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From 2014 to 2021, Tunisian government had a firm will to implement a progressive decentralization of welfare state governance, as outlined in its democratic Constitution. The Tunisian public healthcare system was selected as a pilot sector for experimenting with decentralization to reduce disparities in access to and quality of health services across different regions. This paper aimed to formulate an effective strategy for healthcare system decentralization in low- and middle-income countries, drawing on past experiences of its implementation. Country case study resulted the best methodology to achieve that goal. Top heath management, figured out by regional hospitals' directors, was consulted to describe the technical, managerial and cultural "heritage" collected during the development process of the decentralization reform in public healthcare system in Tunisia. Findings revealed the Tunisian healthcare system decentralization should be, in first instance, the establishment of different decentralization paths according with regional pre-conditions, and then, of common protocols and procedures at national level for overcoming current differences between Tunisian territories. Decentralization process must be tailored to the specific needs of the regional Tunisian contexts to be effective but with a national control on that. Drawing from the Tunisian experience, proposed suggestions were valuable for the definition of an effective national healthcare system decentralization reform strategy more generally in low- and middle- income countries, especially in Middle East and North Africa region's countries. Due to the common recent democratic history and welfare state approach, these countries could use this "heritage" to apply effective decentralizing reform strategies for reducing territorial inequalities, in this case territorial health inequalities. [ABSTRACT FROM AUTHOR]

Background: The burden of chronic non-communicable diseases (NCDs) is a growing public health concern. The availability of cost-of-illness data, particularly public healthcare costs for NCDs, is limited in Sub-Saharan Africa (SSA), yet such data evidence is needed for policy action. Objective: The objective of this study was to estimate the economic burden of type 2 diabetes (T2D) on Kenya's public healthcare system in 2021 and project costs for 2045. Methods: This was a cost-of-illness study using the prevalence-based bottom-up costing approach to estimate the economic burden of T2D in the year 2021. We further conducted projections on the estimated costs for the year 2045. The costs were estimated corresponding to the care, treatment, and management of diabetes and some diabetes complications based on the primary data collected from six healthcare facilities in Nairobi and secondary costing data from previous costing studies in low and middle-income countries (LMICs). The data capture and costing analysis were done in Microsoft Excel 16, and sensitivity analysis was conducted on all the parameters to estimate the cost changes. Results: The total cost of managing T2D for the healthcare system in Kenya was estimated to be US$ 635 million (KES 74,521 million) in 2021. This was an increase of US$ 2 million (KES 197 million) considering the screening costs of undiagnosed T2D in the country. The major cost driver representing 59% of the overall costs was attributed to T2D complications, with nephropathy having the highest estimated costs of care and management (US$ 332 million (KES 36, 457 million). The total cost for T2D was projected to rise to US$ 1.6 billion (KES 177 billion) in 2045. Conclusion: This study shows that T2D imposes a huge burden on Kenya's healthcare system. There is a need for government and societal action to develop and implement policies that prevent T2D, and appropriately plan care for those diagnosed with T2D. [ABSTRACT FROM AUTHOR]

Background: This study aims to propose a semi-automatic method for monitoring the waiting times of follow-up examinations within the National Health System (NHS) in Italy, which is currently not possible to due the absence of the necessary structured information in the official databases. Methods: A Natural Language Processing (NLP) based pipeline has been developed to extract the waiting time information from the text of referrals for follow-up examinations in the Lombardy Region. A manually annotated dataset of 10 000 referrals has been used to develop the pipeline and another manually annotated dataset of 10 000 referrals has been used to test its performance. Subsequently, the pipeline has been used to analyze all 12 million referrals prescribed in 2021 and performed by May 2022 in the Lombardy Region. Results: The NLP-based pipeline exhibited high precision (0.999) and recall (0.973) in identifying waiting time information from referrals' texts, with high accuracy in normalization (0.948-0.998). The overall reporting of timing indications in referrals' texts for follow-up examinations was low (2%), showing notable variations across medical disciplines and types of prescribing physicians. Among the referrals reporting waiting times, 16% experienced delays (average delay = 19 days, standard deviation = 34 days), with significant differences observed across medical disciplines and geographical areas. Conclusions: The use of NLP proved to be a valuable tool for assessing waiting times in follow-up examinations, which are particularly critical for the NHS due to the significant impact of chronic diseases, where follow-up exams are pivotal. Health authorities can exploit this tool to monitor the quality of NHS services and optimize resource allocation. [ABSTRACT FROM AUTHOR]

Pakistan is a developing country under severe pressure to provide efficient and effective healthcare to its population owing to inadequate financial and human resources and limited management capabilities. This study explores the role and practice of human resource management (HRM) in three Pakistani public teaching tertiary hospitals. We interviewed leaders and managers in these hospitals to gain a better understanding of the context, challenges and opportunities for HRM. Our thematic analysis revealed that a lack of specialised human resource (HR) departments staffed by HR professionals in these hospitals negatively impacted HRM functions and practices and created confusion and complexity. This was exacerbated by centralised decision‐making at the provincial level and limited managerial autonomy over key HR issues. However, despite the enormous challenges facing the Pakistani public healthcare sector the informants believed that HR could play a significant role in influencing employees' attitudes and behaviours to provide quality healthcare to more patients. [ABSTRACT FROM AUTHOR]

Background: There is substantial interest in leveraging digital health technology to support hypertension management in low- and middle-income countries such as India. The potential for healthcare infrastructure and broader context to support such initiatives in India has not been examined. We evaluated existing healthcare infrastructure to support digital health interventions and examined epidemiologic, socioeconomic, and geographical contextual correlates of healthcare infrastructure in 544 districts covering 29 states and union territories across India.Methods: The study was a cross-sectional analysis of India's Fourth District Level Household and Facility Survey (DLHS-4; 2012-2014), the most up-to-date nationally representative district-level healthcare infrastructure data. Facilities were the unit of analysis, and analyses accounted for clustering within states. The main outcome was healthcare system infrastructural context to implement hypertension management programs. Domains included diagnostics (functional BP instrument), medications (anti-hypertensive medication in stock), essential clinical staff (e.g., staff nurse, medical officer, pharmacist), and IT specific infrastructure (regular power supply, internet connection, computer availability). Descriptive analysis was conducted for infrastructure indicators based on the Indian Public Health Standards, and logistic regression was conducted to estimate the association between epidemiologic and geographical context (exposures) and the composite measure of healthcare system.Results: Data from 32,215 government facilities were analyzed. Among lowest-tier subcenters, 30% had some IT infrastructure, while at the highest-tier district hospitals, 92% possessed IT infrastructure. At mid-tier primary health centres and community health centres, IT infrastructure availability was 28 and 51%, respectively. For all but sub-centres, the availability of essential staff was lower than the availability of IT infrastructure. For all but district hospitals, higher levels of blood pressure, body mass index, and urban residents were correlated with more favorable infrastructure. By region, districts in Western India tended towards having the best prepared health facilities.Conclusions: IT infrastructure to support digital health interventions is more frequently lacking at lower and mid-tier healthcare facilities compared with apex facilities in India. Gaps were generally larger for staffing than physical infrastructure, suggesting that beyond IT infrastructure, shortages in essential staff impose significant constraints to the adoption of digital health interventions. These data provide early benchmarks for state- and district-level planning. [ABSTRACT FROM AUTHOR]

Parents with physical disabilities face challenges in their relationships with perinatal and early childhood services. This paper aims to better understand the experiences and needs of parents with physical disabilities regarding perinatal and early childhood services in the public healthcare system in Quebec, Canada. We also describe how adequately current services meet the needs of these individuals. Thirteen interviews were conducted with ten mothers and three fathers with physical disabilities. Results indicate challenges in various phases of the parental experience: the decision to have a child and conception; pregnancy follow-up; delivery; postnatal care and parental practices. The main issues reported by participants involved access to information and professionals' attitudes. Participants also emphasized the importance of keeping control over the parenting process. As there is a growing interest in the questions surrounding parents with disabilities in Quebec, this study can provide useful insights for community organizations and political stakeholders. Parents with physical disabilities report needs at various stages in their parental experience: the decision to have a child and conception, pregnancy follow-up, delivery, postnatal care and parental practices. Parents ask to be provided with appropriate information and to be part of the decision-making process during the delivery and with regards to child care. Professional services may fail to address parents' needs. Inclusive services would provide support for parents with physical disabilities surrounding both the medical, and the social aspects of their parenthood. Services of this nature could lead to positive outcomes in their parental practices. [ABSTRACT FROM AUTHOR]

Objectives: The COVID-19 pandemic has been declared a public health emergency of international concern. Singapore was one of the first countries to identify imported cases and also experience a second wave of outbreaks. A slew of measures enacted by the government to 'flatten the curve' has directly impacted upon the way we practice. Study design/Methods: This article describes steps enacted by our department to ensure sustainability of our ophthalmic practice. Results: We share considerations at various time points and policies implemented in a stepwise approach in response to the worsening community situation. We further discuss our phased approach towards reinstating our services safely and effectively for patients and staff in a markedly different practice climate. Conclusions: The COVID-19 pandemic has markedly upended the way we practice medicine. Reflecting on the ideal measures required for such occurrences in the future will empower practices with the ability to respond effectively to future outbreaks. [ABSTRACT FROM AUTHOR]

This study investigated the use of public and private healthcare systems separately and interactively to find solutions to various problems the healthcare sector has faced including waiting time, cost, and quality of service. Patients, private and public healthcare providers, funders, and governments that make rules about healthcare were defined as components of healthcare systems in this study. Mathematical optimization models were developed by deriving scenarios to balance the components of healthcare systems. In addition to derivation of scenarios related to types of healthcare systems and decision variables, including copayment, treatment cost, reimbursement, and premium, numerical studies for the healthcare components were performed to determine which healthcare systems were useful. The minimum fee payable by patients for the easy access to healthcare schemes was calculated. While there was no remarkable change in the waiting time of the patients in the private healthcare system, the waiting time were reduced by 48.70% in the public healthcare system among the findings. The amount of reimbursement decreased significantly as a result of the interaction of healthcare systems. By reducing the amount of co-payment to the amount charged by the public healthcare system, it has been ensured that private healthcare providers treat more patients. Based on computational analyses, because of the agreements provided between the components, we have advocated that public and private healthcare systems must be unified to provide greater benefits for all the components of healthcare. [ABSTRACT FROM AUTHOR]

Inappropriate antimicrobial use favours the spread of resistance, and multidrug-resistant microorganisms (MDR) are currently of major concern. Antimicrobial stewardship programmes (ASPs) are essential for improving antibiotic use in hospitals. However, their impact on entire healthcare systems has not been thoroughly assessed. Our objective was to provide the results of an institutionally supported ASP involving 31 public hospitals in Andalusia, Spain. We designed an ecologic time-series study from 1 January 2014 to 31 December 2017. Quarterly, data on indicators were collected prospectively, and feedback reports were provided. PIRASOA is an ongoing clinically based quality-improvement programme whose key intervention is the educational interview, regular peer-to-peer interventions between advisors and prescribers to reinforce the appropriate use of antibiotics. Seventy-two indicators were monitored to measure prescribing quality (inappropriate treatments), antimicrobial consumption (defined daily doses per 1000 occupied bed-days), incidence density of MDR per 1000 occupied bed-days and crude mortality rate associated with bloodstream infections. We used Joinpoint regression software to analyse the trends. The quality of antimicrobial prescribing improved markedly, and the inappropriate treatment rate was significantly lower, with quarterly percentage change (QPC) = −3.0%, p < 0.001. Total antimicrobial consumption decreased (QPC = −0.9%, p < 0.001), specifically carbapenems, amoxicillin/clavulanic acid, quinolones and antifungal agents, whereas antipseudomonal cephalosporin use increased. While the incidence of MDR showed a sustained decreasing trend (QPC = −1.8%; p 0.002), the mortality of patients with bloodstream infections remained stable (QPC = −0.2%, p 0.605). To date, the PIRASOA programme has succeeded in optimizing the use of antimicrobial agents and has had a positive ecologic result on bacterial resistance at level of an entire healthcare system. [ABSTRACT FROM AUTHOR]

In a number of countries, unemployment rates for people with psychiatric disabilities are much higher than in the general population. On the one hand, the expenses for mental health reach 3.5% of the total public health and social services budget in Québec. On the other hand, social firms (SFs) receive government subsidies. The objective was to compare public healthcare expenses for people with psychiatric disabilities who work in SFs with those associated with people with a similar condition who are looking for a job in the competitive labour market. This study followed a retrospective comparative design and considered two groups, namely: 122 employees working in SFs and 64 individuals participating in a supported employment program as job‐seekers. Two complementary datasets were used: a self‐report questionnaire and public healthcare databases. The cost analysis was performed from the perspective of the public healthcare system and included outpatient visit fees to physicians, outpatient visits to health professionals other than physicians in public healthcare centres, inpatient expenses due to hospitalisations, emergency room visits and amounts reimbursed to patients for medication. Regression analyses using generalised linear models with a gamma distribution and log link were used. Our results revealed that when controlling for sociodemographic variables (gender, age, marital status, education, physical disability), global health (EuroQol EQ‐5D‐5L), the severity of psychiatric symptoms (18‐item Brief Symptom Inventory) and self‐declared primary mental health diagnosis, annual healthcare costs paid by the public insurance system were between $1,924 and $3,912 lower for people working in SFs than for the comparison group. An explanatory hypothesis is that working in SFs could act as a substitute for medical treatments such as outpatient visits and medication use. There might be a form of compensation between supporting SFs and financing the public healthcare system, which provides valuable insights for public decision‐making. [ABSTRACT FROM AUTHOR]

Aging is associated with a higher prevalence of chronic diseases, which can be minimized by a healthy and active lifestyle. The aim of this study was to analyze the occurrence of chronic diseases in Public Healthcare System patients, according to the level of physical activity. In total 542 patients, 29.7% (n = 161) male and 70.3% (n = 381) female, were evaluated in two Basic Health Units. The level of physical activity, presence of diseases and economic condition were verified through the use of questionnaires. Obesity was assessed using the Body Mass index (in kg/m²). Cardiac arrhythmia diseases (p = 0.033), arthritis/osteoarthritis (p = 0.010) and a herniated disc (p = 0.006) were associated with the level of physical activity. It is concluded that the level of physical activity is associated with the occurrence of chronic diseases in patients over the age of 50 years served by the Public Healthcare System of Presidente Prudente/SP city. [ABSTRACT FROM AUTHOR]