Primary healthcare planning,bottleneck analysis and performance improvement: An evaluation of processes and outcomes in a Nigerian context

Operational planning of interventions defines roadmaps, timelines and resources necessary for translating policies into expected health outcomes along the evidence-policy-implementation continuum. However, bottlenecks often hinder the attainment of objectives and the timely delivery of intervention packages leading to sub-optimal performance of health systems. Bottleneck identification, analysis and removal approaches to planning, which requires key stakeholders’ participation, have been recommended to improve health system outcomes in LMICs. This study demonstrates how integration of participatory action research (PAR) within a quality improvement model can help navigate the complexities of health system bottleneck analyses, planning and performance improvement in a Nigerian sub-national context.The study is based on data collected between June 2016 and June 2017, from Chikun LGA in Kaduna State Nigeria. PAR was integrated into a quality improvement model called DIVA (Diagnose-Intervene-Verify-Adjust) applied across selected interventions (eMTCT, Antenatal care, skilled birth attendance, immunization and Integrated Management of Childhood Illnesses). PAR was used to identify and analyse health system bottlenecks, as well as develop, monitor implementation and follow-up on action plans to address them. Evaluations were conducted involving 2 cycles of DIVA. The outputs (bottleneck analysis charts, driver diagrams, operational plans, M/E reports, etc.) from each cycle of the DIVA process were collated and analysed. Bottlenecks identified include availability of human resources for health, availability of health commodities as well as geographical accessibility. These had implications on acceptability and quality of services. Mean Improvements recorded were 20.4%, 14.0% and 10.8% and 11.2%, 7.5%; 5.5% (across eMTCT, maternal health and child health interventions) in the 1 st and 2nd DIVA cycles respectively. This study highlights processes and outcomes of integrating PAR in quality improvement design and operations in health intervention programmes with a focus on health systems strengthening in a Nigerian context. Implementing the DIVA model using a PAR approach may be considered an effective strategy for planning and implementing health interventions in comparable settings.     

Independence pays: a cost and resource analysis of direct payments in two local authorities

Although there is an increasing amount of literature on direct payments (DP), to date there have been few studies which have examined in any detail the costs and resources associated with them. This paper presents findings from a two year study conducted in two Welsh local authorities that jointly fund an Independent Living Support (ILS) scheme. The main study was not designed to provide definitive cost comparisons with conventional services, however, cost and resource implications of DP were considered and an analysis to determine comparative costs between DP and traditional services was undertaken. The study notes the difficulty in identifying the true cost of DP and reasonable comparators with traditional services. A set of four case studies are presented comparing actual costs of DP and in‐house and independent sector services in the two local authorities studied. The comparison of costs and resources, which did not include significant costs for traditional local authority services but included the cost of the DP support scheme, found that DP was cheaper than traditional in‐house service provision and relatively cost neutral when compared with independent sector provision. User satisfaction, however, was significantly greater with DP than traditional service delivery methods. The paper also examines factors which can potentially influence the cost of DP. The study suggests that DP represent a substantial improvement over traditional arrangements from a cost–benefit perspective. There is strong evidence to suggest that greater ‘opportunity cost’ savings can be anticipated when DP schemes become more fully integrated into policy, practice and procedures.     

The process is the plan: defining strategic community futures

This case study describes the application and assessment of a community-based strategic planning model to a faith-based organization. The United Jewish Communities of MetroWest New Jersey is responsible for programming, raising and allocating funds to serve a mission both global and local. A board-sanctioned process opened planning and allocations to a broader audience of community and service agencies, resulting in both dynamic synergy and conflict for the organization and its beneficiaries. This article looks at how a more strategic and inclusive planning process shaped decision-making and program evaluation. With input from professional staff and lay leadership, we consider lessons learned in the context of profound challenges facing non-profit, philanthropy-dependent organizations.     

进一步落实和完善促进中小企业发展的税收政策法规

中小企业是促进我国经济社会平稳健康发展的重要有生力量,但当前中小企业大多面临成本高、用工难、融资难问题,为此要进一步完善促进中小企业发展的税收等政策环境,积极鼓励帮助企业合理合法地用好国家的各项优惠扶持政策,从而更好地促进中小企业发展,发挥中小企业在促进我国经济转型中的重要作用。     

An overview of concept mapping in Dutch mental health care

About 25 years ago, concept mapping was introduced in the Netherlands and applied in different fields. A collection of concept mapping projects conducted in the Netherlands was identified, in part in the archive of the Netherlands Institute of Mental Health and Addiction (Trimbos Institute). Some of the 90 identified projects are internationally published. The 90 concept mapping projects reflect the changes in mental health care and can be grouped into 5-year periods and into five typologies. The studies range from conceptualizing the problems of the homeless to the specification of quality indicators for treatment programs for patients with cystic fibrosis. The number of concept mapping projects has varied over time. Growth has been considerable in the last 5 years compared to the previous 5 years. Three case studies are described in detail with 12 characteristics and graphical representations. Concept mapping aligns well with the typical Dutch approach of the “Poldermodel.” A broad introduction of concept mapping in European countries in cooperation with other countries, such as the United States and Canada, would strengthen the empirical basis for applying this approach in health care policy, quality, and clinical work.     

Lessons from a project to create performance measures for public health

This paper uses a specific example to illustrate complications that arise in formulating and implementing performance measures. The context of this demonstration is a Centers for Disease Control and Prevention (CDC)-funded project to explore the feasibility of performance measures developed at the national level for local sexually transmitted disease (STD) prevention and control programs. Grantees provided local data and reported on their experience in eliciting the data and using the results for program development. The experience of this project suggests that measures can be made operationally feasible and programmatically useful only if terminologies are subjected to extensive definition and clarification activities. These activities must include development of common language, mapping of workflows, and clarification of spheres of influence. Finally, performance measures must be used with some caution, as they often unintentionally capture extraneous program elements.     

A Historical,Interdisciplinary Analysis of the Animal and Human Social Ecosystem

No abstract available for this article.     

Permanency Planning in Foster Care: A Research Review and Guidelines for Practitioners

Abstract

Permanency planning is a systematic, goal-directed and timely approach to case planning for children subject to child protection intervention aimed at promoting stability and continuity. The present paper reviews research into the area of permanency planning within the foster care system, with the aim of promoting research-informed policy and practice. Research published in both journals and books between 1998 and 2005 was reviewed. Exceptions to this were previously published seminal articles and texts that are theoretically and empirically important. The results of the present review indicate that permanency planning is theoretically informed by attachment theory and understandings of child development and identity formation. Decision making should be individualised, timely and culturally appropriate. Children themselves, their parents and carers all need to be involved in planning. Practitioners must be prepared to undertake extensive observation and assessment to serve the best interests of children when making permanency decisions.     

从战略成本管理视角分析SD酒店的成本控制问题

酒店经营的最终目标是实现利润最大化,要实现此目标,成本管理是关键.在理解酒店战略成本控制理论的基础上,以SD花园酒店为案例,剖析其企业战略成本控制存在的主要问题,并从现代战略成本控制的视角,提出了改进酒店成本控制的方法与措施.     

Caring for informal caregivers: policy approaches to the provision of direct support services

Despite being the backbone of modern welfare states, the informal care sector for elderly people in need of long-term care is highly dysfunctional. The majority of informal caregivers are overburdened on account of their care-related activities, although an evolving market for support services directly aimed at relieving informal caregivers is observable. In this paper, we examine the reasons for the imperfect exchange between demand and supply in this market, applying the economic theory of market failure. Through a case study of Austria based on an empirical, qualitative survey of all direct support services and their suppliers on the national level as well as in three provinces, an understanding of this market's main players and mechanisms is derived. Thus, the authors determine that three different system types can be identified beyond the historical regional discrepancies. They illustrate the approaches to service provision for informal caregivers: centralized and public, laissez-faire and private, and a radically decentralized network for informal caregivers. Still, lack of information, social and psychological barriers, as well as high transaction costs, are identified which undermine the support service market for informal care. If the costs of the formal long-term care sector are to be contained despite demographic developments, better policy approaches will be necessary to overcome this challenge. In light of this, recommendations are derived to ensure a better exchange between supply and demand. By providing an initial empirical understanding and analysis of this market and its imperfections, the authors pioneer future quantitative research in this field.     

Towards an effective strategy to cope with housing land scarcity in the Gaza Strip as a sustainable development priority

Consistent with the global trends towards the adoption and implementation of sustainable urban planning strategies, this study discusses the problem of housing land shortage, considering the ever rapidly growing human population. Urban land is one of the most precious resources that need to be consumed and developed wisely. In this context, housing density is a widely used tool to control housing land consumption and ensure acceptable housing environments. With reference to the Gaza Strip (Palestinian Territories), the main aim of this study is to highlight the role of increasing housing density in order to face the problem of housing land scarcity. Within this scope, building legislation implemented in Gaza has been reviewed with reference to housing density. A questionnaire and a case study have been analyzed to propose recommendations related to housing planning and design. It has been concluded that rationalising urban land consumption in Gaza can be achieved by a dual strategy approach that increases housing density above the currently specified limit, and reduces the area of the typical Palestinian housing unit. This has to be done without sacrificing the limited open spaces available in the local housing environment. Thus, solutions that strike a balance between dense housing patterns and adequate urban environment, are essentially required here.     

Social and Health Factors Affecting Community Service Use by Vulnerable Older People

Abstract

This article reports on Outcomes for older people with complex or chronic care needs, a study undertaken by the Brotherhood of St Laurence and La Trobe University, examining older Victorians’ use of community services following Aged Care Assessment Service (ACAS) recommendations that they remain living at home. The paper reports on interviews with older people and carers undertaken at three-monthly intervals, over 12 months. This paper contributes to understanding the factors that impede or facilitate uptake of community aged care services that are critical to meeting the needs of older people and their carers. The study found that among other factors social isolation, high carer burden, and the older person reporting low mood were important barriers to service uptake. Cost, waiting lists, and service satisfaction were also identified in qualitative data as influencing factors. The study concludes there is a need for better means of identifying and supporting older people and carers at risk to improve community service uptake.     

Kaiser Permanente's Manifesto 2005 Demonstration

Summary

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on “unprofitable” populations, for example, those who are chronically ill, poor, and/or disabled.     

Achieving Permanence in Foster Care for Young Children: A Comparison of Kinship and Non-Kinship Placements

ABSTRACT

A number of child welfare policies have reinforced the use of kinship care as the most preferred placement for foster children, reflecting the philosophy that maintaining children within their own extended family system contributes to their stability and well-being. Given the growing utilization and legislative emphasis on kinship care along with the push for an immediate implementation of permanency plans for children in foster care, this study examines how the permanency goal under the 1997 Adoption and Safe Families Act (ASFA) is being implemented and achieved. The reunification and permanency placement (adoption or legal guardianship) outcomes of children in relative and non-relative care are analyzed, focusing on the experiences of young children. Based on public child welfare agency data from 2000 to 2003, child, case, and placement variables are explored to identify which set of factors best explains case outcomes. The present study identifies the total length of foster placement (kinship and non-kinship), the length of family maintenance services, and the number of placement changes as the most important variables in determining family reunification and permanent placement (legal guardianship and adoption) outcomes for young children.     

The role and relevance of domain knowledge, perceptions of planning importance, and risk tolerance in predicting savings intentions

The need for individuals to increase retirement savings has been widely promoted, yet our understanding of the motivations of individuals to save at a higher rate remains sparse. This paper reports the findings of a survey of 2300 retirement savings fund members and their motivations to contribute more to savings and to actively manage their investment strategy. Utilising the theory of planned behavior, the study reveals respondent’s self-reported attitudes, subjective norms and perceptions of behavioral control account for a high proportion of the variance in behavioral intention. Contrary to expectations, the study finds that respondent’s risk tolerance adds little to the prediction of behavioral intention. By contrast, perceptions of planning importance and self-assessed planning preparedness (domain knowledge) are found to exert powerful indirect influences on behavioral intentions via the perceived behavioral control construct. This novel finding confirms the relevance of planning constructs and financial literacy to an understanding of retirement savings behavior, and establishes a need to improve levels of financial literacy in society.     

Do Disabled Elderly Medicare Beneficiaries with Major Depression Make Less Use of a Consumer-Directed Home Care Voucher Benefit?

Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers.     

Young Mothers' Time Spent at Work and Time Spent Caring for Children

The association between the time a mother spends at work and in different child care activities is investigated, using data from the 1981 National Longitudinal Survey of Youth (NLSY). The mothers who worked on the index day spent almost one hour less time in physical care, one-half hour less time in interactive care, and over two hours less time in passive supervision of their children. The effects of a set of predictors on time use at work, time use in physical care, interactive care, and passive supervision of children were estimated using a covariance structure model. When the effects of these predictors are controlled, the number of hours at work predicts: (a) a small reduction in time spent in interactive care, and (b) larger reductions in time spent in physical care and passive supervision.     

Child care quality and affordability: Are they compatible?

Mothers have traditionally been the primary caregivers of children under school age in the United States. Increasing numbers of parents are seeking part-time or full-time alternatives for assistance with parenting and child care outside of the home. The variety of types of child care arrangements has greatly increased in the past 50 years. This paper addresses quality child care, child care options and cost. Despite the increase in child care provided outside the home, parents often have difficulty distinguishing quality care from less than quality care. Two prime considerations are quality and affordability. This paper addresses the need for a comprehensive spectrum of policies and child care programs for families in various cultural, economic, and social environments.     

Perspectives of Young People in Care About their School-to-Work Transition

Abstract

Achieving in education and employment has long-term effects on quality of life. With below-average levels of educational attainment, many young people in care are ill-equipped for the transition from school to further education and work. This paper presents findings from a qualitative study that explored the school to work transition experiences of young people currently or previously in care, and their ideas about future employment. A range of personal and contextual factors that influence study and work goals were identified. Young people spoke about the importance of personal confidence and determination, supportive relationships, someone to believe in them and encourage them, opportunities to pursue their goals, avenues to gain information about how to get desired jobs, positive school experiences, and the need for stability in their lives. The study suggests widening the agenda for case planning, transition from care and after-care support, to include career planning and vocational assistance.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.