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2.  Decentralisation of Health Services in Fiji: A Decision Space Analysis 
Background: Decentralisation aims to bring services closer to the community and has been advocated in the health sector to improve quality, access and equity, and to empower local agencies, increase innovation and efficiency and bring healthcare and decision-making as close as possible to where people live and work. Fiji has attempted two approaches to decentralisation. The current approach reflects a model of deconcentration of outpatient services from the tertiary level hospital to the peripheral health centres in the Suva subdivision.
Methods: Using a modified decision space approach developed by Bossert, this study measures decision space created in five broad categories (finance, service organisation, human resources, access rules, and governance rules) within the decentralised services.
Results: Fiji’s centrally managed historical-based allocation of financial resources and management of human resources resulted in no decision space for decentralised agents. Narrow decision space was created in the service organisation category where, with limited decision space created over access rules, Fiji has seen greater usage of its decentralised health centres. There remains limited decision space in governance.
Conclusion: The current wave of decentralisation reveals that, whilst the workload has shifted from the tertiary hospital to the peripheral health centres, it has been accompanied by limited transfer of administrative authority, suggesting that Fiji’s deconcentration reflects the transfer of workload only with decision-making in the five functional areas remaining largely centralised. As such, the benefits of decentralisation for users and providers are likely to be limited.
PMCID: PMC4770923  PMID: 26927588
Decentralisation; Health Reform; Decision Space; Access to Healthcare; Principal Agent Approach; Fiji
3.  Implementing integrated models of care: the importance of the macro-level context 
Reports of how different countries are responding to the need to develop more integrated health and social care services for older adults can provide useful lessons for other health systems. However an understanding of how the wider structural, political, economic and cultural context affects implementation of these models of care is essential when considering the potential for models to be scaled up or transferred to other jurisdictions.
PMCID: PMC4628506  PMID: 26528094
models of care; older adults; implementation; transferability; policy context
4.  Under the same roof: co-location of practitioners within primary care is associated with specialized chronic care management 
BMC Family Practice  2014;15:149.
International and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice.
We used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions.
We found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25–1.65), hypertension (1.20, 1.03–1.39), and the elderly (1.22, 1.05–1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services.
The care of people with chronic disease is the ‘challenge of the century’. Co-location of practitioners may improve access to services and equipment that aid chronic disease management.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2296-15-149) contains supplementary material, which is available to authorized users.
PMCID: PMC4171578  PMID: 25183554
Canada; New Zealand; Chronic disease; Patient care team; Primary care; Co-location
5.  Selecting long-term care facilities with high use of acute hospitalisations: issues and options 
This paper considers approaches to the question “Which long-term care facilities have residents with high use of acute hospitalisations?” It compares four methods of identifying long-term care facilities with high use of acute hospitalisations by demonstrating four selection methods, identifies key factors to be resolved when deciding which methods to employ, and discusses their appropriateness for different research questions.
OPAL was a census-type survey of aged care facilities and residents in Auckland, New Zealand, in 2008. It collected information about facility management and resident demographics, needs and care. Survey records (149 aged care facilities, 6271 residents) were linked to hospital and mortality records routinely assembled by health authorities. The main ranking endpoint was acute hospitalisations for diagnoses that were classified as potentially avoidable. Facilities were ranked using 1) simple event counts per person, 2) event rates per year of resident follow-up, 3) statistical model of rates using four predictors, and 4) change in ranks between methods 2) and 3). A generalized mixed model was used for Method 3 to handle the clustered nature of the data.
3048 potentially avoidable hospitalisations were observed during 22 months’ follow-up. The same “top ten” facilities were selected by Methods 1 and 2. The statistical model (Method 3), predicting rates from resident and facility characteristics, ranked facilities differently than these two simple methods. The change-in-ranks method identified a very different set of “top ten” facilities. All methods showed a continuum of use, with no clear distinction between facilities with higher use.
Choice of selection method should depend upon the purpose of selection. To monitor performance during a period of change, a recent simple rate, count per resident, or even count per bed, may suffice. To find high–use facilities regardless of resident needs, recent history of admissions is highly predictive. To target a few high-use facilities that have high rates after considering facility and resident characteristics, model residuals or a large increase in rank may be preferable.
PMCID: PMC4118262  PMID: 25052433
Long-term care; Risk assessment; Hospitalization; Health services for the aged; facility selection; Research design
6.  Hospitalizations of nursing homes residents: the role of reimbursement policies 
Factors which contribute to hospitalization of nursing home residents are multiple and complex. They include dimensions of the policy setting as well as patient management practices. In seeking interventions to reduce such hospitalizations, most research has focussed on changing patient management. But provider reimbursement policies may also influence the decision to hospitalize nursing home residents. This includes payments to hospitals and general practitioners as well as to the nursing homes themselves. Differences in payment methods may mean that interventions that work well in one setting do not work well in another.
This is a commentary on
PMCID: PMC3902430  PMID: 24457048
7.  Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol 
In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?
The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.
At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.
PMCID: PMC3311075  PMID: 22353694
Health Policy; Emergency Medicine; Health Services Research; Quality of Health Care; Models; Theoretical; Inequalities
8.  Ladies in waiting: the timeliness of first trimester services in New Zealand 
Reproductive Health  2010;7:19.
Termination of pregnancy (TOP) services are a core service in New Zealand. However, compared to other developed countries, TOP services are accessed significantly later in the first trimester, increasing the risk for complications. The aim of this study is to examine the timeliness of access to first trimester TOP services and establish the length of delay between different points in the care pathway for these services.
Data were collected from all patients attending nine TOP clinics around the country between February and May 2009 (N = 2950). Patient records were audited to determine the timeline between the first point of entry to the health system to the date of termination. In addition, women were invited to fill out a questionnaire to identify personal level factors affecting access to services (N = 1086, response rate = 36.8%).
Women waited an average of almost 25 days between the date of the first visit with the referring doctor and the date of their termination procedure. There was a delay of 10 days between the first visit with the referring doctor and the date that the appointment for the procedure was booked, and a further 10 days delay between the date the appointment was booked and the first appointment date. Over half of the women in this study had their pregnancy terminated at ten weeks or above.
Women in New Zealand are subject to a lengthy delay while seeking TOP services. Efforts should be made by TOP clinics as well as referring doctors to reduce the waiting times for this service.
PMCID: PMC2918568  PMID: 20653931
9.  The Healthy Steps Study: A randomized controlled trial of a pedometer-based Green Prescription for older adults. Trial protocol 
BMC Public Health  2009;9:404.
Graded health benefits of physical activity have been demonstrated for the reduction of coronary heart disease, some cancers, and type-2 diabetes, and for injury reduction and improvements in mental health. Older adults are particularly at risk of physical inactivity, and would greatly benefit from successful targeted physical activity interventions.
The Healthy Steps study is a 12-month randomized controlled trial comparing the efficacy of a pedometer-based Green Prescription with the conventional time-based Green Prescription in increasing and maintaining physical activity levels in low-active adults over 65 years of age. The Green Prescription interventions involve a primary care physical activity prescription with 3 follow-up telephone counselling sessions delivered by trained physical activity counsellors over 3 months. Those in the pedometer group received a pedometer and counselling based around increasing steps that can be monitored on the pedometer, while those in the standard Green Prescription group received counselling using time-based goals. Baseline, 3 month (end of intervention), and 12 month measures were assessed in face-to-face home visits with outcomes measures being physical activity (Auckland Heart Study Physical Activity Questionnaire), quality of life (SF-36 and EQ-5D), depressive symptoms (Geriatric Depression Scale), blood pressure, weight status, functional status (gait speed, chair stands, and tandem balance test) and falls and adverse events (self-report). Utilisation of health services was assessed for the economic evaluation carried out alongside this trial. As well, a process evaluation of the interventions and an examination of barriers and motives for physical activity in the sample were conducted. The perceptions of primary care physicians in relation to delivering physical activity counselling were also assessed.
The findings from the Healthy Steps trial are due in late 2009. If successful in improving physical activity in older adults, the pedometer-based Green Prescription could assist in reducing utilisation of health services and improve cardiovascular health and reduction of risk for a range of non-communicable lifestyles diseases.
Trial registration
Australian and New Zealand Clinical Trials Registry ACTRN012606000023550
PMCID: PMC2780414  PMID: 19878605
10.  Recent developments in the funding and organisation of the New Zealand health system 
During the 1990s, the New Zealand health sector went through a decade of turbulence with a series of major structural changes being introduced in a relatively short period of time. The new millennium brought further change, with the establishment of 21 district health boards and the restoration of a less commercially-oriented system. The sector now appears to be more stable. However many incremental changes are in train and there has been considerable turbulence below the surface as key players jostle for position. This paper reports on some of the recent changes that have occurred in the restructuring of the New Zealand health system. Three issues are discussed: the devolution of funds and decision-making to district health boards, developments in primary health care, and the position of the private health insurance industry.
PMCID: PMC1142303  PMID: 15877820

Results 1-10 (10)