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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.

Intro -- HEALTH CARE QUALITY: SELECT RESEARCHAND ANALYSES -- HEALTH CARE QUALITY: SELECT RESEARCHAND ANALYSES -- CONTENTS -- PREFACE -- Chapter 1 HEALTH CARE QUALITY: ENHANCING PROVIDER ACCOUNTABILITY THROUGH PAYMENT INCENTIVES AND PUBLIC REPORTING -- SUMMARY -- INTRODUCTION -- THE ROLE OF QUALITY MEASUREMENT -- PAYMENT INCENTIVES FOR QUALITY -- The Role of Medicare -- Overview of Payment Incentives -- PUBLIC REPORTING OF PERFORMANCE INFORMATION -- The Theory Underlying Public Reporting -- Issues with Consumer Use of Performance Information -- The Effectiveness of Public Reporting -- End Notes -- Chapter 2 PHYSICIAN SUPPLY AND THE PATIENT PROTECTION AND AFFORDABLE CARE ACT -- SUMMARY -- INTRODUCTION -- SIZE OF THE PHYSICIAN POPULATION -- Measuring the Physician Population -- Determining the Appropriate Size of the Physician Population -- PPACA and the Size of the Physician Population -- PPACA Provisions Targeting the Number of Physicians Trained -- PPACA Provisions Targeting Physician Productivity -- COMPOSITION OF THE PHYSICIAN POPULATION -- Primary Care Supply and Factors Influencing Primary Care Supply -- PPACA and the Composition of the Physician Population -- PPACA Provisions Targeting Primary Care Supply -- Primary Care Content in Physician Training -- Primary Care Physician Payment -- Care Coordination by Primary Care Physicians -- PPACA Provisions Targeting Shortages in Specialties -- GEOGRAPHIC DISTRIBUTION OF THE PHYSICIAN POPULATION -- Health Professional Shortage Areas and Medically Underserved Areas/Populations -- Why Geographic Shortages May Exist -- PPACA and the Geographic Distribution of the Physician Population -- PPACA Provisions Targeting the NHSC -- PPACA Provisions Targeting the Diversity of the Physician Workforce -- PPACA Provisions Targeting Rural Practice -- PPACA Provisions Amending HPSA and MUP Designation Criteria

BACKGROUND A sizeable fraction of tuberculosis (TB) cases go undiagnosed. By analysing data from enhanced demographic, microbiological and geospatial surveillance of TB registrations, we aimed to identify modifiable predictors of inequitable access to diagnosis and care. METHODS Governmental community health workers (CHW) enumerated all households in 315 catchment areas during October-December 2015. From January 2015, government TB Officers routinely implemented enhanced TB surveillance at all public and private TB treatment registration centres within Blantyre (18 clinics in total). This included collection from registering TB patients of demographic and clinical characteristics, a single sputum sample for TB microscopy and culture, and geolocation of place of residence using an electronic satellite map application. We estimated catchment area annual TB case notification rates (CNRs), stratified by microbiological status. To identify population and area-level factors predictive of CHW catchment area TB case notification rates, we constructed Bayesian spatially autocorrelated regression models with Poisson response distributions. Worldpop data were used to estimate poverty. RESULTS In total, the 315 CHW catchment areas comprised 753,489 people (range 162 to 13,066 people/catchment area). Between 2015 and 2017, 6077 TB cases (61% male; 99% HIV tested; 67% HIV positive; 55% culture confirmed) were geolocated, with 3723 (61%) resident within a CHW catchment area. In adjusted models, greater distance to the nearest TB registration clinic was negatively correlated with TB CNRs, which halved for every 3.2-fold (95% CI 2.24-5.21) increase in distance. Poverty, which increased with distance from clinics, was negatively correlated with TB CNRs; a 23% increase (95% CI 17-34%) in the mean percentage of the population living on less than US$2 per day corresponded to a halving of the TB case notification rates. CONCLUSIONS Using enhanced surveillance of TB cases in Blantyre, we show an ecological relationship consistent with an 'inverse care law' whereby poorer neighbourhoods and those furthest from TB clinics have lower relative CNRs. If confirmed as low case detection, then pro-poor strategies to facilitate equitable access to TB diagnosis and treatment are required.

General hospitals provide a wide range of primary and secondary healthcare services. They accounted for 38% of government funding to health facilities, 8.8% of outpatient department visits and 28% of admissions in Uganda in the financial year 2016/17. We assessed the levels, trends and determinants of technical efficiency of general hospitals in Uganda from 2012/13 to 2016/17. Methods We undertook input-oriented data envelopment analysis to estimate technical efficiency of 78 general hospitals using data abstracted from the Annual Health Sector Performance Reports for 2012/13, 2014/15 and 2016/17. Trends in technical efficiency was analysed using Excel while determinants of technical efficiency were analysed using Tobit Regression Model in STATA 15.1. Results The average constant returns to scale, variable returns to scale and scale efficiency of general hospitals for 2016/17 were 49% (95% CI, 44–54%), 69% (95% CI, 65–74%) and 70% (95% CI, 65–75%) respectively. There was no statistically significant difference in the efficiency scores of public and private hospitals. Technical efficiency generally increased from 2012/13 to 2014/15, and dropped by 2016/17. Some hospitals were persistently efficient while others were inefficient over this period. Hospital size, geographical location, training status and average length of stay were statistically significant determinants of efficiency at 5% level of significance. Conclusion The 69% average variable returns to scale technical efficiency indicates that the hospitals could generate the same volume of outputs using 31% (3439) less staff and 31% (3539) less beds. Benchmarking performance of the efficient hospitals would help to guide performance improvement in the inefficient ones. There is need to incorporate hospital size, geographical location, training status and average length of stay in the resource allocation formula and adopt annual hospital efficiency assessments.

This report reviews the quality of health care in Sweden. It begins by providing an overview of the range of policies and practices aimed at supporting quality of care in Sweden (Chapter 1). It then focuses on three key areas particularly relevant to elderly populations: strengthening primary care in Sweden (Chapter 2), better assurance for quality in long-term care (Chapter 3), and improving care after hip fracture and stroke (Chapter 4). In examining these areas, this report highlights best practices and provides recommendations to improve the quality of care in Sweden

This book presents a comprehensive review of health care quality in Norway. It finds that Norway has an impressive and comprehensive health system, which is the result of sustained commitment to providing health care for the whole Norwegian population, investment in the health system, and readiness to make changes to drive improvements. On most indicators Norway's health system appears to be performing well, although there is some room for improvement. There have been a number of significant health care reforms in Norway over the last decade, most recently the Coordination Reform, which took e

Statement on Quality of Care -- Copyright -- ROSTER -- PREFACE AND ACKNOWLEDGMENTS -- Additional Contributors to the Roundtable -- CONTEXT OF THIS STATEMENT -- ACTIVITIES OF THE ROUNDTABLE -- Conferences -- Sponsors -- Support to the Roundtable by the Institute of Medicine -- The Urgent Need to Improve Health Care Quality -- ABSTRACT -- CONSENSUS STATEMENT -- QUALITY CAN BE DEFINED AND MEASURED -- QUALITY PROBLEMS ARE SERIOUS AND EXTENSIVE -- OTHER QUALITY-OF-CARE ISSUES -- CURRENT APPROACHES TO QUALITY IMPROVEMENT ARE INADEQUATE -- AN URGENT NEED FOR RAPID CHANGE -- References -- NATIONAL ROUNDTABLE ON HEALTH CARE QUALITY.

Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired. One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care. The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of care.

This review of health care quality in Denmark examines policies related to quality and includes chapters covering primary and integrated care, hospital specialisation and equity. It finds that with a dense array of disease- and service-focused quality initiatives, and with information on the quality of care stored in separate data repositories, Denmark needs to create effective links and synergies between them to drive up quality in the healthcare system as a whole, rather than in disconnected elements. Primary care will be central in meeting Denmark's future healthcare challenges of an ageing

This report reviews the quality of health care in Italy, seeks to highlight best practices, and provides a series of targeted assessments and recommendations for further improvements to quality of care. Italy's indicators of health system outcomes, quality and efficiency are uniformly impressive. Life expectancy is the fifth highest in the OECD. Avoidable admission rates are amongst the very best in the OECD, and case-fatality after stroke or heart attack are also well below OECD averages. These figures, however, mask profound regional differences. Five times as many children in Sicily are adm

Different concepts of quality in health care have implications for nature, structure and composition of health service systems. Issues of access, cost and quality of care are intricately linked; for recipients, providers as well as for policy-makers. Quality in health care is a complex construct because it is linked not just with the quality of services provided at the institution and systemic level but has several tangible and intangible dimensions including individual patient's interests and larger societal concerns about improvement in health status. Quality is an important consideration for choosing the services for recipients, accreditation of hospitals for care providers, and for policy-makers while making decisions regarding health service system models. This article traces the way the issue has been dealt with at the policy and planning level so far, including the National Rural Health Mission (NRHM) as well as in the proposed models for Universal Health Care by the High Level Expert Group (HLEG) and 12th Plan Steering committee reports.

Intro -- FrontMatter -- Reviewers -- Contents -- Preface -- Acknowledgments -- Acronyms and Abbreviations -- Abstract -- Summary -- 1 A New Vision for Primary Care -- 2 Defining High-Quality Primary Care Today -- 3 Primary Care in the United States: A Brief History and Current Trends -- 4 Person-Centered, Family-Centered, and Community-Oriented Primary Care -- 5 Integrated Primary Care Delivery -- 6 Designing Interprofessional Teams and Preparing the Future Primary Care Workforce -- 7 Digital Health and Primary Care -- 8 Primary Care Measures and Use: Powerful, Simple, Accountable -- 9 Payment to Support High-Quality Primary Care -- 10 Enhancing Research in Primary Care -- 11 The Committee's Approach to an Implementation Strategy -- 12 A Plan for Implementing High-Quality Primary Care -- Appendix A: Committee Member, Fellow, and Staff Biographies -- Appendix B: Primary Care: America's Health in a New Era Report Recommendations -- Appendix C: Committee's Calculations to Determine the Impact of the Decreased Density of Primary Care Physicians Between 2005 and 2015 -- Appendix D: Three System-Level Tables of Actors and Actions -- Appendix E: The Health of Primary Care: A U.S. Scorecard.

BACKGROUND Global health policy prioritizes improving the health of women and girls, as evident in the Sustainable Development Goals (SDGs), multiple women's health initiatives, and the billions of dollars spent by international donors and national governments to improve health service delivery in low-income countries. Countries recovering from fragility and conflict often engage in wide-ranging institutional reforms, including within the health system, to address inequities. Research and policy do not sufficiently explore how health system interventions contribute to the broader goal of gender equity. METHODS This paper utilizes a framework synthesis approach to examine if and how rebuilding health systems affected gender equity in the post-conflict contexts of Mozambique, Timor Leste, Sierra Leone, and Northern Uganda. To undertake this analysis, we utilized the WHO health systems building blocks to establish benchmarks of gender equity. We then identified and evaluated a broad range of available evidence on these building blocks within these four contexts. We reviewed the evidence to assess if and how health interventions during the post-conflict reconstruction period met these gender equity benchmarks. FINDINGS Our analysis shows that the four countries did not meet gender equitable benchmarks in their health systems. Across all four contexts, health interventions did not adequately reflect on how gender norms are replicated by the health system, and conversely, how the health system can transform these gender norms and promote gender equity. Gender inequity undermined the ability of health systems to effectively improve health outcomes for women and girls. From our findings, we suggest the key attributes of gender equitable health systems to guide further research and policy. CONCLUSION The use of gender equitable benchmarks provides important insights into how health system interventions in the post-conflict period neglected the role of the health system in addressing or perpetuating gender inequities. Given the frequent contact made by individuals with health services, and the important role of the health system within societies, this gender blind nature of health system engagement missed an important opportunity to contribute to more equitable and peaceful societies.