Continuous quality improvement in public health in Ghana: CQI as a model for primary health care management and delivery.

This article describes the context and examines factors influencing the quality of primary health care delivery and management in Ghana, West Africa. It describes the potential of continuous quality improvement as a management philosophy and tool to improve the quality of primary health care delivery and management in Ghana. It compares the Ghanaian context in which the use of continuous quality improvement in health care is new and untried with the developed country context (mainly the U.S.), where continuous quality improvement has a relatively long history of use in health care and is a requirement for the accreditation of health institutions. Finally, the article discusses the steps that have to be taken to translate continuous quality improvement from a theoretical management concept to improve quality of care to an actual managerial intervention in Ghana. In conclusion, continuous quality improvement is shown to be a potential viable approach to improving quality of care in the Ghanaian context and merits further investigation.

China's one-child policy: the economic choices and consequences faced by pregnant women.

This paper addresses the important issue of the effect of China's one-child policy on prenatal and obstetric care utilization. The paper provides the first detailed empirical approach to this question, exploiting a unique high quality household survey. China officially codified a set of rules and regulations in 1979 governing the approved size of Chinese families, commonly known as the one-child policy. The policy imposed economic and social costs on families failing to adhere to the family size limits. In particular, the policy raised the price of obstetric medical services for unapproved pregnancies in comparison to approved pregnancies and imposed fines on families with unapproved births. Using data from an eight-province longitudinal household survey (The China Health and Nutrition Survey), we investigate whether or not the one-child policy's financial penalties were associated with the avoidance of obstetric care by pregnant Chinese women with unapproved pregnancies. The one-child policy variables of particular interest were a dichotomous measure of the approval status of the pregnancy, a continuous measure of the fine imposed upon families with unapproved births, and a continuous measure of the prices of prenatal care and delivery services net of any subsidy available for approved births. The results partially confirm the hypotheses that the one-child policy's economic and social costs caused women to forego seeking modern obstetric care services. The fine was found to be a significant deterrent to the utilization of prenatal care. Additionally, the unapproved-status of a pregnancy was strongly negatively associated with "the use of obstetric care. However, higher prices were not consistently found to be a significant deterrent to the use of obstetric care.

In search of failure: guidelines for ministries of health.

PIP: Experience indicates that while ministries of health presumably seek to improve service delivery and people's health status, they often seem to act as if they are actually trying to fail by providing few and inadequate services and in limiting improvements in health status. In order to assure failure, ministries of health can proceed as follows: select high-sounding, but unattainable goals; assure inadequate funding for the health sector; centralize all decision making; establish an unwieldy management information system; post untrained personnel and move them often; create an illogical organizational structure; assure the ineffective use of supervision; decentralize the administrative structure, but not authority; delegate as little authority over money and people as possible; limit communication; target the relatively well-off; and use donors creatively. Ministries of health which desire to succeed must acknowledge their fundamental system flaws and commit to correct them. No innovative program nor influx of resources will achieve the desired results until a given ministry creates rational policies and procedures as well as a sound organizational structure.^ieng

Performance-based management in local health departments: measuring the success of implementation.

Six of eight local health departments in North Carolina's Southwest Perinatal Region III participated in a PBMS demonstration project also involving the state health department, the Centers for Disease Control, and the School of Public Health of the University of North Carolina at Chapel Hill. In all six counties the problem of reducing prematurity and low birthweight was selected to test this innovation. Using standardized instruments, staff awareness of and concern for low birthweight problems and programs were measured, as was level of success of implementation of PBMS. Factor analysis of three rounds of Awareness and Concern responses produced three uncorrelated factors: awareness of low birthweight problems, awareness of low birthweight programs, and concern for low birthweight. The results suggest that the PBMS increased awareness of the problem and the program, and that the project succeeded in half of the counties, helped some counties achieve some goals, and provided some benefits to some counties. The implications for Total Quality Management are discussed.

Designing clinical protocols for optimal use: measuring attributes of treatment and cancer control trials.

The design of clinical protocols is an important factor in assuring patient accrual and compliance. This paper describes the methods used to assess the attributes of treatment and cancer control research protocols. Measures are presented for assessing three attributes considered important: relative advantage, complexity, and compatibility.

Control and service implementation in drug abuse treatment programs.

The major purpose of this paper is to examine the relationship between control and implementation of drug treatment services while controlling for the structure of the organization. It is based on a study of 19 drug abuse programs in eight counties of North Carolina. The analysis of the data indicates that greater control will not necessarily increase the effectiveness of organization performance; rather, for change to occur, control by professional personnel will have to decrease. This would allow the organization to be more responsive to environmental concerns, and therefore more effective.

Types of changes and hospital planning strategies.

A major purpose of health planning agencies is to promote constructive changes among health institutions that are in the public interest. The approaches to promoting such changes in hospitals are examined in this article. The focus is on three types of change, the relationship of change to the environment, and three kinds of control mechanisms.

Consumer participation and social accountability.

Consumer participation in the planning and management of health care programs is prescribed as a method for increasing provider responsiveness to the goals and needs of users of services. However, issues related to the nature of mandates to implement consumer participation has not had the impact on policy development proposed for it. While structural changes can be identified which might enhance the consumer role in decision making, it will also be necessary for the consumer sector to develop a strategy which will prompt major rather than incremental movement.