Waking the health plan giant: Group Health Cooperative stops counting sheep and starts counting key tobacco indicators.
Implementing a comprehensive approach to decreasing tobacco use in a large health plan requires hard work and commitment on the part of many individuals. We found that major organisational change can be accomplished and sustained. Keys to our success included our decision to remove access barriers to our cessation programmes (including cost); obtaining top leadership buy-in; identifying accountable individuals who owned responsibility for change; measuring key processes and outcomes; and finally keeping at it tenaciously through multiple cycles of improvement. (+info)
The limited use of digital ink in the private-sector primary care physician's office.
Two of the greatest obstacles to the implementation of the standardized electronic medical record are physician and staff acceptance and the development of a complete standardized medical vocabulary. Physicians have found the familiar desktop computer environment cumbersome in the examination room and the coding and hierarchic structure of existing vocabulary inadequate. The author recommends the use of digital ink, the graphic form of the pen computer, in telephone messaging and as a supplement in the examination room encounter note. A key concept in this paper is that the development of a standard electronic medical record cannot occur without the thorough evaluation of the office environment and physicians' concerns. This approach reveals a role for digital ink in telephone messaging and as a supplement to the encounter note. It is hoped that the utilization of digital ink will foster greater physician participation in the development of the electronic medical record. (+info)
Micro-level planning using rapid assessment for primary health care services.
This paper describes the use of a rapid assessment technique in micro-level planning for primary health care services which has been developed in India. This methodology involves collecting household-level data through a quick sample survey to estimate client needs, coverage of services and unmet need, and using this data to formulate micro-level plans aimed at improving service coverage and quality for a primary health centre area. Analysis of the data helps to identify village level variations in unmet need and develop village profiles from which general interventions for overall improvement of service coverage and targeted interventions for selected villages are identified. A PHC area plan is developed based on such interventions. This system was tried out in 113 villages of three PHC centres of a district in Gujarat state of India. It demonstrated the feasibility and utility of this approach. However, it also revealed the barriers in the institutionalization of the system on a wider scale. The proposed micro-level planning methodology using rapid assessment would improve client-responsiveness of the health care system and provide a basis for increased decentralization. By focusing attention on under-served areas, it would promote equity in the use of health services. It would also help improve efficiency by making it possible to focus efforts on a small group of villages which account for most of the unmet need for services in an area. Thus the proposed methodology seems to be a feasible and an attractive alternative to the current top-down, target-based health planning in India. (+info)
The fall and rise of cost sharing in Kenya: the impact of phased implementation.
The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems. (+info)
Strengthening health management: experience of district teams in The Gambia.
The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level. (+info)
Breastfeeding promotion and priority setting in health.
An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost-effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost-effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost-effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each. (+info)
Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy.
Attention to the sustainability of health intervention programs both in the US and abroad is increasing, but little consensus exists on the conceptual and operational definitions of sustainability. Moreover, an empirical knowledge base about the determinants of sustainability is still at an early stage. Planning for sustainability requires, first, a clear understanding of the concept of sustainability and operational indicators that may be used in monitoring sustainability over time. Important categories of indicators include: (1) maintenance of health benefits achieved through an initial program, (2) level of institutionalization of a program within an organization and (3) measures of capacity building in the recipient community. Second, planning for sustainability requires the use of programmatic approaches and strategies that favor long-term program maintenance. We suggest that the potential influences on sustainability may derive from three major groups of factors: (1) project design and implementation factors, (2) factors within the organizational setting, and (3) factors in the broader community environment. Future efforts to develop sustainable health intervention programs in communities can build on the concepts and strategies proposed here. (+info)
Health promotion: perceptions of Project 2000 educated nurses.
The new approach to pre-registration nursing education in the UK (Project 2000) has an overt health focus as well as a specific remit to prepare nurses for a role as promoters of health. Data reported in this paper illuminate Project 2000 students' understanding of the concepts of health promotion and health education, and indicate the extent to which qualified nurses who have completed this new Project 2000 programme perceive themselves to be prepared for a health promotion role. Findings indicate that students are confused about the terms health education and health promotion, although most feel there is a distinction between the two. Students' descriptions emphasize individualistic approaches, and lifestyle and behaviour changes. Many recognize that health promotion should have a broader application and demonstrate a sophisticated grasp of the philosophy underpinning the promotion of health through their general perceptions of nursing. This understanding is not labelled health education or health promotion, but is embedded in their articulation of concepts such as holism, patient-centred care and enhancing independence. Paradoxically, both students and Project 2000 qualified nurses (diplomates) illustrate a clear grasp of the more complex issues surrounding the concept of health promotion while remaining confused by the terminology and its relationship to practice. (+info)