Difference between observed and predicted length of stay as an indicator of inpatient care inefficiency.
(49/1092)
OBJECTIVES: To evaluate the performance of the difference between observed and predicted length of stay (OLOS-PLOS) as an inefficiency of care indicator for inpatients. SETTING: The Internal Medicine and the General Surgery departments of Hermanos Ameijeiras Hospital in Havana. DESIGN AND STUDY PARTICIPANTS: Two sets of clinical histories were needed for each department: one for deriving the predictive equation and another to validate it. The equation was a linear multiple regression model which included variables recognized as affecting length of stay. The validation group of histories was thoroughly examined and separated into two groups: (i) adequate efficiency or mild problems and (ii) inefficiencies considered to be moderate or severe. This classification was the gold standard to obtain a receiver operating characteristic (ROC) curve for the indicator. RESULTS: The function explained 41% of the total variation for Internal Medicine and 70% for General Surgery. The indicator's mean difference between the two validation groups of histories was around 10 days for both departments. The areas under the ROC curve were 0.80 for Internal Medicine and 0.88 for General Surgery. Sensitivity and specificity > 0.7 for detecting inefficiencies of care are achieved with a cut off point of 2 days for Internal Medicine and 1 day for General Surgery. CONCLUSIONS: The use of predictive equations might be quite useful for detecting efficiency problems in inpatient health care. (+info)
Health sector development: from aid coordination to resource management.
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Aid coordination has assumed a prominent place on health policy agendas. This paper synthesizes the findings of research undertaken to explore the changing practices of aid coordination across a number of countries. It begins by reviewing the key issues giving rise to increased attention to aid coordination in the health sector. The second section describes, assesses and compares the strengths and weaknesses of the dominant mechanisms or instruments which were found to be employed to coordinate health sector aid in the case studies. From this analysis, four factors become clear. First, in many countries, coordination mechanisms have been introduced as a part of an incremental process of trying out different approaches--there is no one model that stands out at any one time. Secondly, some instruments function largely for consultation, predominantly coordinating inputs, while others are more directive and operational, and are used to manage inputs, processes and outputs. Third, many of the mechanisms have not excelled, although, fourth, it is difficult to judge the effectiveness or impact of aid coordination. It is therefore argued that concern with the effectiveness of aid coordination arrangements must give way to a broader analysis of the processes, outputs and outcomes governing the use of both external and domestic resources, focusing on institutional characteristics, the distribution and nature of influence among the actors, and the interests which they pursue through the aid regime. These factors varied considerably across the countries indicating that aid management is context dependent and subject to continuing changes. Finally, the paper looks at the findings in the light of the introduction of sector-wide approaches. (+info)
Keeping a tight grip on the reins: donor control over aid coordination and management in Bangladesh.
(51/1092)
A long-standing consensus that aid coordination should be owned by recipient authorities has been eclipsed by accord on the desirability of recipient management of aid along-side domestic resources. Nonetheless, in many low and lower-middle income countries, donors remain remarkably uncoordinated; where attempts at coordination are made, they are often donor-driven, and only a small proportion of aid is directly managed by recipients. This paper draws on evidence from an in-depth review of aid to the health sector in Bangladesh to analyze the systems by which external resources are managed. Based on interviews with key stakeholders, a questionnaire survey and analysis of documentary sources, the factors constraining the government from assuming a more active role in aid management are explored. The results suggest that donor perceptions of weak government capacity, inadequate accountability and compromised integrity only partially account for the propensity for donor leadership. Equally important is the consideration that aid coordination has a markedly political dimension. Stakeholders are well aware of the power, influence and leverage which aid coordination confers, an awareness which colours the desire of some stakeholders to lead aid coordination processes, and conditions the extent and manner by which others wish to be involved. It is argued that recipient management of external aid is dependent on major changes in the attitudes and behaviours of recipients and donors alike. (+info)
Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies.
(52/1092)
The end of the Cold War brought with it opportunities to resolve a number of conflicts around the world, including those in Angola, Cambodia, El Salvador and Mozambique. International political efforts to negotiate peace in these countries were accompanied by significant aid programmes ostensibly designed to redress the worst effects of conflict and to contribute to the consolidation of peace. Such periods of political transition, and associated aid inflows, constitute an opportunity to improve health services in countries whose health indicators have been among the worst in the world and where access to basic health services is significantly diminished by war. This paper analyzes the particular constraints to effective coordination of health sector aid in situations of 'post'-conflict transition. These include: the uncertain legitimacy and competence of state structures; donor choice of implementing channels; and actions by national and international political actors which served to undermine coordination mechanisms in order to further their respective agendas. These obstacles hindered efforts by health professionals to establish an effective coordination regime, for example, through NGO mapping and the establishment of aid coordinating committees at national and provincial levels. These technical measures were unable to address the basic constitutional question of who had the authority to determine the distribution of scarce resources during a period of transition in political authority. The peculiar difficulties of establishing effective coordination mechanisms are important to address if the long-term effectiveness of rehabilitation aid is to be enhanced. (+info)
Managing external resources in Mozambique: building new aid relationships on shifting sands?
(53/1092)
The Mozambican health sector is recovering from war and general disruption. This massive endeavour is supported by several donor agencies, which contribute a substantial proportion of national health expenditure. The final years of the war and the transition period have seen an extreme fragmentation of the health sector. To correct it, serious efforts to coordinate the plethora of aid agencies and related external inputs have taken place. This paper reviews the actors present on the Mozambican health scene and their interactions. The existing aid management mechanisms are described and their effectiveness appraised. The factors affecting both the process and its outcomes are analyzed. Given the prevailing complexity, this research presents a number of tentative conclusions. First, the evidence suggests that coordination efforts have paid off. However, progress has required intense and sustained work. Incremental approaches, where donor demands are progressively raised as the system is strengthened, have been crucial. The initiative has come mainly from donors, with the Ministry of Health receptive and reactive. When the recipient administration has been able to take advantage of donor initiatives, success has ensued. Individual people have been crucial in shaping the process. Critical factors contributing to positive developments on both sides of the donor-recipient relationship have been frankness, risk-taking and a long-term perspective. (+info)
Zambia: the role of aid management in sustaining visionary reform.
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As part of its ongoing reform of the health sector, Zambia has developed a number of systems and structures to coordinate and manage external resources. With increasing attention being given to the potential for sector-wide approaches (SWAps) to enhance the efficiency and effectiveness of health systems in low-income countries, Zambia provides an interesting case study of how this is emerging in practice over time. The paper outlines the different coordination mechanisms and assesses them in terms of selected criteria of effectiveness, finding that the potential to meet reform objectives is currently not being met. Factors influencing the effectiveness of these mechanisms are identified as falling into categories around personalities and human interaction, the nature of reform processes, and the impact of broader context. The need to maintain dialogue in the face of external constraints and uncertainties is stressed. (+info)
Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)?
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Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps. (+info)
The rise and fall of the physician practice management industry.
(56/1092)
The dominant view among academic economists is that the financial markets value financial securities "efficiently," in the sense that the prevailing prices of widely traded securities fully and properly reflect, at any time, all publicly available information that bears on these securities. Although that theory has great intuitive appeal, it requires intellectual effort to reconcile it with the rise and fall of the physician practice management industry. This paper explores how acquisition-driven firms are valued in the financial markets and what structural factors may stand in the way of truly efficient security valuation. (+info)