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PubMedDate not supplied

[The nurse in the decentralization process of the health system].

Study about the decentralization process of the health system in the '80s and '90s in the city of Itabuna-BA. It is aimed at describing the city's health decentralization process, identifying the nurse's insertion/participation in this process. Descriptive/qualitative study of exploratory nature that utilized both the semistructured interview and documental analysis for data collection. The results show that the nurse's insertion in the decentralization process took place according to the changes that occurred at every municipal management, where the nurse acted more effectively as the set of circumstances was established and was influenced by the several conjunctures formed by the implemented policies or implemented in each context of the management of the municipal health system.

Brazil↗
PubMed2000

Health financing changes in the context of health care decentralization: the case of three Latin American countries.

OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.

Delivery of Health Care↗
PubMed2004

[Impact of decentralization on health financing in Mexico].

OBJECTIVE: To identify trends and to describe the impact of health care decentralization on health financing policies in Mexico. METHODS: The study population comprised four states selected according with six technical criteria: socioeconomic development, implementation of decentralization process, database on economical features, data consistency and reliability, and technical support from a multidisciplinary team. In-depth interviews with key personnel as well as analysis of technical reports of state budgets for health in the period 1990-2000 were conducted. RESULTS: The analysis model applied allowed to determine the trends and the impact of health care decentralization on main financing sources: householders, and federal, state and municipal governments. There was evidence of different change effectiveness, especially regarding trends of financing per source. CONCLUSIONS: There are states where householders and state and municipal governments effectively increased financing support for health care system. But there are also states where householders and state and municipal governments do not agree on the increase of financing support for health care system.

Databases as Topic↗
PubMed2006

Effects of health decentralization, financing and governance in Mexico.

OBJECTIVE: To identify the effects of decentralization on health financing and governance policies in Mexico from the perspective of users and providers. METHODS: A cross-sectional study was carried out in four states that were selected according to geopolitical and administrative criteria. Four indicators were assessed: changes and effects on governance, financing sources and funds, the final destination of resources, and fund allocation mechanisms. Data collection was performed using in-depth interviews with health system key personnel and community leaders, consensus techniques and document analyses. The interviews were transcribed and analyzed by thematic segmentation. RESULTS: The results show different effectiveness levels for the four states regarding changes in financing policies and community participation. Effects on health financing after decentralization were identified in each state, including: greater participation of municipal and state governments in health expenditure, increased financial participation of households, greater community participation in low-income states, duality and confusion in the new mechanisms for coordination among the three government levels, absence of an accountability system, lack of human resources and technical skills to implement, monitor and evaluate changes in financing. CONCLUSIONS: In general, positive and negative effects of decentralization on health financing and governance were identified. The effects mentioned by health service providers and users were related to a diversification of financing sources, a greater margin for decisions around the use and final destination of financial resources and normative development for the use of resources. At the community level, direct financial contributions were mentioned, as well as in-kind contributions, particularly in the form of community work.

Community Participation↗
PubMed2007

[The implementation of decentralized health systems: a comparative study of five cases in Bahia, Brazil].

Understanding the effects of health decentralization policies in Brazil requires different methodological approaches to capture the issue's complexity from distinct angles. Five case studies were thus performed to evaluate the degree of implementation of components related to decentralization of the health system management in selected municipalities (counties) in Bahia State, Brazil. A logical model was elaborated with definitions related to policy goals. A comparative study of the five municipalities, considered "exemplary cases", showed that decentralization alone does not explain the organizational changes in the municipal health systems. Local government characteristics such as the municipal master plan, governing capacity, and governance proved important for heath care changes. The main problems and insufficiencies were found in the system's management and quality of healthcare delivered to the population. The authors discuss their findings and identify critical areas for future interventions with special emphasis on the institutionalization of planning and evaluation and the development of inter-sector projects.

Brazil↗
PubMed2005

Decentralization strategies and provider incentives in healthcare: evidence from the english national health service.

INTRODUCTION: This article examines the incentive effects of delegating operational and financial decision making from central government to local healthcare providers. It addresses the economic consequences of a contemporary policy initiative in the English National Health Service (NHS)-earned autonomy. This policy entails awarding operational autonomy to 'front-line' organisations that are assessed to be meeting national performance targets. In doing so, it introduces new types of incentives into the healthcare system, changes the nature of established agency relationships and represents a novel approach to performance management. METHODS: Theoretical elements of a principal-agent model are used to examine the impact of decentralization in the context of the results of an empirical study that elicited the perceptions of senior hospital managers regarding the incentive effects of earned autonomy. A multi-method approach was adopted. In order to capture the breadth of policy impact, we conducted a national postal questionnaire survey of all Chief Executives in acute-care hospital Trusts in England (n = 173). To provide added depth and richness to our understanding of the impact and incentive effects of earned autonomy at an organisational level, we interviewed senior managers in a purposeful sample of eight acute-care hospital Trusts. RESULTS: This theoretical framework and our empirical work suggest that some aspects of the earned autonomy as currently implemented in the NHS serve to weaken the potential incentive effect of decentralization. In particular, the nature of the freedoms is such that many senior managers do not view autonomy as a particularly valuable prize. This suggests that incentives associated with the policy will be insufficiently powerful to motivate providers to deliver better performance. We also found that principal commitment may be a problem in the NHS. Some hospital managers reported that they already enjoyed a large degree of autonomy, regardless of their current performance ratings. We also found evidence that the objectives of providers may differ from those of both the central government and local purchasers. There is, therefore, a risk that granting greater autonomy will allow providers to pursue their own objectives which, whilst not self-serving, may still jeopardize the achievement of strategic goals. CONCLUSION: It is apparent that the design and implementation features of decentralizing policies such as earned autonomy require careful attention if an optimal balance is to be struck between central oversight and local autonomy in the delivery of healthcare.

Hospitals, Public↗
PubMed1990

Health services and decentralized government: the case of primary health services in Norway.

Decentralized forms of government are becoming more common in Western European countries. The effects of decentralization of public health services are explored in this article. In 1984 the Norwegian Municipal Health Act allocated the responsibility for primary health care to the municipalities. Based on data from a sample of 70 municipalities, the author shows that the number of primary health service personnel has expanded considerably during 1984-88, but the distribution of services has not become more equitable. Though the formal role of local politicians in the decision-making process has increased, the health sector officers and the Municipal Executives have in practice controlled the evolution of the municipal health services. The author concludes that decentralization does not necessarily lead to more democracy, and that an equitable distribution of public health services becomes more difficult to attain.

Decision Making, Organizational↗
PubMed1995

Decentralized diagnostics of beta haemolytic streptococci group A--introduction of a developmental model for microbiological consultation in primary health care.

OBJECTIVE: To define and evaluate forms for introduction of decentralized diagnosis in primary care. DESIGN: The study was divided into three phases. Intervention I. An intensive course on microbiological diagnostics in cases of tonsillitis with information about rapid EIA-based test kits for beta haemolytic streptococci group A. Intervention II. External quality assurance of the decentralized test. Evaluation. Recording of changes in work practice and attitude regarding decentralized diagnosis by means of a questionnaire. PARTICIPANTS: Thirty-three GPs and 36 laboratory technicians from 37 primary health care centres (PHC) in the county of Ostergötland, Sweden. RESULTS: Thirty-one of the responding GPs (94%) considered that the information gained from quality assurance was useful. Twenty-nine GPs (88%) reported that they had changed their clinical practice to some extent, and 26 of the responding laboratory technicians (72%) reported that they had changed method after the interventions. CONCLUSION: Uniform acceptance was not achieved, but a large number of GPs and PHC laboratory technicians did conform to a rational-empirical strategy for change in clinical practice.

Family Practice↗
PubMed1999

Analysis of the factors affecting decentration in photorefractive keratectomy and laser in situ keratomileusis for myopia.

To evaluate the relationship between ablation zone decentration measured by corneal topography and various factors such as sex, age, order of operation, preoperative sedative prescription, ablation diameter and depth, type of procedure (photorefractive keratectomy = PRK, laser in situ keratomileusis = LASIK), and the use of a passive eye tracker, we examined the data of 80 eyes in 50 patients. The patients received PRK (43 eyes in 30 patients) or LASIK (37 eyes in 20 patients), and were followed for 3 months postoperatively. Statistical analysis of the data was performed using t-test, ANOVA and multiple regression analysis. The overall average ablation decentration from the pupil center was 0.43 +/- 0.27 mm, 0.35 +/- 0.22 mm in PRK and 0.47 +/- 0.30 mm in LASIK. Overall 91.3% of patients were decentered less than 0.75 mm and 95.0% were decentered less than 1.00 mm, while 93.9% of patients were decentered less than 0.75 mm in PRK and 88.7% were decentered less than 0.75 mm in LASIK. The most meridional displacement was toward the superonasal quadrant; 46% in PRK and 51% in LASIK. There was less decentration in males, in the 2nd-operated eye, in older age, PRK, in larger ablation diameter, and in shallower ablation depth, but these differences were not statistically significant.

Adult↗
PubMedDate not supplied

Decentralized nursing education: does it work?

University-based nursing schools throughout the nation have attempted to decentralize nursing education from urban health science centers into rural areas. This article summarizes the outcomes of such a program. Data were collected from nurses working in rural North Carolina about their perceptions of the decentralized nursing education program in their region. The data have been used to gain continuing support and funding for the decentralized program.

Education, Nursing, Continuing↗
PubMedDate not supplied

Decentration after refractive surgery.

PURPOSE: To examine factors useful in evaluation of suspect decentration after refractive surgery. METHODS: We evaluated 148 cases (eyes) referred to us for recentering procedures by review of information obtainable by evaluation of pupil position, corneal topography, and corneal curvature gradient. RESULTS: Only a minority of eyes (n=5, 3.4%) were truly decentered; in the remaining majority a high dioptric gradient with consequent focal scarring was present (n=107, 72.3%). In 28 eyes (18.9%), a drifting of the eye during treatment was responsible, and in eight eyes (5.4%), a central island was observed. CONCLUSIONS: Proper corneal topographical diagnosis reduces the risk of improperly suspecting decentration, and for most cases, smoothing of the central cornea is a simple and efficacious solution. Recommendations for the prevention of decentration include proper patient positioning, special care in treating high myopes, preoperative check of pupil displacement nasally, evaluation of preoperative map with detection of high temporal curvature gradient, and use of the cross-cylinder technique in the treatment of astigmatism.

Cornea↗
PubMed1990

Unit dose drug distribution in teaching hospitals: key characteristics and centralized versus decentralized approaches.

A comparative review of decentralized versus centralized unit dose drug distribution systems for teaching hospitals is discussed. A drug distribution system Task Force, established at the Toronto Western Division of The Toronto Hospital, identified key characteristics of a safe, accountable and efficient drug distribution system. Included were considerations of patient safety, cost effectiveness, efficient use of nursing time, security, clarification of professional role, hospital and professional standards of practice, and evaluation criteria. Interdisciplinary task force discussions and extensive literature review resulted in a recommendation for the implementation of a decentralized unit dose drug distribution system. It was recognized that physical plant and material handling systems must be considered for each individual facility before a decision to decentralize can be made.

Centralized Hospital Services↗
PubMed1985

Implementation and evaluation of a decentralized pharmacy service.

The implementation of a decentralized pharmacy service on a 59 bed acute patient care area was evaluated. Over a ten-month period four criteria were used to evaluate the decentralized service: (1) reported medication errors, (2) reported medication discrepancies, (3) drug costs per patient day and (4) availability and utilization of drug information. Data was collected over the ten month period for all criteria except for drug information interactions in which a self reporting data card was utilized over a six week period. Medication errors and medication discrepancies decreased by 12.5% and 80% respectively on the pilot floor as compared to the hospital (+14.8%, -18.0% respectively). Drug costs per patient day increased the least on the pilot floor (+9.1%) as compared to other areas in the hospital (range: 10.8% to 49.3%). Seventy-six percent of drug information interactions occurred on the pilot floor as compared to the central pharmacy accounting for 24% of interactions for all other hospital areas combined. It is concluded that a decentralized pharmacy service can make a significant impact on a unit dose drug distribution system by reducing medication errors, discrepancies, drug costs and by increasing the utilization of drug information resources.

Centralized Hospital Services↗
PubMed1986

Evaluation of an inpatient decentralized pharmacy team program in an HMO setting.

Decentralized drug distribution and clinical pharmacy services were implemented on two nursing units, orthopedics and oncology, of a health maintenance organization-owned hospital. The use of targeted high-cost drugs was assessed before and during the decentralized pharmacy services intervention on the experimental units and on a comparison unit. Other assessments included a survey of nurses from the experimental units and surveillance of telephone encounters between the central pharmacy and the experimental units. In the experimental units, there were significant changes in cefazolin therapy for prophylaxis, aminoglycoside therapy, and metoclopramide use from baseline to the intervention periods. Cefazolin use for prophylaxis essentially remained the same in the comparison unit. Telephone encounters decreased substantially from the before- to the during-program period. An increase in the proportion of inappropriately drawn aminoglycoside blood levels was also noted in the during-program period. Decentralized pharmacy services appeared to reduce the cost of targeted drugs and improve communications with the nursing units.

Cefazolin↗
PubMed2000

A study comparing centralized CD-ROM and decentralized intranet access to MEDLINE.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of a decentralized intranet access in each medical department as opposed to centralized unique MEDLINE access in the medical library. DESIGN: A two-phase questionnaire to evaluate MEDLINE use was given to junior and senior physicians at Rouen University Hospital (RUH). Phase I (August-October 1996) corresponded to a time period when centralized access was the only means of access available and phase II (August-October 1997) to a time period following the introduction of decentralized intranet access. RESULTS: A total of 168 physicians filled out at least one phase of the questionnaire, among whom 123 (73%) filled out both phases. Use of MEDLINE significantly increased in 1997 (average of 10.2+/-1.1 searches in three months) versus 1996 (average of 4.9+/-0.7 searches in three months, P<0.0001). The aim of searches changed, becoming significantly more care oriented in phase II (P<0.0001). The number of searches performed by the physicians alone increased (P<0.0001) and searches performed by the librarian decreased (P<0.0001) in phase II. The method of searches also changed, as searches by author (P< 0.0001), by journal (P = 0.0042), and by free word (P = 0.0027) increased in phase II. Knowledge of the following concepts of MEDLINE significantly increased: explosion (P<0.0001), scope note (P<0.0001), Abridged Index Medicus (AIM) journals (P<0.0001), Medical Subject Headings (MeSH) qualifier (P<0.0001), and focus (P<0.0001). CONCLUSION: A decentralized intranet access to MEDLINE increased the number of searches and knowledge of this bibliographic database. MEDLINE intranet access modified the purpose and the methods of searching.

CD-ROM↗
PubMed2000

Resource allocation and budgetary mechanisms for decentralized health systems: experiences from Balochistan, Pakistan.

This paper identifies key political and technical issues involved in the development of an appropriate resource allocation and budgetary system for the public health sector, using experience gained in the Province of Balochistan, Pakistan. The resource allocation and budgetary system is a critical, yet often neglected, component of any decentralization policy. Current systems are often based on historical incrementalism that is neither efficient nor equitable. This article describes technical work carried out in Balochistan to develop a system of resource allocation and budgeting that is needs-based, in line with policies of decentralization, and implementable within existing technical constraints. However, the development of technical systems, while necessary, is not a sufficient condition for the implementation of a resource allocation and decentralized budgeting system. This is illustrated by analysing the constraints that have been encountered in the development of such a system in Balochistan.

Budgets↗
PubMed2000

[Health care reform, decentralization, prevention and control of vector-borne diseases].

Economic policies are changing Latin American health programs, particularly promoting decentralization. Numerous difficulties thus arise for the control of endemic diseases, since such activities traditionally depend on vertical, and centralized structures. Theoretical arguments in favor of decentralization notwithstanding, no such tradition exists at the county level. The lack of program expertise at peripheral levels, intensive staff turnover, and even corruption are additional difficulties. Hence, the simple bureaucratic transfer of activities from the Federal to county level is often irresponsible. The loss of priority for control of endemic diseases in Latin America may mean the inexorable extinction of traditional control services. Malaria, dengue fever, and Chagas disease programs are examples of the loss of expertise and effectiveness in Latin America. A better strategy for responsible decentralization is required. In particular, a shared transition involving all governmental levels is desirable to effectively modernize programs. Maintenance of regional reference centers to ensure supervision, surveillance, and training is suggested.

Animals↗
PubMed1998

Determination of intraocular lens tilt and decentration using simple and rapid method.

PURPOSE: To determine the tilt and decentration of implanted intraocular lens (IOL) in vivo one year postoperatively. METHODS: A retrospective study was performed on 67 eyes by the method introduced by Guyton using the third and fourth Purkinje imagesm through undilated pupil. RESULTS: The average decentration of implanted IOL was 0.68 mm, and the average tilt was 6.03 degrees. The result was similar to the histopathological study in postmortem eyes and the measurement in vivo. Linear-regression analysis showed there was no relationship between the tilt and decentration and the residual astigmatism, axial length, IOL power, etc. CONCLUSION: The result is similar to the other methods. The method using the third and fourth Purkinje images is simple and easy to perform. It can be used for determining the IOL position through undilated pupil and does not require special apparatus.

Adult↗