1) The document summarizes preliminary findings from a process evaluation of the Salud Mesoamerica Initiative (SMI) which aims to strengthen health systems in Mesoamerica.
2) Key findings include that SMI has improved health facility management, logistics and medical supply availability, information systems, and human resource training.
3) SMI also influenced policies by changing conversations to focus on results and accelerating policy approval processes in Chiapas, Mexico. However, stakeholders disagreed on whether SMI adequately prioritized the poor.
April 18, 2018
Decision aids can be highly-effective tools to promote shared decision making and support patients in becoming engaged participants in their healthcare. Join us for the first-ever convening with leaders behind a Washington experiment in certifying decision aids, as state officials, health systems, and on-the-ground implementation experts share lessons learned and discuss policy recommendations for national or statewide approaches to decision aid certification.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/decision-aids-for-patients-with-serious-illness
Sills MR. Overview of the SAFTINet Program. Presented to the Emergency Department Research Committee, Department of Pediatrics, University of Colorado School of Medicine. 6 January 2015.
April 18, 2018
Decision aids can be highly-effective tools to promote shared decision making and support patients in becoming engaged participants in their healthcare. Join us for the first-ever convening with leaders behind a Washington experiment in certifying decision aids, as state officials, health systems, and on-the-ground implementation experts share lessons learned and discuss policy recommendations for national or statewide approaches to decision aid certification.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/decision-aids-for-patients-with-serious-illness
Sills MR. Overview of the SAFTINet Program. Presented to the Emergency Department Research Committee, Department of Pediatrics, University of Colorado School of Medicine. 6 January 2015.
ODF III - 3.15.16 - Day Two Morning SessionsMichael Kerr
Slide presentations delivered during morning sessions of Day Two of the California Statewide Health and Human Services Open DataFest - March 14 - 15, 2016, Sacramento, CA
PIHCI programmatic grants webinar (en) for circulationAlexandra Enns
These are the slides from CIHR’s webinar providing information for the upcoming PIHCI Network Programmatic Grant funding opportunity.
The complete instructions are on ResearchNet: https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2734&view=currentOpps&org=CIHR&type=EXACT&resultCount=25&sort=program&next=1&all=1&masterList=true
Network physicians, hospitals, and other care continuum providers work collaboratively in active clinical process improvement programs across service lines and specialties to define, establish, implement, monitor, evaluate and periodically update the processes of:
- Evidence-based medicine
- Beneficiary engagement
- Care coordination
- Conservation of healthcare resources
- Clinical data reporting
Health information system is that that system in which collection, utilization, analysis and transmission of information is done for conducting health services, training and research.
Quality improvement is integral to the practice of medicine. Sometimes, QI strays over into clinical research. This presentation provides an overview of the intersection between QI and research
ODF III - 3.15.16 - Day Two Morning SessionsMichael Kerr
Slide presentations delivered during morning sessions of Day Two of the California Statewide Health and Human Services Open DataFest - March 14 - 15, 2016, Sacramento, CA
PIHCI programmatic grants webinar (en) for circulationAlexandra Enns
These are the slides from CIHR’s webinar providing information for the upcoming PIHCI Network Programmatic Grant funding opportunity.
The complete instructions are on ResearchNet: https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2734&view=currentOpps&org=CIHR&type=EXACT&resultCount=25&sort=program&next=1&all=1&masterList=true
Network physicians, hospitals, and other care continuum providers work collaboratively in active clinical process improvement programs across service lines and specialties to define, establish, implement, monitor, evaluate and periodically update the processes of:
- Evidence-based medicine
- Beneficiary engagement
- Care coordination
- Conservation of healthcare resources
- Clinical data reporting
Health information system is that that system in which collection, utilization, analysis and transmission of information is done for conducting health services, training and research.
Quality improvement is integral to the practice of medicine. Sometimes, QI strays over into clinical research. This presentation provides an overview of the intersection between QI and research
Verbal autopsy interviews were conducted with caretakers for all deaths of children under the age of 5 in Yucatán, Mexico during 2015-2016. Results from the verbal autopsy were triangulated with data from vital registration systems and medical records to check for concordance at both the individual and population level. Findings suggest that overall the vital registration system for deaths of children under 5 is strong, however concordance between vital registration systems and medical records varies based on cause of death and age of the deceased (neonatal vs. child). This presentation summarizes methods and results for the quality of mortality statistics analysis and was presented at the 2019 Instituto Nacional de Salud Public Conference in Cuernavaca, Mexico in March 2019.
The first phase of the “Under-5 Child Health and Mortality Statistics Project” sough to strengthen the evidence and understanding of key factors related to under-5 mortality in Yucatán, Mexico using Verbal Autopsy data collection tools with an added battery on search for care processes for U5 deaths which occurred in Yucatán during 2015-2016, and the triangulation of Verbal Autopsy reports with data from vital registration systems and medical records. This presentation, presented to stakeholders at a results dissemination workshop in October 2017 in Mérida, Yucatán, provides an overview of the project and summarizes key results and learnings from the research.
The second phase of the “Under-5 Child Health and Mortality Statistics Project” sough to strengthen the evidence and understanding of key factors related to under-5 mortality in Yucatán, Mexico through the implementation and evaluation of both community and facility-based interventions, aimed at improving recognition of alarm signs among mothers and caretakers for common causes of death in children and improving the quality of cause of death certification for deaths of children under 5, respectively. This presentation, presented virtually to stakeholders at a results dissemination workshop in January 2021, provides an overview of the project and summarizes key results and learnings from the research.
The Prospective Country Evaluation is an embedded mixed-methods evaluation platform designed to examine the Global Fund business model, investments and contribution to disease program outcomes and impact in eight countries. Findings were synthesized across the 8 countries to provide timely and actionable recommendations to support program improvements and accelerate progress towards the objectives of the Global Fund 2017-2022 Strategy.
Published in The Lancet in November 2018, GBD 2017 provides for the first time an independent estimation of population, for each of 195 countries and territories and the globe, using a standardized, replicable approach, as well as a comprehensive update on fertility. GBD 2017 incorporates major data additions and improvements, using a total of 68,781 data sources in the estimation process.
In “Measuring human capital: a systematic analysis of 195 countries and territories, 1990–2016” IHME provides the first internationally comparable index of human capital. Building on past efforts, the study offers a measure of expected human capital that incorporates educational attainment, education quality or learning, functional health status, and survival for 195 countries, from 1990 to 2016.
“Follow the money” in order to better understand the framework for global health governance: this presentation by Dr. Tim Mackey employs IHME-coordinated research while teaching the evolution of global health financing.
SM2015 is an ambitious project with the Ministry of Health and local support. This presentation outlines the design and activities around the data collection and analysis of the evaluation, as well as the results, conclusions, and future activities.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Salud Mesoamerica Process Evaluation: Evidence on Culture Change in Health Systems
1. Salud Mesoamerica Process Evaluation
Evidence on Culture Change in Health Systems
Charbel El Bcheraoui, PhD, MSc
Assistant Professor,
Institute for Health Metrics and Evaluation,
Seattle, WA, USA
Ali Mokdad, PhD
Director, Middle Eastern Initiatives
Professor, Global Health
Institute for Health Metrics and Evaluation,
Seattle, WA, USA
6 October 2016
3. SMI Initial Results - Chiapas
• Tremendous improvement in
supplies from baseline to 18-
month, to 24-month
measurements
• Performance targets were
not met at first follow-up in
Mexico, but were achieved
when given extra time
Mexico indicator for basic child care
Baseline (%)
18-Month
(%)
24-Month
(%)
7.3 40.7 100
Equipment 27.3 64.4 100
Pediatric scale/salter scale 70.9 81.7 100
Child scale/salter scale 52.7 98.3 100
Height rod 69.1 100 100
Pediatric stethoscope 38.9 50 100
Stethoscope 60 100 100
Pediatric blood pressure apparatus 22.2 50 100
Digital/mercury thermometer 97.3 95.6 100
Growth & development card/National
vaccination
card/National health card (0-9 years old) 97.3 100 100
Vaccines1
26.9 29.6 100
Pentavalent (DPT + HepB + Hib) 73.1 59.3 100
MMR 80.8 88.9 100
Rotavirus 73.1 81.5 100
Pneumococcal conjugate 34.6 40.7 100
BCG 69.2 48.1 100
Pharmacy inputs 40.4 88.3 100
Oral rehydration salt/serum 75 100 100
Ferrous sulfate drops/micronutrients 57.7 90 100
Albendazole/mebendazole 76.9 100 100
Antibiotics 76.6 98 100
Ringer's lactate/Hartmann's solution/
saline solution 31.3 100 100
1Only applicable to facilities that store vaccines
3
4. Need for process evaluation
• Unexpected findings to explain
• Crucial design topics not explored
• Inability to assess certain topics quantitatively
• Basically, the “How” and “Why” questions
4
5. Process Evaluation Questions
• SMI influential components
o Use of information
• SMI contribution in the performance of health systems
o Technical assistance
• SMI contribution to the visualization and prioritization of the poor
o Policy dialogue model
• SMI vs. other financing or intervention models
o SMI Design
• Effects of specific interventions and possibility of scale-up
o Sustainability
5
10. SMI-generated Information is used for different
purposes
• Having a baseline to acknowledge the health status of the population
• Making decisions regarding SMI implementation
• Continuous monitoring of improvements and delays and taking corrective actions
• Evaluating the effectiveness and real impact of the initiative
• Providing accurate data to measure quality of services and countries data
• Dissemination of the information as feedback to stakeholders
• Sharing evidence through scientific articles
• Improving a culture of using information to take decisions
• Using the information for internal learning purposes
SSA members believe that the state and IDB are the main users of SMI data and the data
are not being used by the federal level which has its own indicators and sources of data.
10
11. External evaluation valued by all stakeholders
• In general, there is not trust on accuracy and timeliness of the health system information
data and an independent evaluation is necessary.
• Donor organizations have been a huge consumer of the external evaluative surveys
• IHME provides easy access to original data through solid household and health facilities
surveys
• The most important decisions were based on external evaluation baseline data. The
federal level found some facts about the vaccination coverage and detected weak points
of the cold chain.
• The results of external evaluation were used to set political priorities and helped in
negotiation with the Senate to modify the national health law in terms of vaccination.
11
12. Examples of use of
information
Jurisdictional
warehouses storage
conditions for
medications and
inputs; a revision
after decades
A research in Chiapas
on vaccine potency
(assessment of dried
blood spot): effect on
cold chain and
immunization policies
Time-bound
assessment of
maternal deaths in
Chiapas; installation
of a specific center
(not limited to SMI)
Data from Nicaragua:
challenge of service
coverage gap vs.
quality of care and its
impact on second
operation
Sharing experience at
regional level;
Putting SMI as an
integral part of the
MoH programs in
Guatemala
Local solutions: Some
remote villages went
together to send
someone to the
capital to sort out
commodities
12
13. Improved practices due to knowledge shared
• SMI has facilitated knowledge sharing at all levels: between
countries, states, jurisdictions
• Quality improvement methods that are applied within SMI areas are
being transferred to other areas
• The capacity to draw lessons from and benchmark against other
countries is valued; Chiapas respondents mention reading
newsletters about other countries’ implementation and using
lessons learned
• Regional learning events have been memorable and impactful for
participants; shared ideas such as maternal waiting homes were
shared by respondents from multiple audiences
13
15. Increased role for IDB from fiduciary to technical
• The coordination unit’s role changed from an intermediary between
the bank and the donors, to a pivotal one in organizing and
structuring the technical assistance to support countries in their
operations
• They are perceived as flexible and adaptive to the local context,
where their in-depth analyses of problems has been useful.
• Federal ministry of health respondents, whose attentions are split
between Mexico’s 31 states, valued the local coordination unit
• Chiapas representatives see the technical assistance from IDB as a
great help.
15
16. Improvements were introduced at an appropriate pace
• “You could ask me why I haven’t told you that earlier. You know, it’s
because it was too much. We have been building the whole- since
the start of the initiative, we have been progressively introducing
different tools, according to our opinion, where maturity is good
enough to do so. Yeah? Even though we have that risk management
tool and plan during the design and updated every six months, we
knew it was already too much. And we have to pick our battles.
Every time.”
16
17. MSH is perceived as an essential factor in
strengthening the health system
• MSH provides technical assistant to the Ministries of Health through
SMI
• The focus of their role has evolved from inputs to service delivery
• Seen as successful in improving hospital processes and bringing
alignment between norms and implemented processes
• Collaborative entities who exchange ideas and solve problems,
rather than imposing orders
• Despite the strengths of MSH, the sociopolitical environment of
Chiapas is noted as a barrier to their success
17
18. Health facility management
• SMI has contributed to standardization, the introduction of new
policies, and the increased use and enforcement of protocols at
health facilities
o increased efficiency of internal emergency alert systems (specifically,
when an obstetric emergency is detected)
o Increased organization while applying existing protocols
o implementation of zero rejection policy (for all pregnant women)
o increased use of clinical practice guidelines
o Standardization of staff protocol and procedures from paperwork to
patient intake
18
19. Health facility management
• Consensus that communication has increased and collaboration has
improved at many levels due to SMI
o Increased communication between the staff, the directors, and Mesored
o More contact with the municipal government
o Increase of evidence-based decision making
─ Decision making has become more inclusive and a team based process
• Health facilities note patient-oriented changes in facility management
o Active follow up with patients that miss appointments
o Cultural adapted service provision
o Community outreach
19
20. Logistics and medical products
• General agreement that the increased availability of supplies and
equipment has led to improved operations and processes
o Appropriate equipment directly affected quality of service provision
o New equipment allowed staff to refine skills when dealing with
complicated pregnancies
o Additional materials led to updated procedures
• SMI focus on supplies has increased responsiveness towards health
facility needs/requests
o The majority of informants note more timely responses from ISECH/
Jurisdiction for material requests
20
21. Human resources
• Increased quality and frequency of trainings is well received and
seen as having a direct impact on health system strengthening
o Increased focus on attention protocols and use of flow charts
o Increased knowledge of topics such as family planning, child care, and
postpartum care is perceived to have led to better quality service and a
reduction of deaths/complications.
o Staff self-assessments are now used to track staff progress
• Better defined roles of staff and use of attendance lists have
increased frequency and quality of communication and distribution
of activities
• Increased involvement of jurisdiction to provide human capital
21
22. Human resources
• Though improvements seen, lack of human resources remains a key
issue in Chiapas and is frequently noted as a barrier to improved
health services in the region
o Lack of personnel and specialists continue to prevent some
facilities from effectively reaching their indicator goals and
increasing patient wait times significantly
o Current staff is being stretched across many tasks
o Understaffing, high volume/frequent turnover, and lack of
protocol knowledge has led to patient dissatisfaction
22
23. Information Systems
• Significant improvements and increased use of registries
• Improved documentation of processes, reorganization of services
and human resources
• Implementation of vaccination program with increased record
keeping
• Record keeping trainings led to better materials management and
reduction in stock-outs
• Increased use of management tools, such as a patient database, led
to better informed and more precise decision making in regards to
corrections, improvements, and healthcare risk assessments
23
25. SMI changed the conversation around policies
• SMI has created new discussions around policies in Chiapas, although
some believe they have been in a limited sector within ISECH
• Conversation has changed to a result-based conversation
• Most of the affected policies are cited at the operation level; in the mid-
level, existing policies are being put to operation
• Opinions of SSA staff were generally different with other groups
o They do not feel a policy change and think that SMI has aligned to the
health policies of the Federal Ministry of Health. At the state level,
however, the care quality has been improved.
25
26. Policy changes in Chiapas
• The general approach has been changed from an immediate response
approach to planning with a preventative approach
• Policies which have been developed, amended, and implemented or
have been reinforced due to SMI, include:
o Installation of logistic unit for formal follow-up to supply medical units
o Quality management and continuous quality improvement brought to the
level of the general management
o Managerial information system
o Monitoring or accountability system
o Approval of the CONE strategy
26
27. Faster policies process in Chiapas
• SMI made all the approval processes of policies reportedly faster
o In addition, it created new needs such as quality improvement
─ This was not a big need until SMI.
• IDB developed a methodology for the State to estimate their inputs to
program the acquisitions for the next year
o ISECH applied the methodology to maternal and child health and everything
in the health centers, hospital level, and even the blood banks
• SSA interviewees believe what SMI processes is similar to the previous
processes; there were some changes at the Chiapas State level, but not
at the federal level.
27
28. Disagreement among respondents whether SMI
contributed to the prioritization of the poor
• Some of the interventions (Zinc supplement for management of
diarrhea) are not pro-poor by themselves, but mainly affect the poorest
populations
• Even though the country and state know where the poorest regions are,
they do not know what their needs are
o SMI helped identify these needs
• The main difficulty or weakness cited from SSA is that to have a real
impact, SMI cannot only happen only in one state or 30 municipalities
28
30. Original timeline shorter than needed or expected
Times for measurements, negotiations, and preparation for following
operations was not totally accounted for. In result, more time was
given for countries to change was they do business
30
31. SMI goals aligned with National Health Plans
• SMI goals fit under MDGs and hence under national health plans to
reduce maternal and child mortality
o National health plans include everything
o Timelines misaligned as SMI continued beyond 2015
─ SDG include maternal and child mortality as well
• In Mexico, while the initiative is aligned with country priorities,
stakeholders at the State level found that the design did not account
for possible social and political difficulties like the ones faced during
first and second operations
o Nevertheless, this risk is accounted for in the risk management plans
and accepted as one that can’t be mitigated
31
32. The RBF model held countries accountable
• It is the defining factor that makes this initiative different from
others and it creates an additional stimulus to achieve results
• It provides a learning platform and the fact that there will be
consequences holds actors accountable
• It forces the mobilization of decision-makers around this financing
• The measurement component promotes continuous monitoring of
pre-established and well-defined goals
32
33. The regional model promoted competition
• “Though not a lot of money from SMI, being measured and fear of
failing is a big motivator for the country and it pushes everybody to
start mobilizing. We mobilize everybody in terms of this objective
and this goal. It's like we are taking an exam and we want to pass"
• “The fact that it is RBF on a regional scale adds a lot of pressure to
achieve results and to not look bad”
• Specifically for Chiapas, competition will be stronger for the second
operation with focus on service delivery
33
34. Caveats during design stages improved from first to
second operation
• Stakeholders engaged down to the State level at the appropriate
stages, but:
o Engagement of local level players was weaker in first, compared to
second operation
o Needs assessment relied on barriers studies and workshops attended by
subject matter experts from participating countries
─ More frequent assessments, including this process evaluation
─ Human resources capacity to implement were reportedly assessed but
informants are in disagreement whether the assessment was accurate
» High staff turnover cited as an issue not taken into account
34
35. Not all stakeholders had equal power in decision
making at al stages
• Deferment of decision-making from SSA to ISECH is seen as the decision to
not decide, to not take part
• Ultimately it was up to ISECH and IDB to make decisions about the
operation in Chiapas
o The country team submitted the operational design for review by a central
IDB review board and other experts.
o The IDB produced a revised version of the proposal including their
comments and recommendations, and submitted it to the Donor Committee
• Few respondents from initial stages of SMI felt that it was not an equal
partnership between IDB and Chiapas to design the operation, but that IDB
was often imposing from above and trying to force policy changes
o Current stakeholders from Chiapas see an equal relationship with IDB
35
37. Sustainability of changes is possible
• Constant changes in governance impacts public employees at all
levels, all the time.
o This risk is seen as a barrier to sustainability, as priorities are re-
evaluated and knowledge is lost with each shift
o Hard work on technical assistance side (PCU)
─ Active engagement of newly appointed leaders and key stakeholders
• However, policy changes due to SMI are a lasting legacy of the
initiative
• Potentially sustainable changes include accountability,
communication, improved culture of service provision, and close
monitoring and data use at the local level
• Mexico proved willing to fund programs between 1st and 2nd
operation
37
38. Root cause analysis: sustainability of changes due to
SMI
38
Shortage in
human
resource
quantity and
specialists
Improved
quality in
human
resources
Stronger
facilities in
most SMI
areas
Use of
evidence in
decision
making
Between-
country
competition
environment
Continued
monitoring
and
evaluation
SMI as a
regional
model
SMI as a
results-based
aid model
SMI as a policy
dialogue
model
Availability
of supplies
Better health
services
Improved
processes
Technical
assistance Availability
of evidence
New and modified
policies
Need to meet
indicators
Start of a reform
of health
systems
Birth of a
culture of
accountability
Increased demand
from SMI and non-
SMI areas
Longer implementation and
planning time allowing for
changing habits in health
system
Times for measurements,
negotiations, and preparation
for following operations not
well accounted for
Application of newly-
introduced
approaches from SMI
to non-SMI areas
Positive environment for
sustainability of changes
introduced by SMI
Root cause
Obstacle
Context
Consequence
Success
39. Exit plans following SMI are underway in Mexico
• At the local level, the plan is to continue shifting responsibility over
communication, monitoring, and information processes from the
SMI project coordinating unit and MSH to the country
• Federal respondent feels that Mexico will continue to invest in SMI
programs and areas once SMI has ended
• As suggested by a key informant: “Economists have a saying that
“Policy without budget is poetry.” And I think in a way that co-
financing is an attempt to try to put – ministries all have policies
about getting services into the most disadvantaged areas. But in a
way, this actually forces them to put skin in the game and put money
there.”
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40. Country perspectives on SMI
• SMI is seen as extremely aligned with country priorities to reduce
maternal and child mortality and aim for the MDGs/SDGs
• The initiative empowers countries to revamp existing programs and
revisit adherence to existing health norms and policies
• Many norms, standards, and policies have been directly affected by
SMI, including for the use of micronutrients for children in
Honduras, the treatment of adolescents in Costa Rica, and the
reorganization of service platform levels (the EONC strategy)
• SMI provides a platform for learning and generating new evidence
for health strategies
40
41. In Summary
• Greatest strengths
o SMI is well perceived by countries
─ Making a huge difference in health systems in the area
─ Many lessons for outside donors and global health in general
o Culture of accountability born in many of participating countries
o Beyond knowledge: wisdom in decision making
o Sustainability through policies, scale-up, and spillover
o Drivers of success: regionality, RBF, use of information, and technical
assistance
• Weaknesses and room for improvement
o Local politics: social, institutional, systemic
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42. Next Steps
• Convergence of findings between quantitative and qualitative data
• Qualitative methods were valuable in complementing the
quantitative ones
o Explained many of the “Hows” and “Whys”
o Also uncovered new fields for investigation
o Will benefit the next rounds of surveys
• Need for process evaluations in remaining countries to account for
their particularities
• Major implication on IHME
o Pragmatic mixed-methods evaluations
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45. Multilevel contextual factors slowed Chiapas from
meeting targets in first round
• Change in government caused delays in implementation
o Government shifts caused immense delays in the operation and delays
in access to funds
─ Similar situation for the second operation
o Short period of time between start of implementation and
measurement
• Political instability/political upheaval
o Difficulty to operate with such high turnover
• Less than optimal support from federal to state level
• An information problem/ weakness in the supply chain and the
delays in both procurement and distribution
• Evaluation challenges / all-or-nothing indicators
45
46. Lessons learned from first operation
• Better communication was needed
o Health care staff need to know what the indicators are and what is expected
of them
o The initiative involves working as a team and not in silos or isolation
o Need to continuously strive and to plan well so that there's no rush at the
last minute
• Stronger support from the federal level was needed
• Community involvement and accountability and the role of social factors
are key to success
o The culture of the indigenous people must be integrated into the initiative
• Donors feel that transparency around results is crucial and that the
targets may have been too high
46
47. Changes during the improvement plan
• Positive aspects:
o Communication improved across all levels in the country – federal, state,
jurisdiction, all the way to health care providers
o Banners were placed everywhere and information better known
o IDB provided technical assistance for internal monitoring
o Changes to supply logistics
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48. Changes during the improvement
• Negative aspects:
o State level acknowledged that this was not a sustainable process – especially
in regard to supply and stocks being prioritized
o May have detracted focus away from other health areas and jurisdictions
during this push for success
o Disagreement amongst donors - some still feel that letting Chiapas and
Guatemala move forward despite not having the requisite equipment in time
is setting the second operation up to fail
48
49. Delays and bottlenecks in the availability of funds and
financial flows (KIIs, C)
There was an almost general agreement between different groups of interviewees
(except some of the SSA members) about the presence of delays and bottlenecks in the
availability of funds and financial flows.
Donors
• Donor organizations: Delays due to internal decision making and audit processes at donor organizations;
Spain government failure to provide committed fund
Donor-
IDB
• Donor-IDB: The necessity of including a highly bureaucratic organization such as IDB between the donors and
the Chiapas government;
IDB
• IDB: The necessity of changing Mexico’s 2009-2010 budget law to make the contribution of CSF possible
(donations from philanthropic organizations to other countries)
Federal
MoF
• Federal level, Ministry of Finance: Lack of trust in government to handle the resources; Delay in audit and
approval process from the Federal government to the State level;
State
MoF
• State level, Ministry of Finance: Social unrest and financial deficit in the State; Non-straight forward and
uneasy access to Federal funds
ISECH
• ISECH: Complexity of the process of allocation of international funds to ISECH through the Ministry of Finance
JD
• Jurisdictions: Complexity of the process in the local bank such as opening a specific account and signature
verification
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50. Data Analysis
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1. Transcribe data
2. Group transcribed data by topic
a. Data can be used to answer more than one topic and in these cases are
grouped in both sections
3. Highlight essential portion of each comment
4. Remove portions of comment not relevant to topic at hand
5. Keep code-like sentences for the answers provided
6. Write narrative according these codes with a focus on
a. Agreement of different audiences on responses
b. Level of shared knowledge on same topics or themes by different audiences
c. Agreement between responses from KIIs and document review
7. Compare and interpret information from different groups and
stakeholders
51. Design: Sequential Explanatory/Exploratory
QUAN qual
QUAN
Data
Collection
QUAN
Data
Analysis
qual
Data
Collection
qual
Data
Analysis
Interpretation of
entire analysis
QUAL quan
QUAL
Data
Collection
QUAL
Data
Analysis
quan
Data
Collection
quan
Data
Analysis
Interpretation of
entire analysis
51
53. Document Review (DR)
• Operational plans
• Proposal documents from Mexico, including meeting minutes,
approval letters, and requests for clarification
• Budget documents and expenditure reports for Mexico
• SMI cost-benefit analysis for indicator and target setting
• Mexico National Health Norms
• Master plans
• SMI-Chiapas official reports and memos
• Available meeting notes related to SMI in Chiapas and mission
reports
53
54. Key Informants (KIs)
Study Audience* KIs
SMI Donor Representatives 11
IDB/SMI Coordinating Unit + Management Sciences for Health 12
Regional MOH Representatives (outside of Mexico) 9
SSA + ISECH, including Jurisdiction Leaders 21
TOTAL 53
*Key informants include both individuals who are currently involved in the initiative and
individuals who were previously involved, but are no longer in the same position.
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55. Key Informants (KIs)
Study Audience* KIs
Health care providers - SMI 44
Health care providers - non- SMI 12
Midwives 11
TOTAL 67
*All health care providers interviews were in their position for at least two years
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56. Focus Group Discussions (FGDs)*
FGD audience Total FGDs Total Participants
SMI (234) Health committees 4 35
Women with children under 5 17 110
Women without children 7 44
Men 8 45
Non- SMI (56) Health committees 2 10
Women with children under 5 4 26
Women without children 2 11
Men 2 9
TOTAL 46 290
*Data from FGDs not included in the analysis included in this presentation
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