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BACKGROUND: Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia. METHODS: A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance. FINDINGS: The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation. CONCLUSIONS: Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.
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Personal de Salud , Política de Salud , Investigación Cualitativa , Tuberculosis Resistente a Múltiples Medicamentos , Humanos , Zambia , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Política , Participación de los Interesados , Accesibilidad a los Servicios de Salud/organización & administración , Atención a la Salud/organización & administración , Conducta Cooperativa , Agentes Comunitarios de Salud/organización & administración , Femenino , MasculinoRESUMEN
The efficient and accurate analysis of illicit drugs remains a constant challenge in Australia given the high volume of drugs trafficked into and around the country. Portable drug testing technologies facilitate the decentralisation of the forensic laboratory and enable analytical data to be acted upon more efficiently. Near-infrared (NIR) spectroscopy combined with chemometric modelling (machine learning algorithms) has been highlighted as a portable drug testing technology that is rapid and accurate. However, its effectiveness depends upon a database of chemically relevant specimens that are representative of the market. There are chemical differences between drugs in different countries that need to be incorporated into the database to ensure accurate chemometric model prediction. This study aimed to optimise and assess the implementation of NIR spectroscopy combined with machine learning models to rapidly identify and quantify illicit drugs within an Australian context. The MicroNIR (Viavi Solutions Inc.) was used to scan 608 illicit drug specimens seized by the Australian Federal Police comprising of mainly crystalline methamphetamine hydrochloride (HCl), cocaine HCl, and heroin HCl. A number of other traditional drugs, new psychoactive substances and adulterants were also scanned to assess selectivity. The 3673 NIR scans were compared to the identity and quantification values obtained from a reference laboratory in order to assess the proficiency of the chemometric models. The identification of crystalline methamphetamine HCl, cocaine HCl, and heroin HCl specimens was highly accurate, with accuracy rates of 98.4â¯%, 97.5â¯%, and 99.2â¯%, respectively. The sensitivity of these three drugs was more varied with heroin HCl identification being the least sensitive (methamphetamine = 96.6â¯%, cocaine = 93.5â¯% and heroin = 91.3â¯%). For these three drugs, the NIR technology provided accurate quantification, with 99â¯% of values falling within the relative uncertainty of ±15â¯%. The MicroNIR with NIRLAB infrastructure has demonstrated to provide accurate results in real-time with clear operational applications. There is potential to improve informed decision-making, safety, efficiency and effectiveness of frontline and proactive policing within Australia.
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Drogas Ilícitas , Espectroscopía Infrarroja Corta , Drogas Ilícitas/análisis , Australia , Humanos , Detección de Abuso de Sustancias/métodos , Aprendizaje Automático , Metanfetamina/análisis , Heroína/análisis , Heroína/químicaRESUMEN
BACKGROUND: Managing the transition of a health system (HS) from a centralised to a decentralised model has been touted as a panacea to the complex challenges in developing countries like Malawi. However, recent studies have demonstrated that decentralisation of the HS has had mixed effects in service provision with more dominant negative outcomes than positive results. The aim of this study was to develop a substantive grounded theory (GT) that elaborates on how activities of central decision-makers and local healthcare mangers shape the process of shifting the HS to a decentralised model in Machinga, Malawi. METHODS: The study was qualitative in nature and employed the Straussian version of GT. Some participants were interviewed twice, and a total of 36 semi-structured interviews were conducted with 25 purposively selected participants using an interview guide. The interviews were conducted at the headquarters of the Ministry of Health (MoH) and other ministries and agencies, and in Machinga District. Data were analysed using open, axial, and selective coding processes of the GT methodology; and the conditional matrix and paradigm model were used as data analysis tools. RESULTS: The findings of this study revealed seven different activities, forming two opposing and interactional sub-processes of enabling and impeding patterns that derailed the decentralisation drive. The study generated a GT labelled "decentralisation of the HS derailed by organisational inertia," which elaborates that decentralisation of the HS produced mixed results with more predominant negative outcomes than positive effects due to resistance at the upper organisational echelons and members of the District Health Management Team (DHMT). CONCLUSION: This article concludes that organisational inertia at the personal and strategic levels of leadership entrusted with decentralising the HS in Malawi, contributed immensely to the derailment of shifting the HS from the centralised to the decentralised model of health service provision.
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Atención a la Salud , Política , Investigación Cualitativa , Malaui , Humanos , Atención a la Salud/organización & administración , Teoría Fundamentada , Entrevistas como AsuntoRESUMEN
BACKGROUND: Although primary care models for the care of common non-communicable diseases (NCD) have been developed in sub-Saharan Africa, few have described an integrated, decentralized approach at the community level. We report the results of a four-year, Ethiopian project to expand this model of NCD care to 15 primary hospitals and 45 health centres encompassing a wide geographical spread and serving a population of approximately 7.5 million people. METHODS: Following baseline assessment of the 60 sites, 30 master trainers were used to cascade train a total of 621 health workers in the diagnosis, management and health education of the major common NCDs identified in a scoping review (hypertension, diabetes, chronic respiratory disease and epilepsy). Pre- and post-training assessments and regular mentoring visits were carried out to assess progress and remedy supply or equipment and medicines shortages and establish reporting systems. The project was accompanied by a series of community engagement activities to raise awareness and improve health seeking behaviour. RESULTS: A total of 643,296 people were screened for hypertension and diabetes leading to a new diagnosis in 24,313 who were started on treatment. Significant numbers of new cases of respiratory disease (3,986) and epilepsy (1,925) were also started on treatment. Mortality rates were low except among patients with hypertension in the rural health centres where 311 (10.2%) died during the project. Loss to follow up (LTFU), defined as failure to attend clinic for > 6 months despite reminders, was low in the hospitals but represented a significant problem in the urban and rural health centres with up to 20 to 30% of patients with hypertension or diabetes absenting from treatment by the end of the project. Estimates of the population disease burden enrolled within the project, however, were disappointing; asthma (0.49%), hypertension (1.7%), epilepsy (3.3%) and diabetes (3.4%). CONCLUSION: This project demonstrates the feasibility of scaling up integrated NCD services in a variety of locations, with fairly modest costs and a methodology that is replicable and sustainable. However, the relatively small gain in the detection and treatment of common NCDs highlights the huge challenge in making NCD services available to all.
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Política de Salud , Enfermedades no Transmisibles , Humanos , Enfermedades no Transmisibles/terapia , Enfermedades no Transmisibles/epidemiología , Etiopía/epidemiología , Atención Primaria de Salud , Recursos en Salud/provisión & distribuciónRESUMEN
BACKGROUND: Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation. METHODS: This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis. RESULTS: The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes. CONCLUSIONS: Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.
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Reforma de la Atención de Salud , Investigación Cualitativa , Irlanda , Reforma de la Atención de Salud/organización & administración , Humanos , Política de Salud , Formulación de Políticas , Estudios de Casos Organizacionales , Entrevistas como Asunto , Responsabilidad SocialRESUMEN
Background: Childhood tuberculosis (TB) remains underdiagnosed largely because of limited awareness and poor access to all or any of specimen collection, molecular testing, clinical evaluation, and chest radiography at low levels of care. Decentralising childhood TB diagnostics to district hospitals (DH) and primary health centres (PHC) could improve case detection. Methods: We conducted an operational research study using a pre-post intervention cross-sectional study design in 12 DHs and 47 PHCs of 12 districts across Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone and Uganda. The intervention included 1) a comprehensive diagnosis package at patient-level with tuberculosis screening for all sick children and young adolescents <15 years, and clinical evaluation, Xpert Ultra-testing on respiratory and stool samples, and chest radiography for children with presumptive TB, and 2) two decentralisation approaches (PHC-focused or DH-focused) to which districts were randomly allocated at country level. We collected aggregated and individual data. We compared the proportion of tuberculosis detection in children and young adolescents <15 years pre-intervention (01 August 2018-30 November 2019) versus during intervention (07 March 2020-30 September 2021), overall and by decentralisation approach. This study is registered with ClinicalTrials.gov, NCT04038632. Findings: TB was diagnosed in 217/255,512 (0.08%) children and young adolescent <15 years attending care pre-intervention versus 411/179,581 (0.23%) during intervention, (OR: 3.59 [95% CI 1.99-6.46], p-value<0.0001; p-value = 0.055 after correcting for over-dispersion). In DH-focused districts, TB diagnosis was 80/122,570 (0.07%) versus 302/86,186 (0.35%) (OR: 4.07 [1.86-8.90]; p-value = 0.0005; p-value = 0.12 after correcting for over-dispersion); and 137/132,942 (0.10%) versus 109/93,395 (0.11%) in PHC-focused districts, respectively (OR: 2.92 [1.25-6.81; p-value = 0.013; p-value = 0.26 after correcting for over-dispersion). Interpretation: Decentralising and strengthening childhood TB diagnosis at lower levels of care increases tuberculosis case detection but the difference was not statistically significant. Funding source: Unitaid, Grant number 2017-15-UBx-TB-SPEED.
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Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach. We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents. Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (-110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed. Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.
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Objetivos , Estudios de Casos Organizacionales , Evaluación de Resultado en la Atención de Salud , Inglaterra/epidemiología , Medicina Estatal/organización & administración , Medicina Estatal/tendencias , Estudios de Casos Organizacionales/estadística & datos numéricos , Salud Pública/normas , Salud Pública/estadística & datos numéricos , Determinantes Sociales de la Salud/estadística & datos numéricos , Pacientes Ambulatorios/estadística & datos numéricos , Servicios de Salud Materna/estadística & datos numéricos , Servicios de Salud Dental/estadística & datos numéricos , Distribución por Edad , Atención Primaria de Salud/estadística & datos numéricos , Medicina de Emergencia/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Apoyo Social/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Atención al Paciente/estadística & datos numéricos , Humanos , Masculino , Femenino , Adulto , Adolescente , Adulto Joven , Persona de Mediana Edad , AncianoRESUMEN
Background: The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods: In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings: For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation: The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding: Unitaid.
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BACKGROUND: The People's Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. METHODS: We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. RESULTS: Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM's frontline health workers, ASHAs, emerged as leaders in LSGs. CONCLUSION: The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation - these contradictions may vex progress going forward and warrant further study.
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Reforma de la Atención de Salud , Salud Rural , Humanos , India , Pueblo Asiatico , Cambio ClimáticoRESUMEN
OBJECTIVES: The aim of the study was to answer whether the central government has been more efficient than the regional governments or vice versa. Likewise, through the analysis of the data, the aim was to shed light on whether decentralisation has had a positive impact on the efficiency of the hospital sector or not. DESIGN: In this paper, we have used data envelopment analysis to analyse the evolution of efficiency in the last 10 Autonomous Regions to receive healthcare competences at the end of 2001. PARTICIPANTS: For this study, we have taken into account the number of beds and full-time workers as inputs and the calculation of basic care units as outputs to measure the efficiency of the Spanish public sector, private sector and jointly in the years 2002, 2007, 2012 and 2017 for the last Autonomous Regions receiving healthcare competences. RESULTS: Of the Autonomous Regions that received the transfers at the end of 2001, the following stand out for their higher efficiency growth: the Balearic Islands (81.44% improvement), the Madrid Autonomous Region, which practically reached absolute efficiency levels (having increased by 63.77%), and La Rioja which, together with the Balearic Islands which started from very low values, improved notably (46.13%). CONCLUSION: In general, it can be observed that the transfer of responsibilities in the health sector has improved efficiency in the National Health Service. JEL CLASSIFICATION: C14; I18; H21.
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Atención a la Salud , Medicina Estatal , Humanos , Sector Público , Hospitales Públicos , Eficiencia Organizacional , PolíticaRESUMEN
BACKGROUND: Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS: We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS: Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION: Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.
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Médicos , Humanos , Kenia , Uganda , Personal de Salud/educación , Grupos FocalesRESUMEN
Inter-regional patient mobility represents both a resource and a challenge for the organization and financing of health systems, particularly in decentralised countries. We use cross-sectional time series regression analysis to test the determinants of imbalances in regional funds to finance inter-regional patient mobility for the 17 Spanish regions for the period 2014-2020. The findings indicate that highly specialised health centres and bilateral agreements partly explain the budget imbalance from inter-regional patient referrals, while local tourism partly explains the budget imbalance from non-referred patient mobility. Developing effective national schemes to compensate net patient recipient regions would be fundamental to addressing territorial imbalances.
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Presupuestos , Política , España , Estudios Transversales , Humanos , Transferencia de Pacientes/economíaRESUMEN
Macroeconomics data was collected through the Central Statistics Agency (BPS) Central Java Province for the thirty-five regencies and municipalities in Central Java Province from 2017 to 2021. The Fundamental index of fiscal decentralisation (FFDI) and Enhanced index of fiscal decentralisation (EFDI) were adapted from [1] and corresponding datasets matched to fiscal data from the Central Java province government. The data sources and indices' calculation methodologies were described in detail. The resulting indices, together with labour participation rate, as well as foreign and domestic investment data were analysed in a panel data analysis model with Gross Regional Domestic Product as the outcome variable. The collected data enables researchers and policy-makers to update observations on the impact of Indonesia's 'Big Bang' fiscal decentralisation on economic growth in a province with above-average growth rate but which had experienced significant challenges arising from the Covid-19 pandemic. This is in light of previous research findings which found that the Indonesian decentralisation has had mixed outcomes due to institutional and fiscal capability limitations within the local governments. The detailed sources and steps to obtain the required data and calculate the FFDI and EFDI enables researchers to apply the indices in providing updated observations on the impact of fiscal decentralisation on various socioeconomic phenomenon.
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In view of the impending ageing of the population, countries have been searching for ways to restructure their social care system. Reforms often involve a decentralisation of authority from central to local government. Although such a decentralisation presents the opportunity to be receptive to social demand, it could provide the incentive for local governments that bear the burden of the costs to (partly) transfer their costs back to the central level. In this paper we examine the impact of fiscal distress of municipalities on cost-shifting behaviour to the central long-term care system in the Netherlands. Using data on both the municipal level as well as the level of individual applicants for the period 2016-2019, we find that municipalities with fiscal distress in social care have higher percentages of applications for centrally funded long-term care. However, we also observe that higher percentages of applications and rejections are positively correlated suggesting that the Dutch independent need assessor has the capacity to (partly) discard cost-shifted applications.
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Conventional HIV testing performed by a health professional has shown its limitations in targeting marginalized and vulnerable populations. Indeed, men who have sex with men (MSM) due to social discrimination are often uncomfortable using this service at the health facilities level. In this perspective, new differentiated approaches have been thought through de-medicalized and decentralized HIV testing (DDHT). This HIV testing strategy enables overcoming the structural, legal, and social barriers that prevent these populations from quickly accessing HIV services. This article discusses the prerequisites and added value of implementing this strategy for MSM living in a criminalized context and its implication in decentralizing health services toward the community level.
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Infecciones por VIH , Minorías Sexuales y de Género , Masculino , Humanos , Homosexualidad Masculina , Camerún , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Accesibilidad a los Servicios de SaludRESUMEN
The article by Rotulo and colleagues suggests that health sector fiscal decentralisation has been bad for Italy. But given the complexity of fiscal decentralisation, this interpretation is not necessarily so. Their analysis was based on assumptions about causality that are better suited for simple interventions. Assumptions of simplicity show up as misleading artefacts in the conclusion of evaluations of complex interventions. Complex interventions work by triggering mechanisms - eg, reasoning and learning processes - that manifest differently across the units of a decentralised system, contingent on context, evolving over time. Evaluation findings can only be partial and provisional; neither summarily good nor bad. The goal of evaluating a complex intervention - such as decentralised governance - should be to understand how, under what circumstances and for whom they are good or bad - at a point in time.
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Servicios de Salud , Política , Humanos , Atención a la Salud , ItaliaRESUMEN
Several member countries of the Organisation for Economic Co-operation and Development are reforming their primary care systems to improve continuity and co-ordination of care. In May 2022, the Italian health minister issued a new Decree on 'defining models and standards for the development of primary care in the national health service', which addresses some of the major challenges outlined by the National Recovery and Resilience Plan. The reform will target many aspects of the Italian national health system by transforming primary care into community care, while aiming to overcome geographical disparities and achieve greater effectiveness of services. The reform seeks to establish a new organisational model of the primary care network. There exists the potential to guarantee the same quality of care nationwide, thereby reducing geographical differences in the provision of services and improving healthcare services overall. Nevertheless, in a decentralised health system such as Italy's, reform implementation could actually proliferate rather than reduce regional disparities. This study explains the main points of the Decree, shows how the primary care models of the Italian regions may evolve in relation to the specified criteria, and examines the Decree's capacity to bridge regional discrepancies.
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Atención Primaria de Salud , Medicina Estatal , Humanos , Italia , Encuestas y Cuestionarios , Reforma de la Atención de SaludRESUMEN
In dealing with water pollution and freshwater scarcity, on-site treatment and reuse of domestic wastewater has shown to be a promising solution. To increase on-site wastewater treatment and reuse, some cities, among them Bengaluru in India, have mandated the installation and use of the necessary technology in certain building types. However, even with a mandate, a successful and sustainable implementation of the technology, including reliable operation, monitoring, and maintenance, depends on the acceptance (i.e. positive valuation) of the technology and its use by the (prospective) users. Literature on technology acceptance indicates perceived costs, risks, and benefits of the respective technology as key predictors of acceptance. Therefore, the present online study assessed this relationship for on-site systems in Bengaluru. The relation was analysed separately for mandated users of on-site systems (N = 103) and current non-users (i.e. potential prospective users, should the mandate be expanded; N = 232), as the perceptions might differ between the two groups, due to the personal experience with the technology among users. The results show that for mandated users and non-users, acceptance of on-site systems is explained by perceived benefits only, namely a positive image of users, environmental benefits, and, only for non-users, also financial benefits for the city. The findings suggest that interventions aimed at promoting on-site systems should include emphasis on the benefits of on-site systems. Whenever possible, interventions should be tailored to the target group's individual cost, risk, and benefit perception.
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Aguas Residuales , Purificación del Agua , Eliminación de Residuos Líquidos/métodos , Estudios Prospectivos , IndiaRESUMEN
Numerous innovative decentralised urban water solutions have been described over many years, yet their application in practice is still not common at all. While many proposed solutions may have some techno-economic advantages over current systems, the real reasons for the slow uptake have more to do with system-wide inertia and technology 'lock-in' where existing solutions are preferred for simplicity and familiarity. A key factor is also the inadequate assessments in project decision making processes that should consider all relevant social, environmental and economic benefits and values. This paper highlights some key barriers and how to address them in a more holistic way. It also identifies opportunities where more integrated, hybrid solutions could offer significant benefits over current technologies. It calls on all key partners in this sector to foster broad and strong collaborations, and on water service providers to be empowered to take an inclusive leadership role in creating such innovative solutions that help address our growing challenges driven by rapid urbanisation and climate change.
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Healthcare decentralisation is a model of public service management founds on the wider distribution of the decisional power about healthcare. The decision power is split by central government also with the local health authorities. Since the 1980s, at worldwide level this reform has being applied for guaranteeing equity, efficiency, quality and financial sustainability in the healthcare services provision. In the last years, healthcare decentralisation is happening especially in low-middle income countries. With regard to the analysis of the effectiveness of decentralisation in healthcare, the obtained results are mixed. This study aims to investigate the contribution of management in the first steps of decentralisation's implementation for reducing health inequalities in Tunisia. To have the management's point of view, a survey was sent to all directors of the Tunisian regional hospitals. Health management was able to offer operative and timely solutions to the homogenisation and the improvement of healthcare services supply in Tunisia. For healthcare managers the guarantee of an equal and effective Tunisian healthcare system is into the application of a differentiated decentralisation. The differentiated decentralisation of healthcare system allows to resolve regional issues in Tunisia. These interventions permit to obtain consistent positive results about the satisfaction of Tunisian population health needs. The differentiated decentralisation of healthcare system could also be useful for similar countries, for example, of MENA are of low-middle income countries.