Bad law or implementation flaws? Lessons from the implementation of the new law on epidemics during the response to the first wave of COVID-19 in Switzerland

After the 2009-2010 H1N1 pandemic, Switzerland overhauled its 1970 law on epidemics. The reform aimed at improving early detection, surveillance, and preparedness for future outbreaks of infectious diseases. Notably, the law introduced stronger coordination between Federal and Cantonal authorities, better management tools and international cooperation. The new law entered into force in 2016 after a long legislative process. During the process, the law survived a referendum fuelled by concerns about vaccine safety and interference of the pharmaceutical industry. The law was first applied during the COVID-19 pandemic in early 2020. The epicentre of the outbreak in Europe was in Lombardy, a large Italian region adjacent to Switzerland and with strong economic ties with its southern region of Ticino. The first months of pandemic response highlighted three major weaknesses. Firstly, the mechanisms introduced by the new law did not fully succeed in reducing the tension between Cantonal autonomy and central coordination of the pandemic response. Central and Cantonal authorities will need to put in place new rules and arrangements to avoid dangerous delayed responses to foreseeable problems related to the spread of infectious diseases. Secondly, relevant stakeholders excluded from the policymaking process (trade unions, firms, large industries) should be involved to allow the introduction of harsh restrictions when needed, both internally and in relation to cross-border workers

A network analysis of patient referrals in two district health systems in Tanzania

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households

Online learning applied to a course on rational therapeutics: an international comparison between final year students of two medical schools

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96234/1/bcp4370.pd

Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS)

BACKGROUND: There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered. METHODS: We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects. RESULTS: The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated. CONCLUSIONS: The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified

An Inquiry into Health Systems Governance: the Case of Tanzania

Over the last decade, the global movement towards universal health coverage (UHC) gradually shifted its focus. For many low- and middle-income countries (LMICs), the late 1990s and early 2000s have been characterized by strong and long-lasting efforts to eradicate infectious diseases and improve maternal and child health, expanding access to effective healthcare services. Over the following decade, global health institutions started to emphasize the role of health systems governance and the need to address high quality of care across local health systems. Governance has been identified as a building block of all health systems and deemed as conducive of improved social health protection, equity in health and increased quality of healthcare provision. Despite its importance, international institutions and researchers failed to provide a unanimous definition of health systems governance. This dissertation aims to contribute to the debate about health systems governance in LMICs, reflecting on the case of a large sub-Saharan country: Tanzania. The broad goal of this thesis is to distil some operational governance dimensions and assess their role in health services provision in Tanzania. The introductory chapter provides an overview of the role of health systems governance in LMICs, offering a working definition of governance that is used throughout the manuscript. Part I also presents the specific research objectives, outlining the methods applied in the subsequent parts of the dissertation. Part II introduces the reader to the health system and the health policy context in Tanzania, focusing on the governance challenges that characterize this large East African country. Part III looks at the role of incentives to health workers and supervision for the provision of high-quality healthcare. The study is based on a multilevel regression analysis of secondary data on a large sample of Tanzanian public health facilities from the Service Provision Assessment (SPA) survey conducted in 2014/2015. In part IV, the focus switches on the impact evaluation of social accountability initiatives on healthcare provision. The analysis builds on the implementation of a social accountability monitoring program - by the local NGO Sikika - in the Tanzanian region of Dodoma. Using a difference-in-differences approach, the research aims at identifying the effect of the program on two specific outcomes targeted by Sikika: availability of essential medicines and infrastructure maintenance in government-managed health facilities. Part V addresses the design, management and regulation of patient referral systems in settings characterized by strong focus on primary healthcare. The study is based on primary data collected in the two rural districts of Kilolo (Iringa region, Southern Highlands zone) and Msalala (Shinyanga region, Lake zone). The analytical approach builds on previous work in the field of social network analysis, mapping the available data to networks with health facilities representing nodes and patient referrals representing directed edges. The discussion in part VI summarizes the previous results putting them into perspective, outlining a framework where interrelated governance dimensions contribute to UHC goals. The section concludes touching upon the limitations of the proposed approaches and discussing the implications for health policy. The findings can be grouped in four main areas, reflecting the operational governance aspects explored empirically across the manuscript. The first area relates to top-down monitoring and supervision arrangements. The Tanzanian case highlights the ineffectiveness of initiatives meant to monitor the activity of local public healthcare providers spread across vast rural areas. Quality of care at point of service shows no association with the intensity of supervision at facility and individual level. Although measurement errors could prevent effective effect identification, the results cast doubts on the implementation of such arrangements. The second area addresses the role of incentive policies to push health workers towards the provision of high-quality healthcare. Financial and non-financial incentives offered to health workers show positive associations with the two measures of quality of care analysed, namely compliance with guidelines for treatment of sick children and patient satisfaction. Salary top-ups improve the otherwise poor salary conditions faced by health workers in public health facilities across the country. The analysis reveals positive effects on both indicators of quality. Among the non-financial incentives included in the analysis, subsidized housing offered to health workers appears to be positively associated to patient satisfaction. The study suggests an interpretation relating increased satisfaction to closeness between communities of health workers living in the health facility compound. The third area is related to bottom-up supervision and social accountability mechanisms. On the one hand, frequency of meetings between health facility staff and local communities is associated with increased patient satisfaction. The result reinforces the finding on subsidized housing, supporting the idea that closeness between providers and communities improves patient satisfaction. A potential pathway for this influence is the increased accessibility of providers (for example in case of emergencies) and improved ability to address the needs of the community. On the other hand, the social accountability monitoring program implemented in the Dodoma region reveals potentially positive effects on availability of essential medicines. Besides favouring effectiveness and appropriateness of treatments, the reduction of stock-outs in essential medicines contributes to improved patient satisfaction and in turn to positive healthcare seeking behaviour. The study does not detect any impact of social accountability monitoring on infrastructure maintenance, possibly suggesting different impact mechanisms related to the need of district level budgeting and resource allocation. Finally, the fourth area discusses the implications of design and regulation of patient referral systems. The results emphasize the importance of appropriate investments in infrastructure, especially in secondary level facilities (i.e. health centres). The study reveals that in Kilolo district most patient are referred directly to the regional referral hospital in Iringa Town, mainly as a result of geographic closeness and infrastructure availability. Health centres have a little role in terms of mediating referrals between primary and tertiary level facilities. A failure in the gatekeeping system may result in negative consequences in terms of increased financial burden for households required to travel to the crowded hospital words in Iringa Town. The analysis also suggests that a strategic orientation towards quality of care at district level may positively influence the functioning of patient referral systems. In Msalala district, besides higher rates of referrals to health centres, the results are consistent with a virtuous cycle of referrals directed towards smaller and more specialized facilities. Although the study is not designed to detect causal effects, these positive results may be associated to the implementation of a system-wide project aimed at strengthening different components of the health systems. Overall, the dissertation sheds light on the complex interaction between the different health systems governance dimensions analysed. What emerges is a set of mutually connected dimensions that contribute together to the three main goals of UHC: coverage and access, financial protection and the delivery of quality health services. The conclusion offers a number of suggestions to policy makers in relation to the potential outcomes associated to the implementation of different governance tools. On a more general note, the results are consistent with the ongoing efforts to promote systems thinking in health systems research. This dissertation supports the message that health system governance is better addressed with a comprehensive approach rather than with partial policies, unleashing a multiplicative effect of self-reinforcing interactions between different governance functions and tools

Bad law or implementation flaws? Lessons from the implementation of the new law on epidemics during the response to the first wave of COVID-19 in Switzerland.

From PubMed via Jisc Publications RouterHistory: received 2020-03-26, revised 2021-01-20, accepted 2021-08-11Publication status: aheadofprintAfter the 2009-2010 H1N1 pandemic, Switzerland overhauled its 1970 law on epidemics. The reform aimed at improving early detection, surveillance, and preparedness for future outbreaks of infectious diseases. Notably, the law introduced stronger coordination between Federal and Cantonal authorities, better management tools and international cooperation. The new law entered into force in 2016 after a long legislative process. During the process, the law survived a referendum fuelled by concerns about vaccine safety and pharmaceutical industry interference. The law was first applied during the COVID-19 pandemic in early 2020. The epicentre of the outbreak in Europe was in Lombardy, a large Italian region adjacent to Switzerland and with strong economic ties with its southern region of Ticino. The first months of pandemic response highlighted two major weaknesses. Firstly, the mechanisms introduced by the new law did not ease the tension between Cantonal autonomy and central coordination of the pandemic response. Central and Cantonal authorities will need to put in place new rules and arrangements to avoid dangerous delayed responses to foreseeable problems related to the spread of infectious diseases. Secondly, relevant stakeholders excluded from the policymaking process (trade unions, firms, large industries) should be involved to allow the introduction of harsh restrictions when needed, both internally and in relation to cross-border workers. [Abstract copyright: Copyright © 2021. Published by Elsevier B.V.