Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

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.

acase@tulane.edu

Background: Mortality from colorectal cancer (CRC) in the Northwest Territories (NWT), a northern region of Canada, is nearly double the national rate. While mortality could be reduced with greater adherence to CRC screening, this requires colonoscopy access which is limited, and difficult to predict in a complex remote health system. Simulation modeling has been used to plan CRC screening but the impact on decision-making and utility in complex remote health system is unclear. Aim: This thesis aims to estimate the colonoscopy requirements and outcomes of CRC screening in the NWT using simulation modeling in a way that will inform feasible patient-centered strategies to enhance screening. Methods: We conducted a systematic review of the validity and utility of simulation modeling in CRC screening delivery (Chapter 1, 2). Next, a retrospective cohort study of CRC screening participation and outcomes between 2014-2019 was conducted (Chapter 3). We used this data and the findings of the systematic review to inform our participatory simulation modeling approach (Chapter 4). With end-users of the simulation model (clinicians, administrators, and patients), we revised an existing simulation model, OncoSim-CRC, to estimate the resource requirements and outcomes of various strategies to deliver a CRC screening program in the NWT. Each scenario model was run for 500 million cases and model validity was assessed. To enhance ongoing collaboration, we shared the concepts of a Communities of Practice (CoP) framework with stakeholders and assisted in generating consensus on priorities for a CoP to address (Chapter 5). Results: The systematic review showed that simulation models have been used to generate evidence critical to informing decision making for a broad range of decisions related to CRC screening delivery. However, the impact of these models on decision making, end-user engagement, and model validity were rarely described. In the retrospective cohort study, we observed that fecal immunohistochemical test(FIT)-based CRC screening did not appear to prevent CRC or provide earlier detection, but did result in more frequent positive pathology results than anticipated for average risk screening. Factors associated with this include long wait times for colonoscopy, over 1 in 3 FIT positive individuals had clinical signs and symptoms of CRC, and higher relative risk of advanced neoplasia among indigenous individuals. These findings and the involvement of end-users, informed the simulation model study. Under the parameters of the model, we estimate that colonoscopy demand with a CRC screening program would surpass capacity within 1-2 years, and continue to increase over the next 10-15 years due to adenoma surveillance. If this colonoscopy demand is met, we estimate screen detected cancers would increase by 110%, and clinically detected cases reduce by 26%. Increasing the phase-in period or revising adenoma follow-up guidelines would reduce demand and still improve cancer detection and prevention. A framework for a CoP, and consensus on priorities among stakeholders were established. Conclusion: Participatory simulation modeling was a useful method of informing CRC screening delivery in a remote northern population. The simulated scenarios provide decision-makers with strategies to enhance programmatic screening while conserving colonoscopy resources. The findings of this thesis helps to characterize the current outcomes of CRC screening in the NWT, and identifies opportunities to improve CRC screening effectiveness for a remote and, largely indigenous population.

INTRODUCTION: Performance–Based Grant Agreements are increasingly being used in Nepal in the healthcare sector, especially at public-private partnership hospitals. As interest in these agreements grows, it is essential to understand the process of implementation so that Nepali healthcare policy–makers can make better informed decisions about how they impact the public health situation of Nepal. This project studied the process of implementing Performance–Based Grant Agreements using qualitative research methods to interview key informants about their opinions, perceptions, and experiences associated with these agreements. METHODS: Semi–structured interviews with open–ended questions were conducted with key informants who have direct knowledge and experience about the design, implementation, and impact of the Performance–Based Grant Agreements. The key informants included healthcare administrators and healthcare workers at the various implementing hospitals, Government of Nepal officials, and members of various External Development Partners; these participants were chosen using a combination of purposive and convenience sampling methods in an attempt to triangulate responses and to generate a diversity of opinions, and perspectives. Participants were asked about their experiences with the Performance–Based Grant Agreements and interviews focused on associated challenges, opportunities, learned experiences, and both expected and unexpected consequences. Data analysis was overlapping with data collection and concentrated on identifying recurrent themes and ideas from transcribed interviews. These themes and ideas along with illustrative quotes guided discussion and results. RESULTS: A total of 16 interviews, ranging from 12 minutes to 75 minutes in length, were conducted with different hospital administrators, Government of Nepal officials, and members of different External Development Partners about the Performance–Based Grant Agreements. Participants had widely varying experiences about the process of implementing these agreements, which yielded a diversity of responses. DISCUSSION: There was an awareness gradient among the participants about the agreements as some participants had barely heard of the contracts while others had detailed knowledge of how their institution was implementing them. The process of implementation for participants and their institutions included grappling with the concept of conditionally tying funding to performance, figuring out how to do monitoring and evaluation, understanding the barriers to implementation, and using new technology and practices to meet the demands of the agreements. Despite the varying experiences associated with implementation or a lack thereof, participants were unanimous in their support for the adoption of these agreements and hopeful that these agreements can enhance partnership while improving the delivery of health services in Nepal.

ABSTRACT Despite changing demographics, policy, technology, and economics; medical education curriculum has changed very little from its inception over 100 years ago. The United States medical system has been under scrutiny for delivery of affordable, quality and accessible care for years. In order to address these challenges, we need to train physicians to consider these criteria when treating patients. A way to do this is through a curriculum that includes Health Systems Science (HSS). The challenge of HSS is that it adds additional topics and competencies to an already full medical education curriculum. In order to move forward in medical school, students are tested on their knowledge of basic science. Because HSS topics are not included in the required testing, students who have not been exposed to an HSS curriculum perceive HSS topics as less valuable than traditional medical school topics. This research sought to understand if students changed their perception of the value of HSS after exposure to an HSS curriculum. First-year medical students from a large, urban medical school were surveyed using a pre-test and post-test survey before and after exposure to an HSS curriculum. This study was conducted with two cohorts over two years to see if there was a change in student perceptions of HSS. An Institutional Cycle design was applied to compare the post-test from the students in cycle 1 to the pre-test of students in cycle 2. This approach was deployed for two reasons. The first because of restrictions placed on the data collection; the pre-test for each person could not be directly linked to the post-test. The second, because there was no way to create a control group. These cohorts could not be randomly assigned to another curriculum. Comparing the post-test of Cohort 1 to the pre-test of Cohort 2 allows for the analysis of change between the two cohorts. Student perceptions did not change significantly between the pre-test in cycle 2 and the post-test in cycle 1. More research is needed to provide guidance for the development of an HSS curriculum that aligns with traditional medical education components. / Educational Administration

<p>Public health infrastructure (PHI) serves as the core foundation for essential public health and its services. However, the U.S. PHI has been weakened by understaffing, underfunding, limited resources and partnerships, and outdated data and information systems over the past few decades. The recent COVID-19 pandemic exacerbated its vulnerability and weakened nature, resulting in increased health disparities and worse health outcomes in general for the nation. The goal of this study was to identify elements of local PHI that are associated with the completion of 20 key public health activities while adjusting for state differences. Cross-sectional secondary data were acquired and linked from two national surveys of local health departments, the National Profile of Local Health Departments survey and the National Longitudinal Survey of Public Health Systems. In total, 20 multivariable logistic regression models were created to analyze the relationships between variables. State fixed effects were used in multivariable models to control for state differences. It was found that state differences affected the correlations of infrastructure variables. Several staffing elements, abilities to provide certain services, and participation in certain types of actions were strongly correlated with the completion of best practice activities. These findings will add to the discussion of what the minimum necessary elements of PHI may be.</p>

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The scope of pharmacy practice in global health has expanded over the past decade creating additional education and training opportunities for students, residents and pharmacists. There has also been a shift from short-term educational and clinical experiences to more sustainable bidirectional partnerships between high-income countries (HICs) and low- to middle-income countries (LMICs). As more institutional and individual partnerships between HICs and LMICs begin to form, it is clear that there is a lack of guidance for pharmacists on how to build meaningful, sustainable, and mutually beneficial programs. The aim of this paper is to provide guidance for pharmacists in HICs to make informed decisions on global health partnerships and identify opportunities for engagement in LMICs that yield mutually beneficial collaborations. This paper uses the foundations of global health principles to identify five pillars of global health engagement when developing partnerships: (a) sustainability, (b) shared leadership, (c) mutually beneficial partnerships, (d) local needs-based care and (e) host-driven experiential and didactic education. Finally, this paper highlights ways pharmacists can use the pillars as a framework to engage and support health care systems, collaborate with academic institutions, conduct research, and interface with governments to improve health policy.

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit. / Ghana Education Trust Fund (GETFund)