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Excess (all-cause) mortality is an important indicator of the severity of humanitarian crises. When standard sources such as vital registration systems are not available, ad-hoc small-scale mortality surveys can give rapid insights into the health status of affected populations. However, this thesis shows that when samples sizes are too small, frequentist analyses of such surveys are prone to misinterpretation, at least when looking at individual surveys. An example is provided of how meta-analysis can be used to overcome this problem by pooling surveys., (SP - Sciences de la santé publique) -- UCL, 2022

Many protracted crises are largely in resource poor settings affecting billions of people around the world. Efforts are being made globally to mitigate the impact of protracted crises on affected populations. However, these places typically lack the required health information systems for the collection of birth and death records needed to conduct a comprehensive assessment of the public health status and needs of the population. In particular, Yemen has been experiencing drawn out conflict, exposing children and adults to untold hardship and diseases as well as the risk of losing their lives increases as the crisis continues. A comprehensive nationwide analysis of the impact of the protracted crisis in Yemen on mortality is lacking. However, over the course of the crisis in Yemen, series of small-scale surveys have been conducted on regional/zonal levels for planning purposes by humanitarian organizations operating on ground. Because of the costs and the impracticability of conducting an indepth, nation-wide assessment, we have attempted to conduct an effective and robust investigation for a better understanding of the impact of the conflict on mortality by combining the sparse, publicly available data. We started by assessing the methods used for the collection and presentation of mortality data obtained from the small-scale survey. We found no strict adherence to standardized methodology guidelines, and reporting of mortality and sample size data. Adherence to methodological guidelines and complete reporting of surveys in humanitarian settings will vastly improve the estimation of mortality rate and also uptake of key data on health indicators of the affected population. We also assessed the change in number of deaths as a result of the conflict using a Bayesian mixture model approach. Despite an increase in the estimated number of deaths attributed to the conflict, we observed uncertainty surrounding the point estimates, which calls for caution while interpretin, (SP - Sciences de la santé publique) -- UCL, 2022

Background: Little is known about the prevalence of people with chronic wounds cared for at home and their care integration needs in Belgium. In high-income countries, chronic wounds are associated with ageing processes, chronic diseases and social and financial vulnerability, resulting in multiple needs. To meet these needs, many health care providers (with nurses figuring prominently) are involved. This can lead to fragmented health care trajectories and the need to strengthen care coordination. Objectives: This study aims to estimate the prevalence of people with chronic wounds cared for at home in Belgium. It also seeks to explore their health care trajectories and the risk of fragmentation of care to inform policy makers, care providers and research. Design: Cross-sectional. Setting(s): Home care. Participants: Routinely collected data of reimbursed care of 3467 people with a chronic wound cared for at home in 2018. Methods: We applied a stratification method to our sample based on health care trajectories. First, we constructed individual sequences of care received during the year. Then we summarised the health care events using a K-mers approach. Finally, a multinomial mixture model was used on the previously obtained summary to cluster individuals according to their health care trajectories. Afterwards, other epidemiological, socioeconomic and health care use indicators were calculated for each health care trajectory group. We also estimated the prevalence of people with chronic wounds treated at home. Results: We constructed six health care trajectory groups for two age categories (<65 and ≥65 years) showing different intensity of care use and type of care. In some health care trajectory groups, generalist care was found to be predominant. In others, specialist care appeared more prevalent. Depending on the health care trajectory group, a significant proportion of people had multiple care providers involved (mainly nurses, medical specialists and GPs), and

The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare systemchange. Yet,many of those projects are managed by healthcare providers’ teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable “learning community.” The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

Cette présentation vise à partager une approche d'analyse des contextes de soins. Dans ces contextes, les infirmières et autres prestataires de soins primaires sont impliqués dans les soins des patients atteints de plaies chroniques soignés à domicile et dans des situations de vie complexes. En Europe, les personnes atteintes de plaies chroniques sont principalement soignées à domicile par des infirmières et d'autres prestataires de soins primaires. Les plaies chroniques sont généralement associées à l'âge, à la présence de maladies chroniques et à la vulnérabilité, ce qui crée des besoins multiples. Cela signifie que de nombreux prestataires de soins peuvent être impliqués dans leurs soins, ce qui peut compromettre la continuité des soins et générer un besoin accru de coordination des soins. La combinaison de facteurs spécifiques au patient et l'interaction avec de multiples prestataires créent des contextes de soins très différents, avec des ressources et des obstacles spécifiques. En raison de ces interactions de facteurs multiples, la situation peut être décrite comme complexe. Nous avons recueilli des récits de prestataires de soins (principalement des infirmières) par le biais d'entretiens et de groupes de travail dans le cadre d'un atelier. Ces histoires sont basées sur les expériences des participants dans divers contextes de soins à domicile de personnes souffrant de plaies chroniques. Au vu de la complexité des situations mais aussi des matériaux, nous avons opté pour une approche réaliste (identification de différentes hypothèses sous forme de contexte-mécanismes-résultats). L'analyse a permis d'identifier des relations hypothétiques entre la collaboration interprofessionnelle, les facteurs spécifiques aux patients et le rôle des infirmières qui ont un impact sur la continuité. Les facteurs contextuels semblent façonner le rôle des infirmières de soins primaires, restreignant ou élargissant leur potentiel d'action pour la pratique collaborative coordonnée

The inappropriate utilization of antibiotics drove to a global public health threat: the antimicrobial resistance. Several strategies were set up to fight the problem such as Infection Prevention and Control which aims to improve the use of antibiotic. Our work identified the bottlenecks of the rational use of antibiotics in Benin in the context of the user fees exemption policy in caesarean section with a national free kit. The findings of our five studies showed: - a misuse, overuse, and underuse of antibiotics before, during and after caesarean section, - a low level of knowledge of antibiotic prophylaxis in healthcare professionals, a lack of confidence in the kit, and some general disagreement with the policy, - some cases of overdosage of active ingredient, - a mixed knowledge of antibiotics and their utilization by patients, - a low involvement of end-implementers during the policy formulation, a mixed-consensual context without scientific evidence-based considerations in the choice of antibiotics in the kit. The analysis of these findings revealed that the bottlenecks of the rational use of antibiotics were in all levels of the Benin healthcare system (healthcare professionals, patients and policymakers). Considering the burden the inappropriate use of antibiotics induces for patient and public health, it is imperative to implement actions to improve the use of antibiotics. Based on the literature, a program named “antimicrobial stewardship” permits to coordinate a set of actions for promoting the prudent use of antimicrobials, with the ultimate goal of optimizing clinical outcomes while minimizing unfavorable consequences including resistance selection as well as adverse drug reactions. This program includes various actions for all actors of the healthcare system such as patient education, healthcare professional training and involvement in Infection Prevention and Control strategies, and policymakers’ commitment. The implementation of this kind of program, (BIFA - Sciences biomédicales et pharmaceutiques) -- UCL, 2022

224 p., ill., SCIENTIFIC REPORT 13 -- 1 INTRODUCTION .13 -- 1.1 WHAT IS INTEGRATED CARE? 13 -- 1.2 INTEGRATED CARE IN BELGIUM 17 -- 1.3 SCOPE OF THE PROJECT 21 -- 1.4 METHODS 21 -- 2 INTEGRATED CARE AS EXPRESSED IN THE BELGIAN POLICIES .24 -- 2.1 INTRODUCTION .25 -- 2.2 METHODS 25 -- 2.3 RESULTS 26 -- 2.3.1 Overview of the selected policy documents by level of authority 27 -- 2.3.2 Aims according to the dimensions of the SCIROCCO self-assessment tool .42 -- 2.4 DISCUSSION AND CONCLUSIONS 61 -- 2.4.1 Consistency in policy documents of both federal and federated entities despite different emphasis 61 -- 2.4.2 The complexity of Belgium's governance structure and its impact on integrated care policy 63 -- 2.4.3 Limitations of the policy documents review 64 -- 3 MATURITY OF INTEGRATED CARE IN BELGIUM 65 -- 3.1 PROFESSIONALS' ASSESSMENT OF INTEGRATED CARE 67 -- 3.1.1 Introduction .67 -- 3.1.2 Methods 67 -- 3.1.3 Results 69 -- 3.2 PATIENTS' EXPERIENCE OF INTEGRATED CARE .87 -- 3.2.1 Introduction .87 -- 3.2.2 Method 87 -- 3.2.3 Results 90 -- 3.3 DISCUSSION .102 -- 4 STAKEHOLDERS’ PROPOSITIONS OF ACTIONS TO DEVELOP AND IMPLEMENT INTEGRATED CARE .106 -- 4.1 INTRODUCTION 107 -- 4.2 METHODS 107 -- 4.3 RESULTS .111 -- 4.3.1 Discussion group participants .111 -- 4.3.2 Facilitators & barriers 112 -- 4.3.3 Action points .116 -- 4.4 DISCUSSION .135 -- 5 PROVIDER PAYMENT REFORMS FOR IMPLEMENTING INTEGRATED CARE AND VALUEBASED HEALTH CARE: A NARRATIVE LITERATURE REVIEW 137 -- 5.1 INTRODUCTION 138 -- 5.2 METHODS 139 -- 5.2.1 Provider payment mechanisms and integrated care 139 -- 5.2.2 Transition from a fee-for-service financing system to a mixed payment system 141 -- 5.3 RESULTS .142 -- 5.3.1 Provider payment mechanisms 142 -- 5.3.2 Mixed Provider Payment Systems (including alternative payment methods) .145 -- 5.3.3 Payment reforms: conditions and conducive factors 153 -- 5.4 DISCUSSION .161 -- 5.4.1 An incremental reform process 162 -- 5.4.2 New mode of governance at meso level is indispensable to

135 p., ill., 1. APPENDIX: TERRITORIAL UNIT FOR ANALYSIS PURPOSES 6 -- 2. APPENDIX: MATURITY OF INTEGRATED CARE IN BELGIUM 7 -- 2.1. PROFESSIONAL’S ASSESSMENT OF INTEGRATED CARE 7 -- 2.1.1. Dutch survey 7 -- 2.1.2. French version of professional questionnaire available upon request 20 -- 2.1.3. Professional’s profiles 34 -- 2.1.4. Results of descriptive analysis by respondent’s professional category and level 38 -- 2.1.5. Scirocco spider diagrams per region 62 -- 2.2. ASSESSMENT OF MATURITY OF INTEGRATED CARE BY THE PATIENTS 63 -- 2.2.1. EuroQol Licence agreement for the EQ-5D-5L 63 -- 2.2.2. French patient questionnaire 67 -- 2.2.3. Dutch version of the patient questionnaire 71 -- 2.2.4. German version of the patient questionnaire 76 -- 2.2.5. Recruitment targets and response per geographical region 81 -- 2.2.6. Detailed list of participating recruiting organisations 82 -- 2.2.7. EQ – 5D -5L profiles 84 -- 2.2.8. EQ-5D-5L dimensions 86 -- 2.2.9. PACIC models 87 -- 3. APPENDIX: PROVIDER PAYMENT REFORMS – NARRATIVE LITERATURE REVIEW 89 -- 3.1. TYPES OF PAYMENT MECHANISMS 89 -- 3.2. PAY-FOR-PERFORMANCE (P4P) 91 -- 3.3. POPULATION-BASED PAYMENTS (INCLUDING ACCOUNTABLE CARE ORGANISATIONS (ACO)) 92 -- 3.4. BUNDLED PAYMENTS 99 -- 3.5. REFERENCE LIST OF THE LITERATURE REVIEW 102 -- 4. APPENDIX – TRAJECTORY OF CHANGE 107 -- 4.1. DUTCH VERSION OF THE TRAJECTORY OF CHANGE 107 -- 4.2. FRENCH VERSION OF THE TRAJECTORY OF CHANGE 116 -- 4.3. RÉFÉRENCES 125 -- 4.4. REFERENCES FOR THE TRAJECTORY OF CHANGE 126 -- 5. APPENDIX: SCRIPT OF DISCUSSION GROUPS AND TEMPLATE OF DATA REPORTING 127

43 p., ill., Ons huidig gezondheidszorgsysteem is hoofdzakelijk gericht op de aanpak van acute ziekte-episodes met een betaling per prestatie als voornaamste financieringsmechanisme. Dit is niet optimaal om de uitdagingen ten gevolge van de vergrijzing en de toename van chronische ziekten het hoofd te bieden. Het is nodig om te evolueren naar geïntegreerde zorg. We verstaan hieronder een zorgsysteem dat beter afgestemd is op de multi-dimensionele noden van mensen met chronische aandoeningen, dat rekening houdt met de behoeften van mensen gedurende hun hele leven, en dat over de verschillende zorglijnen heen. In België lopen er hierover al verschillende initiatieven, zowel op federaal niveau als op het niveau van de deelstaten. Maar de actoren op het terrein hebben de indruk dat deze nog niet voldoende gecoördineerd worden. Het nieuw Interfederaal Plan voor Geïntegreerde zorg, gepland voor begin 2024, zou hierin een belangrijke stap kunnen zijn., VOORWOORD 1 -- SYNTHESE 2 -- 1. INLEIDING 4 -- 1.1. WAT IS ‘GEÏNTEGREERDE ZORG’? 4 -- 1.2. GEÏNTEGREERDE ZORG IN BELGIË 4 -- 1.3. DOELSTELLINGEN VAN DEZE STUDIE 7 -- 2. DOELSTELLINGEN GEÏNTEGREERDE ZORG VERMELD IN BELGISCHE BELEIDSDOCUMENTEN 10 -- 3. MATURITEIT VAN GEÏNTEGREERDE ZORG IN BELGIË 11 -- 3.1. BEOORDELING VAN DE MATURITEIT VAN GEÏNTEGREERDE ZORG DOOR PROFESSIONALS 11 -- 3.2. BEOORDELING VAN DE ERVARINGEN VAN PATIËNTEN 12 -- 4. ACTIEPUNTEN VOORGESTELD DOOR BELGISCHE PROFESSIONALS 14 -- 4.1. BARRIÈRES EN FACILITATOREN 14 -- 4.2. DRIE FUNDAMENTELE ASSEN 17 -- 5. OP WEG NAAR MEER GEÏNTEGREERDE ZORG! 19 -- 5.1. STRUCTURERING VAN HET BELEIDSKADER 19 -- 5.2. DEFINIËREN TERRITORIALE AANPAK 20 -- 5.2.1. De omvang van het gebied/territorium (of de gebieden/territoria) bepalen 20 -- 5.2.2. Integratie van professionals en versterking van de eerstelijnszorg 21 -- 5.2.3. Organisatie van het gegevensbeheer naar een populatiegerichte benadering 22 -- 5.3. HERZIENING VAN HET FINANCIERINGSMODEL 23 -- 5.3.1. Naar gemengde financieringsmodellen 23 -- 5.3.2. Een geleidelijke uitrol 24 -- 5.3.3. Versterking van de eerstelijnszorg 25 -- 5.3.4. Een initiële investering om te beginnen 25 -- 6. CONCLUSIE 26 -- AANBEVELINGEN 28

43 p., ill., Notre système actuel de soins de santé est essentiellement basé sur une approche par maladie et financé par prestation, ce qui n’est pas optimal pour faire face aux défis du vieillissement et de la multiplication des maladies chroniques. C’est pourquoi il est souhaitable d’évoluer vers un système de « soins intégrés », c’est-à-dire des soins plus adaptés aux besoins multidimensionnels des patients atteints de maladies chroniques, tout au long de leur vie et à travers les différentes lignes de soins. Différentes initiatives en ce sens sont déjà en cours en Belgique, tant au niveau fédéral que des entités fédérées, mais les acteurs de terrain ont l’impression que celles-ci ne sont pas encore assez coordonnées. Le nouveau Plan interfédéral sur les Soins intégrés, prévu pour début 2024, devrait pouvoir y remédier., PRÉFACE 1 -- SYNTHÈSE 2 -- 1. INTRODUCTION 4 -- 1.1. QU’EST-CE QUE LES “SOINS INTÉGRÉS” ? 4 -- 1.2. LES SOINS INTÉGRÉS EN BELGIQUE 4 -- 1.3. OBJECTIFS DE CETTE ÉTUDE 7 -- 2. OBJECTIFS DE SOINS INTÉGRÉS MENTIONNÉS DANS LES DOCUMENTS POLITIQUES BELGES 9 -- 3. MATURITÉ DES SOINS INTÉGRÉS EN BELGIQUE 10 -- 3.1. ÉVALUATION DE LA MATURITÉ DES SOINS INTÉGRÉS PAR LES PROFESSIONNELS 11 -- 3.2. ÉVALUATION DU VÉCU DES PATIENTS 12 -- 4. PISTES D’ACTION PROPOSÉES PAR LES PROFESSIONNELS BELGES 13 -- 4.1. OBSTACLES ET FACILITATEURS 14 -- 4.2. TROIS AXES FONDAMENTAUX 17 -- 5. EN AVANT VERS DES SOINS PLUS INTÉGRÉS ! 18 -- 5.1. STRUCTURER LE CADRE POLITIQUE 19 -- 5.2. DÉFINIR UNE APPROCHE TERRITORIALE 20 -- 5.2.1. Choisir la taille du ou des territoire(s) 20 -- 5.2.2. Intégrer les prestataires de soins et renforcer la 1e ligne 21 -- 5.2.3. Organiser la gestion des données vers une approche populationnelle 22 -- 5.3. REVOIR LE MODÈLE DE FINANCEMENT 23 -- 5.3.1. Vers des modèles mixtes 23 -- 5.3.2. Un déploiement progressif 24 -- 5.3.3. Renforcement des soins de 1e ligne 25 -- 5.3.4. Un investissement initial pour démarrer 25 -- 6. CONCLUSION 25 -- RECOMMANDATIONS 28