Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.     

India's integrated child development services scheme: challenges for scaling up

Background

India had around 158 million children under the age of 6 and about 26 million births in 2015. In the same year, India's Integrated Child Development Services Scheme served about 82 million children under 6 years and over 19 million pregnant women and lactating mothers. These 102 million beneficiaries received services in about 1.3 million centres.

Method

This paper reviews the growth of the Scheme and considers challenges to scaling up quality with equity based on results of large‐scale national or multistate studies.

Results

The Scheme is associated with decreased malnutrition and better child development. The size and diversity of the country, the policy context, funding mode and lack of community awareness and engagement have hindered scaling up access while the approach to service delivery, low institutional capacity and poor infrastructure have impeded scaling up of implementation quality.

Conclusions

This review illustrates the challenges associated with scaling‐up access and implementation quality of a multicomponent, integrated early childhood programme in a large, diverse country. The future success of the Integrated Child Development Services will depend on how well it adheres to quality standards and how well it evolves to address current weaknesses.     

The economics of primary prevention of cardiovascular disease – a systematic review of economic evaluations

Background

Global resource needs estimation is a critical part of addressing the HIV/AIDS epidemic. To generate these estimates knowledge of costs and cost structures is required. The evidence base for costs of HIV prevention programmes is limited. Even less is known about the existence of economies scale and whether, as economic theory suggests, average costs form a 'u'-shaped curve as scale increases. Using an econometric analysis, this paper addresses this question by estimating marginal costs and economies of scale for HIV prevention programmes for vulnerable groups in Southern India with different levels of coverage.

Methods

Two hybrid translog-cost functions were estimated. First, expenditure data from 78 state-funded HIV prevention projects in Andhra Pradesh were used to explore the impact of scale, institutional history and price on costs; second, economic cost data from 16 commercial sex worker projects across Tamil Nadu and Andhra Pradesh were analysed to additionally assess the impact of the value of inputs not reported in expenditure data and location. Coefficient estimates were used to calculate marginal costs and economies of scale.

Results

The econometric model yielded a good fit (R² = 0.46, p < 0.001 and R² = 0.79, p < 0.001, for the expenditure and economic cost datasets, respectively). The economies of scale index was greater than 1 for both datasets and fell as coverage increased. Analysis of the expenditure data found economies of scale were not exhausted, with a 0.002% change in total cost for each extra person reached and an 11% difference in total cost between target group categories. Estimation using the economic cost data suggests a point of minimum efficient scale at around 1750–2000 people reached, a 0.03% change in total cost for each extra person reached, and 28% lower costs in Tamil Nadu than Andhra Pradesh.

Conclusion

Econometric analysis of these standardized datasets provides insights into how costs change with coverage, the impact of project location and nature of the project target group. The results demonstrate the importance of understanding the nature of the cost function when designing, budgeting and estimating resource requirements for scaling up coverage of HIV prevention projects.     

Personal strengths reported by people with chronic illness: A qualitative study

Background

Self‐management of chronic illness can be highly demanding and people need to mobilize their personal strengths to live well with their condition. More knowledge is needed about how people with chronic illness perceive and use their personal strengths as a basis for better integrating empowering person‐centred approaches into health care.

Objective

To explore what people with chronic illness describe as their strengths relevant to their health and well‐being.

Setting and Participants

Thirty‐nine participants (11 men) from 4 outpatient self‐management programmes were recruited to individual or group interviews. Participants included patients with chronic respiratory disease (n = 7), chronic pain (n = 18) and morbid obesity (n = 14). Interviews were analysed using content analysis.

Results

A number of personal strengths were reported and categorized into 3 domains: (i) Internal strengths, (ii) External strengths and (iii) Self‐management strategies. Internal strengths included being persistent, having a positive outlook, being kind and caring, experiencing positive emotions, being kind towards oneself, reconciling oneself with the situation, having courage and having knowledge and insight. External strengths included support from family, friends, peers and health‐care providers. Self‐management strategies included being active, planning and prioritizing, reducing stress, goal setting and seeking knowledge and help.

Discussion and Conclusion

The study provides insights into personal strengths as reported by people with chronic illness. The results complement prior findings on strengths in people with health challenges and can aid in incorporating person‐centred approaches into health care.     

Recommendations for undergraduate medical electives: a UK consensus statement

Introduction

Many doctors, across grades and specialities, supervise or advise students and juniors undertaking elective placements. Electives form part of medical curricula on a worldwide scale. The Medical Schools Council (MSC) Electives Committee in the UK identified a gap in the current literature in relation to provision of comprehensive recommendations for the design and management of undergraduate elective programmes. Electives afford many known benefits for medical and other health care students, but the context, and risks (impacting potentially on patient, public and student well‐being) are usually different from those associated with ‘home’ clinical placements.

Aim

The aim is to share experiences and good practice within UK Medical Schools, and inform and inspire others involved with similar programmes across the globe.

Method

This paper reports the results of the formation of a sub‐group to draft a set of recommendations, drawing on the reported experiences of academic elective leads across all UK schools, and including input from the MSC, and the student group Medsin (to capture the learner voice). The final document was the result of a national consultative process of four iterations. The end document was approved at school level, e.g. by curriculum committee, by each of the participating schools.

Recommendations

The recommendations consolidate the experiences of 30 participating UK medical schools. The consultation process generated 17 pre‐departure recommendations, seven during elective recommendations, 11 post elective recommendations and a further four recommendations relating to infectious disease.

Conclusion

We believe developing elective programmes using collective recommendations will provide a basis for a safer and more structured approach to a medical elective without losing the uniqueness and creative experiences valued by participants. Issues relating to undergraduates leaving their home school to experience medicine in a new context or country replicate across sites, so many recommendations will be transferable internationally.     

Identification of factors contributing to successful self‐directed weight loss: a qualitative study

Background

Despite the number of weight management programmes and their wide promotion, most overweight and obese individuals tend to lose weight on their own. The present study aimed to understand the characteristics and strategies of those who successfully engage in self‐directed weight loss, which could empower other overweight and obese individuals with information and strategies to manage their weight on their own.

Methods

Men and women who had lost at least 5% of their body weight without direct interaction with professionals or weight management programmes were recruited. Demographic data were collected by questionnaire and participants' weight‐loss experiences were explored using semi‐ structured interviews to elicit in‐depth individual experiences and perspectives. Iterative thematic method data analysis was used to generate themes describing contributing factors to the success of self‐directed weight loss identified by participants.

Results

Most characteristics of those who successfully self‐managed their weight loss were in line with those reported by successful weight losers participating in professional‐led projects. However, strategies such as early embedding of new lifestyle behaviours into daily routine, the ability to learn from previous weight‐loss experiences, and not requiring social support were identified as distinctive factors that contributed to the success of self‐directed weight loss by participants of the present study.

Conclusions

Overweight or obese individuals with strong internal motivation, problem‐solving skills and self‐reliance are more likely to be successful at achieving self‐directed weight loss. The patients identified with these characteristics could be encouraged to self‐manage their weight‐loss process, leaving the places available in more resource‐intensive professional‐led programmes to those individuals unlikely to succeed on their own.

     

Chart stalking,list making,and physicians’ efforts to track patients’ outcomes after transitioning responsibility

Context

Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians’ activities in practice as they sought follow‐up information about patients.

Methods

Using a constructivist grounded theory approach, semi‐structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants’ strategies when deliberately conducting follow‐up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT ) to explore interactions among the social, cultural and material influences related to follow‐up.

Results

The authors identified three themes related to follow‐up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow‐up. Analysis of participants' follow‐up processes as an activity system highlighted key tensions in the system and participants’ work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients’ outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients’ health information (rules) led to rule‐breaking or abandoning activities of locating information. Finding time to conduct desired follow‐up produced tension between this and other activity systems.

Conclusion

In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow‐up. The authors offer four recommendations to address the tensions identified through AT : (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians’ skill development in developing and maintaining tracking systems for follow‐up; (iii) dedicate time in physicians’ work schedules for conducting follow‐up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians’ learning and respect patients’ privacy.

     

An empirically based conceptual framework for fostering meaningful patient engagement in research

Background

Patient engagement in research (PEIR) is promoted to improve the relevance and quality of health research, but has little conceptualization derived from empirical data.

Objective

To address this issue, we sought to develop an empirically based conceptual framework for meaningful PEIR founded on a patient perspective.

Methods

We conducted a qualitative secondary analysis of in‐depth interviews with 18 patient research partners from a research centre‐affiliated patient advisory board. Data analysis involved three phases: identifying the themes, developing a framework and confirming the framework. We coded and organized the data, and abstracted, illustrated, described and explored the emergent themes using thematic analysis. Directed content analysis was conducted to derive concepts from 18 publications related to PEIR to supplement, confirm or refute, and extend the emergent conceptual framework. The framework was reviewed by four patient research partners on our research team.

Results

Participants’ experiences of working with researchers were generally positive. Eight themes emerged: procedural requirements, convenience, contributions, support, team interaction, research environment, feel valued and benefits. These themes were interconnected and formed a conceptual framework to explain the phenomenon of meaningful PEIR from a patient perspective. This framework, the PEIR Framework, was endorsed by the patient research partners on our team.

Conclusions

The PEIR Framework provides guidance on aspects of PEIR to address for meaningful PEIR. It could be particularly useful when patient‐researcher partnerships are led by researchers with little experience of engaging patients in research.     

Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Background  

Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes.