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Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North's institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice.

Background: Decentralisation has been adopted by many governments to strengthen national systems, including the health system. Decision space is used to describe the decision‐making power devolved to local government. Human resource Management (HRM) is a challenging area that District Health Management Teams (DHMT) need some control over its functions to develop innovative ways of improving health services. The study aims to examine the use of DHMTs' reported decision space for HRM functions in Uganda. Methods: Mixed methods approach was used to examine the DHMTs' reported decision space for HRM functions in three districts in Uganda, which included self‐assessment questionnaires and focus group discussions (FGDs). Results: The decision space available for the DHMTs varied across districts, with Bunyangabu and Ntoroko DHMTs reporting having more control than Kabarole. All DHMTs reported full control over the functions of performance management, monitoring policy implementation, forecasting staffing needs, staff deployment, and identifying capacity needs. However, they reported narrow decision space for developing job descriptions, resources mobilisation, and organising training; and no control over modifying staffing norms, setting salaries and developing an HR information system (HRIS). Nevertheless, DHMTs tried to overcome their limitations by adjusting HR policies locally, better utilising available resources and adapting the HRIS to local needs. Conclusions: Decentralisation provides a critical opportunity to strengthen HRM in low‐and‐middle‐income countries. Examining decision space for HRM functions can help identify areas where district health managers can change or improve their actions. In Uganda, decentralisation helped the DHMTs be more responsive to the local workforce needs and analysing decision space helped identify areas for improvement in HRM. There are some limitations and more power over HRM functions and strong management competencies would help them become more resourceful.

Background: Ensuring delivery of quality health services in a sustainable and equitable manner is a challenge in Nepal. A host of factors may have impeded the access, quality and utilization of the health services particularly by the marginalized and disadvantaged sections of the population. Review essential health care services (EHCS) provided by the public health facilities, level of progress, effectiveness, sustainability, equity and efficiency, quality of care and inclusion of marginalized and disadvantaged populations in health care servicesMethods: A total of 40 VDCs from 10 districts representing five regions and three eco-zones were covered. Altogether 800 mothers with under two year children, 40 health service providers, 145 key informants and 40 exit clients were interviewed. Forty focused group discussions were also conducted. From each district, health records of one hospital, PHCC, HP, SHP and Ayurvedic health facility each were collected.Results: More than two-third (68.2%) of the mothers received antenatal checks, highest in hills (85%) followed by terai (64.5%) and mountain districts (52.8%).Tetanus vaccine coverage (80.7%) seems higher compared to Nepal Demographic Health Survey 2001 (45%). FP use rate in mountain, hill and terai are 57.6%, 54.1% and 49.7%, higher than in DoHS 2003/2004 statistics, which were 26.8%, 36.4% and 45.3% respectively. Nine out of ten patients visiting the health facilities were outpatients. The coverage of DPT 3, Polio 3, BCG and measles are 92.8%, 93.4%, 95.2% and 90.7% respectively. From the service utilization perspective, disparities in terms of gender, ecological regions, season of the year and health facility were revealed.Conclusion: Health sector services are yet to be made responsive to the ecological and district specific health problems, and be made more inclusive linking with doable safety nets. Key words: Essential health care services; Effectiveness; Sustainability; Equity and efficiency; Quality of care and inclusion doi: 10.3126/jnhrc.v6i2.2188Journal of Nepal Health Research Council Vol. 6 No. 2 Issue 13 Oct 2008 Page: 74-83

Background and objectives: This study explores the perceptions of a wide range of stakeholders in Malawi towards the mental health impact of intimate partner violence (IPV) and the capacity of health services for addressing these. Design: In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in three areas of Blantyre district, and in two additional districts. A total of 10 FGDs, 1 small group, and 14 IDIs with health care providers; 18 FGDs and 1 small group with male and female, urban and rural community members; 7 IDIs with female survivors; and 26 key informant interviews and 1 small group with government ministry staff, donors, gender-based violence service providers, religious institutions, and police were conducted. A thematic framework analysis method was applied to emerging themes. Results: The significant mental health impact of IPV was mentioned by all participants and formal care seeking was thought to be impeded by social pressures to resolve conflict, and fear of judgemental attitudes. Providers felt inadequately prepared to handle the psychosocial and mental health consequences of IPV; this was complicated by staff shortages, a lack of clarity on the mandate of the health sector, as well as confusion over the definition and need for 'counselling'. Referral options to other sectors for mental health support were perceived as limited but the restructuring of the Ministry of Health to cover violence prevention, mental health, and alcohol and drug misuse under a single unit provides an opportunity. Conclusion: Despite widespread recognition of the burden of IPV-associated mental health problems in Malawi, there is limited capacity to support affected individuals at community or health sector level. Participants highlighted potential entry points to health services as well as local and national opportunities for interventions that are culturally appropriate and are built on local structures and resilience.

Introduction China has an estimated 5 million people with tuberculosis (TB). Official policy is that treatment of all patients is directly observed by health workers; completion rates are reported to be in excess of 90, and drugs should be supplied for free. However, some research suggests there is a gap between the official policies and practice. Methods Survey of TB patients in four counties of one municipality; record assessment at one TB centre; patient and village doctor in-depth interviews. Results Sixteen per cent (64/401) reported being directly observed every time they took treatment; less than 5 of TB patients (17/401) were observed by health staff. Overall, 12.5 (50/401) reported they had not taken any TB drugs in the previous week, but this varied between the four counties (range 6.2 to 21.7). We used survival analysis with medical records at one centre: 74.1 of new patients collected their drugs for their sixth month of treatment, and 50.3 attended the final visit at 6 months. Qualitative research indicated direct observation is neither well understood nor thought to be necessary, and that patients reported being charged expensive fees for ancillary treatments, such as liver protection drugs. Conclusion In China, direct observation is not well implemented and may not be a feasible policy option. Official completion rates are higher than we found in this study. The concept of free treatment has become blurred, with charges for additional tests and drugs, especially liver protection drugs. The government is already actively tackling these issues, and involvement of managers and others in this process will be helpful.

Research on social inequalities has a very long tradition in sociological research, and discussion of the impact of social inequalities on health and health care delivery has long been one of the more important topics covered by medical sociologists. The research presented in this volume varies in its coverage and its approach to issues of social inequality in health and health care delivery. This volume includes both theoretical and quantitative papers, and deals with complex understandings of macro system issues, the impact of the patient and individual factors on health and health care and the impact of the provider and interaction between providers and patients. The first section focuses on macro system issues and includes both theoretical approaches to the topic and quantitative approaches. The second section includes articles with a greater focus on patient characteristics. These articles vary greatly in their coverage, with some focusing on the US as a whole, and others on specific sections of the US or subgroups within the population such as African American women or the elderly. The third section focuses on providers and issues of social inequality and health care delivery. These papers examine issues of gender, race and poverty as examples of sources of inequality in modern societies. In contrast to the second section these papers pay more attention to individual factors and the focus of the chapters is on aspects of health care providers. Research on providers of care is another long, important research tradition within medical sociology. Social Inequalities, Health and Health Care Delivery should be useful reading for medical sociologists and people working in other social science disciplines studying health-related issues. The volume also provides information for health services researchers, policy analysts and public health researchers.

No health care professional in Canada should be without a clear understanding of the Canadian health care system! Health and Health Care Delivery in Canada, 2nd Edition explores the nation's basic approach to health, wellness, and illness. Set entirely within a Canadian context, this text includes coverage of individual and population health, the role of federal agencies and provincial governments, health care funding, and current issues and future trends in health care. Written by experienced educator and nurse practitioner, Valerie Thompson, this textbook is ideal for all students beginning a career in health care. Clear, easy-to-understand approach to health care in Canada begins with an overview of health, wellness, and illness and proceeds through the fundamentals of the Canadian health care system, such as population health, ethical and legal issues, health care funding and principles, practice settings, and changing trends. Learning Outcomes outline the knowledge that you should gain in each chapter. Key Terms open each chapter and include page references for definitions. Student-friendly learning aids include summary tables and boxes, photographs, figures, and illustrations. Review questions at the end of every chapter test your comprehension of the material. Case examples provide real-world scenarios related to the chapter content. In The News boxes highlight landmark case law, research developments, emerging health issues, and ethical challenges. Thinking It Through questions ask you to critically consider key aspects of health and health care delivery. NEW! Coverage of issues and trends includes expanded information on mental health issues, aboriginal health, privatization, use of electronic health records, and interprofessional health care practice.

This report provides an overview of the Indian Health Service and how it provides for the health care problems and needs of AI/AN.

Intro -- INTEGRATED HEALTH CARE DELIVERY -- NOTICE TO THE READER -- CONTENTS -- PREFACE -- A BRIEF DESCRIPTION OF THE LIMITATIONS OF THE CURRENT HEALTH CARE SYSTEM IN THE UNITED STATES, AND A PROGRAM RESPONSE TO THE COMPLEX ISSUES OF MANY INDIVIDUALS WHO ARE CONFRONTED WITH MULTIPLE, CHRONIC CONDITIONS -- ABSTRACT -- INTRODUCTION -- LITERATURE REVIEW -- THE INTERGRATED HEALTH ADVOCACY PROGRAM -- The Primary Advocate -- The Psychosocial Advocate -- The Medical Advocate -- The Advocacy Team -- The IHAP Participants -- Materials -- DESCRIPTIVE AND STATISTICAL RESULTS -- Descriptives -- Statistical Results -- CONCLUSION -- REFERENCES -- A COMPARISON OF INTEGRATED DUAL DIAGNOSIS TREATMENT SERVICE DELIVERY MODELS ON FIDELITY AND CLIENT OUTCOMES AT 1- AND 2-YEAR FOLLOW-UPS -- ABSTRACT -- INTRODUCTION -- METHOD -- RESULTS -- DISCUSSION -- CONCLUSION -- ACKNOWLEDGMENT -- REFERENCES -- OPERATING ROOM COSTS AND RESOURCE UTILIZATION IN LUMBAR FUSION WITH INSTRUMENTATION PROCEDURES: INTEGRATED DELIVERY SYSTEM IS IMPLICATED -- ABSTRACT -- INTRODUCTION -- MATERIALS AND METHODS -- Sample and Data Sources -- Statistical Analysis -- RESULTS -- CONCLUSION -- REFERENCES -- SOCIAL CAPITAL AND PARTNERSHIP OPPORTUNITIES: MANAGEMENT IMPLICATION IN INTEGRATED HEALTHCARE NETWORKS -- ABSTRACT -- INTEGRATED HEALTH NETWORKS -- MANAGERIAL ISSUES FOR HEALTH CARE NETWORK MANAGEMENT -- WHAT WE FOCUS ON ARE SOCIAL CAPITALS: THE ROLE OF SOCIAL CAPITAL IN THE MANAGEMENT OF INTEGRATED HEALTH NETWORKS -- EXAMPLE OF TAIWAN'S PRIMARY COMMUNITY CARE NETWORK (PCCN) DEMONSTRATION PROJECT: CONCEPTUALIZATION AND MEASURES OF SOCIAL CAPITAL -- Unique Characteristics in Taiwan's Healthcare Industry -- Backgrounds of the Health Reform for PCCNs in Taiwan -- Structures and Responsibilities for PCCNs in Taiwan.

The purpose of this paper is to determine the gender responsiveness of the present mental health delivery system in the Philippines. According to the 1995 Census of the Population, 4.2 percent of the disabled population are mentally ill. In numerical terms, this is about 38,675 of 919,332 persons with disabilities. Of these, 52.64 percent are female while 47.36 percent are male. Most of those afflicted are in the 25-39 age group. The study is based on interviews with selected mental health care givers in an NGO clinic and in a government hospital and on observations of interactions between patients and care givers. At present, interest in mental illness among women is focused on domestic workers or overseas Filipino workers in foreign countries. While studies on psychiatric morbidity may be useful, these do not reflect the need to understand the social construction of gender in society. What is needed are studies that will constribute to changes in institutional treatment and policy development geared towards gender-responsive practices in mental health care settings.

The Service Delivery Indicators (SDIs) provides a set of key indicators serving as a benchmark for service delivery performance in the health and education sectors in Sub-Saharan Africa. The overarching objective of the SDIs is to ascertain the quality of service delivery in primary education and basic health services. This would in turn enable governments and service providers alike to identify gaps and bottlenecks, as well as track progress over time, and across countries. The SDI survey interviewed 403 heath providers across Tanzania between May 2014 and July 2014. This technical report presents the findings from the implementation of the SDI in the health sector in Tanzania in 2014. Survey implementation activities took place following extensive consultations with the government and key stakeholders on survey design, sampling, and adaptation of survey instruments. A major challenge for Tanzania's health sector is the shortage of skilled human resources for health (HRH). This survey found that provider knowledge and abilities were not adequate to deliver quality services. Caseload per provider and absenteeism are relatively low, so the issue is not over burdened providers. There seems to be ample room for a significant increase in the caseload of Tanzanian providers, i.e. the level of productivity in health service delivery, without jeopardizing quality. In addition to increasing the volume of skilled HRH to address the shortage of providers, improvements in management, supervision and training is important to improving service delivery. Health for all in Tanzania will mean the simultaneous availability of widely accessible inputs and skilled providers.

BACKGROUND Limited research on Posting and Transfer (P&T) policies and systems in the public sector health services and the reluctance for an open debate on the issue makes P&T as a black box. Limited research on P&T in India suggests that P&T policies and systems are either non-existent, weak, poorly implemented or characterized by corruption. Hence the current study aimed at opening the "black box" of P&T systems in public sector health services in India by assessing the implementation gaps between P&T policies and their actual implementation. METHODS This was a qualitative study carried out in Department of Health, in a Western State in India. To understand the extant P&T policies, a systems map was first developed with the help of document review and Key Informant (KI) Interviews. Next systems audit was carried out to assess the actual implementation of transfer policies by interviewing Medical Officers (MOs), the group mainly affected by the P&T policies. Job histories were constructed from the interviews to understand transfer processes like frequencies of transfers and to assess if transfer rules were adhered. The analysis is based on a synthesis of document review, 19 in-depth interviews with MOs working with state health department and five in-depth interviews with Key Informants (KIs). Framework analysis approach was used to analyze data using NVIVO. RESULTS The state has a generic transfer guideline applicable to all government officers but there is no specific transfer policy or guideline for government health personnel. The generic transfer guidelines are weakly implemented indicating a significant gap between policy and actual implementation. The formal transfer guidelines are undermined by a parallel system in which desirable posts are attained, retained or sometimes given up by the use of political connections and money. MOs' experiences of transfers were marked by perceptions of unfairness and irregularities reflected through interviews as well as the job histories. DISCUSSION The generic transfer rules and ambiguity in how transfers are treated may explain the discrepancy between policy and implementation leading to systems abuse. This discrepancy could have negative influence on MOs' morale which could in turn affect distribution of MOs. Where possible, ambiguity in the rules should be avoided and a greater transparency on implementation of the transfer rules is needed. However, it may not be possible to make any significant improvements to P&T policies and how they are implemented until the external pressure that creates parallel systems is greatly reduced in translating HR policy into HR practice. CONCLUSIONS Effective P&T policies and implementation may have important implications for organizational performance and may help to improve Human Resource (HR) policy and HR expertise. Also there is a greater need for transparency on implementation of the rules. However, it may not be possible to make any significant improvements to P&T policies and how they are implemented until the external pressure that creates parallel systems is greatly reduced.