillmore Health System joined efforts to initiate a new approach to infection control. The main emphasis of this program is to move infection control to a real-time mode to manage patient outcomes daily. The principal objective was to decrease the number of nosocomial infections by 10%, with a particular emphasis on surgical-site infections. Besides real-time surveillance, we are critically evaluating several aspects of the management of nosocomial infections. High-level computer support has been the frame-work upon which this program was built. We have microcomputers that are linked directly to microbiology, pharmacy, billing, and admissions, downloading data several times daily. An expert software system merges all of the data, and from this we can target patients for real-time interventions. The computer system allows all inpatients to be screened for either infection control or antibiotic management interventions on a daily basis, with minimal time being spent on data collection and maximal efforts devoted to interventions at the bedside. Additionally, the infection management program will assist in maintaining the extraordinarily low expenditures on antimicrobial agents. During 1993, the Millard Fillmore Health System spent $924,884 on antibiotics, an amount approximately 50% that of comparably sized hospitals.

Anti-Bacterial Agents↗

Planning and management of change in health systems.

The modernization of a health system may require priorities to be defined and the responsibilities of staff at the periphery to be increased. With a view to achieving these objectives, senior personnel from Guinea-Bissau's Ministry of Health participated in a seminar on mission mapping, the nature of which is outlined below.

Guinea-Bissau↗

[The need for research to support the emergence of alternative animal health systems].

Animal diseases remain one of the main problems for livestock production in terms of trade development, poverty reduction and public health. Animal health systems are complex because of the diversity of the parties involved and because of various changes in the delivery of veterinary services, such as the redefinition of the roles of the public and private sectors. It is, therefore, often difficult to assess the global performance of animal health systems and sub-systems in terms of their medical, economic and social effectiveness. In addition, the necessary reliability of the health information obtained leads to certification of the status of regions and countries with regard to epizootics, which requires a high degree of standardisation and conformity with international norms. An assessment therefore needs to be made of the advantages of alternative systems compared with conventional systems. An animal health system should be seen as a whole, and when assessing its overall performance several things must be taken into account, e.g. the markets for products and the sometimes contradictory interests of all the different parties involved. There are, therefore, many research needs and avenues to be pursued, including: the methods, data and tools required for assessing the effectiveness of systems, including a definition of what constitutes a reliable indicator; the factors that determine the health of a herd; having a clearer idea of what will affect herd health will make it possible to map risk indicators and animal health care needs; the design and management of realistic and harmonised animal health information systems whose indicators provide reliable measurements of health; the function, organisation and effectiveness of participative surveillance approaches; the definition and effectiveness of animal health contracts, such as health mandates between the State and private veterinarians; the function and role of livestock auxiliaries; the establishment of assessment methods and standards that take into account the specific situation of southern countries that could lead to the certification and accreditation of alternative systems. The efficiency of these systems must then be tested (direct impact, cost-benefit studies) using the above-mentioned indicators, and an implementation 'toolkit' can then be assembled, taking into account the local differences which will affect the suitability of each system for different locations. Research into the assessment of animal health systems is a long-term investment, but it ensures that quality certification is reliable and allows for the safe development of animal product markets.

Animal Diseases↗

[Regional health systems management: a case study in Rio Grande do Sul, Brazil].

This article analyzes the management system in a health district in the State of Rio Grande do Sul, Brazil, through qualitative analysis, using a case study as the methodology and macro-organization theory as the analytical framework. For the current management system in the 6th Health Region, a clear mission statement and wide acceptance by health workers are facilitating factors for the current organizational practices within the health system. Nevertheless, the way health coordinators are currently prioritizing their time has diverted necessary resources from critical problems towards more remedial issues. The 6th Health Region has encouraged social control (or public oversight) in order to improve accountability. However, there is room for improvement in quality assurance management, since there were no well-defined goals, objectives, or accountability. Decentralized consultancy provided to the municipalities and the funding model itself have both promoted decentralization and autonomy, although the strategy requires better regional integration and greater commitment in managerial practices.

Brazil↗

Toward ethical review of health system transformations.

Efforts to transform health systems constitute social experiments on a population. Like clinical research, they deploy measures that are unproven in the context of the reform, and they often impose significant risks on some people in order to achieve a social goal: the improvement of health delivery. The rationale for proactively evaluating clinical experimentation on human subjects also applies to these social experiments. We used the "benchmarks of fairness" methodology to illustrate the elements such an evidence-based review should encompass, leaving open the question of who should perform it. The review must include the ethical objectives of reform, namely, an integrated approach to equity, accountability, and efficiency; the fit between measures taken and these objectives; and the governance of the reform.

Biomedical Research↗