A realistic theory of health sector management. The case for critical realism

To date the practice of health sector management has not been sufficiently theorised. An adequate theory should be able to answer the pre-eminent critique of managerial rationality and ethics mounted by Alasdair MacIntyre in After Virtue and should also offer robust analytical and ethical resources to identify and engage with the social, political, economic and moral issues underlying health sector management. Critical realism with its ontology of generative mechanisms, agency-structure relationships, valorisation of activity and ideology critique offers such resources in an empirically orientated but adequately theorised realist framework. Rather than negate MacIntyre, critical realism incorporates and transcends his key arguments regarding the rationality and ethics of management. This article introduces the main elements of critical realism and clears a conceptual space for the cumulation of critical realist case-studies and managerial craft knowledge.     

Bringing critical realism to nursing practice: Roy Bhaskar's contribution

In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar's work focuses our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar's work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare‐related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing.     

Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector

Background

Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.

Discussion

Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.

Summary

The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.

     

Mental Health System Reform

ABSTRACT

In recent years many countries have embarked on various types of health and mental health reform. These reforms have in large part been driven by governments' concerns for cost containment which has, in turn, been driven by an increasing process of global marketization and the need to control national deficits. A critical issue in these reforms is the increased emphasis on the use of “market mechanisms” in the delivery of health and mental health services.

This paper uses a policy analysis framework to compare recent developments in the mental health sector in Canada, the United States, Britain and Australia. The common framework to be used for this will focus on: the defining characteristics of the society; legislative mandate; sectorial location (within or separate from health sector); funding streams; organising values of the system; locus of service delivery; service technologies; the role of social work; interprofessional dynamics; the role of consumers; and evaluation of outcomes at multiple levels. This analysis provides an opportunity to explore similarities and differences in mental system reform and in particular identify the challenges for social work in the field of mental health in the 21st century.     

Health system reform and safe abortion: A case study of Mongolia

Abstract

Unsafe abortion serves as a marker of global inequity as it is concentrated in the developing world where the poorest and most vulnerable women live. While liberalisation of abortion law is essential to the reduction of unsafe abortion, a number of challenges exist beyond this important step. This paper investigates how popular health system reforms consonant with neoliberal agendas can challenge access to safe abortion. We use Mongolia, a country that has liberalised abortion law, yet, limited access to safe abortion, as a case study. Mongolia embraced market reforms in 1990 and subsequently reformed its health system. We document how common reforms in the areas of finance and regulation can compromise the safety of abortions as they foster challenges that include inconsistencies in service delivery that further foment health inequities, adoption of reproductive health programmes that are incompatible with the local sociocultural context, unregulated growth of the private sector and poor enforcement of standards and technical guidelines for safe abortion. We then discuss how this case study suggests the conversations that reproductive health policy-makers must have with those engineering health sector reform to ensure access to safe abortion in a liberalised environment.     

Australian federal,state and territory policy on the health and wellbeing of young people: A scoping review

BackgroundThe health and wellbeing of young people are critical for the future of society but the extent to which they are addressed by overarching Australian Federal, State and Territory health policy is difficult to determine. Analysing high-level youth health policy will help establish how Australian governments are articulating and prioritising issues and may guide local and international health agendas.MethodsThis scoping review aimed to determine the extent, range and nature of Australian high-level government policy focused on the general health and wellbeing of the general population of young people. Policies published by Australian Federal, State, or Territory government departments between 2008 and 2019 were thematically analysed employing Braun and Clark's six-step recursive framework.FindingsTwelve policy documents met inclusion criteria. Three meta-themes emerged, comprising policy development, youth health challenges, and policy goals. Policy goals fell into three ubiquitous and overarching categories focused on supporting public health, promoting equity, and improving the health system for young people.ConclusionsA number of youth-specific health policies have been developed by Australian governments in recent years. Whilst goals and strategies are clearly articulated, more can be done to ensure a youth voice in policy development. The policy goals of supporting public health, promoting equity and improving the health system deserve consideration from other countries developing youth health policies.     

Engagement or dismissiveness? Intersecting international theory and global health

ABSTRACT

International relations theorists and global health politics scholars largely fail to communicate with one another. We argue that drawing on insights from classic and contemporary international theory more explicitly will positively augment the study of global health politics. This paper highlights four major theoretical orientations in the international relations literature (realism, neoliberal institutionalism, constructivism, and feminism) and discusses how an understanding of these perspectives can strengthen our understanding of global health policy.     

The use of artificial intelligence-based innovations in the health sector in Tanzania: A scoping review

BackgroundArtificial Intelligence (AI) has great potential to transform health systems to improve the quality of healthcare services. However, AI is still new in Tanzania, and there is limited knowledge about the application of AI technology in the Tanzanian health sector.ObjectivesThis study aims to explore the current status, challenges, and opportunities for AI application in the health system in Tanzania.MethodsA scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extensions for Scoping Review (PRISMA-ScR). We searched different electronic databases such as PubMed, Embase, African Journal Online, and Google Scholar.ResultsEighteen (18) studies met the inclusion criteria out of 2,017 studies from different electronic databases and known AI-related project websites. Amongst AI-driven solutions, the studies mostly used machine learning (ML) and deep learning for various purposes, including prediction and diagnosis of diseases and vaccine stock optimisation. The most commonly used algorithms were conventional machine learning, including Random Forest and Neural network, Naive Bayes K-Nearest Neighbour and Logistic regression.ConclusionsThis review shows that AI-based innovations may have a role in improving health service delivery, including early outbreak prediction and detection, disease diagnosis and treatment, and efficient management of healthcare resources in Tanzania. Our results indicate the need for developing national AI policies and regulatory frameworks for adopting responsible and ethical AI solutions in the health sector in accordance with the World Health Organisation (WHO) guidance on ethics and governance of AI for health.     

Supporting the Development of Evidence-Informed Policy Options: An Economic Evaluation of Hypertension Management in Ghana

ObjectivesUniversal healthcare coverage in low- and middle-income countries requires challenging resource allocation decisions. Health technology assessment is one important tool to support such decision making. The International Decision Support Initiative worked with the Ghanaian Ministry of Health to strengthen health technology assessment capacity building, identifying hypertension as a priority topic area for a relevant case study.MethodsBased on guidance from a national technical working group of researchers and policy makers, an economic evaluation and budget impact analysis were undertaken for the main antihypertensive medicines used for uncomplicated, essential hypertension. The analysis aimed to address specific policy questions relevant to the National Health Insurance Scheme.ResultsThe evaluation found that first-line management of essential hypertension with diuretics has an incremental cost per disability-adjusted life-year avoided of GH¢ 276 ($179 in 2017, 4% of gross national income per capita) compared with no treatment. Calcium channel blockers were more effective than diuretics but at a higher incremental cost: GH¢ 11 061 per disability-adjusted life-year avoided ($7189 in 2017; 160% of gross national income per capita). Diuretics provide better health outcomes at a lower cost than angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers. Budget impact analysis highlighted the potential for cost saving through enhanced price negotiation and increased use of better-value drugs. We also illustrate how savings could be reinvested to improve population health.ConclusionsEconomic evaluation enabled decision makers to assess hypertension medicines in a Ghanaian context and estimate the impact of using such evidence to change policy. This study contributes to addressing challenges associated with the drive for universal healthcare coverage in the context of constrained budgets.     

Lean in healthcare: A comprehensive review

BackgroundLean seems to be the next revolution for a better, improved, value-based healhcare. In the last 15 years Lean has been increasingly adapted and adopted in healthcare. Accordingly, Lean healthcare has been developing into a major strand of research since the early 2000s. The aim of this work is to present a comprehensive overview of the main issues highlighted by research on implementation of Lean in a complex contest such as the healthcare one.MethodComprehensive literature review was conducted in order to identify empirical and theoretical articles published up to September 2013. Thematic analysis was performed in order to extract and synthesis data.Findings243 articles were selected for analysis. Lean is best understood as a means to increase productivity. Hospital is the more explored setting, with emergency and surgery as the pioneer departments. USA appears to be the leading country for number of applications. The theoretical works have been focused mainly on barriers, challenges and success factors. Sustainability, framework for measurement and critical appraisal remain underestimated themes. Evaluations of “system wide approach” are still low in number.ConclusionEven though Lean results appear to be promising, findings so far do not allow to draw a final word on its positive impacts or challenges when introduced in the healthcare sector. Scholars are called to explore further the potentiality and the weaknesses of Lean, above all as for the magnitude of investments required and for the engagement of the whole organization it represents increasingly strategic choice, whilst health professionals, managers and policy makers could and should learn from research how to play a pivotal role for a more effective implementation of lean in different health contexts.     

Is channel segmentation necessary to reach a multiethnic population with weight-related health promotion? An analysis of use and perception of communication channels

Objective. To explore similarities and differences in the use and perception of communication channels to access weight-related health promotion among women in three ethnic minority groups. The ultimate aim was to determine whether similar channels might reach ethnic minority women in general or whether segmentation to ethnic groups would be required.

Design. Eight ethnically homogeneous focus groups were conducted among 48 women of Ghanaian, Antillean/Aruban, or Afro-Surinamese background living in Amsterdam. Our questions concerned which communication channels they usually used to access weight-related health advice or information about programs and whose information they most valued. The content analysis of data was performed.

Results. The participants mentioned four channels – regular and traditional health care, general or ethnically specific media, multiethnic and ethnic gatherings, and interpersonal communication with peers in the Netherlands and with people in the home country. Ghanaian women emphasized ethnically specific channels (e.g., traditional health care, Ghanaian churches). They were comfortable with these channels and trusted them. They mentioned fewer general channels – mainly limited to health care – and if discussed, negative perceptions were expressed. Antillean women mentioned the use of ethnically specific channels (e.g., communication with Antilleans in the home country) on balance with general audience-oriented channels (e.g., regular health care). Perceptions were mixed. Surinamese participants discussed, in a positive manner, the use of general audience-oriented channels, while they said they did not use traditional health care or advice from Surinam. Local language proficiency, time resided in the Netherlands, and approaches and messages received seemed to explain channel use and perception.

Conclusions. The predominant differences in channel use and perception among the ethnic groups indicate a need for channel segmentation to reach a multiethnic target group with weight-related health promotion. The study results reveal possible segmentation criteria besides ethnicity, such as local language proficiency and time since migration, worthy of further investigation.     

How workers’ emotional dissonance explains the association between customers’ relations,burnout and health in an Italian supermarket chain

Introduction:Dealing with customers has increasingly became a risk factor that organisations should be aware of. Having to deal with difficult customers, pupils, patients it has been found to be the second most frequent reported risk factor in the recent 2019 ESENER survey (61%, up from 58%), just after repetitive hand or arm movements.Objectives:The aim of the present study is to explore the relationship between negative relations with customers and its association with employees’ burnout and general health.Methods:Data were collected using an anonymous, self-report questionnaire employed in an Italian company working in the large-scale retail sector. The sample was composed of 610 employees (70% women) working in 28 supermarkets.Results:Results showed that negative customer relations were associated to higher levels of emotional dissonance (b = .25; p = .000), which in turn was associated with higher levels of burnout (b = .72; p = .017) and consequently to higher levels of poor general health (b = .03; p = .000).Conclusion:This study contributed to the current understanding of how negative relationship with clients could trigger a health impairment process which could lead to higher levels of burnout and poorer general health in employees. Findings suggest that organizations whose employees’ work activities are characterized by a daily contact with customers should implement interventions such as training activities in order to enhance the employees’ skills in dealing with custumers, for example on how to manage emotions at work.     

Informing Balanced Investment in Services and Health Systems: A Case Study of Priority Setting for Tuberculosis Interventions in South Africa

ObjectivesHealth systems face nonfinancial constraints that can influence the opportunity cost of interventions. Empirical methods to explore their impact, however, are underdeveloped. We develop a conceptual framework for defining health system constraints and empirical estimation methods that rely on routine data. We then present an empirical approach for incorporating nonfinancial constraints in cost-effectiveness models of health benefit packages for the health sector.MethodsWe illustrate the application of this approach through a case study of defining a package of services for tuberculosis case-finding in South Africa. An economic model combining transmission model outputs with unit costs was developed to examine the cost-effectiveness of alternative screening and diagnostic algorithms. Constraints were operationalized as restrictions on achievable coverage based on: (1) financial resources; (2) human resources; and (3) policy constraints around diagnostics purchasing. Cost-effectiveness of the interventions was assessed under one “unconstrained” and several “constrained” scenarios. For the unconstrained scenario, incremental cost-effectiveness ratios were estimated with and without the costs of “relaxing” constraints.ResultsWe find substantial differences in incremental cost-effectiveness ratios across scenarios, leading to variations in the decision rules for prioritizing interventions. In constrained scenarios, the limiting factor for most interventions was not financial, but rather the availability of human resources.ConclusionsWe find that optimal prioritization among different tuberculosis control strategies in South Africa is influenced by whether and how constraints are taken into consideration. We thus demonstrate both the importance and feasibility of considering nonfinancial constraints in health sector resource allocation models.     

Acculturation and Food Intake Among Ghanaian Migrants in Europe: Findings From the RODAM Study

ObjectiveThis study examined the role of migration and acculturation in the diet of Ghanaian migrants in Europe by (1) comparing food intake of Ghanaian migrants in Europe with that of Ghanaians living in Ghana and (2) assessing the association between acculturation and food intake.DesignData from the cross-sectional multicenter study Research on Obesity and Diabetes among African Migrants were used. Food intake was assessed using a Ghana-specific food propensity questionnaire (134 items and 14 food groups); foods were grouped based on a model of dietary change proposed by Koctürk-Runefors.SettingGhana, London, Amsterdam, and Berlin.ParticipantsA total of 4,534 Ghanaian adults living in Ghana and Europe, with complete dietary data. Of these, 1,773 Ghanaian migrants had complete acculturation data.Main Outcome MeasureFood intake (the weighted intake frequency per week of food categories).AnalysisLinear regression.ResultsFood intake differed between Ghanaians living in Ghana and Europe. Among Ghanaian migrants in Europe, there were inconsistent and small associations between acculturation and food intake, except for ethnic identity, which was consistently associated with intake only of traditional staples.Conclusions and ImplicationsFindings indicate that migration is associated with dietary changes that cannot be fully explained by ethnic, cultural, and social acculturation. The study provides limited support to the differential changes in diet suggested by the Koctürk-Runefors’ model of dietary change.     

A delicate web: Household changes in health behaviour enabled by microcredit in Burkina Faso

Abstract

Providing microcredit to women in developing countries has long been highlighted as a simple and effective strategy for poverty reduction and health improvement. However, little is known about how microcredit enables changes in health behaviour. This knowledge is critical to further strengthen microcredit initiatives. This qualitative study, conducted in Burkina Faso, shows how microcredit can not only facilitate savings and investment strategies, but also lead to changes in household decision-making, enabling women to initiate health prevention, seek health treatment and manage health emergencies. Some changes led to increased household burdens for women that impeded health gains, such as administrative loan delays by the microcredit institution and reduced household contributions by the husband. Furthermore, the study highlighted the fragile nature of health gains, which may be eroded due to economic shocks on a household, such as crop failure, drought or illness.     

Ways of unraveling how and why physical activity influences mental health through statistical mediation analyses

ObjectiveKnowledge of the mechanisms responsible for the effects of physical activity on aspects of mental health is limited. Appropriate experimental trials and statistical mediation analyses of experimental, quasi-experimental and observational studies can help shed light on these mechanisms. A critical overview of methods for mediation analyses is provided. Recommendations relevant to studies in the field of physical activity and mental health are made.StrategyMain issues pertaining to the identification of mechanisms of influence (mediators) are discussed. Recommendations on appropriate methods of mediation analysis for cross-sectional and longitudinal data and ways of presenting findings from such analyses are provided. Finally, future directions in methods of mediation analyses are briefly outlined.ConclusionsThere is a dearth of mediation studies in the field of physical activity and mental health, which explains why not much is known about the underlying mechanisms of influence. An array of experimental and statistical methods is available to those who wish to unravel how and why physical activity affects various aspects of mental health in diverse populations and circumstances. The correct use of, and presentation of findings from, methods of mediation analyses is vital for clarifying how mental health can be enhanced through participation in physical activity.     

When state-funded health insurance schemes fail to provide financial protection: An in-depth exploration of the experiences of patients from urban slums of Chhattisgarh,India

ABSTRACT

This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected (‘revelatory’) instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the ‘smart card’), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance.     

Scope and magnitude of private sector financing and provision of immunization in Benin,Malawi and Georgia

BackgroundLittle is known about the role of private sector providers in providing and financing immunization. To fill this gap, the authors conducted a study in Benin, Malawi, and Georgia to estimate (1) the proportion of vaccinations taking place through the private sector; (2) private expenditures for vaccination; and (3) the extent of regulation.MethodsIn each country, the authors surveyed a stratified random sample of 50 private providers (private for-profit and not-for-profit) using a standardized, pre-tested questionnaire administered by trained enumerators. In addition, the authors conducted 300 or more client exit interviews in each country.ResultsThe three countries had different models of private service provision of vaccination. In Malawi, 44% of private facilities, predominantly faith-based organizations, administered an estimated 27% of all vaccinations. In Benin, 18% of private for-profit and not-for-profit facilities provided vaccinations, accounting for 8% of total vaccinations. In Georgia, all sample facilities were privately managed, and conducted 100% of private vaccinations. In all three countries, the Ministries of Health (MoHs) supplied vaccines and other support to private facilities. The study found that 6–76% of clients paid nominal fees for vaccination cards and services, and a small percentage (2–26%) chose to pay higher fees for vaccines not within their countries’ national schedules. The percentage of private expenditure on vaccination was less than 1% of national health expenditures. The case studies revealed that service quality at private facilities was mixed, a finding that is similar to those of other studies on private sector vaccination. The three countries varied in how well the MoHs managed and supervised private sector services.Discussion/ConclusionThe private sector plays a growing role in lower-income countries and is expanding access to services. Governments’ ability to regulate and monitor immunization services and promote quality and affordable services in the private sector should be a priority.