Search

Highly sensitized (HS) patients in need of kidney transplantation (KTx) typically spend a longer time waiting for compatible kidneys, are unlikely to receive an organ offer, and are at increased risk of antibody-mediated rejection (AMR). Desensitization using imlifidase, which is more rapid and removes total body immunoglobulin G (IgG) to a greater extent than other methods, enables transplantation to occur between HLA-incompatible (HLAi) donor–recipient pairs and allows patients to have greater access to KTx. However, when the project was launched there was limited data and clinical experience with desensitization in general and with imlifidase specifically. Hence, this Delphi methodology was used to reach a consensus from a multi-disciplinary team (MDT) of experts from 15 countries on the management of HS patients undergoing imlifidase HLAi from a deceased donor (DD) KTx. This Delphi consensus provides clinical practice guidance on the use of imlifidase in the end-to-end management of HS patients undergoing an HLAi DD KTx and supports centers in the development of guidelines for the utilization and integration of imlifidase into clinical practice.

The UK Deceased Donor Kidney Transplant Outcome Prediction (UK-DTOP) Tool, developed using advanced artificial intelligence (AI), significantly enhances the prediction of outcomes for deceased-donor kidney transplants in the UK. This study analyzed data from the UK Transplant Registry (UKTR), including 29,713 transplant cases between 2008 and 2022, to assess the predictive performance of three machine learning models: XGBoost, Random Survival Forest, and Optimal Decision Tree. Among these, XGBoost demonstrated exceptional performance with the highest concordance index of 0.74 and an area under the curve (AUC) consistently above 0.73, indicating robust discriminative ability and calibration. In comparison to the traditional Kidney Donor Risk Index (KDRI), which achieved a lower concordance index of 0.57, the UK-DTOP model marked a significant improvement, underscoring its superior predictive accuracy. The advanced capabilities of the XGBoost model were further highlighted through calibration assessments using the Integrated Brier Score (IBS), showing a score of 0.14, indicative of precise survival probability predictions. Additionally, unsupervised learning via k-means clustering was employed to identify five distinct clusters based on donor and transplant characteristics, uncovering nuanced insights into graft survival outcomes. These clusters were further analyzed using Bayesian Cox regression, which confirmed significant survival outcome variations across the clusters, thereby validating the model’s effectiveness in enhancing risk stratification. The UK-DTOP tool offers a comprehensive decision-support system that significantly refines pre-transplant decision-making. The study’s findings advocate for the adoption of AI-enhanced tools in healthcare systems to optimize organ matching and transplant success, potentially guiding future developments in global transplant practices.

Summary: Background: 3% of kidney transplant recipients return to dialysis annually upon allograft failure. Development of antibodies (Ab) against human leukocyte antigens (HLA) is a validated prognostic biomarker of allograft failure. We tested whether screening for HLA Ab, combined with an intervention to improve adherence and optimization of immunosuppression could prevent allograft failure. Methods: Prospective, open-labelled randomised biomarker-based strategy (hybrid) trial in 13 UK transplant centres [EudraCT (2012-004308-36) and ISRCTN (46157828)]. Patients were randomly allocated (1:1) to unblinded or double-blinded arms and screened every 8 months. Unblinded HLA Ab+ patients were interviewed to encourage medication adherence and had tailored optimisation of Tacrolimus, Mycophenolate mofetil and Prednisolone. The primary outcome was time to graft failure in an intention to treat analysis. The trial had 80% power to detect a hazard ratio of 0.49 in donor specific antibody (DSA)+ patients. Findings: From 11/9/13 to 27/10/16, 5519 were screened for eligibility and 2037 randomised (1028 to unblinded care and 1009 to double blinded care). We identified 198 with DSA and 818 with non-DSA. Development of DSA, but not non-DSA was predictive of graft failure. HRs for graft failure in unblinded DSA+ and non-DSA+ groups were 1.54 (95% CI: 0.72 to 3.30) and 0.97 (0.54–1.74) respectively, providing no evidence of an intervention effect. Non-inferiority for the overall unblinded versus blinded comparison was not demonstrated as the upper confidence limit of the HR for graft failure exceeded 1.4 (1.02, 95% CI: 0.72 to 1.44). The only secondary endpoint reduced in the unblinded arm was biopsy-proven rejection. Interpretation: Intervention to improve adherence and optimize immunosuppression does not delay failure of renal transplants after development of DSA. Whilst DSA predicts increased risk of allograft failure, novel interventions are needed before screening can be used to direct therapy. Funding: The National Institute for Health Research Efficacy and Mechanism Evaluation programme grant (ref 11/100/34).

The Covid-19 pandemic is still current but has been particularly well addressed, so far, in the Australian context. This article presents an analysis of management practice to describe the experience of one Primary Health Network (PHN) and its approach and response to the pandemic within its geographical region in accordance with Federal government directives. The PHN is a large geographic area that includes the Central Coast, just north of the Sydney basin, the Newcastle and Hunter Valley region and the Northwest/New England region that extends from Tamworth to the Queensland Border. The article describes the PHN function within its primary healthcare role (PHC) in respect to responding to national initiatives to address and reduce the impact Of the Covid-19 event. The article recounts the Federal Governments directive described through the ‘National Cabinet’ and the Federal Health Department and the PHN response to those directives and initiatives. The article also recounts the actual cases of Covid-19 over the period of the epidemic. The article describes the governance, leadership, and management initiatives. The article then describes the PHN approach to evaluation of its approach from the perspective of general practice and other PHC providers as well as providing perspectives from governance, management, and staff. The evaluation process identified significant impacts on providers and strong support for the continuation of telehealth measures. There were positive responses to the PHN activity and as a strong sense of trusted information, ongoing education, and general engagement.

This issue is the fourth and final issue of the Journal for 2021. It reflects a widespread interest in the Asia Pacific with 30 articles from 11 countries. These countries include Australia, India, Iran, Indonesia, the Philippines, Saudi Arabia, Bangladesh. Vietnam, Thailand, Turkey and Hong Kong, China. This represents a significant collaboration of healthcare managers, leaders, academics, students, and health professionals from diverse health systems. This is a credit to them all and our reviewers. The topics addressed within the issue continue to be dominated by Covid_19 but are also more extensive than that topic. The topics include leadership, engagement, health literacy, employee performance, job satisfaction, mentoring, , artificial intelligence, big data to name many but not all. This is extensive collection of health management topics that should be of interest. Another continuing feature of this issue is the interest in publishing articles from international conferences. There are articles from four recent conferences. These included the 2021 Shape Symposium conducted from Australia and online, “Shaping the future for health management education and research in a time of flux and uncertainty”, held online in July and available at http://shape.org.au/. The Hong Kong Polytechnic University’s College of Professional and Continuing Education (CPCE) Conference “Post-pandemic health and long-term care: A new paradigm”. September 2021 with online and ‘in presence’ attendance. Two conferences highlighted in this issue are recognised from India with some eight articles published from these conferences. The conferences were the AICTE sponsored International Conference on Circular Economy, Management and Industry Leading towards Sustainability, October 2021 and the 2nd Conference on Business Data Analytics, November 2021 We wish to specifically mention these conferences and recognise the conference organisers and our guest co -editors on this occasion, who assisted us with the 8 selected articles. The guest co-editors are Mr. Anuj Kumar, Assistant Professor, Apeejay School of Management, Dwarka, Delhi, India https://www.apeejay.edu/asm/?utm_source=google&utm_medium=google+business+listing&utm_campaign=organic. (Top PGDM Colleges Delhi NCR) and Dr. Nimit Gupta, Professor, School of Management, The NorthCap University, Gurugram, India https://www.ncuindia.edu/educate-india- society/.

In writing an editorial it is difficult to ignore the impact and ramifications of addressing the Covid Pandemic. In Australia, there is emerging political and media signals that are saying we must start to move on and get people back to work and living normally. At the same time our health bureaucracies are pointing to higher vaccination rates, new variants, the need for ‘booster shots’ and continued reticence in some about opening state and national borders....

It is a privilege to be asked to present this Oration. Like many similar events, it pays tribute to a well-respected, revered, and past leader in our profession, in education, economics and life in general. Someone, who most of us would not have known personally nor about his involvement in the health system, particularly, SHAPE.

The Earth close approach of near-Earth asteroid 2005 LW3 on 2022 November 23 represented a good opportunity for a second observing campaign to test the timing accuracy of astrometric observation. With 82 participating stations, the International Asteroid Warning Network collected 1046 observations of 2005 LW3 around the time of the close approach. Compared to the previous timing campaign targeting 2019 XS, some individual observers were able to significantly improve the accuracy of their reported observation times. In particular, U.S. surveys achieved good timing performance. However, no broad, systematic improvement was achieved compared to the previous campaign, with an overall negative bias persisting among the different observers. The calibration of observing times and the mitigation of timing errors should be important future considerations for observers and orbit computers, respectively.

This issue is a special issue of the Journal based on the proceedings of a Health Management conference held earlier this year in India. Please read the editorial and the preface to discover how this eventuated. Most articles, 15 in total come from the proceedings of that conference but there are also a significant number of additional articles from our colleagues from India. Our thanks to Professor Prema Basargekar and his colleagues from K. J. Somaiya Institute of Management (K J SIM), Mumbai, India for working to make this issue significant There are some 30 articles in total In the issue. This is a record issue for APJHM.

This special issue has its focus on the nation-state of India, its healthcare system and health services. You may well ask why a special issue on India and the simple response would be that our colleagues from the K. J. Somaiya Institute of Management (K J SIM), Mumbai, India approached the Journal to see if we would publish a special issue base on articles that were presented at the 1st Annual Conference on Healthcare Management conducted earlier this year by them......

Background. HLA incompatible renal transplantation still remains one of best therapeutic options for a subgroup of patients who are highly sensitized and difficult to match but not much is known about its long-term graft and patient survival. Methods. One hundred thirty-four HLA incompatible renal transplantation patients from 2003 to 2018 with a median follow of 6.93 y were analyzed retrospectively to estimate patient and graft survivals. Outcomes were compared with groups defined by baseline crossmatch status and the type and timings of rejection episodes. Results. The overall patient survival was 95%, 90%, and 81%; and graft survival was 95%, 85%, and 70% at 1, 5, and 10 y, respectively. This was similar to the first-time deceased donor transplant cohort. The graft survival for pretreatment cytotoxic-dependent crossmatch (CDC) positive crossmatch group was significantly low at 83%, 64%, and 40% at 1, 5, and 10 y, respectively, compared with other groups (Bead/CDC, P = 0.007; CDC/Flow, P = 0.001; and microbead assay/flow cytometry crossmatch, P = 0.837), although those with a low CDC titer (

Background. The association between specific HLA alleles and risk for posttransplantation diabetes (PTDM) in a contemporary and multiethnic kidney transplant recipient cohort is not clear. Methods. In this single-center analysis, data were retrospectively analyzed for 1560 nondiabetic kidney transplant recipients at a single center between 2007 and 2018, with median follow-up of 33 mo (interquartile range 8–73). HLA typing methodology was by DNA analysis and reported at the resolution required for the national allocation scheme. Diagnosis of PTDM was aligned with International Consensus recommendations. Results. PTDM developed in 231 kidney transplant recipients. Exploring 99 HLA alleles, the presence of Cw12, B52, B38, B58, DQ4, A80, and DR13 and the absence of DQ3 and DR04 were associated with significant increases in PTDM risk. In a multivariable Cox regression model, adjusting for other clinical risk factors for PTDM, the presence of Cw12 (hazard ratio [HR], 1.57; 95% CI, 1.08-2.27; P = 0.017) and DQ4 (HR, 1.78; 95% CI, 1.07-2.96; P = 0.026) were found to be independent risk factors for PTDM. There was also evidence that the presence of B58 increases PTDM risk within the subgroup of recipients of White ethnicity (HR, 5.01; 95% CI, 2.20-11.42; P

Since the last issue when we first spoke of the impact of Covid-19 we continue to be focused on addressing the challenges this virus has on health systems, nation states, communities, and people. The approach of countries and health systems has been variable as has the political interventions and interpretations of policy with some unfortunately placing parochial populism ahead of evidence and common sense......

Abstract Background Chronic rejection is the single biggest cause of premature kidney graft failure. HLA antibodies (Ab) are an established prognostic biomarker for premature graft failure so there is a need to test whether treatment decisions based on the presence of the biomarker can alter prognosis. The Optimised TacrolimuS and MMF for HLA Antibodies after Renal Transplantation (OuTSMART) trial combines two elements. Firstly, testing whether a routine screening programme for HLA Ab in all kidney transplant recipients is useful by comparing blinding versus unblinding of HLA Ab status. Secondly, for those found to be HLA Ab+, testing whether the introduction of a standard optimisation treatment protocol can reduce graft failure rates. Methods OuTSMART is a prospective, open-labelled, randomised biomarker-based strategy (hybrid) trial, with two arms stratified by biomarker (HLA Ab) status. The primary outcome was amended from graft failure rates at 3 years to time to graft failure to increase power and require fewer participants to be recruited. Length of follow-up subsequently is variable, with all participants followed up for at least 43 months up to a maximum of 89 months. The primary outcome will be analysed using Cox regression adjusting for stratification factors. Analyses will be according to the intention-to-treat using all participants as randomised. Outcomes will be analysed comparing standard care versus biomarker-led care groups within the HLA Ab+ participants (including those who become HLA Ab+ through re-screening) as well as between HLA-Ab-unblinded and HLA-Ab-blinded groups using all participants. Discussion Changes to the primary outcome permit recruitment of fewer participants to achieve the same statistical power. Pre-stating the statistical analysis plan guards against changes to the analysis methods at the point of analysis that might otherwise introduce bias through knowledge of the data. Any deviations from the analysis plan will be justified in the final report. Trial registration ISRCTN registry, ID: ISRCTN46157828. Registered on 26 March 2013; EudraCT 2012–004308-36. Registered on 10 December 2012.

I proposed that I would start this editorial with the phrase ‘that we live in interesting times…’given the ongoing challenge to all is the Covid_19 pandemic. The alleged origin of the phrase is said to be from a Chinese curse ‘may you live in interesting times’ but is found not to be directly attributable to a Chinese source, but it does use irony to suggest we are living in difficult and challenging times. It was subsequently used by the likes of Joseph Chamberlain and more recently in the 1960s by the then USA President John F Kennedy. [1] Either way most of us know that pandemics, dissent, war, and environmental disasters are not new and recent, but have occurred throughout history and are repeated often enough for most of us to have some experience or memories of those events.......

At the time of writing, nation states globally are beginning the vaccination process in response to Covid-19. There is great expectation that it will deliver effective protection to most populations. The logistic of the production and delivery of the vaccines, and use are immense and, we are fortunate, in the Australian context that the extent of the virus spread, and impact has been relatively limited and mostly contained. While everyone is wanting rapid progress, our context does allow us the opportunity to ‘hasten slowly’ and have a positive outcome....

This special issue responds to publications arising from presentations at the 2020 CPCE Health Conference held in Hong Kong in January. The conference was conducted by the College of Professional and Continuing Education of the Hong Kong Polytechnic University in association with a number a number of organisations including the Centre for Ageing and Healthcare Management Research and our colleagues from the Hong Kong College of Health Service Executives. The theme of the conference was ‘Ageing with Health and Dignity – Implications for Public Policy, Service Delivery Workforce, Technology and Financing’.....

It is difficult while writing an editorial, at this time, to ignore the extensive impact of the Corona virus (COVID-19) and it is probably important for us, as health professionals to give it some considered thought, outside the immediacy of current activity. I say this as someone recently returned from work related overseas travel, with my travel not meeting the government-imposed return deadline by some seven hours. This required my quarantine and/or isolation for some two weeks. After my first week of exclusion from most of my family, friends and working remotely and online it seems that the rest of Australia has caught up with my circumstance, many stood down from work, many businesses closed, a massive effort by the health system and economic rescue or support packages being implemented by government. It seems that I will have little opportunity to relax and celebrate with others at the end of this week.....

Purpose – The purpose of this paper is to describe progress in an across sectorial approach to primary health care at the district health service (DHS) level in Thailand in response to recent innovative national public policy directions which have been enshrined in constitutional doctrine and publicly endorsed by the Prime Minister. This paper describes one response to the Prime Minister’s challenge for Thailand to become the centre of learning in the sub-region in health management. Design/methodology/approach – The authors utilised a descriptive case study approach utilising an analysis of the Naresuan University initiative of establishing the College of Health Systems Management (NUCHSM). Within that case study, there is a focus on challenges relevant to the socio-economic determinants of health (SOED) and an emphasis on utilising Sustainable Development Goals (SDGs) within the DHS structure. Findings – The findings describe the establishment of the NUCHSM. A Master of Science (Health Systems Management) by research and a PhD degree have been created and supported by an international faculty. The Thailand International Cooperation Agency recognised NUCHSM by providing scholarships. International students are from Bangladesh, Bhutan, Kenya, Malawi and Timor Leste. Research consultancy projects include two in Lao People’s Democratic Republic; plus, a prototype DHS management system responsive to SDG attainment; and a project to establish a sustainable Ageing Society philosophy for a Thai municipality. Originality/value – The case study on NUCHSM and its antecedents in its development have demonstrated originality in a long-standing international collaboration, and it has been recognised by the national government to provide scholarships to citizens of the countries in the sub-region to undertake postgraduate studies in health management. The concept of learning from each other and together, simultaneously as a group, through action research projects funded to enhance the evolution of DHSs is innovative.

We established air pollution modelling to study particle (PM10) exposures during pregnancy and infancy (1990–1993) through childhood and adolescence up to age ~15 years (1991–2008) for the Avon Longitudinal Study of Parents And Children (ALSPAC) birth cohort. For pregnancy trimesters and infancy (birth to 6 months; 7 to 12 months) we used local (ADMS-Urban) and regional/long-range (NAME-III) air pollution models, with a model constant for local, non-anthropogenic sources. For longer exposure periods (annually and the average of birth to age ~8 and to age ~15 years to coincide with relevant follow-up clinics) we assessed spatial contrasts in local sources of PM10 with a yearly-varying concentration for all background sources. We modelled PM10 (μg/m3) for 36,986 address locations over 19 years and then accounted for changes in address in calculating exposures for different periods: trimesters/infancy (n = 11,929); each year of life to age ~15 (n = 10,383). Intra-subject exposure contrasts were largest between pregnancy trimesters (5th to 95th centile: 24.4–37.3 μg/m3) and mostly related to temporal variability in regional/long-range PM10. PM10 exposures fell on average by 11.6 μg/m3 from first year of life (mean concentration = 31.2 μg/m3) to age ~15 (mean = 19.6 μg/m3), and 5.4 μg/m3 between follow-up clinics (age ~8 to age ~15). Spatial contrasts in 8-year average PM10 exposures (5th to 95th centile) were relatively low: 25.4–30.0 μg/m3 to age ~8 years and 20.7–23.9 μg/m3 from age ~8 to age ~15 years. The contribution of local sources to total PM10 was 18.5%–19.5% during pregnancy and infancy, and 14.4%–17.0% for periods leading up to follow-up clinics. Main roads within the study area contributed on average ~3.0% to total PM10 exposures in all periods; 9.5% of address locations were within 50 m of a main road. Exposure estimates will be used in a number of planned epidemiological studies. Keywords: ALSPAC, Air pollution, Dispersion modelling, Exposure assessment, Mother-child, PM10

In this issue continues to explore the theme of health reform by traversing some recent experiences of the Editor in rural health contexts that traverse big data, technology, the social capital of health professionals all currently operating in drought and fire ravaged circumstances. After we pass the current circumstances there will be a need to rebuild rural communities and sustainable health services and workforce should be part of the community building......

During the recent Australian Federal election held on the 18th May 2019 much was made by all sides of the political divide about health and health services, much was praised, and more was promised in the name of health policy and improved approaches to health care delivery. Given that the ‘quiet Australians’ have made their choice and the political angst and dust has diminished, it might be time to return the debate to determine what it was that we all agreed to and where do we go from here.....

The lead Editorial in this issue – a special issue, as it contains six articles presented at the College of Professional and Continuing Education (CPCE) of the Hong Kong Polytechnic University Health Conference of 2019 is provided by Professor Peter Yuen, Dean of that College and Professor, Department of Management and Marketing of the Hong Kong Polytechnic University......

Recently I was talking to a colleague of mine from Hong Kong and he reminded me that Hong Kong had had 28 years of health reform. A period just slightly longer than we had known each other. We are deeply imbued in the management and organisation of health services and health systems and, therefore public health policy. He suggested that there should be a lot of learning for us all from that period and, he was exploring how that might happen. I agreed with the idea and the need to think it through. I also recognised potential for the Journal to play some role in that suggestion. Most national health systems have undergone extensive reform so there should be a lot of learning for all of us from that reform.....

This is the third and final issue for 2018. We continue in transition from publishing three issues a year to the concept of publish as ready. This has resulted in delays to processing and publishing, so we extend our apologies to both authors and readers. We currently have some twenty articles in review and delays are also occurring in this area in finding willing and receptive reviewers. We would appreciate authors suggesting reviewers as they submit articles.....

No abstract

No abstract

In recent years much has been made of the need to effectively translate knowledge developed through research into health systems practice. [1] Literature suggests that the acceptance of research findings would be more likely if the research were achieved and disseminated into practice where it occurs in a more collaborative alignment of researchers and practitioners.....

Introduction: Motivation and retention of village health workers (VHWs) are crucial for the continuity, sustainability, and success of health programs. VHWs are the first point of contact for rural communities, providing health services to improve access and health coverage which, for a variety of logistical reasons, cannot be reached by the district health care system. Thus VHWs are critical for ultimately ensuring universal health coverage. However, systematic review revealed that there are numerous factors that affects their motivation and retention, leading to high dropout rates and hampering the delivery of health services to the community. This review intends to examine contextual factors affecting motivation and retention of VHWs in their roles and identify recommendations and strategies to motivate and retain them in the systems. Method: Five electronic databases and two search engines were accessed. Nineteen studies met the inclusion criteria for the final review. An in-depth reading of all the articles was undertaken to gather and compile the relevant themes. Content analysis was done based on the list of specific categories that are relevant to motivation and retention. Result: Findings from the systematic review revealed different levels of factor affecting motivation and retention of village health workers. It was finally contextualized and categorized into four main domains such as individual, family, social or community and organizational or systems levels. Financial incentives under the organizational factors was highlighted for the demotivation and the discontentment for the VHWs. Conclusion: Financial factors under the organization were often key in the studies reviewed. However, there were also many other factors, sometimes surprising or unintuitive, influencing the motivation and retention of village health workers.

The term ‘publish or perish’ is familiar to most of us engaged in some way in academia and reflects the mantra that to have a successful career as a teacher, researcher and all-round academic wanting to be recognised as an expert in your discipline requires you to be well and regularly published. This directive also has added implications to not publish in ‘any journal’ but in ones that have high impact factors. This suggests that they have recognised quality articles that have been peer reviewed, have rigour in the editorial process and, therefore are difficult to obtain publication in, particularly for students and emerging researchers. Progression of careers are dependant on this mantra and, we all want to ensure that the quality of our research, our science is of the best standard.....

No abstract

Background. ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers. Methods. The comprehensive national registry of AIT in the United Kingdom was investigated to describe the donor, recipient and transplant characteristics of AIT. Kaplan-Meier analysis was used to compare survival of AIT to all other compatible kidney transplants performed in the United Kingdom. Cox proportional hazards regression modeling was used to determine which pretransplant factors were associated with transplant survival in HLAi and ABOi separately. The primary outcome was transplant survival, taking account of death and graft failure. Results. For 522 HLAi and 357 ABO incompatible (ABOi) transplants, 5-year transplant survival rates were 71% (95% confidence interval [CI], 66-75%) for HLAi and 83% (95% CI, 78-87%) for ABOi, compared with 88% (95% CI, 87-89%) for 7290 standard living donor transplants, and 78% (95% CI, 77-79%) for 15 322 standard deceased donor transplants (P < 0.0001). Increased chance of transplant loss in HLAi was associated with increasing number of donor specific HLA antibodies, center performing the transplant, antibody level at the time of transplant, and an interaction between donor age and dialysis status. In ABOi, transplant loss was associated with no use of IVIg, cytomegalovirus seronegative recipient, 000 HLA donor-recipient mismatch; and increasing recipient age. Conclusions. Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.

Book review of "Sociology of Health and Illness Monograph" series

Commentary and published research on the value of healthcare has become more evident in recent times. There has been a noticeable shift from the focus on efficiency of health systems and practice to a greater focus on what effectively works, or more so, what doesn’t work. Health delivery systems struggle with increased demand on existing services and other health priorities remain underserviced. What do we need to do to better examine and understand what delivers value to people, communities, the health system and at the same time improves health outcomes? ........

Thailand has performed admirably in its health reform over the last few decades. Healthcare is provided at a relatively low cost and healthcare needs have transitioned to begin to address diseases and mortality of developed countries. The challenges now faced by Thailand are similar to most developed countries reflecting adult mortality and risk factors of an uppermiddle income population and the need to modify institutional structures to reflect these changing circumstances. The approach to these challenges has focused on the ‘implementation of knowledge based health development’ and critically identifies ‘the triangle that moves the mountain’ (health reform) as a movement that mobilises; the creation of relevant knowledge, social movement and political involvement’ to address ‘inter-connected, complex and extremely difficult to solve’ problems. The move to District Health Systems as the access point to healthcare and the service delivery structure demands competent qualified leadership and management. It requires an understanding of the differences in managing professionally dominated complex adaptive systems compared to traditional approaches of managing within bureaucratic structures. This can be best described as managing connected, integrated care focused both on individuals as patients and communities with a strong emphasis on primary healthcare, prevention and evidence-based practice. It also requires an understanding of how distributed networks of practice (DNOP) provide the potential for researchers, practitioners and other agencies and communities to collaborate, learn and improve healthcare across geographic, jurisdictional and organisational boundaries. This approach provides recognition of the need to build the capacity and capability of health professionals in the management and leadership of health systems and Thailand is moving towards this goal in implementing specific health systems management curriculum which focuses on action-based research and learning together at the District health level augurs well for continued ability to address current health challenges and to achieve SDGs. Abbreviations: DHS – District Health System; DNOP – Distributed Networks of Practice; HSRI – Health Systems Research Institute; MoPH – Ministry of Public Health; NHSO – National Health Security Office; SDG – Strategic Development Goal; UHC – Universal Health Coverage.

Health reform has been a constant feature of most health systems for a number of decades and has often focused on structural change. The lexicon of health reform and health management has also become intertwined with managers reporting that reform has become a constant and that rather than influencing that change they are in fact influenced by it and by its impact on their role, professional development and career. There is a challenge for health service managers to return to a leadership role in enabling health reform. In doing so will this challenge us to think differently about management? This article addresses the significant body of research into health reform and health management through the lens of language used in reporting the context and the significant impact that it has had on the management role. It describes what directions that role might take, the qualities required in selecting capable managers and questions the current status quo in the education, training and development of this significant sector of the health system workforce. It concludes by proposing a way forward that acknowledges that contemporary health reform is shifting the paradigm of healthcare delivery in a way that requires the dominant view of health management to be challenged. This might be achieved by the use of a critical lens on the language of management, a focus on a grounded approach about what managers need to do and an acceptance of variability in that role in adaptive complex contexts. Abbreviations: DNOP – Distributed Networks of Practice; MDG – Millennium Development Goals; PHC – Primary Healthcare; PHN – Primary Health Network; SDG – Sustainable Development Goals; SEDOH – Social Economic Determinants of Health; SHAPE – Society for Health Administration Programs in Education.

In a recent online open forum of the Association of University Programs in Health Administration (AUPHA) two of our American colleagues were discussing the need for a greater focus in health management curricula on ‘transformation’. [1] They indicated that some time ago the American College of Healthcare Executives identified key skill areas for healthcare leaders as ‘operational, people, and transformation’, suggesting that good progress and focus on the first two had been achieved while more focus on the third was required. The discussion suggested that ‘the area of transformation’ needed to ‘specifically include skills in intrapreneurship and also innovation’. ....

BACKGROUND:Causes of "true" late kidney allograft failure remain unclear as study selection bias and limited follow-up risk incomplete representation of the spectrum. METHODS:We evaluated all unselected graft failures from 2008-2014 (n = 171; 0-36 years post-transplantation) by contemporary classification of indication biopsies "proximate" to failure, DSA assessment, clinical and biochemical data. RESULTS:The spectrum of graft failure changed markedly depending on the timing of allograft failure. Failures within the first year were most commonly attributed to technical failure, acute rejection (with T-cell mediated rejection [TCMR] dominating antibody-mediated rejection [ABMR]). Failures beyond a year were increasingly dominated by ABMR and 'interstitial fibrosis with tubular atrophy' without rejection, infection or recurrent disease ("IFTA"). Cases of IFTA associated with inflammation in non-scarred areas (compared with no inflammation or inflammation solely within scarred regions) were more commonly associated with episodes of prior rejection, late rejection and nonadherence, pointing to an alloimmune aetiology. Nonadherence and late rejection were common in ABMR and TCMR, particularly Acute Active ABMR. Acute Active ABMR and nonadherence were associated with younger age, faster functional decline, and less hyalinosis on biopsy. Chronic and Chronic Active ABMR were more commonly associated with Class II DSA. C1q-binding DSA, detected in 33% of ABMR episodes, were associated with shorter time to graft failure. Most non-biopsied patients were DSA-negative (16/21; 76.1%). Finally, twelve losses to recurrent disease were seen (16%). CONCLUSION:This data from an unselected population identifies IFTA alongside ABMR as a very important cause of true late graft failure, with nonadherence-associated TCMR as a phenomenon in some patients. It highlights clinical and immunological characteristics of ABMR subgroups, and should inform clinical practice and individualised patient care.

HLA directed antibodies play an important role in acute and chronic allograft rejection. During viral infection of a patient with HLA antibodies, the HLA antibody levels may rise even though there is no new immunization with antigen. However it is not known whether the converse occurs, and whether changes on non-donor specific antibodies are associated with any outcomes following HLA antibody incompatible renal transplantation.55 patients, 31 women and 24 men, who underwent HLAi renal transplant in our center from September 2005 to September 2010 were included in the studies. We analysed the data using two different approaches, based on; i) DSA levels and ii) rejection episode post transplant. HLA antibody levels were measured during the early post transplant period and corresponding CMV, VZV and Anti-HBs IgG antibody levels and blood group IgG, IgM and IgA antibodies were quantified.Despite a significant DSA antibody rise no significant non-donor specific HLA antibody, viral or blood group antibody rise was found. In rejection episode analyses, multiple logistic regression modelling showed that change in the DSA was significantly associated with rejection (p = 0.002), even when adjusted for other antibody levels. No other antibody levels were predictive of rejection. Increase in DSA from pre treatment to a post transplant peak of 1000 was equivalent to an increased chance of rejection with an odds ratio of 1.47 (1.08, 2.00).In spite of increases or decreases in the DSA levels, there were no changes in the viral or the blood group antibodies in these patients. Thus the DSA rise is specific in contrast to the viral, blood group or third party antibodies post transplantation. Increases in the DSA post transplant in comparison to pre-treatment are strongly associated with occurrence of rejection.

HLA-C is an important ligand for killer immunoglobulin like receptors (KIR) that regulate natural killer (NK) cell function. Based on KIR specificity HLA-C molecules are allocated into two groups, HLA-C1 or HLA-C2; HLA-C2 is more inhibiting to NK cell function than HLA-C1. We studied the clinical importance of HLA-C genotypes on the long-term graft survival of 760 kidney transplants performed at our centre utilising a population based genetic study and cell culture model to define putative mechanisms.Genotyping was performed using conventional DNA PCR techniques and correlations made to clinical outcomes. We found that transplant recipients with HLA-C2 had significantly better long-term graft survival than transplant recipients with HLA-C1 (66% versus 44% at 10 years, log-rank p = 0.002, HR = 1.51, 95%CI = 1.16-1.97). In in-vitro NK and dendritic cell (DC) co-culture model we made several key observations that correlated with the population based genetic study. We observed that donor derived NK cells, on activation with IL-15, promoted differential HLA-C genotype dependent DC maturation. In NK-DC co-culture, the possession of HLA-C2 by DC was associated with anti-inflammatory cytokine production (IL-1RA/IL-6), diminished DC maturation (CD86, HLA-DR), and absent CCR7 expression. Conversely, possession of HLA-C1 by DC was associated with pro-inflammatory cytokine synthesis (TNF-α, IL-12p40/p70), enhanced DC maturation and up-regulation of CCR7 expression. By immunohistochemistry the presence of donor NK cells was confirmed in pre-transplant kidneys.We propose that after kidney transplantation IL-15 activated donor derived NK cells interact with recipient DC with less activation of indirect allo-reactivity in HLA-C2 positive recipients than HLA-C1 positive recipients; this has implications for long-term graft survival. Early events following kidney transplantation involving NK-DC interaction via KIR and HLA-C immune synapse may have a central role in long-term kidney transplant outcomes.