Understanding Resilience and Evolution of IOIS in the Australian Pharmaceutical Distribution Industry

We analyse an empirical case study of an inter-organizational information system (IOIS) in the Australian pharmaceutical distribution industry, using a theoretical data coding approach, to provide a concise grounded account of changes in the material, normative and ideational structures within the participating practices over a 25 year period as the IOIS evolved from a proprietary closed system to a quasi-open shared ordering platform. We find evidence that the resilience of the IOIS over this long time period is explained by a layered accumulation of new structures at the level of individual practices, while the punctuated evolutionary change accompanied the appearance of a new practice, historically connected to the incumbent practices. These findings are in substantial agreement with systems evolution mechanisms proposed by Porra (1999). Understanding IOIS evolution will be important for the provision of key enabling information infrastructures envisioned in existing and planned ICT-mediated healthcare initiatives

Factors affecting supply chain integration in public hospital pharmacies in Kenya

The purpose of this study was to develop and empirically test the Supply Chain Integration Framework (SCI framework) in order to develop a framework to address the inefficiencies experienced in the public hospital pharmacies’ Supply Chain (SC) in Kenya. Supply Chain Management (SCM) can be regarded as a vibrant business entity that is changing and evolving continually because of constant changes in technology, competition and customer demands. The study investigated and analysed how the independent variables, namely SCI initiatives, performance improvement drivers, organisation environmental forces, workforce and management support, financial factors, flow and integration, regulatory framework and information sharing and technology influenced the SCI. The SCI was categorised into three components namely: customer order fulfilment, supplier collaboration and dedicated SC as the dependent variable. The literature reviewed established that globalisation and intensive worldwide competition, alongside technological developments, creates a completely new operating environment for organisations. The researcher reviewed various models and theories related to SCI which include systems theory, value chain models and value ecology models among others. An SCI framework was then developed to capture the interacting variables within the SCI network that could be adopted for the public hospital pharmacies in Kenya. The study was conducted using a survey questionnaire (Annexure B) that comprised both open and closed ended questions that were distributed to managers in public hospitals and pharmacies in Kenya. The population for the survey was 154 public hospital pharmacies in Kenya, with the final sample comprised of 280 respondents. The study was conducted using a survey questionnaire (Annexure B) that comprised both open and closed ended questions that were distributed to 325 respondents in 154 public hospitals and pharmacies in Kenya. The population for the survey was 154 public hospital pharmacies in Kenya, with the final sample comprised of 280 respondents. Exploratory factor analysis was used to ascertain the validity of the measuring instrument and the Cronbach alpha coefficients were used to measure the reliability of the measuring instruments. Key preliminary tests performed were the Kaiser-Meyer-Olkin test (KMO test) of sample adequacy, the Bartlett’s test of sphericity and the Kolmogorov-Smirnov test (Z-Statistic test) for normality and multi-collinearity diagnostic. Analysis of Variance (ANOVA) and multiple linear regressions were the main statistical procedures used to test the regression model fit and the significance of the relationships hypothesised among various variables in the study. Statistical softwares, namely Statistica 10 (2010) and Statistical Package for Social Sciences (SPSS) Version 18, were used to analyse quantitative data. The study identified five statistically significant relationships between customer order fulfilment and workforce and management support, financial factors, flow and integration, information sharing and technology, supplier collaborations and dedicated SCI. In addition, a total of six statistically significant relationships exist between the supplier collaborations and SCI initiatives i.e. performance improvement drivers, workforce and management support, financial factors, flow and integration, information sharing and technology adoption as well as dedicated SCI. Furthermore, four statistically significant relationships were found between dedicated SCI and SCI initiatives, workforce and management support, financial factors, flow and integration, information sharing and technology adoption

How do SME networks evolve? Investigating network context, features and outcomes amongst Agrifood SMEs in Greece

This thesis aims to examine the dynamics and interplay between contextual factors and network features and their role in SME network evolution, with a view to building a theory of how context and features affect SME network performance outcomes. Given the complexity of the phenomenon under investigation, a case study methodology was employed. Specifically, four cases of Greek agrifood SME networks were selected of which two exhibited strong performance and two relatively weak performance. Following literature review, the influence of three categories of contextual factor {market conditions, social cohesiveness, external institutional support), and three types of network feature {member profile, competencies, network governance) were examined empirically via the case studies. The research found that all six had some individual influence on performance, but beyond this, certain patterns of interplay between factors could be distinguished. In particular, certain positive .factors were found to counteract the negative influence of other existing (or lacking) factors. Specifically, in terms of network features, governance structure was found to have a countervailing effect over negative performance outcomes produced by diverse member profile and lack of competencies. In addition, the competencies of the constructor of the governance structure were also important in overcoming deficiencies in other features. In terms of network context, social cohesiveness seemed to have a countervailing effect over contextual disincentives for network strengthening, such as unfavourable market conditions or lack of external institutional support. Overall, the research finds that network features are key to explaining the variability in performance displayed by SME networks operating in a very similar context, since they moderate the impacts of external forces on the evolution and performance outcomes of those networks. The research concludes with a proposed framework to explain how context, features and outcomes interact in SME networks

A systems approach to improving patient safety through medical device purchasing

The purchase of medical devices involves engaging various stakeholders as well as balancing clinical, technical and financial requirements. Failure to consider these requirements can lead to wider consequences in the delivery of care. This study first builds a general knowledge base of current purchasing practice in a sample of NHS Trusts, which confirms the direction and guidance given by policy documents and literature as to the extent of the challenges faced by purchasing stakeholders. This then leads to an analysis to identify inefficiencies in the purchasing process, and how such practice can lead to risks in the delivery of care. These risks range from injury to individuals, impacts to the healthcare delivery service, and financial and litigation risks. Finally, a framework that highlights these potential risks in the life-cycle of medical devices in hospitals is presented. Key policy guidance has encouraged both researchers and implementers of healthcare services to approach patient safety from a systems perspective, acknowledging that medical device errors are not only directly related to device design, but to the design of the healthcare delivery service system in which the device operates. Little evidence exists of successfully applying systems approaches specifically to medical device purchasing practice. Medical device purchasing, because of its implications to patient safety on the one hand, and the uniqueness of the healthcare context, requires a unique approach. By demonstrating the influence of purchasing practice to service delivery and patient care, the thesis made is that taking a holistic systems approach is one method to improve device purchasing practice, and hence influence better care.This work was supported by the UK Engineering and Physical Sciences Research Council [EP/E001777/1

Private International Law Beyond the Schism

The aim of this project is to explore the ways in which, in the absence of traditional forms of government in a global setting, the law can discipline the transnational exercise of private power by a variety of market actors (from rating agencies, technical standard-setters and multi-national agribusinesses to vulture funds). Traditionally, the cross-border economic activities of non-state actors fall within the remit of an area of the law known as 'private international law'. However, despite the contemporary juridification of international politics, private international law has contributed very little to the global governance debate, remaining remarkably silent before the increasingly unequal distribution of wealth and authority in the world. By abandoning such matters to its public international counterpart, it leaves largely untended the private causes of crisis and injustice affecting such areas as financial markets, environmental protection, pollution, the status of sovereign debt, the bartering (or confiscation) of natural resources and land, the use (and misuse) of development aid, (unequal) access to food, the status of migrant populations, and many more. On the other hand, public international law itself, on the tide of managerialism and fragmentation, is now increasingly confronted with conflicts articulated as collisions of jurisdiction and applicable law, among which private or hybrid authorities and regimes now occupy a significant place. According to the genealogy of private international law depicted here, the discipline has developed, under the aegis of the liberal divides between law and politics and between the public and the private spheres, a form of epistemological tunnel-vision, actively providing immunity and impunity to abusers of private sovereignty. It is now more than time to de-closet private international law and excavate the means with which, in its own right, it may impact upon the balance of informal power in the global economy. This means both quarrying the new potential of human rights in the transnational sphere, and rediscovering the specific savoir-faire acquired over many centuries in the recognition of alterity and the responsible management of pluralism. In short, adopting a planetary perspective means reaching beyond the schism between the public and private spheres and connecting up with the politics of international law

Creating corporate advantage in purchasing

Proefschrif

Exploring the facilitators and barriers towards implementation of electronic prescribing, dispensing, and administration of medicines in hospitals in Ireland.

Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow. The aim of this doctoral research was to explore this under-researched area in three phases. Phase one: - Phase one focused on critically appraising and synthesising the available evidence on healthcare professionals perceptions, attitudes, and views of the facilitators and barriers to implementing electronic prescribing, electronic dispensing, and/or electronic administration of medicines in the hospital setting. The review protocol was registered with the Centre for Reviews and Dissemination and conducted according to best practice. Key facilitators included systems improved patient safety and provided better access to patients drug records and that team leadership and hardware/software availability and reliability were essential for successful implementation. Key barriers consisted of hardware and network problems, altered work practices, and weakened interpersonal communication between healthcare professionals and with patients. Phase two: - This phase employed a qualitative phenomenological design to gain original insight into the perceptions of local key stakeholders towards the facilitators and barriers to implementing prescribing, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospitals in Ireland using Normalization Process Theory as a theoretical framework. Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two hospital Information Technology managers. Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multidisciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action. Phase three: - A similar qualitative methodology was employed in phase three of this research in order to explore the perceptions of national key stakeholders and eHealth leads towards the facilitators and barriers to system implementation. Sixteen consenting invitees participated: eight hospital leads, four government leads, two regulatory leads, and two academics. Key facilitators included enhanced patient safety, workflow efficiencies, improvements in governance, and financial gains. Perceived barriers included the introduction of new drug errors, loss of patient contact, initial time inefficiencies, and issues with the complexity of integration and standardisation of work processes. Overall, adequate technology, stakeholder involvement, and organisational leadership and support are required at a national and local level to drive the eHealth agenda forward. Testing at scale, contingency plans, and ongoing evaluations will assist in determining success or otherwise of system implementation. This research has generated novel findings with many potentially transferable themes identified which extend the evidence base. This will assist organisations to better plan for implementation of medication-related eHealth systems

Exploring the Essential Medicines List Concept

Background: Access to medicines is a basic human right. The World Health Organization (WHO) Model List of Essential Medicines was created in 1977, to promote access to essential medicines that satisfy the priority health care needs of the population. In this day and age, access to safe and affordable medicines is not guaranteed to all. There exists global inequality of access to lifesaving or essential medicines. This is referred to by the WHO as the ‘global drug gap’, in which approximately one third of the global population still does not have access to basic medicines. Contributing to the disparity in access, are rising pharmaceutical expenditures and globalisation of complex pharmaceutical supply chain networks. This has resulted in countries of all economies and geographical regions sourcing their medicines from common sources. Therefore, challenges accessing unavailable medicines have become a shared experience, as demonstrated by the relatively recent emergence and recurrence of global drug shortage crises. The WHO framework for access to essential medicines, which considers rational selection of medicines, affordable prices, sustainable financing, and reliable health and supply systems, was used as a theoretical framework to explore the gap in access to medicines. Aims and Objectives: Aim: To explore stakeholder views about the concept of essential medicines. Objectives: (1) To explore the application of the Essential Medicines List (EML) concept and how this was associated with access to essential medicines. (2) To explore the factors that influence access to essential medicines, and understand the roles of international key stakeholders involved in this process. (3) To explore what constitutes an “essential” medicine, and how the EML concept functions in a high income country (HIC) context. Content of This Thesis This thesis is made up of 4 chapters. Chapter 1 contains the background and a review of the literature on access to essential medicines. The challenges identified in chapter 1 lead to the exploration of global perspectives on the supply and management of essential medicines in chapter 2. The qualitative study in chapter 3 describes what constitutes an essential medicine for stakeholders in a high income country (HIC). Lastly, chapter 4 contains general discussions and conclusions from the work described in this thesis. Methods: A narrative literature review (chapter 1) was performed to explore how the application of the EML concept is associated with access to essential medicines. A search strategy developed from the principles of the WHO access to medicines framework was used to identify primary studies from Medline, Embase and PubMed. A qualitative study was conducted to explore perspectives of international (chapter 2) and Australian (chapter 3) key stakeholders about the pharmaceutical supply chain, on the application and relevance of EML concept and what makes a medicine essential. Snowball sampling was used to recruit decision makers, leaders or senior managers involved in medicines decision making across seven stakeholder groups. Stakeholders included: government, health care providers, academics, consumer groups, non-profit organisations, pharmaceutical manufacturers and wholesaler/distributors. Forty-seven semi structured interviews were conducted face-to-face, via Skype or telephone, audio-recorded and transcribed verbatim. Interviews were conducted until thematic saturation was achieved. Data were analysed using a grounded theory approach. The comprehensive theory of collaboration was applied after the grounded theory analysis to organise and understand results within a management context. In addition, chapter 2 used the Ishikawa fishbone diagram to illustrate the complexities of the pharmaceutical supply chain. Meanwhile, chapter 3 illustrated the conceptual model derived from the results. Key Findings: Chapter 1- A literature review showed that there has been improved access to essential medicines for many populations. Findings showed EMLs help promote advocacy and provide reliable evidence at the health systems level. However, there was variable use of EMLs at the health services delivery level (i.e. for a patient at the point of care). Decision making around standard treatment guidelines and EMLs were often not aligned with procurement and management strategies within the supply chain. The literature review showed that accessing medicines was complex. Studies were often not well-designed, had narrow research objectives and few qualitative studies were conducted. Studies focused on resource limited settings in LMICs and scarce data was available for EMLs in HICs. Chapter 2- Qualitative interviews with international stakeholders described the complexities involved in managing the global pharmaceutical supply chain. While stakeholders’ roles and responsibilities were inter-connected, therapeutic decision making was often separated from logistic management of the pharmaceutical supply chain due to potential conflicts of interest. This created many gaps and inconsistencies around pricing and costs, planning and reactivity, communication and transparency, and contributed to difficulties building trust and consistency between stakeholders. Adding to this complexity, individualised or patient-centred care approaches have emphasised the need for consumer choice and demand a wide range of products that has become increasingly challenging to manage. Therefore, drug shortages have highlighted the opportunity for collaborative alliances to identify, prioritise, and manage vulnerabilities in the supply chain to prevent or mitigate patient harm as a result of restricted access to medicines. In particular, wholesalers and distributors were identified as potentially having more valuable roles in managing supply disruptions (e.g. redistribution) and facilitating information exchange between stakeholders (e.g. forecasting or confirming at what level of the system a shortage occurs). Participants also suggested designating drug shortage experts or liaison to manage and communicate shortages, especially to consumers and health providers. Chapter 3- Qualitative interviews with Australian stakeholders demonstrated that the different perceived functions of EMLs seemed to be stratified depending on whether the decision making context was at a health systems level or at an individual level (i.e., for a patient at the point of care). EMLs can function as reimbursement lists at the health systems level, or hospital formularies at the health services level. Meanwhile, non-reimbursed or off-formulary medicines were available to consumers who were willing and able to pay if they were deemed essential to individuals. Conversely, some medicines can be deemed essential but were not available or affordable to individuals. The wide range of views in this study, highlight the complexities of decision-making processes involved in developing and managing EMLs, which has been compounded by the expanding consumer need to have a range of therapeutic options. These findings emphasise the context within the health system determines for whom a medicine is deemed essential. Conclusion: Prior to this thesis, EMLs have been studied with narrow research objectives and mainly in LMICs. This body of research was the first to explore how the application and management of EMLs effected access to medicines, from a broad range of stakeholder views involved in both therapeutic decision making and logistics management. Furthermore, it was also a rare study that examined the EML concept within HIC contexts. Findings from this body of work demonstrated different perceived functions of the EML. Furthermore, it also questioned whether the term ‘essential’ was appropriate and reflected how the EML was used. While EMLs can be useful to guide evidence based decision making for reimbursement at the systems level, the variations in the notion of essential at the individual level is influenced by an individual’s choice. Therefore, this highlights the importance of guiding (or limiting) consumer choice with appropriate and accessible information, to help individuals make informed and responsible decisions. This research confirmed that the access to medicines gap continues to be problematic. The pharmaceutical supply chain has been unable to handle drug shortages adequately. Therefore, in order to sustain patient-centred care practices, concessions by all stakeholders must be made if the supply chain is to withstand global economic, political, and ecological instability. Multi-stakeholder engagement, transparent processes, innovative communication pathways, and EML approaches offer potential solutions to mitigate supply chain disruptions. Future approaches should align decision making priorities with procurement practices. Decision makers and supply chain managers have a valuable opportunity to reflect and understand how the current system is functioning, in order to develop foundations for improved processes, and innovative and cooperative platforms to interact and network

Rationales for traditional medicines utilisation and its equity implications: the case of Ghana

Individuals all over the world continue to utilise traditional health care, but there is very little understanding of why this is the case, especially in light of increased availability and accessibility of effective pharmaceutical medicine and other modern technologies. The overarching objective of this thesis is to investigate rationales for utilisation of traditional medicines, using Ghana as a case study. This thesis argues that institutional constraints and cultural preferences inherited from the past shape pluralistic health systems and, consequently, individual health-seeking behaviour. The thesis fuses investigative approaches from different disciplines (e.g. anthropology, economics, psychology) and uses statistical methods to analyse four aspects of medicines utilisation: the role of culture, income, the possibility of a placebo effect in use and finally, the distributional consequences manifested in utilisation inequities. Findings indicate that cultural attitudes and income constraints are associated with use of traditional systems, and users report high rates of satisfaction that are attributable to procedural factors. Inequities are shown to differ according to whether traditional medicines are included in analysis. Generally, this thesis advocates a holistic approach with respect to health systems, as opposed to interpreting traditional systems as simply appendages to modern health care systems; the latter perspective is liable to yield observers only a partial story of medicines utilisation and its impact on equity