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In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n  = 114), Web of Science (n  = 171), Google Scholar (n  = 153) and Scopus (n  = 52)] and used snowballing (n  = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care. [ABSTRACT FROM AUTHOR]

Problem High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very Iow incomes. Their impact on access to health services must be carefully examined. Approach Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers. Local setting Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes. Relevant changes HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care. Lessons learned HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully. Obstacles a l'acces aux services medicaux et fonction d'achat des fonds de financement de la sante: enseignements provenant du Cambodge Problematique Le montant eleve des depenses et des participations financieres a la charge des usagers et l'absence de financement des exemptions pour ces depenses limitent l'acces aux services de sante pour la population pauvre. Des Fonds de financement de la sante (Health Equity Fonds, HEF) sont apparus au Cambodge en tant que mecanismes strategiques d'achat servant a financer ces exemptions et a reduire la charge liee aux soins medicaux pour les personnes a tres faibles revenus. Leur impact sur l'acces aux services de sante doit etre examine de maniere approfondie. Demarche Les elements provenant du terrain sont examines pour identifier les obstacles a l'acces aux services, analyser le role joue par les fonds HEF et determiner comment ils aplanissent ces obstacles. Contexte local Deux tiers des depenses de sante totales correspondent a des debours a la charge des patients au moment des soins, resultant principalement de l'automedication et du recours aux services de sante prives. Si le secteur prive est a l'origine de la plupart des depenses de sante a la charge des patients, les participations financieres a la charge des usagers restent un obstacle a l'acces aux services publics, pour les personnes tres pauvres. Modifications pertinentes Les fonds HEF ont amene de nouveaux patients dans les etablissements de sante publics, repondant ainsi a une partie des besoins en soins medicaux insatisfaits. On n'a observe aucune stigmatisation a l'egard des patients soignes grace aux fonds HEF, mais nombre d'entre eux ont du encore emprunter de l'argent pour acceder aux soins. Enseignements tires Les fonds HEF constituent un mecanisme d'achat dans le cadre du systeme de sante cambodgien. Ces fonds exercent quatre roles essentiels : financement, soutien aux communautes, assurance de la qualite et dialogue politique. Ces roles repondent aux principaux obstacles a l'acces aux services de sante. L'impact des fonds est maximal lorsqu'un dispositif impliquant une tierce partie est en place. Pour que les HEF exercent pleinement et activement leur fonction de mecanisme d'acquisition, un environnement politique solide et favorable est necessaire. Problema La elevada cuantia de los pagos directos y los honorarios pagados por los usuarios y las exenciones de cobertura limitan el acceso de los pobres a los servicios de salud. Los fondos de inversion en acciones para la salud (FIAS) surgieron en Camboya como un mecanismo de compra estrategico utilizado para financiar esos pagos no reembotsados y reducir el gasto sanitario que deben costear las personas con ingresos muy bajos. Es necesario estudiar detenidamente el efecto de esos instrumentos en el acceso a los servicios de salud. Enfoque Se analizan los datos obtenidos sobre el terreno para describir las barreras al acceso, analizar la funcion desempenada por los FIAS y determinar como abordan estos dichas barreras. Contexto local Las dos terceras partes del gasto sanitario total corresponden a pagos directos realizados por los pacientes en el momento de recibir atencion, principalmente cuando se automedican o acuden a la medicina privada. Si bien el sector privado absorbe la mayor parte de los pagos directos, los honorarios cobrados a los usuarios siguen obstaculizando tambien el acceso a los servicios publicos por parte de las personas con muy bajos ingresos. Cambios destacables Los FIAS favorecieron la llegada de nuevos pacientes a los centros publicos y permitieron asi cubrir algunas necesidades sanitarias que no estaban atendidas. No se observaron problemas de estigmatizacion de los pacientes beneficiados por los FIAS, pero muchos de ellos aun tuvieron que pedir dinero prestado para acceder a la atencion de salud. Ensenanzas extraidas Los FIAS son un mecanismo de compra empleado por el sistema de atencion de salud de Camboya que cumple cuatro funciones esenciales: financiacion, apoyo comunitario, garantia de la calidad y dialogo normativo. Dichas funciones corresponden a las barreras principales al acceso a los servicios de salud. EI impacto Iogrado es maximo cuando entra en juego un acuerdo con terceros. Se requiere un entorno normativo solido y propicio para que los FIAS revelen todo su potencial como instrumento activo de adquisicion., Introduction The Cambodian public health-care system is financed through a national budget, donor funding and user fees. However, two-thirds of total health expenditure consists of patients' out-of-pocket spending at the [...]

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure, explicit and functional) and "soft" (de facto, tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity. [ABSTRACT FROM AUTHOR]

Abstract Background Road traffic injuries (RTIs) are a major public health problem, requiring concerted efforts both for their prevention and a reduction of their consequences. Timely arrival of the Emergency Medical Service (EMS) at the crash scene followed by speedy victim transportation by trained personnel may reduce the RTIs' consequences. The first 60 minutes after injury occurrence - referred to as the "golden hour"- are vital for the saving of lives. The present study was designed to estimate the average of various time intervals occurring during the pre-hospital care process and to examine the differences between these time intervals as regards RTIs on urban and interurban roads. Method A retrospective cross-sectional study was designed and various time intervals in relation to pre-hospital care of RTIs identified in the ambulance dispatch centre in Urmia, Iran from 20 March 2005 to 20 March 2007. All cases which resulted in ambulance dispatches were reviewed and those that had complete data on time intervals were analyzed. Results In total, the cases of 2027 RTI victims were analysed. Of these, 61.5 % of the subjects were injured in city areas. The mean response time for city locations was 5.0 minutes, compared with 10.6 minutes for interurban road locations. The mean on-scene time on the interurban roads was longer than on city roads (9.2 vs. 6.1 minutes, p < 0.001). Mean transport times from the scene to the hospital were also significantly longer for interurban incidents (17.1 vs. 6.3 minutes, p < 0.001). The mean of total pre-hospital time was 37.2 (+/-17.2) minutes with a median of 32.0. Overall, 72.5% of the response interval time was less than eight minutes. Conclusion The response, transport and total time intervals among EMS responding to RTI incidents were longer for interurban roads, compared to the city areas. More research should take place on needs-to and access-for EMS on city and interurban roads. The notification interval seems to be a hidden part of the post-crash events and indirectly affects the "golden hour" for victim management and it needs to be measured through the establishment of the surveillance systems.

In many low-and middle-income countries, health systems decision-makers are facing a host of new challenges and competing priorities. They must not only plan and implement as they used to do but also deal with discontented citizens and health staff, be responsive and accountable. This contributes to create new political hazards susceptible to disrupt the whole execution of health plans. The starting point of this article is the observation by the first author of the limitations of the building-blocks framework to structure decision-making as for strengthening of the Moroccan health system. The management of a health system is affected by different temporalities, the recognition of which allows a more realistic analysis of the obstacles and successes of health system strengthening approaches. Inspired by practice and enriched thanks a consultation of the literature, our analytical framework revolves around five dynamics: the services dynamic, the programming dynamic, the political dynamic, the reform dynamic and the capacity-building dynamic. These five dynamics are differentiated by their temporalities, their profile, the role of their actors and the nature of their activities. The Moroccan experience suggests that it is possible to strengthen health systems by opening up the analysis of temporalities, which affects both decision-making processes and the dynamics of functioning of health systems. [ABSTRACT FROM AUTHOR]