Blockchain Papers

Tin Htet Oo, Sukanya Tianviwat, Songchai Thitasomakul

INTRODUCTION The health system is one of the essential parts to promote the population’s quality of life. Currently, there are oral health system analyses with various specific focuses, for example, stewardship, service delivery, improvement of oral health outcomes through research, and continued education and overviews of the framework, from some countries such as India, Iran, Uganda, and the European Union countries..[12345] Myanmar has 135 different ethnic groups living in 14 states/regions of the country, with about 54.13 million in 2019.[67] There are around 111 spoken languages in Myanmar with eight significant languages, and Burmese as the official national language.[7] Therefore, there are many impediments to providing adequate health services to the whole nation, such as lack of personnel, language barriers, different cultures and beliefs, and inadequate transportation infrastructure. Myanmar government recently started the NHP covering four years (2017–2021), which is a part of a long-term NHP of achieving UHC by 2030.[8] Nevertheless, the oral health policy has been neglected in most NHPs.[59] This study aims at reviewing the oral health system in Myanmar, with the WHO’s six building blocks of the health system.[10] Scientific articles about oral diseases and oral health in Myanmar had already been published.[1112131415161718192021] Although information about the health system and human resources for health in Myanmar were found in some articles,[67,22] items related to the oral health system have not yet been mentioned. Therefore, this article reports the current conditions and challenges of Myanmar’s oral health system based on the published articles and the reliable local documents that are inaccessible by non-native speakers and non-health professionals added value to the academic world in the overview of the oral health system. MATERIALS AND METHODS The oral health system analysis was conducted based on the WHO’s six building blocks of the health system: health service delivery, health workforce, health information systems, access to essential medicines, health financing, and leadership and governance.[10] For inclusion in the review, articles and documents dealing with oral health and the health system in Myanmar based on the WHO’s six building blocks of the health system and oral health status were considered: dental caries, gingival diseases, periodontal diseases, dental fluorosis, cleft lip and palate, and oral cancer in Myanmar. Articles were searched from PubMed and Google Scholar. The search terms used were Myanmar, oral health system, health system, oral health services, health resources, health financing, health information, essential medicine, and leadership and governance for oral health and health system-related information. The terms: oral health status, Myanmar, dental caries, gingival diseases, periodontal diseases, dental fluorosis, cleft lip and palate, and oral cancer were used to inform oral health status. Moreover, related information on dental health from reliable websites of governmental and nongovernmental sectors was also searched. Articles published until August 2020 were explored. All electronic records were imported into Endnote X7. Titles, abstracts, keywords, and contents of articles and documents were scanned to meet the eligibility criteria and eliminate irrelevant items. Articles with information unrelated to the standards were excluded. Potentially relevant articles were selected and collected as full-text records. Selected full-text journals were appraised for their meeting the eligibility criteria. A total of twenty-nine articles and documents matching these criteria were used as included articles in this review. ORAL HEALTH STATUS IN MYANMAR Dental caries and periodontal disease are the most common oral diseases in Myanmar. Two studies of Thwin et al.[1112] showed that the prevalence of dental caries in 3-year-, 4-year-, and 20- to 45-year-olds were 78.9%, 87%, and 90.8%, respectively. In the Pathfinder survey of different regions,[1314] dental caries’ prevalence was high (above 50%) in the 5-year, 12-year, and 35–44 age groups. According to the national oral health survey, the untreated caries level is very high among 6-year-old children (84.1%).[1415] The prevalence was lower than 50% in other studies, such as in those by Chu et al.,[16] Aung et al.,[17] and Mon et al.[18] The National Oral Health Survey (2016)[1415] showed that the percentages of bleeding on probing in the 12-, 15–18-, 35–44-, and 60- to 74-year age groups were higher than 60%. The prevalence of dental caries, as shown in Table 1, and that of gingival and periodontal diseases was high among Myanmar people and was followed by an upward trend with age.Table 1: Prevalence of dental caries and decayed, missing, filled teeth (DMFT/dmft) by age groups in MyanmarOther common oral health problems in Myanmar are oral cancer, dental fluorosis, cleft lip, and palate.[1415,192021] According to a review of oral cancer in Myanmar, oral cancer is the fifth most common cancer[19] in Myanmar. Betel quid chewing has been considered one of the important risk factors for oral cancer.[1920] Moreover, based on the statistical report of representative cancer referral hospitals in Myanmar, oral cancer accounted for 3.5% of all cancer cases. It ranked at the sixth position in males (5.3%) and the 10th position in females (2.2%).[20] The National Oral Health Survey also reported that the prevalence of dental fluorosis was high (13.3%–21.67%) in the areas of Central Myanmar.[1415] According to the Annual Hospital Statistics Report (2013), cleft lip and palate is the third most common congenital disability in Myanmar and it accounted for 18.5% of all congenital malformations.[1421] ORAL HEALTH SERVICE DELIVERY There are two sectors for oral health service delivery: governmental and nongovernmental. In the governmental sector, departments under the Ministry of Health and Sports (MOHS) are shown in Chart 1.[23]Chart 1. Organization chart of departments under the Ministry of Health and Sports (MOHS)Public dental clinics in state and region hospitals, district hospitals, township hospitals, station hospitals, and health centers under the Department of Medical Service and the Department of Public Health take the primary responsibility to deliver oral health-care services to the Myanmar population.[7] Universities of Dental Medicine (Yangon and Mandalay) under the Department of Health Professional and Resource Development also provide dental care services to the community.[7] Among the nongovernmental organizations, Myanmar Dental Association (MDA) gives continuous educational training programs for Myanmar dental professionals and also provides dental care services to the population in both urban and some rural areas.[24] Moreover, community-based organizations provide public dental health-care services on a nonprofit basis. Private dental clinics offer services to the population for which the people have to pay for out-of-pocket. Oral health promotion activities The following oral health promotion programs were established in Myanmar for different targeted groups:[1425] Early Childhood Caries Prevention Program for younger than five-year-old children, including toothbrushing and oral health education to caregivers Institution-based School Oral Health-care Activity for school children, including toothbrushing, oral examination, oral health education, and essential dental treatment Maternal Oral Health Education Program, including oral health services for pregnant women, improved maternal and child health Feasible Effective and Affordable Fluoride Program for the whole population Oral Cancer Awareness Program by screening among tobacco and betel quid consumers in suburban and rural areas The primary prevention of oral health is to prevent diseases from occurring; the secondary prevention is to get an early diagnosis and prompt treatment; and the tertiary prevention is to restore oral health functions.[26] In Myanmar, most dentists are extensively involved in the parts of secondary prevention and tertiary prevention.[27] However, the role of Myanmar dentists in primary prevention is currently limited.[27] Accessibility for oral health-care services Dental clinics under the government sectors, including the two universities, implement free-of-charge services for necessary dental treatments such as dental checkups, tooth extraction, restoration, and sedative dressing. Other services such as endodontics treatment, minor or major oral surgery, fixed or removable prosthetic treatment, and orthodontics treatment can be fulfilled with some contribution fees.[7] Dentists involved in school health teams administer the oral health examination, dental health education, tooth extraction, sedative dressing, and atraumatic restorative treatment for free-of-charge to appropriate cases among school children.[7] Coverage of percentage of the population with selected oral health-care services in Myanmar Although Myanmar people can access dental services from both public and private sectors, reported data of services coverage were available only from the public sector, as follows. According to reports of the South East Asia region, 2008,[28] the coverage percentage of the regular oral examination in 12-year-old children was 73%, and emergency dental care in adults and elderly was 35% and 34.5%, respectively. Also, the percentage of fluoride toothpaste use was 100%. DENTAL WORKFORCE There are insufficient numbers of dentists and dental nurses, and there are no dental therapists or dental hygienists in Myanmar.[2228] Dental professionals educated from two dental universities (Yangon and Mandalay) provide oral health-care services in the public and private sectors for the whole population in Myanmar.[29] In addition, there are limited numbers of army-dentists trained under the Defense Services Medical Academy (DSMA) to serve.[29] The latest total number of registered dentists under the Myanmar Dental Council till 2018 was 4,539,[29] where the dental nurses’ number was 503,[22] as shown in Figure 1. The dentist to population ratio is approximately 1:16,000,[29] fewer than the WHO recommended proportion of 1:7500.Figure 1: Number of dentists and dental nurses working in the public and private sectorDentists working in the public sector are under the Department of Medical Service and the Department of Public Health of MOHS, Myanmar, whereas private dentists work in private dental clinics or private hospitals. According to Figure 1, the number of dentists working in the public sector was decreased, and private dentists were increased based on 2016 data compared with 2014 data.[622] However, the number of dental nurses working in the public sector has increased since 2009. Figure 2 shows the number of dentists working in the public sector in 14 states/regions of the country according to the data of 2016.[22] The numbers of dentists working in the public sector are higher, approximately around 100 in big cities: Yangon and Mandalay Divisions, and Shan State.[22]Figure 2: Number of dentists working in the public sector by 14 states/regions and Nay Pyi Taw Union territoryORAL HEALTH INFORMATION SYSTEM The National Health Information System is an organized system of keeping the records, processing, analysis, reporting, usage, and feedback of information based on systematic data collection, community surveys, clinical studies, health system research, and census data. It is used to make decisions and formulate policies for health programs.[30] Data are collected manually by trained basic health staff using standardized forms (monthly, quarterly, and annually) in the current information system.[7] To strengthen the current information system, an electronic information system has been introduced and its robustness identified.[7] The current system comprises hospital information and public-health information. All the data are sent through the Township Health Department and the respective Region or State Health Department to the Department of Health Planning.[7] The Central Statistical Organization under the Ministry of National Planning and Economic Development takes responsibility for analyzing statistics for the country according to the Central Statistical Authority Act 1952.[7] Oral health status, risk factors, utilization of dental services, and service coverage are constituents of the oral health information system.[31] The dentists working in the public sector report monthly dental patients’ data from their hospitals or fields through the current health information system. ACCESS TO ESSENTIAL MEDICINE Myanmar Essential Medicines Project has been implemented in collaboration with the WHO since 1988 and has developed a National List of Essential Medicines (NLEM) to follow the concepts of essential medicine use.[32] For dental use, the dental cartridge (local anesthesia) and anti-bacterial drugs for oral diseases shown in Table 2 are included in the new edition of the National List of Essential Medicines (2016), which contains 486 items of medicine.[32] Drugs, including essential medications, are mainly supplied by the Central Medical Store Department (CMSD) under the MOHS to all hospitals under governmental sectors.[32] The crucial medicines, equipment, and materials required for dental use are also distributed by the CMSD to dental clinics under government sectors periodically.[732]Table 2: Local anesthesia and anti-bacterial drugs for dental use Category A = for any doctor, B= Alternative to A, C = for experienced doctors, D, E1 =Trained personnel with expert qualifications (drugs to be used in the specialized center)HEALTH FINANCING Health financing is one of the critical issues that Myanmar is currently facing. The primary sources of finance for health-care services are the government, private households, social security systems, community contributions, and external aid.[3033] Total health expenditure as a share of GDP was reported as approximately 4.7% (Myanmar MOHS, 2017), which in absolute terms of health spending per capita was 70,100 kyat, or about US$54.[34] The government share of total health expenditure, including government budgetary and social insurance, was 23% (Myanmar MOHS, 2017).[34] Governmental health expenditure increased from 647 million USD in 2014 to 1048 million USD in 2019,[35] as shown in Figure 3. This expenditure is for medical, dental, and other medical-related fields, including the funding of medical equipment, electro-surgical technology, the provision of free medical treatment for government employees, and medical professionals’ training.[3536] According to the WHO, Myanmar has the highest out-of-pocket-payment rates of health-care spending in the Association of Southeast Asian Nations (ASEAN) (73.9%).[3435]Figure 3: Government expenditure on health care (2014–2022f), USD millionsThe MOHS primarily grants funds for dental equipment and materials required in public dental sectors. Around 1,100 million kyats (715,786.50 USD) for 125 dental health units with an average of about 5,726 USD for each dental unit was provided in the last NHP (2006–2011).[37] One study[38] reported that the percentage of household expenditure spent on dental care in Myanmar was 1.5%. LEADERSHIP AND GOVERNANCE Health legislation plays a crucial role in the governance and leadership components of the health system. They are described next.[30] The National Health Committee (NHC) The NHC was founded on 28 December 1989. It takes the leadership role as a compositional committee with the MOHS and other ministries’ collaboration. It gives guidance for implementing the health programs systematically and efficiently. The NHC sets the policies for the whole nation and makes decisions to guide the health-care sectors based on the It the long-term NHP the of achieving UHC by which covering four The of the NHP to public health problems and promote the health status of the to coverage of health services for the whole nation, to and human resources for to medical to and to of essential Nevertheless, the of for oral health is in the is the to health service to and human resources for all It gives to on each and decisions working in the public hospitals and clinics under the government the policy health coverage The long-term NHP aims at the the Health Coverage The is to provide health-care services, including essential dental services, to of social status, and from The current which four years in the UHC framework, was to access primary health-care services, essential services, and at the township level and the The secondary and tertiary health-care services be in the NHP and Nevertheless, it has been that there is no specific or for the coverage of oral health care services to the Myanmar health sector committee is the health sector and in Myanmar. The specific of the the MOHS on the health providing a on as a for the health sector in the of improved health care health status, medical education, and health of the of health and and a in through information, education, and Nevertheless, the role of in the of oral health issues is Health The primary of is to and to the of implementing different It is essential to the health of the It also health such as factors, factors, social and community living and working and which health and oral It can be that the oral health status of Myanmar is which access to dental services in Essential oral health care service delivery, necessary to strengthen the oral health system, is one of its significant The MOHS is the primary for public health and dental care Therefore, the government take responsibility for it by both governmental and nongovernmental Nevertheless, dental services for some areas in Myanmar to transportation are among the challenges by government and dental the Myanmar dental in primary prevention and oral health promotion including oral health education, oral examination, toothbrushing, fluoride and specific for be since primary prevention is a to strengthen oral health in Myanmar as a of the registered dentists and dental nurses are working in the public It is that the dental for oral health is and there is public and private oral health sectors for dental services in Myanmar. This be some dentists from government to various or working and working recently dentists not to the MOHS continued their There is also no oral health such as dental hygienists and dental in some other countries in the South East Asia India, and there is no to the health-care since the with the to deliver the health-care services to the people in the is a Nevertheless, one study an to this are It can be described as a from both and of the health-care in terms of the based on factors, factors, and services utilization rates and from and However, it be to implement in Myanmar as it is a country with limited where data are required to the Therefore, a of this review about the oral health-care is to training dental health-care to provide services and to dental personnel to in the and of the national level of oral health policy for policies and oral health care services based on available dental the essential medicine was developed by collaboration with the WHO, Myanmar be included in the countries that than necessary of the WHO Although local anesthesia and some anti-bacterial drugs used in dental care were included in the Myanmar National List of Essential Medicine items and supplied by the current of dental materials and equipment is insufficient for the public dental the other the oral health information system not a to the collected data the dentists working in the public sector report monthly dental through the current information system. This be to the to related information from private dental clinics and Other for of the current health information system are the of and the limited of services for the electronic information system, as as data in where security are Myanmar’s health spending as a share of GDP was average and the government share of total health spending was also average compared with other countries at a The percentage of the household expenditure on dental care in Myanmar was the among and which was the as Myanmar is a country, and around of Myanmar people in and rural people living in rural areas are considered to have status, and people are to education and health According to one health-care utilization was with household there are no data for dental services utilization in Myanmar. it was that those with dental treatment not to to private dental clinics to their of for dental services utilization also the of the diseases and treatment and the financing governmental funding for the dental role is not oral health expenditure data for dental dental professionals and public oral health care programs are not Moreover, funding for dental materials and equipment was only reported in the last NHP and this was considered the other current spending is not Public spending on health in Myanmar is lower than that in other countries of with a level of and health a in years is a major of spending and there is a lack of health Therefore, a specific in oral health be a for the In as a country of Myanmar, its policy on UHC has since and is to access essential and health Also, it is that the primary health care system from basic health care to and care with a national for its UHC oral health was a part of UHC with a through a services to access to services and oral health status in In the of Myanmar’s UHC by has a to the current NHP in UHC policy on primary care This is of very in the coverage of health services the UHC of high risk to and in services the and and urban and rural Moreover, oral health in Myanmar’s UHC is and there are no specific for oral Therefore, to this one study to the coverage of health services and risk for and at in important decisions for in In the of oral the of essential oral health care services in hospitals or health centers level also be considered in the UHC a Myanmar dental professionals be in specific and oral health policy for oral health in The current oral health-care system in Myanmar is such as oral health status and dental services utilization be using all oral health human resources the public and private dental Moreover, the of dental in primary programs be be with a public to an oral health information system. A prompt and appropriate to the insufficient of dental equipment and materials be issues be with the MOHS and the Therefore, the Myanmar government to a oral health policy for an oral health system and specific for specific challenges to promote oral health-care coverage for the whole AND The of There are no of AND

Catherine L. Mavroudis, Jason Tong, Rachel R. Kelz

The cost of surgical care is a substantial part of the rising costs of healthcare in the United States: an operation performed in this country costs 1 to 1.5 times more than that in other countries. The total cost of surgical care in the United States constitutes approximately half of inpatient costs, though only a third of inpatient volume.1–3 This multifactorial problem may be in part due to the pseudo-competitive market for healthcare delivery in the United States, in which the supply and demand curves are distorted by regionalization and payer mix. In response to these pressures, health system formation has increased dramatically in the past decade4 with an unclear impact on surgical value. To date, the true effect of health system formation remains undetermined. Proponents have suggested that health systems are able to spread evidence-based protocols and quality improvement initiatives across all hospitals within a given system. This would further improve both outcomes and efficiency through financial and intellectual economies of scale, and thereby improve value.5 Opponents have raised concerns that system expansion poses risks to patient safety due to inadequately supported changes in infrastructure, staffing, and patient population.6 In practice, not all health systems provide an equal opportunity to improve the value of surgical care. At one extreme, a large, geographically disparate system with hospitals scattered across the country may be able to realize the financial benefits of large-scale supply-chain sourcing, but is unlikely to be able to concentrate complex surgical volume in order for patients to realize potential clinical benefits of operating at scale. On the other hand, a smaller network of hospitals within a single region may be well-suited towards building a hub-and-spoke operative referral network, with resources concentrated on bringing patients to the best surgical infrastructure in one central hospital. Unfortunately, it is also more likely to have the advantage in contract negotiations with payers, thus driving up the cost of care and potentially limiting access for patients due to payer mix. Until we have a clear understanding of what it means to be a health system, we will not be able to evaluate the value of health system formation in surgery. To demonstrate the wide variation in system structure, we present the following case series of health systems in the United States. Using the American Hospital Association (AHA) annual survey dataset,7 we identified 413 systems that contained at least one surgical hospital, defined for this purpose as a hospital with at least 3 operating rooms. We generated multiple random two-percent samples. In studying both hospital and system characteristics, we found few similarities across systems, resulting in significant differences across samples. Two such samples can be seen in Table 1. In the first, we see that system size ranged from two to 27 hospitals. Six out of 7 health systems were in one state, while one 27-hospital system was spread across 14 states. Five systems contained hospitals of at least two different bed-size categories (eg, small and medium), while two contained only small hospitals. Three systems had at least one hospital that was a designated trauma center; five had at least one academic medical center. Four health systems were defined as “independent” system clusters by the AHA, which are “largely horizontal affiliations of autonomous hospitals,” while three were “centralized,” with centrally organized hospital services, physician arrangements, and insurance products.7 The second sample highlights the individuality of each system. These random samples of health systems demonstrate wide variation across the characteristics studied, with more observed differences than discernable similarities. TABLE 1 - A Case Series of Health System Characteristics Among 2 Random Samples of Health Systems in the United States Sample 1 System ID A B C D E F G H No. of hospitals 4 6 27 6 2 2 2 7 No. of states in system 1 1 14 1 1 1 1 1 Bed size category Small (<100 beds) 1 0 25 5 0 2 2 5 Medium (100–299 beds) 2 3 2 1 1 0 0 2 Large (≥300 beds) 1 3 0 0 1 0 0 0 No. of trauma center hospitals 0 2 0 0 1 0 0 4 No. of academic medical center hospitals 3 4 2 0 2 0 0 2 System cluster Ind. Cent. Ind. Ind. Cent. Unk. Ind. Cent. Sample 2 System ID I C J K L M N O No. of hospitals 104 27 2 6 2 73 2 32 No. of states in system 16 14 2 1 1 18 1 4 Bed size category Small (<100 beds) 56 25 2 4 1 29 2 26 Medium (100–299 beds) 25 2 0 1 1 22 0 5 Large (≥300 beds) 23 0 0 1 0 22 0 1 No. of trauma center hospitals 45 0 0 0 1 32 2 14 No. of academic medical center hospitals 40 2 0 0 0 35 1 3 System cluster Dec. Ind. Unk. Ind. Ind. Dec. Ind. Dec. (1) System Clusters: Ind., Independent, Cent., Centralized, Dec., Decentralized, Unk. = Unknown/Missing.(2) Due to random chance, system C was included in both samples. Our findings suggest that system designation does not confer information about hospital structure or the role of each hospital within the system. The heterogeneity of health system structure implies substantial differences in the organization of healthcare delivery across systems. The structure of health systems must be better characterized before their value—or lack thereof—can be determined. In order to do this, as a health services research community, we must develop a cohesive scientific taxonomy analogous to that which exists for cell biology—understanding each organelle, its role within the cell, and that cell's role in maintaining the vitality of a larger organism. The interactions between patients, hospitals, and health systems are no less complex, and the ramifications for the future of our health system are significant. Delineating the characteristics of health systems that confer optimal conditions for high-value care will enable the construction of health systems that maximize the value of healthcare for the patient, payer, and provider. Systems must be accountable to their outcomes to deliver on the promise of improved healthcare delivery, as they enjoy financial privileges associated with the business relationships between entities. Although our examples are focused on surgery and in-hospital care, these principles can be applied across the breadth of medicine. By doing so, we may be able to see substantial gains in the value of care delivery across the United States.

Thomas B. Dodson

No abstract is available for this record.

Salvador Macip

No abstract is available for this record.

James D. Bentley, J Chusid, G D'Antuono, Joyce V. Kelly · 5 authors

The contemporary academic medical center is a complex organization providing medical and other professional health education, biomedical and behavioral research, and a comprehensive range of patient care services. This paper presents data from the Association of American Medical Colleges' 1989 survey of 125 member faculty practice plans. The survey data showed that 62% of the 74 responding plans were units or associations within the medical school corporate structure. Plans were organized along a broad continuum from the autonomous, departmental model with decentralized governance and management to the group model with centralized governance and management. The growth of managed care, increased competition, and a greater reliance by the medical school on clinical practice income as a financing source are causing the practice plan to expand beyond billing of professional fees. The survey data showed that 75% of the practice plans operated satellite centers, and 61% planned to build new ambulatory care facilities in order to expand and improve services to patients. The practice plans also have adapted to changes in third-party reimbursement and are establishing mechanisms to negotiate managed care contracts involving multiple clinical departments to increase referrals and maintain patient shares; 86% of the plans participate in at least one managed-care organization. The role of the practice plan will continue to evolve in response to the needs of the academic medical center for a cooperative and supportive environment in which to conduct its traditional missions of teaching, research, and patient care.

Lorraine S. Mashioff

No abstract is available for this record.