Objectives. To determine the factors associated with mortality during the first hospitalization of patients admitted to a hemodialysis unit. Materials and methods. Observational and retrospective study of patients admitted to “Dos de Mayo” National Hospital between January 2012 and December 2013. For the survival analysis we used the Kaplan-Meier method. A multivariate logistic regression was performed to evaluate the factors associated with hospital mortality. Results. 216 patients with a mean age of 56.9 ± 15.5 years were studied. 24% of patients (n = 51) died during their hospital stay. The mortality rate was 9.3 deaths/100 person-weeks (95% CI: 7.0 to 12.3). We found a tendency of less risk of death in patients with between 1 and 6 months from chronic kidney disease diagnosis (OR 0.84, 95% CI: 0.32 to 2.26) and in those with more than six months from chronic kidney disease diagnosis compared with those who had less than a month from chronic kidney disease diagnosis (OR 0.55, 95% CI: 0.19 to 1.57). Previous care by a nephrologist was not associated with differences in lower mortality (OR 1.14, 95% CI: 0.39 to 3.31). Conclusions. There is poor prior care among hemodialysis patients that form part of an inadequate health care structure and this is associated with high inhospital mortality. / Objetivos. Determinar los factores asociados a la mortalidad durante la primera hospitalización de una población incidente en hemodiálisis. Materiales y métodos. Estudio observacional y retrospectivo de pacientes que ingresaron al Hospital Nacional Dos de Mayo entre enero de 2012 y diciembre de 2013. Para el análisis de la supervivencia utilizamos el método de Kaplan-Meier. Se realizó un análisis de regresión logístico multivariado para evaluar los factores asociados a mortalidad intrahospitalaria. Resultados. Se estudiaron 216 pacientes con edad promedio de 56,9 ± 15,5 años. El 24% de los paciente (n=51) fallecieron durante la estancia hospitalaria. La tasa de mortalidad fue de 9,3 muertes/100 personas-semanas (IC 95%: 7,0 a 12,3). Se evidenció una tendencia a menor riesgo de fallecer en pacientes que tenían entre uno y seis meses con diagnóstico de enfermedad renal crónica (OR 0,84; IC 95%: 0,32 a 2,26), y en aquellos con más de seis meses comparado con aquellos que lo tenían hace menos de un mes (OR 0,55; IC 95%: 0,19 a 1,57). La atención previa por un nefrólogo no estuvo asociada a diferencias en la mortalidad menor (OR 1,14; IC 95%: 0,39 a 3,31). Conclusiones. Existe una deficiente atención previa entre los pacientes en hemodiálisis que forman parte de una inadecuada estructura de atención de salud y que está asociado a una alta mortalidad intrahospitalaria.

Philosophiae Doctor - PhD / National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts.

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

During the last decade, there has been growing international interest in generating new knowledge regarding understanding, developing and evaluating mechanisms that support the use of research evidence by policymakers as a strategy to strengthen health systems in low-and middle-income countries (LMICs). This thesis contributes to this knowledge through three original scientific contributions that employ a mixed methods approach, with the goal of supporting the use of research evidence in the Colombian health system. Specifically, in the chapters I present: 1) the development of an analytical schema that explains the conceptualization of the Colombian government, research funder and universities of an evidence-informed health system; 2) two case studies that explain whether and how political factors influenced the role of research evidence in the agenda-setting and policy-development stages of two past health policy decisions in Colombia; and 3) a protocol for a randomized controlled trial evaluating the effectiveness of a multifaceted intervention in increasing the utilization of an evidence service and the intention to use synthesized research evidence by policy advisors and analysts at the Colombian Ministry of Health. As a whole, the chapters presented in this thesis provide substantive, methodological and disciplinary contributions to the field of health systems research and particularly to the study of efforts that aim to support evidence-informed policy in LMICs. They also help to provide insights that can be utilized to support a more nuanced approach to the use of research evidence in LMICs that takes into account the many factors that can influence health system policymaking. Ideally, this will help those engaged in developing mechanisms to support the use of research evidence in the policy process, and contribute to stronger health systems across the world. / Thesis / Candidate in Philosophy

Following recipes is an analogy for maintaining intervention integrity, or, fidelity. Fidelity is the extent to which an intervention is implemented as intended. This editorial presents a recipe for assessing fidelity in family and health systems. The author discusses the challenges posed by the complex recipes of families and health systems interventions, in both research and clinical practice. The author concludes that increasing the measurement and reporting of fidelity is paramount in the exploding literature around family and health systems research. Researchers and practice improvement champions must find ways to assess fidelity or its proximal indicators and work to innovate new, more efficient methods that allow for ubiquitous fidelity assessment and monitoring systems, ensuring the best care for the families and system stakeholders they serve.

Yes / Corruption in the health sector costs over 500 billion USD every year, weakening health system preparedness and response to health crises like the COVID-19 pandemic. The lack of resources to deal with a shock limit the capacity to protect the population, exposing them to a greater risk of infection and mortality. There is an urgent need to improve health policy to reduce corruption in the health sector during times of crisis. This article aims to propose a prepare and response strategy to address corruption during times of health crises. We first explore the inherent characteristics of health systems that make them vulnerable to corruption and present the different faces corrupt practices take. We then explain why anticipatory governance is fundamental in addressing corruption in health systems and draw upon examples of corruption during the COVID-19. Finally, we conclude by proposing that anticipatory governance could decrease the impact of corruption during health crises by increasing the availability of resources required to improve the population’s health.

Yes / Understanding patients' perspective to get an insight into cancer, and how best the public health systems can battle with this disease is the way forward in this current world. This study aimed to explore patients' knowledge about common cancers, barriers to assessing cancer information and cancer preventative approaches in Fiji. The study used a qualitative method approach that was conducted among patients who attended Special Outpatients (SOPD) at the four selected health centres in Lautoka Subdivision, Fiji from 1st March to 30th April 2021. A semi-structured open-ended questionnaire was used to guide in-depth interviews. These audio recordings were transcribed and analysed using thematic analysis. All interview transcripts were read and similar words and phrases were assigned numbers which were grouped together to identify themes and sub themes. Twenty-eight patients took part in the in-depth interview and the responses were grouped into four themes including; cancer knowledge, diagnosis of cancer in a close friend/family, barriers of communication and optimizing cancer awareness. Patients' awareness about common cancers and cancer risk factors was low. Many barriers for cancer screening were highlighted including stigmatization, fear, worry, death, lack of information, herbal medicine use, lack of resources and delay in diagnosis. Awareness strategies highlighted by participants included community outreach programs, house to house visits, opportunistic screening, engagement of community health care workers and the concept of a cancer hub centre. It is evident that there is a range of views from patients towards cancer and it is important to understand these perceptions to better guide public health interventions concerning cancer. This puts more focus on the need to invest more in information, education, and communication material for public campaigns that target a variety of people for a wider reach.

Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions. Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs. Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance. Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

p. 1-88 / Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2013-04-23T18:17:42Z No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) / Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-05-04T17:29:01Z (GMT) No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) / Made available in DSpace on 2013-05-04T17:29:01Z (GMT). No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) Previous issue date: 2010 / Com o objetivo de sistematizar as principais abordagens metodológicas voltadas para a avaliação de Sistemas de Saúde Públicos e Universais, foi realizada uma revisão sistemática da literatura e busca nos sites de governos nacionais de países selecionados. A busca de artigos científicos foi realizada nas bases de dados Scielo e Web of Science, e os documentos institucionais nos sites dos governos nacionais e de algumas organizações internacionais. Foram tomados como critérios para a análise: existência de referenciais teóricos que orientam a avaliação e os conceitos utilizados na abordagem metodológica, a perspectiva da avaliação (se externa ou interna), os níveis de análise selecionados no que diz respeito à gestão e dimensões/componentes do sistema, os atributos e indicadores selecionados, bem como formas de retroalimentação dos resultados. A maioria das abordagens metodológicas apóia-se na elaboração de modelos lógicos (framework) para definição das dimensões da avaliação e seleção de indicadores. Verificou-se ainda na maioria dos modelos a combinação das perspectivas externa e interna e incorporação do ponto de vista de diversos atores na seleção de indicadores. As dimensões relacionadas ao estado de saúde, determinantes da saúde, desempenho dos serviços e aspectos contextuais foram as mais frequentes. Os atributos mais priorizados dizem respeito à qualidade dos serviços, efetividade, eficiência e às relações entre os agentes das ações. A articulação da avaliação com o planejamento e a gestão foi referida em pequeno número de casos. Discutem-se limites e possibilidades de incorporação dos resultados da presente síntese na gestão dos sistemas de saúde. / Salvador

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.