Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to

Background: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and ''price'' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. Methods: Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. Results: Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of (sic) 384, 200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and ''price'' factors. Conclusions: Utilization, rather than ''price'' factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure

Channelized melt flow in downwelling mantle: Implications for 226Ra-210Pb disequilibria in arc magmas

We present the results of an analytical model of porous flow of viscous melt into a steadily dilating ‘‘channel’’ (defined as a cluster of smaller veins) in downwelling subarc mantle. The model predicts the pressure drop in the mantle wedge matrix surrounding the channel needed to drive melt flow as a function of position and time. Melt is sucked toward the dilatant region at a near-constant velocity (105 s1) until veins comprising the channel stop opening (t = t). Fluid elements that complete their journey within the time span t < t arrive at a channel. Our results make it possible to calculate the region of influence sampled by melt that surrounds the channel. This region is large compared to the model size of the channelized region driving flow. For a baseline dilation time of 1 year and channel half width of 2 m, melt can be sampled over an 80-m radius and has the opportunity to sample matrix material with potentially contrasting chemistry on geologically short timescales. Our mechanical results are consistent with a downgoing arc mantle wedge source region where melting and melt extraction by porous flow to a channel network are sufficiently rapid to preserve source-derived 238U-230Th-226Ra, and potentially also 226 Ra-210Pb, disequilibria, prior to magma ascent to the surface. Since this is the rate-determining step in the overall process, it allows the possibility that such short-lived disequilibria measured in arc rocks at the surface are derived from deep in the mantle wedge. Stresses due to partial melting do not appear capable of producing the desired sucking effect, while the order of magnitude rate of shear required to drive dilation of 107 s1 is much larger than values resulting from steady state subduction. We conclude that local deformation rates in excess of background plate tectonic rates are needed to ‘‘switch on’’ the dilatant channel network and to initiate the sucking effect

Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019

Introduction Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city's facility births. Methods Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. Results Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). Conclusions This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.Research into fetal development and medicin

Trends in population health and demography

Obstetric

Reasons for performing a caesarean section in public hospitals in rural Bangladesh

Background It is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as “unnecessary”. Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure. Methods Retrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS. Results The commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and “post-term dates” were common indications for elective CS with “post dates” – the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to “lobby” for CS. Conclusion Factors other than evidence based practice or the presence of a clear medical indication influence providers’ decision to perform both elective and emergency CS in public hospitals in Bangladesh