A network analysis of patient referrals in two district health systems in Tanzania.
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ABSTRACT:
SUBMITTER: Francetic I
PROVIDER: S-EPMC7996649 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundTrachomatous trichiasis (TT), inturned eyelashes from repeated infection with Chlamydia trachomatis, is the leading infectious cause of blindness in the world. Though surgery will correct entropion caused by trachoma, uptake of TT surgery remains low. In this case-control study, we identify barriers that prevent TT patients from receiving sight-saving surgery.Methodology/principal findingsParticipants were selected from a database of TT cases who did (acceptors) and did not (non-acceptors) have surgery as of August 2015. We developed an in-home interview questionnaire, using open and closed-ended questions on perceived barriers to accessing surgical services. We compared responses between the acceptors and non-acceptors, examining differences in reasons for and against surgery, sources of TT information, and suggestions for improving surgical delivery. 167 participants (mean age 61 years, 79.7% females) were interviewed. Compared to acceptors, non-acceptors were more likely to report they had no one to accompany them to surgery (75.3% vs. 42.6%, p<0.0001), they could manage TT on their own (69.9% vs. 31.5%, p<0.0001), and the surgery camp was too far (53.4% vs. 28.7%, p = 0.001). Over 90% of both acceptors and non-acceptors agreed on the benefits of having surgery. Fear of surgery was the biggest barrier stated by both groups. Despite this fear, acceptors were more likely than non-acceptors to also report fear of losing further vision without surgery.Conclusions/significanceBarriers included access issues, familial and/or work responsibilities, the perception that self-management was sufficient, and lack of education about surgery. Fear of surgery was the biggest barrier facing both acceptors and non-acceptors. Increasing uptake will require addressing how surgery is presented to community residents, including outlining treatment logistics, surgical outcomes, and stressing the risk of vision loss.
| S-EPMC5215731 | biostudies-literature
Project description:BackgroundAn estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges.MethodsWe employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016.ResultsAt all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year.ConclusionCost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.
| S-EPMC8299644 | biostudies-literature
Project description:BackgroundDevelopment Assistance for Health (DAH) represents an important source of health financing in many low and middle-income countries. However, there are few accounts on how priorities funded through DAH are integrated with district health priorities. This study is aimed at understanding the operational challenges of engaging development partners in district health planning in Tanzania.MethodsThis explanatory mixed-methods study was conducted in Kinondoni and Bahi districts, representing urban and rural settings of the country. Data collection took place between November and December 2015. The quantitative tools (mapping checklist, district questionnaire and Development partners (DPs) questionnaire) mapped the DPs and their activities and gauged the strength of DP engagement in district health planning. The qualitative tool, a semi-structured in-depth interview guide administered to 20 key informants (the council health planning team members and the development partners) explained the barriers and facilitators of engagement. Descriptive and thematic analysis was utilized for quantitative and qualitative data analysis respectively.ResultsEighty-six per cent (85%) of the development partners delivering aid in the studied districts were Non-Governmental Organizations. Twenty percent (20%) of the interventions were HIV/AIDS interventions. We found that only four (4) representing 25 % (25%) DPs had an MOU with the District Council, 56 % (56%) had submitted their plans in writing to be integrated into the 2014/15 CCHP. Six (6) representing 38 % (38%) respondents had received at least one document (guidelines, policies and other planning tools) from the district for them to use in developing their organization activity plans. Eighty-seven point 5 % (87.5%) from Bahi had partial or substantial participation, in the planning process while sixty-two point 5 % (62.5%) from Kinondoni had not participated at all (zero participation). The operational challenges to engagements included differences in planning cycles between the government and donors, uncertainties in funding from the prime donors, lack of transparency, limited skills of district planning teams, technical practicalities on planning tools and processes, inadequate knowledge on planning guidelines among DPs and, poor donor coordination at the district level.ConclusionsWe found low engagement of Development Partners in planning. To be resolved are operational challenges related to differences in planning cycles, articulations and communication of local priorities, donor coordination, and technical skills on planning and stakeholder engagement.
| S-EPMC8800550 | biostudies-literature
Project description:Distribution networks-from vasculature to urban transportation pathways-are spatially embedded networks that must route resources efficiently in the face of pressures induced by the costs of building and maintaining network infrastructure. Such requirements are thought to constrain the topological and spatial organization of these systems, but at the same time, different kinds of distribution networks may exhibit variable architectural features within those general constraints. In this study, we use methods from network science to compare and contrast two classes of biological transport networks: mycelial fungi and vasculature from the surface of rodent brains. These systems differ in terms of their growth and transport mechanisms, as well as the environments in which they typically exist. Though both types of networks have been studied independently, the goal of this study is to quantify similarities and differences in their network designs. We begin by characterizing the structural backbone of these systems with a collection of measures that assess various kinds of network organization across topological and spatial scales, ranging from measures of loop density, to those that quantify connected pathways between different network regions, and hierarchical organization. Most importantly, we next carry out a network analysis that directly considers the spatial embedding and properties especially relevant to the function of distribution systems. We find that although both the vasculature and mycelia are highly constrained planar networks, there are clear distinctions in how they balance tradeoffs in network measures of wiring length, efficiency, and robustness. While the vasculature appears well organized for low cost, but relatively high efficiency, the mycelia tend to form more expensive but in turn more robust networks. As a whole, this work demonstrates the utility of network-based methods to identify both common features and variations in the network structure of different classes of biological transport systems.
| S-EPMC6145589 | biostudies-literature
Project description:Increases in incidents involving so-called confused persons have brought attention to the potential costs of recent changes to public mental health (PMH) services in the Netherlands. Decentralized under the (Community) Participation Act (2014), local governments must find resources to compensate for reduced central funding to such services or "innovate." But innovation, even when pressure for change is intense, is difficult. This perspective paper describes experience during and after an investigation into a particularly violent incident and murder. The aim was to provide recommendations to improve the functioning of local PMH services. The investigation concluded that no specific failure by an individual professional or service provider facility led to the murder. Instead, also as a result of the Participation Act that severed communication lines between individuals and organizations, information sharing failures were likely to have reduced system level capacity to identify risks. The methods and analytical frameworks employed to reach this conclusion, also lead to discussion as to the plausibility of an unconventional solution. If improving communication is the primary problem, non-hierarchical information, and organizational networks arise as possible and innovative system solutions. The proposal for debate is that traditional "health system" definitions, literature and narratives, and operating assumptions in public (mental) health are 'locked in' constraining technical and organization innovations. If we view a "health system" as an adaptive system of economic and social "networks," it becomes clear that the current orthodox solution, the so-called integrated health system, typically results in a "centralized hierarchical" or "tree" network. An overlooked alternative that breaks out of the established policy narratives is the view of a 'health systems' as a non-hierarchical organizational structure or 'Open Network.' In turn, this opens new technological and organizational possibilities in seeking policy solutions, and suggests an alternative governance model of huge potential value in public health both locally and globally.
| S-EPMC5337250 | biostudies-other
Project description:Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT).This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods.The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes.District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.
| S-EPMC4237792 | biostudies-other
Project description:Introduction:Memory clinics (MCs) are the main model for dementia diagnosis and care. Following the development of a MC network in Northern France, our objectives were to assess its impact on patient characteristics over 20 years. Methods:The characteristics of new consultants were studied from 1997 to 2016. Results:New consultants increased from 774 per year in 1997 to 26258 per year in 2016, as the number of MCs increased from 12 to 29. Over time, patients were progressively older and less educated, and more were living alone. A greater proportion of patients were referred by specialists. Referral delay and home-to-MC distance kept decreasing. The oldest patients were referred at a progressively less-severe stage. The proportion of young patients kept increasing in the tertiary referral center. Discussions:The development of a region-wide MC network led to increased referral of vulnerable patients and differentiation of the tertiary referral center over time.
| S-EPMC7449245 | biostudies-literature
Project description:Background: A mobile health (mHealth) technology based application was developed to help rural health care providers (RHCPs) identify and refer presumptive tuberculosis (TB) patients to the nearest microscopy centre for sputum examination using mobile applications on their smart phones. Objective: To determine the feasibility and yield of presumptive TB case referrals by RHCPs using mHealth technology. Methods: The project was implemented in the tribal population of Khunti District, Jharkhand State, India, from April 2012 to February 2015. 'ComCare', a mobile application designed as an aid for health care providers, was introduced and RHCPs were trained in its use. Results: Of 171 RHCPs who were formally trained to identify and refer presumptive TB patients, 30 were trained in the use of the mobile application. There were 35 referrals of presumptive TB patients per RHCP using the mobile application, and four each by RHCPs who were not using the application. Of the 194 TB cases diagnosed, RHCPs using the application contributed 127 (i.e., 4 TB cases per RHCP), while other RHCPs contributed 67 (0.5 TB case per RHCP). Conclusion: mHealth technology was highly effective, and increased both public and private health care provider accountability to patients.
| S-EPMC5493093 | biostudies-other
Project description:Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.
| S-EPMC7386590 | biostudies-literature
Project description:BACKGROUND:A twinning partnership is a formal and substantive collaboration between two districts to improve their performance in providing primary healthcare services. The 'win-win' twinning partnership pairs are categorized under relatively high and low-performing districts. The purpose of this formative evaluation is to use the empirically derived systems model as an analytical framework to systematically document the inputs, throughputs and outputs of the twinning partnership strategy. METHODS:This explanatory sequential mixed method study design was conducted from October 2018 to September 2019, in Amhara, Oromia, Southern, Nations, Nationalities and Peoples' (SNNP) and Tigray regions. The quantitative research approach used an observational design which consists of three measurements: at baseline (October 2018), midterm (March 2019) and end-line (September 2019), and the qualitative approach employed a case study. Qualitative data was collected using interviewer-guided semi-structured interview tools. The data were transcribed verbatim, translated from Amharic and Afan Oromo into English and analyzed through a theoretical framework named the Bergen Model of Collaborative Functioning (BMCF). Quantitative data were extracted from routine health management information system. The results are presented as averages, percentages and graphs. To claim statistical significance, non-parametric tests: Friedman test at (p?<?0.05) and Wilcoxon signed ranks test (p?<?0.017) were analyzed. RESULTS:The District Health System Performance (DHSP) was determined using data collected from eight districts. At baseline, the mean DHSP score was 50.97, at midterm, it was 60.3 and at end-line, it was 72.07. There was a strong degree and statistically significant relationship between baseline, midterm and end-line DHSP scores (r?>?0.978**), using the Friedman test ?2(2)?=?16.000, p?=?0.001. Post hoc analysis using Wilcoxon signed-rank test was conducted with a Bonferroni correction and the results elicit higher DHSP values from baseline to midterm and from midterm to end-line with significance level set at p?<?0.017. The qualitative results of the case study revealed that scanning the mission of the twinning partnership and focusing on a shared vision coupled with mobilizing internal and external resources were the fundamental input elements for successful twinning partnerships at the district level. In addition, the context of pursuing Universal Health Coverage (UHC) through achieving transformed districts can be enhanced through deploying skilled and knowledgeable leadership, defining clear roles and responsibilities for all stakeholders, forming agreed detailed action plans, and effective communication that leads to additive results and synergy. The twinning partnership implementing districts benefit from the formal relationship and accelerate their performances towards meeting the criteria of transformed districts in Ethiopia. CONCLUSIONS:Twinning partnerships help to accelerate the health system's performance in achieving the district transformation criteria. Therefore, scaling up the implementation of the twinning partnership strategy is recommended.
| S-EPMC7507737 | biostudies-literature