Background: In Italy, Departments of Prevention (Dipartimenti di Prevenzione, DPs) are primary organizational units for disease prevention, health promotion, and environmental health. Constitutional decentralization (2001) generated significant regional variability. While national data exist, in-depth regional analyses are lacking. Objectives: To provide a systematic descriptive analysis of organizational structure, governance mechanisms, and workforce composition of DPs in the Triveneto area (Veneto, Friuli Venezia Giulia, Autonomous Provinces of Trento and Bolzano), contextualized within national and international frameworks. Methods: Cross-sectional descriptive study using 2022 Italian Prevention Observatory national survey data. A structured 87-item questionnaire assessed organizational structure, governance, staffing, and quality systems. Results: A total of 10 of 14 DPs participated (71.4% coverage; 5.2 million inhabitants, 87% of Triveneto population). All maintained three mandated core services (Public Health and Hygiene, Veterinary Public Health, and Occupational Health and Safety), employing medians of 35%, 23%, and 14% of staff, respectively. Management Committees were active in 80% of DPs (vs. 77.6% nationally). Quality certification (30%) and institutional accreditation (50%, Veneto only) showed inconsistent implementation. The workforce was predominantly non-executive (65% vs. 67% nationally), reflecting progressive task reallocation. Median staff density: 3235 inhabitants/staff member (vs. 2608 nationally). Conclusions: Participating DPs—predominantly from the Veneto Region—demonstrate comprehensive service coverage and established governance structures, yet face standardization challenges. Findings should be interpreted in light of Veneto overrepresentation (8/10 participating DPs). Alignment with territorial care reforms (Ministerial Decree 77/2022) and National Recovery Plan investments could enhance integration, digital infrastructure, and preparedness capacity.
Abstract Performance management in the public sector is both multifaceted and convoluted. This is particularly pertinent in hospitals, which are complex institutional organizations. Our paper explores the key drivers compelling Irish public acute‐care hospitals to monitor their performance. The context of our study is located against the unique historical backdrop of the Irish health service, whose evolution over time reflects religious control, underfunding by the State and reliance on a decentralized structure up until the early 2000s. This study was conducted during 2009–2010, in the aftermath of the financial crisis of 2008–2009. Interviews were conducted with members of the hospital executive management team, comprising clinical and nonclinical senior managers, using the framework of Kelly et al. (2015) to explore and analyze respondent perspectives. We propose that a combination of key forces, emanating from new public management, the institutional environment, and its constituent elements spurs hospitals to monitor their performance. The confluence of these forces reveals a perceived change in the institutional logic underpinning hospital performance management. This change involved the substitution of autonomous clinical decision‐making for a more team‐based managerial logic whereby clinicians engaged as part of a multidisciplinary executive unit and accepted responsibility for hospital performance. This paper contributes to the literature on performance management in public services and, more specifically, builds on and addresses the paucity of research on Irish acute‐care hospitals.
Springtime always sees plenty of activity in the IFST calendar. This year the AGM was at the end of March, where we take necessary and important decisions that support the governance of the Institute, but also where we have the opportunity of acknowledging the changes to our Board. We say thanks to those members who are outgoing and have done so much for IFST and also confirm the appointment and welcome those who are incoming. We have four new trustees joining the Board this year including President Elect Sterling Crew. Much of our engagement is now ‘remote/electronic’ procedures, which included, for the first time this year, the President-Elect ballot and, indeed, the AGM itself. It is good to see the numbers of members who can engage in such important processes increasing as a result – good democratic governance in action! It was also very gratifying to see the strength of the field putting themselves forward for President Elect and I hope this is a sign of the ambition many members have for IFST. Whilst online engagement has many benefits, by the time this volume of the Journal is in print, many of us will have met in Birmingham for the SC22 Conference Lunch and Lecture. Our Spring Conference (SC22) is a much-welcomed staple of our calendar. We took the difficult decision many months ago that holding SC22 itself in person was probably still not a viable proposition, but the opportunity to have a face to face ‘companion’ event seemed like a good option. We hope that accommodating the needs of everyone is something we can continue to do, whilst adapting to the changing environment. The theme of this issue is ‘Future Foods’. Whilst IFST has a major role to play in ensuring the safety and so much more, of today's food, the opportunities to ‘invent our future’ is what gets many of our members out of bed in the morning! I think it is safe to say, that there will be something for everyone in this edition. In talking to members, we know that this publication is one of most valued benefits of IFST membership. So, as we head into summer I wonder if we might indulge in a little fun! Where do you like to read your Journal? If you would like to share, why not join me in posting on the community pages: community.ifst.org/ IFST has elected Sterling Crew as its new President-Elect. Sterling's election was formally noted during IFST's Annual General Meeting on 31 March 2022. Of his appointment, Sterling said: ‘It is a great pleasure and privilege to be elected to be the next President of the Institute of Food Science and Technology, especially as the selection was by my professional peers. The IFST is a fantastic organisation with a marvellous membership at its very heart. I pledge to play my part in adding further value to membership and promoting the organisation's worthy charitable aims. This is an exciting time for IFST as we approach our 60th Diamond Jubilee and with chartership potentially on the horizon. Food science and technology has a major part to play in our country's future in these very challenging times. The food sector has responded by developing innovative solutions and creative products. The role our members play has never been more important.’ Sterling Crew Honorary Fellow and FIFST is an experienced food sector director who currently holds a portfolio of positions including Chair of the Food Authenticity Network. Find out more about Sterling here: ifst.org/president-elect22 Sterling will serve as President- Elect for one year before being automatically elected as President and Chair of the Board of Trustees in 2023 for a term of three years. Meet our Board of Trustees here: ifst.org/meet-board IFST has reviewed its Code of Professional Conduct and its accompanying Disciplinary Procedures that apply to all its members. The Code of Professional Conduct – which members are bound by – remains unchanged but IFST's Board approved minor changes to the Disciplinary Procedures to clarify the use of electronic communications, confidentiality requirements and ensure any member against whom a complaint was upheld had adequate time to lodge an appeal. The updated procedures which came into force on 7 April 2022 are available on our website: ifst.org/about-ifst/professional-conduct In March 2022, IFST was invited to attend and exhibit at IFE Manufacturing at ExCeL London. We were given a stand in the ‘Ask the expert’ zone. IFE Manufacturing is a gigantic exhibition, it's an international food and drink event, which brought together ingredients, packaging, processing and food technology companies to showcase their solutions to manufacturers from all over the UK. The event was an opportunity for the food and drink manufacturing industry to discover, learn and source the latest products from the best suppliers in the market. At IFST we're always looking at new ways to expand our membership and provide a benefit to the whole of the food sector, no matter how big or small the business. We went to IFE to meet new food businesses and to introduce IFST to a new audience who may have not heard of us before. IFE provided IFST with a great opportunity to reconnect with current members, meet potential new industry-based members and understand some of the challenges facing the food sector through the thought-provoking presentations and seminars provided throughout the show. The geographical coverage, category span and quality of the exhibitors was impressive and provided interesting (and tasty!) insights into where food products are heading next. Each day, three or four members of the IFST executive team represented IFST at our stand, including Deborah Kendale, Andrew Gardner, Delia Mertoiu, Sarah Drumm, Mariam Zaki, Daiane Cazuza, Patricia Florit and Robin Leaper. Despite being at the back of the expo, we received a good number of visitors who all had interesting questions for us and lots of enquiries about IFST membership and what it comprises. We were also approached by a lot of new product developers and new businesses looking for support for their endeavours. It was interesting to see the breadth of producers and the strong focus on sustainability, using waste products, innovation and current trends in the food sector. We were delighted to meet our current members at the expo, who came over to our stand each day. The geographical coverage, category span and quality of the exhibitors was impressive and provided interesting (and tasty!) insights into where food products are heading next. I was delighted to be invited by IFE Manufacturing to chair one of the NPD sessions titled From kitchen table to factory floor. This took place on the Innovation Platform on the opening day. It was the first of two back to back sessions examining the NPD process and how to get products from the idea and concept stage through to a fully manufactured product. This session focused on the early development process and highlighted some of the common roadblocks and key considerations that need to be addressed during the initial stages of a development project. Andrew Gardner and Patricia Florit at the IFST stand We drew a large audience (including more IFST members), with every seat in the auditorium taken. There were some great questions from the audience – and we kept going even when the set behind us collapsed mid-session! The panel gave some sound advice about how to get started and how to protect your ideas. We discussed how to make sure products are legal and safe, how to find partners for co-manufacturing and signposted the audience to other resources available to help at this early stage of development. It was a great pleasure to chair this session, and to work with such an experienced and knowledgeable panel of IFST Fellows. One of the many great benefits of being a member of IFST is having access to a wide network of food industry experts. Thank you to IFE Manufacturing for inviting me to take part and for a great show. It was great to finally meet people face to face after two years! There was certainly a buzz about the place. Three big trends were very evident throughout the show: vegan, environment and health. Without a doubt vegan products and meat alternatives are starting to move into mainstream, with new products using mainstream flavours and targeting everyday eating occasions. Many of the companies were keen to talk about their environmental credentials. I saw a cereal carton made from agricultural waste rather than wood pulp, that had the same look and feel as carton. There were also a number of businesses advertising that they use no plastic bags for their snack products. From a hero ingredient perspective, I noticed that seaweed is entering the savoury snack market, highlighting its health benefits. Also, there were a lot of dried fruit snacks as alternatives to more traditional snack products. The panel discussion on The National Food Strategy between the Food Foundation, Compass Group, Guy's and St Thomas’ Foundation and Mission Ventures was notable. Apart from reiterating the importance of and need to take action, the panellists shared the fact that Tesco and JS have agreed to report on how much of the food they sell is ‘healthier’ products. If you missed the panel discussion From kitchen table to factory floor, there is a recording available on the IFE website to watch on demand: web ifemanufacturing.co.uk/seminar-programme Join IFST ifst.org/membership Prof Robin May delivering the SC22 lecture On 25 April, at University College Birmingham, Professor Robin May, Chief Scientific Advisor to the Food Standards Agency, pictured above, gave his talk to a group of members, speakers and friends of IFST at our preconference lunch and lecture. He opened by stating that eating is one of the few universal human behaviours and that trust in food is critical and is underpinned by science. However, science is becoming more complicated and harder to explain, and becomes increasingly challenging especially around foods that are not yet on the market, but will be, in the future. For context, May indicated that food shopping is habitual and purchasing takes on average six to nine seconds. Reading a product label fully would take many minutes and therefore messaging on labels is often not the best way to communicate information. The challenge is to combine a high level of science and communication about risk with a digestible, easy to compute output. He commented that the FSA has a very strong science and evidence based position. Good science communication is critical and risk must be communicated effectively for people to understand this. He highlighted the FSA has a very high trust rating of 75% of people trusting the FSA and nine out of 10 consumers in the UK are confident in the safety of the food they eat. This is partly due to a strong emphasis on clear communication, such as the food hygiene rating system, which 87% of the population are aware of and over 50% state they have used within the last year. In terms of behaviours, people underestimate long term risks, such as those around smoking and obesity, and act accordingly. Using percentages to communicate risks is effective but even more effective is the use of real-world frequencies e.g. ‘one-in-20 people’. Translating these into graphics is attractive but the danger is that nuance and detail can be lost with the example of using just green and red traffic light symbols. We need to change the food system to cope with sustainability and health impacts, for the planet and a healthy population. Part of this is the need to advise people on new foods that are coming to market. Prof May stated that his passion is being ready to communicate these necessary changes to the public and the implications they will have on peoples’ diets and food choices. Examples of new foods were insects, lab grown meat, novel crops e.g. chia seeds and, finally, genetically modified (GM) and genetically edited (GE) crops that are being, or will be introduced, to tackle challenges in agriculture, such as drought tolerance and vitamin yield. We need to be able to communicate the benefits of these foods if they are to be accepted by the general public. May also mentioned changes to packaging types and systems. Both these developments are innovations which the public welcome. However, innovators are viewed with greater suspicion, as they are often perceived as being driven by commercial gain. In terms of opinions and behaviours – people state they are driven by ethical choices, such as animal welfare and sustainability, but are, in reality, driven by price, when it comes to choices and shopping habits. To be effective communicators, we need to work with human behaviour and develop a balance between ethical choices and real world drivers that determine food choice behaviours. Attendees at the lecture Day 1 on The Gap in Consumer Understanding began with Jon Alexander's presentation on The Power of Citizenship. He poignantly began with some food for thought that overuse of the word ‘consumer’ is fundamentally flawed. To reshape the way in which we collectively interact as humans, we must focus on the concept of ‘citizens’. Next, Tom Sheldon at the Science Media Centre delivered a selection of case studies. He advocates for businesses to support senior scientists in engaging with the press, believing this connection is the way forward to help the public separate fact from fiction. The day ended with a panel discussion exploring how we can build trust in consumers. Michelle Patel (FSA) remarked that as scientists we need a ‘shift in how we communicate’. The emerging themes were consistency, courage, honesty and humility. Day 2 on The Gap in Skills and Professional Development began with another panel discussion on new and future skills, with Jacinta George succinctly explaining, ‘the skills we'll need in 20 years need to be developed now’. The group discussed key future skills crucial to the food industry including AI, robotics and green skills, as well as soft skills like resilience, flexibility and compassion. Attendees saw Andras Sebok present a Digital Skills case study using an EIT Food competency framework on Campden BRI Hungary. He discussed ‘Industry 4.0’, which refers to a new phase in the industrial revolution focusing on interconnectivity, automation, machine learning and real-time data. Finally, speakers from CAFRE and Linden Foods presented the positive impacts that apprenticeship schemes have had in Northern Ireland. We heard a personal account from Lewis Connelly, a NPD Technologist at Linden Foods, who started a High Level Apprenticeship (HLA) with CAFRE. Day 3 began with an inspiring presentation on early stage NPD with Sarah Gaunt. The concept of ‘front-end innovation’ was introduced and the developmental stages in the early-product pipeline covering ideation, identification, application, selection and incubation were explored. Following this, Lucia Capogna spoke about cyber-security. Examples of food industry cyber-attacks in recent years were presented and Lucia closed with the final thought that ‘no system is 100% secure’, but with the right knowledge 90% of cyber-attacks can be prevented (see p46). Next, Tom Hollands presented the digital sandwich, a technology that digitises food production processes and creates a ‘golden thread’ from farm to fork, tracing ingredients back to the source. Tom used a fictional example of grey ham identified in a shop sandwich to track an ingredient's journey. Missed SC22? As a paid attendee, you have access to our Conference platform, Whova, for three months where you can watch all of the conference sessions and the lecture recording. Starting from mid-June, as a member of IFST, you can watch all the recordings in our IFST Webinar hub via ifst.org/webinars Across the world 90% of people are meat eaters and global consumption of meat is rising. Meat production is already contributing to potentially catastrophic climate change and if nothing changes, future demands will require impossible amounts of land and water. The ‘Meat the Future’ exhibition considered some of the key findings of the LEAP (Livestock, Environment and People) project, which studied the health, environmental, social and economic impacts of meat and dairy production and consumption. 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As for the it remains of the meat consumption at a person day in and in the land – agricultural and how they have over the years This exhibit was presented as a set of with and on of the land is currently to agriculture, to how develop from a traditional to the global industry it is how has science to the increasing for In the people of land from the of the the they kept the and on the the used to their There are in the each to in and or of the are as was to more food when but this came at a to as were and to High – the environmental of meat production now more than to for of are for into the and changing grown for animal require more and – for and other resources for human As food they which is more to the environment than contributing to climate The IFST group noted that there was no of the or of meat animal welfare or animal in the As scientists we were to understand more about current into for food – consumers with on the environmental of their food choices is a strong public for choice in what we but in reality, our is already by what businesses us to and how it is and LEAP on the labels of the being food products to their positive or on and As well as consumers more hope that food producers will by developing new products with environmental to find the most effective have been have much environmental impacts of all to and products as much as than most animal products. 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This is made to or who have made personal to the and of the Institute and to the food science and technology FIFST in food sustainability, and from farm to is of the Food Find out more about here: On I first IFST in the early of my I had no idea that I would one day be joining IFST's of Honorary I often in and in my To be by people I as and to a is I the IFST for this and will this with Food science is more than a sustainability and food I that any can be using food as the and that food on food science in its one can food, so its future has to be through and communication at all by all of us in the This year the of the UK Our has many products that would be in by companies the great and of those to the future of the food market. the time this issue has been the will have their products to the on 7 and the will be at the event at Tesco where will be able to some and meet other industry and from the industry including and Food Institute of Food Science and and Campden For more and We have a new IFST to and to resources to support small and food and food need to healthy and food, and in an and to cope with the challenges of a population. food and the of food throughout the from farm to the The consumption of or foods is increasingly being as an emerging to and the of This evidence on human and the of processing on and of key these food and human have been to and these on therefore more
Abstract This chapter offers an in-depth look at health politics and the decentralized, tax-financed health system in Italy. It traces the development of the Italian healthcare system, including the processes leading to hospital reform and regionalization in the 1960s and 1970s and the creation of the national health service in 1978. Since the late 1980s, health policy has been shaped by the transformation of the Italian political system, further transfer of powers to the regions, and public expenditure constraints due to public debt. Policies inspired by the New Public Management approach that aimed to increase the health system’s cost-effectiveness through steps towards fiscal federalism were introduced and reversed. Over the course of the 2000s, agreements between the central state and regional governments have become the main tool for coordinating health policy and trying to settle recurring disputes regarding health expenditure responsibilities. Ongoing debates on healthcare concern measures to ensure the national health service’s sustainability, typically the control and containment of its costs, and to reduce the territorial gap and other gaps that clash with the system’s universalist design.
Healthcare Systems and Practices
Healthcare Quality and Management
Health Systems, Economic Evaluations, Quality of Life
Abstract This chapter offers an in-depth look at health politics and the tax-financed, universal health system in Denmark. It traces the development of the Danish healthcare system, characterized by an evolving division of labor between central authorities and decentralized municipal and regional governments. Since the late 1980s, Danish health policy has seen a number of gradual changes and a major structural reform passed in 2005 that amalgamated municipalities and regions and changed healthcare financing rules, thus shifting the balance of shared power toward the center. Other healthcare issues have been cost containment, patient rights, and promotion of local integrated health services. A negotiated policy style contributes to efficient implementation of reforms once a decision has been made.
Healthcare Systems and Practices
Health Systems, Economic Evaluations, Quality of Life
Mehdi Jafarı, Amin Habibirad, Arefeh Pourtaleb, Mohammad Hossein Salarianzadeh
BACKGROUND: Since the early 1990s, Iran has initiated structural and decentralization reforms in the hospital system. This policy led to the formation of a Board of Trustees (BOTs) for the governing of public educational hospitals and making important modifications in hospitals' financing. This study was conducted to identify the barriers in implementing this policy. METHODS: All the Iranian Medical Sciences Universities and hospitals involved in the policy implementation were included in this qualitative study. The data were analyzed by using content analysis. RESULTS: In total, 403 problems were divided into 9 classes including problems related to implementing regulation, financial problems in policy implementation, problems related to faculty members, ambiguity in executive regulation, problems related to the BOTs, authority level, hospital structure, the quality and quantity of hospital human resources, and fee for services. CONCLUSION: It appears that "implementing regulation" and "financial problems" embrace over 50% of the barriers. Apparently, the new approach to hospitals' autonomy has not achieved the desired goals. Considering the contextual factor, the evidence and identification of the clear role of various stakeholders should be essential determinants. Partial implementation of this policy without paying attention to the other aspects would end in failure. The results showed insufficient budget to be the most influential factor that posed a dilemma in implementing the BOTs' policy. However, BOTs in Iranian health system need to strive toward a higher level of performance that will improve effectiveness and efficiency now more than ever.
Sabina Nuti, Federico Vola, Anna Bonini, Milena Vainieri
The Italian Health care System provides universal coverage for comprehensive health services and is mainly financed through general taxation. Since the early 1990s, a strong decentralization policy has been adopted in Italy and the state has gradually ceded its jurisdiction to regional governments, of which there are twenty. These regions now have political, administrative, fiscal and organizational responsibility for the provision of health care. This paper examines the different governance models that the regions have adopted and investigates the performance evaluation systems (PESs) associated with them, focusing on the experience of a network of ten regional governments that share the same PES. The article draws on the wide range of governance models and PESs in order to design a natural experiment. Through an analysis of 14 indicators measured in 2007 and in 2012 for all the regions, the study examines how different performance evaluation models are associated with different health care performances and whether the network-shared PES has made any difference to the results achieved by the regions involved. The initial results support the idea that systematic benchmarking and public disclosure of data are powerful tools to guarantee the balanced and sustained improvement of the health care systems, but only if they are integrated with the regional governance mechanisms.
Open access
Healthcare Quality and Management
Patient Satisfaction in Healthcare
Health Systems, Economic Evaluations, Quality of Life
Nader Markazi Moghaddam, Aidin Aryankhesal, Mohammad Arab
BACKGROUND: Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms. METHODS: Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase. RESULTS: Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments". CONCLUSION: The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.
Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy \nof teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in \neach hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor \npolicy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as \nenhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were \nnever realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of \ntrustees’ policy did not achieve its perceived objectives. \nMethods:We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 \nand 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive \nand snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed \nverbatim and analyzed thematically, following a mixed inductive-deductive approach. \nResults: Three main themes emerged from the analysis. The implementation approach (including the processes, views \nabout the policy and the links between the policy components), using research evidence about the policy (local and \nglobal), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity \nand actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization \npolicies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration \nof the above factors in policy implementation into account. \nConclusion:The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals \nin Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not \nprepared appropriately and key stakeholders, particularly the government, did not support the decentralization of \nIran’s health system.
The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.
Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.
Open access
Health Systems, Economic Evaluations, Quality of Life
Hans Okkels Birk, Karsten Vrangbæk, Andreas Rudkjøbing, Allan Krasnik · 7 authors
Denmark has a tradition of a decentralized health system. However, during recent years, reforms and policy initiatives have gradually centralized the health system in different ways. The structural reform of 2007 merged the old counties into fewer bigger regions, and the old municipalities likewise. The hospital structure is undergoing similar reforms, with fewer, bigger and more specialized hospitals. Furthermore, a more centralized approach to planning and regulation has been taking place over recent years. This is evident in the new national planning of medical specialties as well as the establishment of a nationwide accreditation system, the Danish Healthcare Quality Programme, which sets national standards for health system providers in Denmark. Efforts have also been made to ensure coherent patient pathways - at the moment for cancer and heart disease - that are similar nationwide. These efforts also aim at improving intersectoral cooperation. Financially, recent years have seen the introduction of a higher degree of activity-based financing in the public health sector, combined with the traditional global budgeting.A number of challenges remain in the Danish health care system. The consequences of the recent reforms and centralization initiatives are yet to be fully evaluated. Before this happens, a full overview of what future reforms should target is not possible. Denmark continues to lag behind the other Nordic countries in regards to some health indicators, such as life expectancy. A number of risk factors may be the cause of this: alcohol intake and obesity continue to be problems, whereas smoking habits are improving. The level of socioeconomic inequalities in health also continues to be a challenge. The organization of the Danish health care system will have to take a number of challenges into account in the future. These include changes in disease patterns, with an ageing population with chronic and long-term diseases; ensuring sufficient staffing; and deciding how to improve public health initiatives that target prevention of diseases and favour health improvements.
Along with resource generation, financing, and health service delivery, stewardship is a key health system function. However, very little empirical analysis has been carried out on it. This paper aims to fill this gap in the literature by assessing the Ministry of Health's (MoHs) role as a steward of the Spanish National Health System (NHS) after the 2001 decentralization reform of health care management to the Autonomous Communities. We use the following stewardship framework with six sub-functions for the analysis, looking at the MoH's ability to: (1) formulate strategic policy framework; 2) ensure a fit between policy objectives and organizational structure and culture; (3) ensure tools for implementation; (4) build coalitions and partnerships; (5) generate intelligence, and (6) ensure accountability. We describe the stewardship function, identify existing challenges and issues in the Spanish case, and reflect upon methodological aspects of this exercise. We use reports, documents, articles, and official statistics to complete the analysis. Overall, we find the MoH to give an average performance in its role as the steward of the health system. The MoH has progressed particularly well in generating intelligence as well as formulating a strategic policy framework over recent years. However, it lacks the appropriate authority to efficiently coordinate the health system and to ensure that the Autonomous Communities implement policies that are in-line with overall NHS objectives.
The design of the decentralized co-operative governance system, conditioned and \nregulated by the South African constitution is of critical importance for policy design and \nimplementation. The division of powers falls within a unitary form of government. This \nstudy, which is about the processes, mechanisms and modalities of public policies \ndesign and implementation uses the public finance and health sectors, as a case study \nor lens through which policy design and implementation is examined within a \ndecentralized cooperative governance system. The study is per se not about the public \nhealth system, but rather a review and an analysis about how the decentralization and \ncooperative governance nature, practice and dynamic of government system, influences \nand condition the policy processes and practice on finance and health, separately and \ncollectively within the public health system. \nIn its attempt to unbundle the health function, but also reform the public health system, \ncentral and provincial governments have introduced a number of reforms. These reforms \nwere ostensibly driven by different policies and programmes originating either from the \npublic finance or public health sectors with significant consequences for the provinces. \nMoreover, these different policies also outlined structural and functional responsibilities \nand authority among the central and provincial government departments. The \nimplementation of these policies was at times based on different interpretations of policy \ndesign and implementation responsibilities and authority between the central and \nprovincial governments within co-operative governance system. \nThe argument of this study is that despite intentions implicit to public policy, co-operative \ngovernance system is contested at a central government level within the public health \nsystem, as well as between levels of government and the public health and finance \nsectors. This dissertation explores the nature of the relationship between the central and \nprovincial governments by exploring co-operative governance in the health sector on \npolicy and financing processes and mechanisms. The central question is how does \ndecentralized co-operative governance really work in the public health system? \nA case study method was used to conduct this research. Data was collected over a four \nand half year period using a variety of data collection methods, including semi-structured \nin-depth interviews; documents and reports analyses; policy content review and \nanalyses; and revenue and expenditure reviews and analyses. \nThe study’s findings are: \na) the functional and structural decentralization of policy-making and implementation \nwithin the co-operative governance system contributes to undermining the cooperative \ngovernance relationship between the public finance and health sector and \ncentral and provincial governments; \nb) the central government is using its overriding powers to “impose co-ordinated \nsolutions” to problems within the co-operative governance system, leading to \nsituations where ‘imposed co-ordination’ is considered as ‘co-operative governance’; \nc) the theory provides a classical distinction between state control, supervision and \ninterference models. This dissertation shows that, depending on the policy context \nand circumstances, the uniqueness of South Africa’s co-operative governance \nsystem allows the central government to mobilize any of these models to achieve its \npolicy intentions, whether written or unwritten; and \nd) the classical arguments of decentralization, particularly within a devolved system of \nco-operative governance where greater autonomy and authority are given to subnational \ngovernments, are found wanting within the South African governance \nsystem, given both the policy-making and fiscal resource strength of the central \ngovernment relative to the provinces. \nThis dissertation leads me to conclude that the South African practice of co-operative \ngovernance in the health system is actually imposed co-ordination and that provinces \nare de facto administration outposts of central government policies, programmes and \nservice delivery responsibilities. Therefore in reality there is no autonomy and \nindependence of the provinces from the central government as envisaged in the \nConstitution of the Republic of South Africa. In fact, provinces only exist, in terms of their \nconstitutional competencies as far the central government allows it to exist given its \nplenipotentiary powers over both micro and macro matters affecting institutions, fiscus \nand social policies.
BACKGROUND: The Ministry of Defense budget constitutes 16% of the state budget. The budget for the Ministry of Health and for civilian health care is derived from the state budget. The health care funds receive their budgets from several sources. The capitation formula, which is determined by law, is the main factor that affects the size of the budget each fund receives. OBJECTIVE: The objective of this study is to describe the manner of planning, managing, monitoring, and controlling the budget allocated to medical services, which is a public budget for soldiers. METHODS: Several parameters are suggested for comparison, including the interface with the civilian health system, the method for budgeting a health care system, possible results of managing a medically centered budget, and the possibilities for monitoring the provided services. We also examine the potential for decentralization of authority. CONCLUSIONS: Managing the budget and locating appropriate alternatives, as well as the availability and accessibility of medical services, are important for procurement and for forming contracts with both military and civilian systems. Turnover based on updated information might serve to improve future health services.
A central concern of this research has been to understand more about how and why organisations change. My initial research question posed was: What is 'strategy', how does it emerge in health care organisations and how can I influence its development? This is explored within the context of my field of practice as a Director of Nursing in a National Health Service (NHS) Trust. I have approached this enquiry through using a methodology known as emergent exploration of experience (Stacey et al., 2003). This methodology is informed by insights from Complexity Science and the theories of complex responsive processes of relating. What emerged through the enquiry were a number of key areas of concern related to national healthcare strategy and the management of risk within my NHS trust. The findings from this research radically challenge the way we are practising together in my organisation in moving from the position of locating accountability for mistakes with either the individual or the system. Instead it is suggested that, as part of our ongoing process of interaction, we co-create what others are describing as a 'system' through our participation with each other. Accepting the notion of co-creation requires us to examine very carefully the influence of our own participation in the dangerous situations that arise in our everyday work, and to acknowledge our own accountability for what emerges. I am proposing that this makes a new contribution to knowledge in this field for two reasons. First, because it explores for what I believe to be the first time the validity of the theory of complex responsive processes in the discourse of risk management in health care. I am proposing that this theory has a legitimate contribution to make in this field of practice, that is worthy of further enquiry and research. Second, in making this shift to a perspective that understands accountability for error as something that we co-create in groups, my thesis poses a radical challenge to many of the activities that are traditionally undertaken when mistakes occur in organisations. Specifically, I have questioned the usefulness of approaches that seek remedies through focusing on individuals outside the context of the group and those that focus on re-engineering what other authors refer to as the 'whole system'. I offer an alternative through describing examples in my narrative of a different approach grounded in the research methodology of emergent exploration of experience. This focuses on the micro-interactions between participants in groups as a way of understanding the transformation of practice .I am arguing that such transformation may not always be an improvement, because we cannot always accurately predict the outcomes of our actions in advance. This perspective therefore also challenges the assumption made by some authors in this field, who believe it is possible to 'human-proof' systems and thus guarantee ‘zero defects'. In seeking an answer to my research question I have therefore moved from understanding strategy as a vision for the future that can be planned and implemented by a few powerful individuals whom others follow to a different understanding. I now see strategy as an emergent phenomenon arising from micro-interactions between people in the present – hence we co-construct our future as the actions we take in the present. From this perspective I have argued we all have the potential to influence what is emerging through our actions, for which we are constantly held to account, through both our inner dialogue with ourselves and our conversations with each other.
Introduction Sweden, with about nine million inhabitants, has a decentralized public health care system. Three political and administrative levels – central government, county councils and local municipalities – are involved in financing, providing and evaluating health care activities. The central government has only a legislative supervisory role, while county councils and municipalities are responsible both for financing and providing health services (Figure 4.1). The county councils are entitled to collect direct income tax revenues as their major financial source, but they are also politically accountable through their directly elected political assemblies. The vast majority of Swedish hospitals are public, owned and financed by the county councils. Primary care settings are also financed by the county councils but they are both publicly and privately owned. Swedish hospitals have traditionally been financed via global budgeting. This is due to the fact that Sweden has a tradition of publicly owned hospitals and that cost control has been an important issue. Moreover, before the introduction of DRGs, there was no accepted system in use to describe performance. The counties had poor knowledge of hospital activity and productivity. There was a great need to find ways to measure productivity. In Sweden, DRGs have been used as a prospective payment system, to describe performance and increase the transparency of hospital activities, as an analyzing tool and to measure productivity.
Although both are publicly owned and financed, the health care systems of England and Sweden are widely different in levels of funding, patterns of resource allocation, and types of planning and management. In England, control is more closely tied to national government; in Sweden, it is shared between national and local governments. A comparative analysis of decision making in the two systems reveals critical differences in determinations of how resources are allocated among competing interests, and how resources are used. Interestingly, as the English move toward more decentralization, the Swedes are considering greater central controls, but, in any event, convergence is unlikely.