Health systems, like commercial enterprises, face wide-ranging challenges and need to develop an adaptive capacity in order to remain effective. There is increasing recognition in the health sector that the concept of the learning organisation, which has long been popular in the business management field, could be a key strategy to develop this adaptive capacity in health systems. Although examples exist of the application of learning organisation principles to health care facilities, there is little guidance for how units or groups responsible for health policy and strategies can apply them more widely. In order to provide some initial guidance to the Western Cape Department of Health, which has expressed an interest in developing into a learning organisation, this project sought to identify the enablers of, and barriers to learning organisation creation by conducting a systematic review of learning organisation interventions across multiple sectors. As multiple definitions and models of a learning organisation exist in the literature, this systematic review was complemented by an initial review of conceptual literature which synthesised the existing definitions and models of a learning organisation and identified a core set of learning organisation dimensions. Findings indicate that a foundation of good organisational software such as a shared understanding of, and commitment to a learning organisation vision, a culture which is conducive to learning organisation creation, and a secure, supportive and interpersonally non-threatening environment, is essential for learning organisation creation. Building on this foundation it is then important to invest in staff time (i.e. that staff are officially allowed, and incentivised, to spend time on learning during work hours), and the infrastructure and processes necessary to support knowledge transfer, such as physical meeting spaces, online learning databases, mentorship programmes, and feedback mechanisms.

No description available.

Introduction: Understanding health service user perceptions of the quality of care is critical to developing measures to increase the utilisation of healthcare services. To relate patient experiences to a common set of standards, the World Health Organization (WHO) developed the concept of health system responsiveness. This measures what happens during user’s interactions with the system, using a common scale, and requires that the user has had a specified encounter, which they evaluate. The concept of responsiveness has only been used in a very few studies previously to evaluate healthcare sub-systems, such as mental healthcare. Since the concept of responsiveness had not been previously applied to a middle income country, such as Iran, there is a need to investigate its applicability and to develop a valid instrument for evaluating health system performance. The aim of this study is to assess the responsiveness of the mental healthcare system in Tehran, the capital of Iran, in accordance with the WHO responsiveness concept. Methods: This thesis is a health system research, based on qualitative and quantitative methods. During the qualitative phase of the study, six focus group discussions were carried out in Tehran, from June to August 2010. In total, 74 participants, comprising 21 health providers and 53 users of the mental healthcare system, were interviewed. Interviews were analysed through content analysis. The coding was synchronised between the researchers through two discussion sessions to ensure the credibility of the findings. The results were then discussed with two senior researchers to strengthen plausibility. Responses were examined in relation to the eight domains of the WHO’s responsiveness model. In accordance with the WHO health system responsiveness questionnaire and the findings of the qualitative studies, a Farsi version of the Mental Health System Responsiveness Questionnaire (MHSRQ) was tailored to suit the mental healthcare system in Iran. This version was tested in a cross-sectional study at nine public mental health clinics in Tehran. A sample of 500 mental health services patients was recruited and subsequently completed the questionnaire. The item missing rate was used to check the feasibility, while the reliability of the scale was determined by assessing the Cronbach’s alpha and item total correlations. The factor structure of the questionnaire was investigated by performing confirmatory factor analysis (CFA). To assess how the domains of responsiveness were performing in the mental healthcare system, I used the data collected during the second phase of the study. Utilising the same method used by the WHO for its responsiveness survey, we evaluated the responsiveness of outpatient mental healthcare, using a validated Farsi questionnaire. Results: There were many commonalities between the findings of my study and the eight domains of the WHO responsiveness model, although some variations were found. Effective care was a new domain generated from my findings. In addition, the domain of prompt attention was included in two newly labelled domains: attention and access to care. Participants could not differentiate autonomy from choice of healthcare provider, believing that free choice is part of autonomy. Therefore these domains were unified under the name of autonomy. The domains of quality of basic amenities, access to social support, dignity, and confidentiality were considered important for the responsiveness concept. Some differences regarding how these domains should be defined were observed, however. The results of the qualitative study were used to tailor a Farsi version of the MHSRQ. A satisfactory feasibility, as the item missing value was lower than 5.2%, was found. With the exception of the access domain, the reliability of the different domains in the questionnaire was within a desirable range. The factor loading showed an acceptable uni-dimensionality of the scale, despite the fact that the three items related to access did not perform well. The CFA also indicated good fit indices for the model (CFI = 0.99, GFI = 0.97, IFI = 0.99, AGFI = 0.97). The results of the mental healthcare system responsiveness survey showed that, on average, 47% of participants reported experiencing poor responsiveness. Among the responsiveness domains, confidentiality and dignity were the best performing factors, while autonomy, access to care and quality of basic amenities were the worst performing. Respondents who reported their social status as low were more likely to experience poor responsiveness overall. Autonomy, quality of basic amenities and clear communication were dimensions that performed poorly but were considered to be highly important by the study participants. Conclusion and implications: This is the first time that mental healthcare system responsiveness has been measured in Iran. Our results showed that the concept of responsiveness developed by the WHO is applicable to mental health services in this country. Dignity and confidentiality were domains which performed well, while the domains of autonomy, quality of basic amenities and access performed poorly. Any improvement in these poorly performing domains is dependent on resources. In addition, attention and access to care, which were rated high in importance and poor in performance, should be priority areas for intervention and the reengineering of referral systems and admission processes. The role of subjective social status in responsiveness should be further studied. These findings might help policymakers to better understand what is required for the improvement of mental health services.

Health-system guidance (HSG) is expected to assist with making decisions about addressing problems or achieving goals in health systems. However, the implementation of HSG is challenging due to the complexity of health-system policymaking. Existing guideline implementation tools focus on clinical practice guidelines and might not be suitable for HSG. This dissertation aims to bridge this gap by developing a theoretical framework and a tool designed to support HSG implementation at both national and subnational levels. It achieves these objectives through three original scientific contributions. The first study uses a critical interpretive synthesis of the existing literature to develop a theoretical framework. This framework identifies facilitators of, barriers to, and strategies for supporting HSG implementation across six different levels: the political system, health system, community, organization, providers, and the public/patients. The second study employs a modified Delphi method to identify the components of an HSG implementation tool based on this framework. The third study adopts a formative evaluation study design to explore – through interviews with guideline implementers – whether, how, and why the HSG implementers will use the tool and how it can be refined, leading to the further development of the tool. These studies collectively offer theoretical, methodological and substantive insights into understanding the facilitators, barriers, and strategies crucial for the effective implementation of HSG. The developed HSG implementation framework and accompanying tool can be useful for supporting the implementation of HSG covering varied topics and in different contexts, including low-, middle- and high-income countries. / Thesis / Doctor of Philosophy (PhD) / Health-system guidance (HSG) is advice created to help governments make better decisions on how to improve health systems. The implementation of HSG is complicated due to the complex ways in which government policy about health systems is made. Most existing implementation tools are designed for implementing clinical practice guidelines, not HSG. This dissertation addresses this gap by focusing on HSG implementation, bringing together insights from a series of three studies. The first study develops a framework about the facilitators of, barriers to, and strategies for HSG implementation at different levels (e.g., patients, organizations and communities). The second study gathers expert opinions about how the framework can be used to develop the components of a tool. The third study examines whether, how, and why this tool will be used with people who implement HSG, which supports the further refinement of the tool.

The current approach to performance measurement in British Columbia is to select and match performance measures with strategic goals and objectives so that health administrators and decision makers can evaluate the performance of different care sectors (e.g. primary, community and acute care) within the provincial health system. Although this approach offers basic understanding of system performance, it is static and considers the performance of organizational components in isolation from their interrelationships and external influences. The purpose of this research is to enhance the current performance measurement approach in BC by linking health system variables through causal relationships and feedback loops that can impact and lead to health system sustainability. The qualitative system dynamics method was applied to develop a conceptual performance measurement model. Fifteen interviews with stakeholders were conducted at the BC Ministry of Health to validate and improve the pre-validation model. A post-validation model was then created based on the feedback and comments from the 15 interview participants. As a product of this research, the post-validation model, Web of Measures 2.0, will explain how the identified cause and feedback mechanisms both internal and external to the BC health system may help determine policy levers for designing and developing quality improvement initiatives. Although quantitative analysis is out of scope for this research, potential benefits of inputting BC data into the proposed model are discussed at the end of this thesis. / Graduate / 0769 / 0790 / qi.william.yang@gmail.com

La culture de la naissance peut être assimilée à un rituel de passage à la base de la construction identitairepour la mère et pour l’enfant. Cette transition est conçue de manière différente selon les contextesculturels.À partir d’un travail ethnographique au Portugal et dans l’Amazonie équatorienne, nous avons mis enévidence l’existence de trois systèmes de santé : le biomédical ou système officiel (qui se constituecomme tel à partir du XIX s.), le système traditionnel ou ancestral et le système alternatif (dans ce cas,incarné par les doulas).Autour de ces trois systèmes de santé se tisse une culture de la naissance porteuse, dans chaque cas, d’undiscours légitimant des pratiques présentées comme « adéquates » et les représentations associées.Malgré des différences importantes entre les procédures des protocoles médicaux – propres au systèmeofficiel de santé, au système traditionnel de santé et au système alternatif - pour la prise en charge del’accouchement, de l’alimentation pré-lactée (don du colostrum) et du postpartum, nous avons identifiédes points communs entre eux. Les frontières entre ces différents systèmes de santé, entre la tradition etla modernité, peuvent s’effacer ou demeurer floues.Les pratiques diverses sont associées à des représentations relatives à la mort, les corps, la douleur, lesparadigmes de santé et de maladie, la religion, la propreté et l’hygiène, les liens sociaux, entre autres. / The culture of birth is a ritual of passage which is the basis of the construction of identity for the motherand for the child. This transition is conceived in different ways in distinct cultural contexts.Based on an ethnographic work in Portugal and the Amazonia of Ecuador, we have identified threeexisting health systems: biomedicine or the official system (which was constituted as “official” from the19th century onwards), the traditional system or ancestral system, and the alternative system (in this case,embodied by doulas).In the framework of these three health systems, a culture of birth is woven into a discourse legitimizingtheir practices, which are presented as "adequate", and their representations.Although there are important differences between the procedures of the medical protocols - specific tothe formal health system, to the traditional health system, and to the alternative system - for the deliveryof childbirth, for pre-lactated feeding (colostrum feed), and for postpartum, we also found bridgesbetween them.Sometimes the boundaries between these different health systems, between tradition and modernity, areeither disappeared or blurred.Various practices are associated with representations relating to death, bodies, pain, health and diseaseparadigms, religion, cleanliness and hygiene, social ties, among others.

Philosophiae Doctor - PhD / South Africa has not responded well to recommendations in national evaluation reports to address human resource challenges associated with the implementation of nutrition programmes and improved service delivery. Twenty-four years have passed since the dawning of democracy and the nutrition situation within the population has actually deteriorated, with persistently high levels of stunting in young children and the growing prevalence of overweight and obesity in all age groups. These conditions not only rob people of their potential, but they carry a high cost for the state and society as a whole. This study aimed to develop a comprehensive and empirically sound nutrition workforce development planning framework for the public health sector so that it is better equipped to address the nutrition-related burden of disease in South Africa. The study explored the provision of nutrition services in South Africa, focusing on the nutrition-specific work components of health personnel ‒ doctors, nurses, dietitians, nutritionists, health promoters and community health workers working at the primary health care level in the public health sector. Evidence-based workforce information was collected through a mixed methodology comprising: literature reviews, document reviews, analysis of scopes of practice, job descriptions, competencies, workforce surveys, key informant interviews and consensus assessments through the application of the Delphi technique. Permission was obtained to adapt and use questionnaires from an Australian workforce study. Ethical approval, permission to conduct the study and informed consent were obtained prior to the commencement of the interviews. Data was then analysed using descriptive statistics, content and thematic analysis and triangulation of all findings, followed by consensus assessments to describe the nutrition workforce and delineate the roles and functions thereof. The comprehensive planning framework that was developed was applied to the Western Cape province.

O autor traça um perfil do setor saúde, em um contexto da crise do Estado, que sob a ordem mundial de globalização da economia está associada, no Brasil, a reforma neoliberal. Fatos geoeconômicos e político- institucionais, são confrontados com as múltipras determinações históricas e culturais que configuram a pós-modernidade. O estudo do inter-relacionamento das áreas de educação, saúde e trabalho, com suas singularidades, revelou, ao longo do tempo, a reprodução de modelos de desenvolvimento para a instituição e para os profissionais, ou a emergência de situações determinantes de novos modelos. Através de pesquisa qualitativa, realizada durante 1995, como um estudo de caso, busca-se compreender e interpretar no conflito de cotidiano, a realidade e as representações imaginárias dos profissionais, acerca do trabalho, num serviço básico e regionalizado de saúde de Niterói, na área metropolitana do Rio de Janeiro. A análise dos documentos escritos e de conteúdos de discursos colhidos nas entrevistas dos indivíduos e no grupo focal, apóia-se, fundamentalmente, numa linha de pensamento hermenêutica-dialética. Os resultados revelaram dimensões do dia-a-dia da \"equipe\" de saúde, que permitiram a criação de novas categorias analíticas, em especial àquelas inerentes à ação comunicativa entre os sujeitos sociais, à mudança de paradigmas da atenção à saúde e à articulação intra e intersetorial. O autor, através das falas dos servidores e das suas próprias análises, tenta apresentar a lógica do desenvolvimento institucional e profissional. O processo de formação dos profissionais se dá no cotidiano, que ora promove, ora oculta, um desenvolvimento educacional latente, que mantém uma relação intrínseca com o poder simbólico e as condições materiais, do trabalho e de vida dos participantes da investigação. O autor conclui que determinadas questões, de ordem sócio-econômica e antropológico-cultural, desempenham relevante papel no enfrentamento, ou na superação, de problemas vivenciados pelos profissionais e pela comunidade, no espaço das instituições,e assim, podem ampliar as bases de luta por uma vida melhor. / The author outlines a profile of the health sector in a context of the State crisis, that, under the world order of economical globalization, is associated, in Brazil, with a neoliberal reform. Geoeconomic and politicoinstitutional facts are confronted with the multiple historical and cultural determinants that configure postmodernity. The study of the interrelation of the education, health and work areas revealed the reproduction of models of development of institution and professionals, or the emergence of situations that determine new models. By means of a qualitative research - performed in the year of 1995, as a case study - the author tries to understand and interpret the reality and the imaginary representations, concerning their own work, of the professionals; the research was conducted in a basic, regionalized, health service, in Niterói, in the metropolitan area of Rio de Janeiro. The analysis of written documents and of the contents of the speeches obtained through interviews of individuais and of the focal group, relies, in essence, in an hermeneutic-dialectical line of thought. The results of the study revealed dimensions, in the conflict of the quotidien activities of the health \"team\" that permitted the creation of new analytical categories, in special those inherent to the communicative action of the social actors, to the changing of paradigms in the field of health care and to the articulation inside and outside this field. According to the author, the process of formation of the professionals occurs through quotidien activities that reveal, or occult, a latent educational development and that maintain an intrinsical relationship with the symbolic power and with the material conditions, of work and life, of the participants. In the conclusions, the author indicates socioeconomical and anthropological situations that perform a relevant role in the confronting, or in the superation, of problems that professionals and community face in the space of the institution, and that may, so, amplify the foundations of the continuous effort towards the improvement of life.

O autor traça um perfil do setor saúde, em um contexto da crise do Estado, que sob a ordem mundial de globalização da economia está associada, no Brasil, a reforma neoliberal. Fatos geoeconômicos e político- institucionais, são confrontados com as múltipras determinações históricas e culturais que configuram a pós-modernidade. O estudo do inter-relacionamento das áreas de educação, saúde e trabalho, com suas singularidades, revelou, ao longo do tempo, a reprodução de modelos de desenvolvimento para a instituição e para os profissionais, ou a emergência de situações determinantes de novos modelos. Através de pesquisa qualitativa, realizada durante 1995, como um estudo de caso, busca-se compreender e interpretar no conflito de cotidiano, a realidade e as representações imaginárias dos profissionais, acerca do trabalho, num serviço básico e regionalizado de saúde de Niterói, na área metropolitana do Rio de Janeiro. A análise dos documentos escritos e de conteúdos de discursos colhidos nas entrevistas dos indivíduos e no grupo focal, apóia-se, fundamentalmente, numa linha de pensamento hermenêutica-dialética. Os resultados revelaram dimensões do dia-a-dia da \"equipe\" de saúde, que permitiram a criação de novas categorias analíticas, em especial àquelas inerentes à ação comunicativa entre os sujeitos sociais, à mudança de paradigmas da atenção à saúde e à articulação intra e intersetorial. O autor, através das falas dos servidores e das suas próprias análises, tenta apresentar a lógica do desenvolvimento institucional e profissional. O processo de formação dos profissionais se dá no cotidiano, que ora promove, ora oculta, um desenvolvimento educacional latente, que mantém uma relação intrínseca com o poder simbólico e as condições materiais, do trabalho e de vida dos participantes da investigação. O autor conclui que determinadas questões, de ordem sócio-econômica e antropológico-cultural, desempenham relevante papel no enfrentamento, ou na superação, de problemas vivenciados pelos profissionais e pela comunidade, no espaço das instituições,e assim, podem ampliar as bases de luta por uma vida melhor. / The author outlines a profile of the health sector in a context of the State crisis, that, under the world order of economical globalization, is associated, in Brazil, with a neoliberal reform. Geoeconomic and politicoinstitutional facts are confronted with the multiple historical and cultural determinants that configure postmodernity. The study of the interrelation of the education, health and work areas revealed the reproduction of models of development of institution and professionals, or the emergence of situations that determine new models. By means of a qualitative research - performed in the year of 1995, as a case study - the author tries to understand and interpret the reality and the imaginary representations, concerning their own work, of the professionals; the research was conducted in a basic, regionalized, health service, in Niterói, in the metropolitan area of Rio de Janeiro. The analysis of written documents and of the contents of the speeches obtained through interviews of individuais and of the focal group, relies, in essence, in an hermeneutic-dialectical line of thought. The results of the study revealed dimensions, in the conflict of the quotidien activities of the health \"team\" that permitted the creation of new analytical categories, in special those inherent to the communicative action of the social actors, to the changing of paradigms in the field of health care and to the articulation inside and outside this field. According to the author, the process of formation of the professionals occurs through quotidien activities that reveal, or occult, a latent educational development and that maintain an intrinsical relationship with the symbolic power and with the material conditions, of work and life, of the participants. In the conclusions, the author indicates socioeconomical and anthropological situations that perform a relevant role in the confronting, or in the superation, of problems that professionals and community face in the space of the institution, and that may, so, amplify the foundations of the continuous effort towards the improvement of life.

acase@tulane.edu / The Sustainable Development agenda, which will be driving the development discourse of the world in next fifteen years, has 17 goals and 169 target. Goal 3 is related to health and it has 13 targets. Target 3.8 states “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. This target - related to universal health coverage (UHC) is considered the linchpin of all other health targets. Although more than 100 countries across the world are pursuing UHC reforms, there is no one-size-fits-all approach to achieving UHC. It has been recommended that governments should develop approaches that fit the social, economic, demographic, and political context of their countries. Pakistan, the sixth most populous country in the world, underwent its first democratic transition after elections 2013. The 18th constitutional amendment of devolution has made health a provincial subject in the country. As promised in election manifestoes, all the three major political parties ruling provincial governments have recently committed to health financing reforms for achieving UHC. Though the existing literature provides a few key health financing indicators at the national level, there is a paucity of evidence for planning and monitoring UHC reforms at the provincial level. This dissertation, comprised of three papers, addressed this gap by providing empirical evidence on: i) incidence and determinants of catastrophic health expenditure, ii), efficiency of division level health systems in producing UHC tracer indicators. and iii) provincial progress towards Universal health coverage and associated in-equities from 2001-14. / 1 / Faraz Khalid