Governance in health care delivery : raising performance

The impacts of health care investments in developing and transition countries are typically measured by inputs and general health outcomes. Missing from the health agenda are measures of performance that reflect whether health systems are meeting their objectives; public resources are being used appropriately; and the priorities of governments are being implemented. This paper suggests that good governance is central to raising performance in health care delivery. Crucial to high performance are standards, information, incentives and accountability. This paper provides a definition of good governance in health and a framework for thinking about governance issues as a way of improving performance in the health sector. Performance indicators that offer the potential for tracking relative health performance are proposed, and provide the context for the discussion of good governance in health service delivery in the areas of budget and resource management, individual provider performance, health facility performance, informal payments, and corruption perceptions. What we do and do not know about effective solutions to advance good governance and performance in health is presented for each area, drawing on existing research and documented experiences.Health Monitoring&Evaluation,Health Systems Development&Reform,Public Sector Expenditure Policy,Health Economics&Finance,Health Law

Three essays on schooling and health in Indonesia. Assessing the effects of family planning on fertility and of supply-side education programmes on BMI, schooling attainment, and wages

In 1969, Indonesia established a national family planning programme and total fertility has declined rapidly since but there is little consensus over the relative contribution of family planning to the observed decline. The first chapter constructs a new measure of family planning exposure to examine the role of family planning in reducing fertility. The causal effects of infant mortality is also examined based on a new instrumental variable, water supply and sanitation programme exposure, and that of schooling using father’s schooling as an instrument. The findings strongly indicate that family planning contributes to lower fertility together with reductions in infant deaths and improvements in women’s schooling, and that the effects of family planning and decreases in infant mortality are larger than that of schooling. In 2002, nearly one-in-ten men and more than one-in-five women in Indonesia were overweight and noncommunicable diseases had become the main cause of death but there exists no evidence on the causal effect of schooling on BMI for developing countries. The second chapter assesses whether more schooling causes healthier BMI in Indonesia by using two instrumental variables to capture exogenous variation in schooling. The first instrument takes advantage of the primary school construction programme (SD INPRES) in the 1970s; the second instrument is father’s schooling. Two results stand out: more schooling causes higher BMI for men and there is no causal effect of schooling on BMI for women. This chapter also provides some very preliminary evidence that the shift from blue collar to white collar and service sector occupations is one contributing factor to why more schooling increases BMI for men. The third chapter also uses the SD INPRES programme but to examine the effect of increased school supply on schooling attainment: overall, by gender, and by socioeconomic background. It also constructs a new SD INPRES programme exposure variable as an instrument for schooling to assess the causal effect of schooling on wages. The results strongly suggest that the SD INPRES programme increased schooling for men and women but that women benefited more as did individuals from less advantageous socioeconomic backgrounds. More schooling also causes higher wages and there appears to be an added positive effect for women through the additional schooling induced by the SD INPRES programme

Schooling Inequality, Crises, and Financial Liberalization in Latin America

Latin America is characterized by high and persistent schooling, land, and income inequalities and extreme income concentration. In a highly unequal setting, powerful interests are more likely to dominate politics, pushing for policies that protect privileges rather than foster competition and growth. As a result, changes in policies that political elites resist may be postponed in high-inequality countries to the detriment of overall economic performance. This paper examines the relationship between structural, high inequality—measured by high levels of schooling inequality—and liberalization of the financial sector for a sample of 37 developing and developed countries for the period 1975 to 2000. Liberalization of the financial sector can be broadly thought of in the Latin American pre-2000 context as opening credit markets that earlier were largely restricted, including by ending directed credit. For our measure of structural inequality we use data on schooling Gini coefficients that have not previously been used in this context. In our sample, we find that increases in financial liberalization were associated with bank crises and other domestic and external shocks, and that higher schooling inequality reduces the impetus for liberalization brought on by bank crises.Latin America, education, inequality, financial liberalization

Who Wants to Work in a Rural Health Post? The Role of Intrinsic Motivation, Rural Background and Faith-Based Institutions in Rwanda and Ethiopia

Most developing countries face shortages of health workers in rural areas. This has profound consequences for health service delivery, and ultimately for health outcomes. To design policies that rectify these geographic imbalances it is vital to understand what factors determine health workers' choice to work in rural areas. But empirical analysis of health worker preferences has remained limited due to the lack of data. Using unique contingent valuation data from a cohort survey of 412 nursing and medical students in Rwanda, this paper examines the determinants of future health workers' willingness to work in rural areas, as measured by rural reservation wages, using regression analysis. These data are also combined with those from an identical survey in Ethiopia to enable a two-country analysis. We find that health workers with higher intrinsic motivation – measured as the importance attached to helping the poor – as well as those who have grown up in a rural area, and Adventists who participate in a local bonding scheme are all significantly more willing to work in a rural area. The main Rwanda result for intrinsic motivation is strikingly similar to that obtained for Ethiopia and Rwanda together. These results suggest that in addition to economic incentives, intrinsic motivation and rural origin play an important role in health workers' decisions to work in a rural area, and that faith-based institutions matter.health care delivery, health workers, labour supply, public service

Who Wants to Work in a Rural Health Post? The Role of Intrinsic Motivation, Rural Background and Faith-Based Institutions in Rwanda and Ethiopia

Background: Most developing countries face shortages of health workers in rural areas. This has profound consequences for health service delivery, and ultimately for health outcomes. To design policies that rectify these geographic imbalances it is vital to understand what factors determine health workers’ choice to work in rural areas. But empirical analysis of health worker preferences has remained limited due to the lack of data. Methods: Using unique contingent valuation data from a cohort survey of 412 nursing and medical students in Rwanda, this paper examines the determinants of future health workers’ willingness to work in rural areas, as measured by rural reservation wages, using regression analysis. These data are also combined with those from an identical survey in Ethiopia to enable a two-country analysis. Results: Health workers with higher intrinsic motivation - measured as the importance attached to helping the poor - as well as those who have grown up in a rural area, and Adventists who participate in a local bonding scheme are all significantly more willing to work in a rural area. The main Rwanda result for intrinsic motivation is strikingly similar to that obtained for Ethiopia and Rwanda together. Discussion: The results suggest that in addition to economic incentives, intrinsic motivation and rural origin play an important role in health workers’ decisions to work in a rural area, and that faith-based institutions matter.

Направления реализации образовательно-профилактической программы "Здоровую улыбку - детям" и их эффективность

СТОМАТОГНАТИЧЕСКИЕ БОЛЕЗНИ /профЗУБНЫХ БОЛЕЗНЕЙ ПРОФИЛАКТИКАДЕТИПРОФИЛАКТИЧЕСКАЯ СТОМАТОЛОГИ

Tafoxiparin, a novel drug candidate for cervical ripening and labor augmentation : results from 2 randomized, placebo-controlled studies

Background: Slow progression of labor is a common obstetrical problem with multiple associated complications. Tafoxiparin is a depolymerized form of heparin with a molecular structure that eliminates the anticoagulant effects of heparin. We report on 2 phase II clinical studies of tafoxiparin in primiparas. Study 1 was an exploratory, first-in-pregnant-women study and study 2 was a dose-finding study. Objective: Study 1 was performed to explore the effects on labor time of subcutaneous administration of tafoxiparin before onset of labor. Study 2 was performed to test the hypothesis that intravenous treatment with tafoxiparin reduces the risk for prolonged labor after spontaneous labor onset in situations requiring oxytocin stimulation because of dystocia. Study Design: Both studies were randomized, double-blind, and placebo-controlled. Participants were healthy, nulliparous females aged 18 to 45 years with a normal singleton pregnancy and gestational age confirmed by ultrasound. The primary endpoints were time from onset of established labor (cervical dilation of 4 cm) until delivery (study 1) and time from start of study treatment infusion until delivery (study 2). In study 1, patients at 38 to 40 weeks of gestation received 60 mg tafoxiparin or placebo daily as 0.4 mL subcutaneous injections until labor onset (maximum 28 days). In study 2, patients experiencing slow progression of labor, a prolonged latent phase, or labor arrest received a placebo or 1 of 3 short-term tafoxiparin regimens (initial bolus 7, 21, or 35 mg followed by continuous infusion at 5, 15, or 25 mg/hour until delivery; maximum duration, 36 hours) in conjunction with oxytocin. Results: The number of participants randomized in study 1 was 263, and 361 were randomized in study 2. There were no statistically significant differences in the primary endpoints between those receiving tafoxiparin and those receiving the placebo in both studies. However, in study 1, the risk for having a labor time exceeding 12 hours was significantly reduced by tafoxiparin (tafoxiparin 6/114 [5%] vs placebo 18/101 [18%]; P=.0045). Post hoc analyses showed that women who underwent labor induction had a median (range) labor time of 4.44 (1.2–8.5) hours with tafoxiparin and 7.03 (1.5–14.3) hours with the placebo (P=.0041) and that co-administration of tafoxiparin potentiates the effect of oxytocin and facilitates a shorter labor time among women with a labor time exceeding 6 to 8 hours (P=.016). Among women induced into labor, tafoxiparin had a positive effect on cervical ripening in 11 of 13 cases (85%) compared with 3 of 13 participants (23%) who received the placebo (P=.004). For women requiring oxytocin because of slow progression of labor, the corresponding results were 34 of 51 participants (66%) vs 16 of 40 participants (40%) (P=.004). In study 2, tafoxiparin had no positive effects on the secondary endpoints when compared with the placebo. Except for injection-site reactions in study 1, adverse events were no more common for tafoxiparin than for the placebo among either mothers or infants. There were few serious or treatment-related adverse events. Conclusion: Subcutaneous treatment with tafoxiparin before labor onset (study 1) may be effective in reducing the labor time among women undergoing labor induction and among those requiring oxytocin for slow progression of labor. Moreover, tafoxiparin may have a positive effect on cervical ripening. Short-term, intravenous treatment with tafoxiparin as an adjunct to oxytocin in patients with labor arrest (study 2) did not affect labor time or other endpoints. Both studies suggest that tafoxiparin has a favorable safety profile in mothers and their infants.Peer reviewe

Minimizing Variability of Cascade Impaction Measurements in Inhalers and Nebulizers

The purpose of this article is to catalogue in a systematic way the available information about factors that may influence the outcome and variability of cascade impactor (CI) measurements of pharmaceutical aerosols for inhalation, such as those obtained from metered dose inhalers (MDIs), dry powder inhalers (DPIs) or products for nebulization; and to suggest ways to minimize the influence of such factors. To accomplish this task, the authors constructed a cause-and-effect Ishikawa diagram for a CI measurement and considered the influence of each root cause based on industry experience and thorough literature review. The results illustrate the intricate network of underlying causes of CI variability, with the potential for several multi-way statistical interactions. It was also found that significantly more quantitative information exists about impactor-related causes than about operator-derived influences, the contribution of drug assay methodology and product-related causes, suggesting a need for further research in those areas. The understanding and awareness of all these factors should aid in the development of optimized CI methods and appropriate quality control measures for aerodynamic particle size distribution (APSD) of pharmaceutical aerosols, in line with the current regulatory initiatives involving quality-by-design (QbD)

Destination Sandhamn : En studie om hur ett ösamhälle skapas med berättelser

Ösamhället Sandhamn ligger på Sandön i Stockholms skärgård och är för de flesta känt som ett besöksmål för turister. Namnet Sandhamn används ofta för både byn och hela ön. Syftet med uppsatsen är att undersöka hur platsen Sandhamn laddas med betydelse genom olika aktörers berättelser. Jag vill undersöka hur de gestaltas, hur de uppfattas och påverkar oss samt samverkar med varandra i ett konstruktivistiskt perspektiv samt hur detta påverkar samhället. Ur de dominerande berättelserna om Sandhamn valdes tre återkommande mindscape: skärgårdsidyll, konsumtion, och historia. Därefter analyserades hur dessa mindscape används, samverkar med varandra och skapar konsekvenser. Resultatet av analyserna gav att mindscapen användes i olika syften och med olika dominans och spridning. De samverkar med varandra vilket ger en förstärkande effekt. Konsekvenserna av de större och dominerande aktörernas berättelser kan bli att samhället anpassas till att möta de besökandes förväntningar i så hög grad att det inte går att leva upp till dem. Eftersom turismen är den största näringsgrenen skulle det i så fall påverka samhället negativt.    The village Sandhamn is located on Sandön in the Stockholm archipelago and is known by most as a tourist destination. The name Sandhamn is often used to refer to both the village Sandhamn and the island on which it is located. The purpose of this essay is to explore how Sandhamn is perceived, this through different agents stories. I've explored how they are formed, perceived, affect us and also relate to each other in a constructivistic perspective and how this affects the community. From the dominating stories about Sandhamn three recurring mindscapes were chosen: archipelago paradise, consumption and history. Later on an analysis was made on how these mindscapes are used, collaborates and which consequences they cause. The results of these analyses showed that the mindscapes were used for different purposes, with different dominance and spread. They collaborate with each other which results in an amplified effect. The consequences of the bigger and dominating stories could be that the community is adapted to meet the expectations of the visitors, to an extent where the expectations can't be met. Since tourism is the major source of income, this would affect the community in a negative way.

Kontinuitet för patienter med svårläkta bensår : En studie av ett förbättringsarbete på en distriktssköterskemottagning

Enligt Hälso- och Sjukvårdslagen ska goda kontakter mellan patienter och hälso- och sjukvårdspersonalen främjas samt att patientens behov av kontinuitet och säkerhet ska tillgodoses. Studier har visat att patienter får träffa många olika vårdare. Kontinuitet är en viktig förutsättning för att sår ska läka så snabbt som möjligt. Det finns tydliga riktlinjer för hur svårläkta sår ska skötas men studier har visat att följsamheten till dessa många gånger är dålig. Patienter får också ofta olika information från olika vårdpersonal och det skapar förvirring. Studien belyser de erfarenheter som patienter och medarbetare har av processen att skapa en ökad kontinuitet; i betydelsen kontinuerlig relation, information och behandling för patienter med svårläkta bensår på en distriktssköterskemottagning. Syftet med förbättringsarbetet var att skapa en förbättrad kontinuitet för patienter med svårläkta bensår. Syftet med studien av förbättringsarbetet var att belysa de erfarenheter som sjuksköterskor har av processen att skapa en ökad kontinuitet. Studien har en beskrivande och utvärderande design med kvalitativ ansats. Interventionen bestod av utbildning, ny bokningsrutin, ändrad schemaläggning, broschyr om svårläkta bensår och datoriserad sårläkningsjournal. Före interventionen intervjuades fem patienter och tolv sjuksköterskor och efter interventionen fem patienter och sex sjuksköterskor. Journalgranskning utfördes för att följa hur många olika sjuksköterskor patienter fått träffa under en åttaveckorsperiod före och efter förändring. Alla sjuksköterskor fick besvara frågor om förändringsklimatet genom enkäten PARIHS. Enkäten PARIHS visade att förändringsklimatet var bra på arbetsplatsen och stöddes av ledningen men att det fanns dåligt med tid för att kunna diskutera och reflektera över forskningsresultat. Sjuksköterskorna upplevde att kontakten med patienterna blev bättre när det blev ett mindre vårdlag. Informationen kunde läggas på rätt nivå och patienten kunde då vara mer delaktig i sin behandling. Patienterna upplevde en förbättrad personalkontinuitet men tyckte det var svårt att vara delaktiga i vården. De hade fått information om kost, motion och kompression men de mindes inte att de fått broschyren. Målet att patienterna skulle få en kontinuerlig relation har blivit förbättrad men om kontinuitet i information och behandling har blivit bättre råder delade meningar. PARIHS var en bra metod för att beskriva förutsättningar för förbättringsarbetet