plueme/wizJson huggingface dataset:
location: nan, 'Global 
year: 2014 source: BMC 
title: Developing recommendations to improve the quality of diabetes care in Ireland: a policy analysis 
abstract:BackgroundIn 2006, the Health Service Executive (HSE) in Ireland established an Expert Advisory Group (EAG) for Diabetes, to act as its main source of operational policy and strategic advice for this chronic condition. The process was heralded as the starting point for the development of formal chronic disease management programmes. Although recommendations were published in 2008, implementation did not proceed as expected. Our aim was to examine the development of recommendations by the EAG as an instrumental case study of the policy formulation process, in the context of a health system undergoing organisational and financial upheaval.MethodsThis study uses Kingdon’s Multiple Streams Theory to examine the evolution of the EAG recommendations. Semi-structured interviews were conducted with a purposive sample of 15 stakeholders from the advisory group. Interview data were supplemented with documentary analysis of published and unpublished documents. Thematic analysis was guided by the propositions of the Kingdon model.ResultsIn the problem stream, the prioritisation of diabetes within the policy arena was a gradual process resulting from an accumulation of evidence, international comparison, and experience. The policy stream was bolstered by group consensus rather than complete agreement on the best way to manage the condition. The EAG assumed the politics stream was also on course to converge with the other streams, as the group was established by the HSE, which had the remit for policy implementation. However, the politics stream did not converge due to waning support from health service management and changes to the organisational structure and financial capacity of the health system. These changes trumped the EAG process and the policy window remained closed, stalling implementation.ConclusionsOur results reflect the dynamic nature of the policy process and the importance of timing. The results highlight the limits of rational policy making in the face of organisational and fiscal upheaval. Diabetes care is coming on to the agenda again in Ireland under the National Clinical Care Programme. This may represent the opening of a new policy window for diabetes services, the challenge will be maintaining momentum and interest in the absence of dedicated resources.
location: nan, 'Global 
year: 2014 source: BMC 
title: The making of nursing practice Law in Lebanon: a policy analysis case study 
abstract:BackgroundEvidence-informed decisions can strengthen health systems, improve health, and reduce health inequities. Despite the Beijing, Montreux, and Bamako calls for action, literature shows that research evidence is underemployed in policymaking, especially in the East Mediterranean region (EMR). Selecting the draft nursing practice law as a case study, this policy analysis exercise aims at generating in-depth insights on the public policymaking process, identifying the factors that influence policymaking and assessing to what extent evidence is used in this process.MethodsThis study utilized a qualitative research design using a case study approach and was conducted in two phases: data collection and analysis, and validation. In the first phase, data was collected through key informant interviews that covered 17 stakeholders. In the second phase, a panel discussion was organized to validate the findings, identify any gaps, and gain insights and feedback of the panelists. Thematic analysis was conducted and guided by the Walt & Gilson’s “Policy Triangle Framework” as themes were categorized into content, actors, process, and context.ResultsFindings shed light on the complex nature of health policymaking and the unstructured approach of decision making. This study uncovered the barriers that hindered the progress of the draft nursing law and the main barriers against the use of evidence in policymaking. Findings also uncovered the risk involved in the use of international recommendations without the involvement of stakeholders and without accounting for contextual factors and implementation barriers. Findings were interpreted within the context of the Lebanese political environment and the power play between stakeholders, taking into account equity considerations.ConclusionsThis policy analysis exercise presents findings that are helpful for policymakers and all other stakeholders and can feed into revising the draft nursing law to reach an effective alternative that is feasible in Lebanon. Our findings are relevant in local and regional context as policymakers and other stakeholders can benefit from this experience when drafting laws and at the global context, as international organizations can consider this case study when developing global guidance and recommendations.
location: nan, 'Global 
year: 2014 source: BMC 
title: The application of systems thinking in health: why use systems thinking? 
abstract:This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful. The paper reviews the origins of systems thinking, describing a range of the theories, methods, and tools. A common thread is the idea that the behavior of systems is governed by common principles that can be discovered and expressed. They each address problems of complexity, which is a frequent challenge in global health. The different methods and tools are suited to different types of inquiry and involve both qualitative and quantitative techniques. The paper concludes by emphasizing that explicit models used in systems thinking provide new opportunities to understand and continuously test and revise our understanding of the nature of things, including how to intervene to improve people’s health.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India 
abstract:BackgroundGoverning immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage.MethodsWe used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage.ResultsWe identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena.ConclusionsAs illustrated in this study, a complex adaptive system lens helps to uncover the ‘real’ drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: analysing the contextual and social network factors influencing the use of sustainability indicators in a health system – a comparative study in Nepal and Somaliland 
abstract:BackgroundHealth systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data.MethodsUsing the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified.ResultsDifferences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system’s two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil.ConclusionsThe structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: sustainability evaluation as learning and sense-making in a complex urban health system in Northern Bangladesh 
abstract:BackgroundStarting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services. A mid-term evaluation identified sustainability challenges. Concern relied on systems thinking implicitly to re-prioritize sustainability, but stakeholders also required a method, an explicit set of processes, to guide their decisions and choices during and after the project.MethodsConcern chose the Sustainability Framework method to generate creative thinking from stakeholders, create a common vision, and monitor progress. The Framework is based on participatory and iterative steps: defining (mapping) the local system and articulating a long-term vision, describing scenarios for achieving the vision, defining the elements of the model, and selecting corresponding indicators, setting and executing an assessment plan,, and repeated stakeholder engagement in analysis and decisions . Formal assessments took place up to 5 years post-project (2009).ResultsStrategic choices for the project were guided by articulating a collective vision for sustainable health, mapping the system of actors required to effect and sustain change, and defining different components of analysis. Municipal authorities oriented health teams toward equity-oriented service delivery efforts, strengthening of the functionality of Ward Health Committees, resource leveraging between municipalities and the Ministry of Health, and mitigation of contextual risks. Regular reference to a vision (and set of metrics (population health, organizational and community capacity) mitigated political factors. Key structures and processes were maintained following elections and political changes. Post-project achievements included the maintenance or improvement 5 years post-project (2009) in 9 of the 11 health indicator gains realized during the project (1999–2004). Some elements of performance and capacity weakened, but reductions in the equity gap achieved during the project were largely maintained post-project.ConclusionsSustainability is dynamic and results from local systems processes, which can be strengthened through both implicit and explicit systems thinking steps applied with constancy of purpose.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts 
abstract:BackgroundThis paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals.MethodsThe study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities.ResultsThe study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development.ConclusionsThis history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan 
abstract:BackgroundUsing measles and tuberculosis as case examples, with a systems thinking approach, this study examines the human advice-seeking behavior of primary health care (PHC) physicians in a rural district of Pakistan. This study analyzes the degree to which the existing PHC system supports their access to human advice, and explores in what ways this system might be strengthened to better meet provider needs.MethodsThe study was conducted in a rural district of Pakistan and, with a cross-sectional study design, it employed a range of research methods, namely extensive document review for mapping existing information systems, social network analysis of physicians’ advice-seeking practice, and key stakeholder interviews for an in-depth understanding of the experience of physicians. Illustrations were prepared for information flow mechanism, sociographs were generated for analyzing social networks, and content analysis of qualitative findings was carried out for in-depth interpretation of underlying meanings.ResultsThe findings of this study reveal that non-availability of competent supervisory staff, a focus on improving performance indicators rather than clinical guidance, and a lack of a functional referral system have collectively created an environment in which PHC physicians have developed their own strategies to overcome these constraints. They are well aware of the human expertise available within and outside the district. However, their advice-seeking behavior was dependent upon existence of informal social interaction with the senior specialists. Despite the limitations of the system, the physicians proactively used their professional linkages to seek advice and also to refer patients to the referral center based on their experience and the facilities that they trusted.ConclusionsThe absence of functional referral systems, limited effective linkages between PHC and higher levels of care, and a focus on programmatic targets rather than clinical care have each contributed to the isolation of physicians and reactive information seeking behavior. The study findings underscore the need for a functional information system comprising context sensitive knowledge management and translation opportunities for physicians working in PHC centers. Such an information system needs to link people and resources in ways that transcend geography and discipline, and that builds on existing expertise, interpersonal relationships, and trust.
location: nan, 'Global 
year: 2014 source: BMC 
title: Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India 
abstract:BackgroundHealth systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations. However, such interventions often work in some settings and not in others. Local health systems could be visualised as complex adaptive systems that respond variously to inputs of capacity building interventions, depending on their local conditions and several individual, institutional, and environmental factors. We aim at demonstrating how the realist evaluation approach advances complex systems thinking in healthcare evaluation by applying the approach to understand organisational change within local health systems in the Tumkur district of southern India.MethodsWe collected data on several input, process, and outcome measures of performance of the talukas (administrative sub-units of the district) and explore the interplay between the individual, institutional, and contextual factors in contributing to the outcomes using qualitative data (interview transcripts and observation notes) and quantitative measures of commitment, self-efficacy, and supervision style.ResultsThe talukas of Tumkur district responded differently to the intervention. Their responses can be explained by the interactions between several individual, institutional, and environmental factors. In a taluka with committed staff and a positive intention to make changes, the intervention worked through aligning with existing opportunities from the decentralisation process to improve performance. However, commitment towards the organisation was neither crucial nor sufficient. Committed staff in two other talukas were unable to actualise their intentions to improve organisational performance. In yet another taluka, the leadership was able to compensate for the lack of commitment.ConclusionsCapacity building of local health systems could work through aligning or countering existing relationships between internal (individual and organisational) and external (policy and socio-political environment) attributes of the organisation. At the design and implementation stage, intervention planners need to identify opportunities for such triggering alignments. Local health systems may differ in their internal configuration and hence capacity building programmes need to accommodate possibilities for change through different pathways. By a process of formulating and testing hypotheses, making critical comparisons, discovering empirical patterns, and monitoring their scope and extent, a realist evaluation enables a comprehensive assessment of system-wide change in health systems.
location: nan, 'Global 
year: 2014 source: BMC 
title: The accountability for reasonableness approach to guide priority setting in health systems within limited resources – findings from action research at district level in Kenya, Tanzania, and Zambia 
abstract:BackgroundPriority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT).MethodsThis intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods.ResultsThe values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes.ConclusionsDistrict stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.