Improving clinical practice in primary care for the prevention and control of noncommunicable diseases: a multi-actor approach to two regional pilot projects in Kazakhstan.
ABSTRACT: Improving access to quality services is integral to achieving better outcomes for noncommunicable diseases (NCDs). In Kazakhstan, like other countries with historically centralized governance models, key to improving quality is instilling a common and shared understanding of the roles and responsibilities in correspondence with the multifaceted nature of quality of care. This review details the experience of two pilot projects implemented in Kazakhstan's regions of Kyzylorda and Mangystau over a three-year period with the aim to improve clinical practice through a multi-actor, multi-intervention approach. Adopting a health system perspective, the pilots, by design, introduced interventions targeting four actors: policy-makers; health facility managers; health practitioners and patients. The review draws on the following sources of data: rapid baseline assessments; implementation plans, curriculums and other pilot-related material; a mid-way joint implementation meeting; intervention-specific evaluations; and a final external evaluation. The multi-actor, multi-intervention approach to the pilot projects showed some improvements to service outputs, in particular for cardiovascular disease (CVD) risk assessment and decreases in hospitalization rates for hypertension. The pilot projects also illustrated progress in working towards a shared understanding of the different roles of actors for improving quality of care, appreciating the complementarity of individual actors working towards improved population health and in establishing a culture of learning through the exchange of ideas and practices. The importance of responsibility across health system actors for outcomes is vital for the NCD agenda. This approach offers relevant policy lessons for similar centralized governance systems.
Project description:Although concerns over clinical research have been expressed, the governance of clinical research has been little studied. The aim was to describe research policy, volume, funding and concerns over clinical research in Finland.A qualitative study and the data were collected from various sources, including documents, statistics and semistructured expert interviews.Finland.We found no national policy for clinical research. Many actors were responsible for facilitating, directing, regulating and funding clinical research, but no actor had the main responsibility. Health professionals were the main drivers for clinical research. The role of the health ministry was small. The ministry distributed state money for clinical research in health services (EVO-money), but did not use it to direct research. Municipalities responsible for health services or national health insurance had little interest in clinical research. The Academy of Finland had had initiatives to promote clinical research, but they had not materialised in funding. Clinical research was common and internationally competitive, but its volume had declined relatively in the 2000s. Industry was an important private funder, mainly supporting drug trials made for licensing purposes. Drug trials without an outside sponsor (academic projects) declined between 2002 and 2010. The funding and its targeting and amount were no one's responsibility. Concerns over clinical research were similar as in other countries, but it had appeared late.Our results suggest fragmented governance and funding in clinical research. The unsystematic research environment has not prevented clinical research from flourishing, but the public health relevance of the research carried out and its sustainability are unclear.
Project description:Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.
Project description:Until recently, governmental organizations played a dominant and decisive role in natural resource management. However, an increasing number of studies indicate that this dominant role is developing towards a more facilitating role as equal partner to improve efficiency and create a leaner state. This approach is characterized by complex collaborative relationships between various actors and sectors on multiple levels. To understand this complexity in the field of environmental management, we conducted a social network analysis of floodplain management in the Dutch Rhine delta. We charted the current interorganizational relationships between 43 organizations involved in flood protection (blue network) and nature management (green network) and explored the consequences of abolishing the central actor in these networks. The discontinuation of this actor will decrease the connectedness of actors within the blue and green network and may therefore have a large impact on the exchange of ideas and decision-making processes. Furthermore, our research shows the dependence of non-governmental actors on the main governmental organizations. It seems that the Dutch governmental organizations still have a dominant and controlling role in floodplain management. This challenges the alleged shift from a dominant government towards collaborative governance and calls for detailed analysis of actual governance.
Project description:BACKGROUND:The need for organisational development in primary care has increased as it is accepted as a means of curbing rising costs and responding to demographic transitions. It is only within such inter-organisational networks that small-scale practices can offer treatment to complex patients and continuity of care. The aim of this paper is to explore, through the experience of professionals and patients, whether, and how, project management and network governance can improve the outcomes of projects which promote inter-organisational collaboration in primary care. METHODS:This paper describes a study of projects aimed at improving inter-organisational collaboration in Dutch primary care. The projects' success in project management and network governance was monitored by interviewing project leaders and board members on the one hand, and improvement in the collaboration by surveying professionals and patients on the other. Both qualitative and quantitative methods were applied to assess the projects. These were analysed, finally, using multi-level models in order to account for the variation in the projects, professionals and patients. RESULTS:Successful network governance was associated positively with the professionals' satisfaction with the collaboration; but not with improvements in the quality of care as experienced by patients. Neither patients nor professionals perceived successful project management as associated with the outcomes of the collaboration projects. CONCLUSIONS:This study shows that network governance in particular makes a difference to the outcomes of inter-organisational collaboration in primary care. However, project management is not a predictor for successful inter-organisational collaboration in primary care.
Project description:Highlights • The OIS concept can be used to analyse multi-actor co-innovation partnerships.• Co-innovation partnerships in agriculture and forestry occur in many forms.• Often based on existing networks, they mobilise complementary forms of knowledge.• ‘Outreach’ practices to foster dialogue with a ‘larger periphery’ are commonly used.• The ‘enabling environment’ affects the performance of the co-innovation partnership. Innovation rests not only on discovery but also on cooperation and interactive learning. In agriculture, forestry and related sectors, multi-actor partnerships for ‘co-innovation’ occur in many forms, from international projects to informal ‘actor configurations’. Common attributes are that they include actors with ‘complementary forms of knowledge’ who collaborate in an innovation process, engage with a ‘larger periphery’ of stakeholders in the Agricultural Knowledge and Innovation System (AKIS) and are shaped by institutions. Using desk research and interviews, we reviewed, according to the Organisational Innovation Systems framework, the performance of 200 co-innovation partnerships from across Europe, selected for their involvement of various actors ‘all along the process’. Many of the reviewed partnerships were composed of actors that had previously worked together and most interviewees believed that no relevant actors had been excluded. In almost all cases, project targets and objectives were co-designed to a great or some extent, and the mechanisms applied to foster knowledge sharing between partners were considered to be very effective. Great importance was attached to communication beyond the partnership, not simply for dissemination but also for dialogue, and most interviewees evaluated the communication/outreach performance of their partnership very highly. Most partnerships received external funding, most did not use innovation brokers during the proposal writing process and two thirds had access to information they needed. We discuss the implications of these findings and question whether the AKIS concept as currently interpreted by many policy makers can adequately account for the regional differences encountered by co-innovation partnerships across Europe.
Project description:This paper presents the Actor in 4 dimensions (A4D) model as a complementary tool to the Social-ecological systems framework (SESF) in order to better integrate individual and groups' representations into local environmental governance analysis. As the A4D is based on actors' representations of their social-ecological system (SES) and of its governance, it mainly informs the Actors subsystem of the SESF, even if it can also give useful insights for other framework's sub-systems. We define the SESF actor's sub-tiers and the corresponding A4D indicators and highlight the complementarity between both approaches in order to operationalize the SESF. This parallel is exemplified by the case of Maio island (a small-scale fishing community in Cape Verde). Our comparison also highlights other assets of the A4D methodology for the advancement of environmental governance's study. •The A4D allows actors' participation and discussion on the SES and analyses common and divergent discourses and values between actors.•The A4D points to power relations by integrating strong, weak and absent actors in its analysis.•By highlighting subjective and reflexive elements, the A4D complements the SESF in their common attempt to analyze SES.
Project description:BACKGROUND:Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS:Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS:A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS:The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.
Project description:The Hennovation project, an EU H2020 funded thematic network, aimed to explore the potential value of practice-led multi-actor innovation networks within the laying hen industry. The project proposed that husbandry solutions can be practice-led and effectively supported to achieve durable gains in sustainability and animal welfare. It encouraged a move away from the traditional model of science providing solutions for practice, towards a collaborative approach where expertise from science and practice were equally valued. During the 32-month project, the team facilitated 19 multi-actor networks in five countries through six critical steps in the innovation process: problem identification, generation of ideas, planning, small scale trials, implementation and sharing with others. The networks included farmers, processors, veterinarians, technical advisors, market representatives and scientists. The interaction between the farmers and the other network actors, including scientists, was essential for farmer innovation. New relationships emerged between the scientists and farmers, based on experimental learning and the co-production of knowledge for improving laying hen welfare. The project demonstrated that a practice-led approach can be a major stimulus for innovation with several networks generating novel ideas and testing them in their commercial context. The Hennovation innovation networks not only contributed to bridging the science-practice gap by application of existing scientific solutions in practice but more so by jointly finding new solutions. Successful multi-actor, practice-led innovation networks appeared to depend upon the following key factors: active participation from relevant actors, professional facilitation, moderate resource support and access to relevant expertise. Farmers and processors involved in the project were often very enthusiastic about the approach, committing significant time to the network's activities. It is suggested that the agricultural research community and funding agencies should place greater value on practice-led multi-actor innovation networks alongside technology and advisor focused initiatives to improve animal welfare and embed best practices.
Project description:BACKGROUND: In rural health and other health service development contexts, there is frustration with a reliance on pilot projects as a means of informing policy and service innovation. There is also an emerging recognition that existing research methods do not draw lessons from the failed sustainability that characterises many of these pilots and demonstration projects. DISCUSSION: This article describes critical aspects of the methodology of a successful collaborative, multi-method, systematic synthesis of exemplary primary health care pilot projects in rural and remote Australia, which synthesised principles from a number of pilot projects to inform policy makers and planners. Hallmarks of the method were: the nature of the source materials for the research, the subsequent research engagement with the actual pilot projects, the extent of collaboration throughout the study with end-users from policy and planning arenas, and the attention to procedural quality. SUMMARY: The methodology, while time consuming, has resulted in applied, policy-relevant findings, and evidence of consideration by policy-makers.
Project description:INTRODUCTION:Simulation is a powerful tool for training and evaluating clinicians. However, few studies have examined the consistency of actor performances during simulation based medical education (SBME). The Simulated Communication with ICU Proxies trial (ClinicalTrials.gov NCT02721810) used simulation to evaluate the effect of a behavioral intervention on physician communication. The purpose of this secondary analysis of data generated by the quality assurance team during the trial was to assess how quality assurance monitoring procedures impacted rates of actor errors during simulations. METHODS:The trial used rigorous quality assurance to train actors, evaluate performances, and ensure the intervention was delivered within a standardized environment. The quality assurance team evaluated video recordings and documented errors. Actors received both timely, formative feedback and participated in group feedback sessions. RESULTS:Error rates varied significantly across three actors (H(2) = 8.22, p = 0.02). In adjusted analyses, there was a decrease in the incidence of actor error over time, and errors decreased sharply after the first group feedback session (Incidence Rate Ratio = 0.25, 95% confidence interval 0.14-0.42). CONCLUSIONS:Rigorous quality assurance procedures may help ensure consistent actor performances during SBME.