Fair space for life: A dynamic care monitor working up to growth and flourishing for all.

BACKGROUND: Mental health disparities persistently cause inequity and social exclusion. Extensive research underpins the need to embrace the social determinants of health and facilitate network learning at various ecosystem levels. Despite valuable quality frameworks and ratified conventions, local practices which counter health inequity are scarce. METHODS: The Dutch HOP-TR study collected health and needs of Homeless Service Users (HSU) in a rights-based, transdiagnostic, recovery framework. We assessed the survival modes and conducted a socio-ecological analysis, exploring what happened in care pathways at three ecosystem levels: individual HSU, caregiver networks, society. While documenting vital conditions for growth and citizenship, we explore major opportunities to develop 'fair space for life'. RESULTS: Under low distress levels, prosocial behavior is prominent (32.9%). High distress levels are found with an avoidant (42.0%) or aggressive mode (24.9%). Rising distress levels give more frictions in relations, psychiatric admissions, and police-justice contacts. The distress-induced descent in the social hierarchy causes social withdrawal, alienation, and marginalization. At society level, fair conditions for growth and citizenship are challenged by the cumulative impact of distress over the HSU' lives. DISCUSSION: This care monitor uncovers the impact of distress on caregiver interactions. The care pathways reveal that the survival strategies reflect a systematic, pervasive neglect. Unfair representations hold HSU personally responsible of their situation, disregarding the cumulative impact of environmental conditions over their lives. The diverse sources of unfairness are intrinsic to the health care system and culture. Therefore, the survival modes ask for profound culture transformations in a whole-system-whole-society approach. CONCLUSION: Given the need for action on health equity and the social determinants of health, this paper provides an example of a dynamic care monitor. The actionable data elicit dialogs and stimulate to enrich opportunities for inclusion and growth in communities and societies.

Vital Needs of Dutch Homeless Service Users: Responsiveness of Local Services in the Light of Health Equity.

BACKGROUND: Healthcare and social services aim to ensure health equity for all users. Despite ongoing efforts, marginalized populations remain underserved. The Dutch HOP-TR study intends to expand knowledge on how to enable the recovery of homeless service users. METHODS: A naturalistic meta-snowball sampling resulted in a representative sample of homeless services (N = 16) and users (N = 436). Interviews collected health and needs from user and professional perspectives in a comprehensive, rights-based ecosystem strategy. We calculated the responsiveness to needs in four domains (mental health, physical health, paid work, and administration). RESULTS: Most service users were males (81%) with a migration background (52%). In addition to physical (78%) and mental health needs (95%), the low education level (89%) and functional illiteracy (57%) resulted in needs related to paid work and administration support. Most had vital needs in three or four domains (77%). The availability of matching care was extremely low. For users with needs in two domains, met needs ranged from 0.6-13.1%. Combined needs (>2 domains) were hardly met. CONCLUSIONS: Previous research demonstrated the interdependent character of health needs. This paper uncovers some causes of health inequity. The systematic failure of local services to meet integrating care needs demonstrates the urgency to expand recovery-oriented implementation strategies with health equity in mind.

Health Patterns Reveal Interdependent Needs of Dutch Homeless Service Users.

Background: Homelessness is an increasing problem in Western European countries. Dutch local authorities initiated cross-sectional reviews to obtain accurate health and needs information on Homeless Service (HS) users. Methods: The Homeless People Treatment and Recovery (HOP-TR) study uses a comprehensive assessment strategy to obtain health data. Using a naturalistic meta-snowball sampling in 2015-2017, 436 Dutch HS users were assessed. The lived experience of HS users was the primary data source and was enriched with professional assessments. The InterRAI Community Mental Health questionnaire and "Homelessness Supplement" provided information in different areas of life. The approach for mental health assessments was transdiagnostic. Raw interview data were recoded to assess health and needs. The positive health framework structured symptomatic, social, and personal health domains relevant to recovery. Results: Most subjects were males, low educated, with a migration background. The majority were long-term or intermittently homeless. Concurrent health problems were present in two domains or more in most (95.0%) subjects. Almost all participants showed mental health problems (98.6%); for a significant share severe (72.5%). Frequent comorbid conditions were addiction (78%), chronic physical conditions (59.2%), and intellectual impairments (39.9%). Conclusion: The HOP-TR study reveals significant concurrent health problems among Dutch HS users. The interdependent character of different needs requires an integrated 3-D public health approach to comprehensively serve symptomatic, social, and personal dimensions, required to facilitate recovery.

[Good governance in the Burundi health sector financial reform]. / La bonne gouvernance dans la réforme du financement du système de santé au Burundi.

INTRODUCTION: Burundi introduced free healthcare for children under five and pregnant women in 2006. In 2010, this was linked to the Performance-Based Financing (PBF) approach. This article is designed to identify factors in these health financing reforms that have contributed to good governance in the health sector. METHODS: Six criteria of good governance were used as an analytical framework. Results were derived from official reports and the international literature. RESULTS: The main contributions of these reforms to good governance in Burundi were the separation of functions, transparency in management and a meticulous description of administrative procedures. Scrupulous monitoring resulted in several corrective measures. DISCUSSION: Several unresolved questions remain, concerning the integration of vertical programmes and the sustainability of the system given the considerable costs, since funding is not yet fully ensured by the State and its partners.

Relationship of patient volume and service concentration with outcome in geriatric rehabilitation.

OBJECTIVE: Although geriatric rehabilitation (GR) is beneficial for restoration of activities and participation after hospitalization of vulnerable older persons, little is known about the optimal organization of care of these postacute facilities. This study examines the relationship of patient volume and service concentration with successful GR (short length of stay and discharge home) in skilled nursing facilities (SNFs). DESIGN: A national multicenter retrospective cohort study. SETTING AND PARTICIPANTS: All patients indicated for GR in a Dutch SNF. MEASUREMENTS: Nurses filled out digital registration forms from patient records. Patients were studied in 3 predefined diagnostic groups: total joint replacement, traumatic injuries, and stroke. Facility characteristics were obtained by structured telephone interviews with facility managers. Volume was based on the number of discharges in a 3-month period and categorized in low-, medium-, and high-volume facilities. Concentration was defined at the organizational level in which the population consists of 80% or more of 1 or 2 diagnostic groups, with the prerequisite of having a minimum of 10 rehabilitation beds. RESULTS: From 88 facilities, 2269 GR patients (mean age 78.2 years [SD 9.7]; 68.2% female) were included. The median length of stay in the SNF was 45 days (interquartile range 23-81), 57% of the patients were discharged home, and 9.8% died during GR. Of patients with total joint replacement (n = 501), concentration was related to successful rehabilitation (odds ratio 5.7; 95% confidence interval 1.3-24.3; P = .020, adjusted for age and gender); this relationship was not found for patients with traumatic injuries or stroke. Volume showed no relation with successful rehabilitation in any of the 3 diagnostic groups. CONCLUSION: This study may indicate that concentration in an SNF, as a proxy for specialization, favors successful GR in total joint replacement. This relationship was not found for the traumatic injuries or stroke groups, or for volume. The relation on functional outcome in GR needs further investigation.

Performance-based financing experiment improved health care in the Democratic Republic of Congo.

In some low-income countries such as Cambodia and Rwanda, experimental performance-based payment systems have led to rapid improvements in access to health care and the quality of that care. Under this type of payment scheme, funders--including foreign governments and international aid programs--subsidize local health care providers for achieving certain benchmarks. The benchmarks can include such measures as child immunizations or childbirth in a health facility. In this article we report the results of a performance-based payment experiment conducted in the Democratic Republic of Congo, which is one of the poorest countries in the world and has an extremely high level of child and maternal mortality. We found that providing performance-based subsidies resulted in lower direct payments to health facilities for patients, who received comparable or better services and quality of care than those provided at a control group of facilities that were not financed in this way. The disparity occurred despite the fact that the districts receiving performance-based subsidies received external foreign assistance of approximately $2 per capita per year, compared to the $9-$12 in external assistance received by the control districts. The experiment also revealed that performance-based financing mechanisms can be effective even in a troubled nation such as the Democratic Republic of Congo.

Performance-based financing and changing the district health system: experience from Rwanda.

Evidence from low-income Asian countries shows that performance-based financing (as a specific form of contracting) can improve health service delivery more successfully than traditional input financing mechanisms. We report a field experience from Rwanda demonstrating that performance-based financing is a feasible strategy in sub-Saharan Africa too. Performance-based financing requires at least one new actor, an independent well equipped fundholder organization in the district health system separating the purchasing, service delivery as well as regulatory roles of local health authorities from the technical role of contract negotiation and fund disbursement. In Rwanda, local community groups, through patient surveys, verified the performance of health facilities and monitored consumer satisfaction. A precondition for the success of performance-based financing is that authorities must respect the autonomous management of health facilities competing for public subsidies. These changes are an opportunity to redistribute roles within the health district in a more transparent and efficient fashion.