It is unrealistic to expect that all entry points will offer comprehensive or even complete care. Priorities for where (what service delivery point) to integrate will have to be determined based on a country assessments of the national health priorities, epidemiology and health service use defined above. Other decision points include what additional interventions and services to offer and the mech- anism of access (e.g., referral or onsite provision). As sug- gested by the cervical cancer example, what will also be informed by the operational evidence of the screening, pre- vention, or treatment options available to integration and whether these technologies are feasible and cost-effective. Another decision point is how organizations, providers, and others will work together to coordinate care, including informal interactions and information sharing, collaboration through mutual agreements or guidelines, more formal co- ordination mechanisms such as common management and supervision, oversight committees, merged services, etc. . Other health system considerations need to be factored into to supporting integrated service delivery such as whether training or decision tools are needed to strengthen human resources. Research and evaluation can help understand the optimal intervention packages and mechanisms of delivery. Case studies can be useful to docu- ment how organizations and others coordinate care and what changes to health system functions are necessary.
Every monitoring report includes action plan for the next year, based on analyzed experience and development needs of previous years. The action plan also contains measures for 3 years budget planning period and is linked to region’s formal functions. Also prospective functions are identified, which could be transferred to the region and is logical accordingly to region’s planning and coordination role. Action plan should be linked with decision making and budget planning, but due to uncertain region’s role and insufficient policy implementation instruments currently it has advisory character. Economical crisis is the right time for evaluation on how reasonable budget is created and how long term priorities are considered. Such situation usually leads to critical evaluation of the decisions taken in previous years, and to make appropriate conclusions (Jakobsons, 2009).
An evaluation of the implementation of the School Monitoring, Evaluation and Adjustment (SMEA) System of the Department of Education (DepEd) was conducted to aid on the improvement and upgrading of the system. A researcher-made instrument was utilized to quantitatively analyze the implementation and interviews were conducted to identify the challenges and struggles of its implementation. Also, a close look at the SMEA questionnaires was done to identify the level of compliance with the established standards. The analysis showed high levels of implementation, however, the qualitative analysis showed gaps in the validity and reliability of results. The burden of too many indicators and the confusion by questions that are hard to quantify in a single questionnaire were identified as the major problem. The need for indicators, which consider the setting and context of each school, was identified as the primary need. A sense of ownership of the indicators and commitment building were among the recommendations. In addition, a systems approach of integrating established school systems such as School Improvement Planning, Results-Based Performance Management System and the Monitoring and Evaluation System was also suggested. The result of the study could contribute to the management of schools, enhancement of policies and improvement of DepEd systems.
To achieve the study purpose, the researcher adopted descriptive survey to make assertions on how project planning, stakeholder participation and monitoring and evaluation affect implementation of government projects in Machakos County Government. The researcher observed and described the phenomena and the situations or events in a scientific manner. The design can be used in longitudinal studies to allow researchers to gather information for the long duration of time at different periods and summarize, present and interpret data for the purpose of clarification (Orodho, 2003). According to Mugenda and Mugenda (2003), the main purpose of descriptive research was to find out and report the way the data is and it establishes the current status of the population under study. The research also described and explained the existing status of two or more variable
Nzioki (1998, 21) points out that the first study to estimate rural poverty in Kenya was done in 1994 under the analysis of the Integrated Rural Survey 1 (IRS 1). The poverty incidence by 1994 was estimated to be at 30 percent using a poverty line of Kshs 2,200 per month for small holder households. The report continues to argue that quantitative approach to measuring poverty defines the poor as those who cannot afford basic food and non-food items. In 1997 the absolute poverty line was estimated at Kshs. 1,239 per person per month and Kshs 2,648 respectively for rural and urban areas according to the Welfare Monitoring Survey (PRSP, 2001-2004, 11). Through the 7 th national Development Plan, the Government committed itself to enhancing the participation of communities in development planning and implementation, and promotion of the private sector in order to stimulate investments and savings, increase household incomes and create job opportunities (Nzioki, 1998, 28)
Project approaches to development remain a vital instrument by development agencies to reach and assist poor communities in the developing world. Development interventions in the past have tended to focus on resource and knowledge transfer to beneficiary communities through the ‘top-down’ approach. In the ‘top-down’ approach, decisions are made at the top and then passed to lower levels for adoption by the beneficiaries. However, several decades of development funding have demonstrated the failures of the ‘top-down’ approaches to reach and benefit the rural poor. A possible reason for these failures is attributed to the lack of beneficiary participation in identification, planning, implementation and monitoring and evaluation of development projects (FAO, 1991; Cernea and Ayse, 1997; Blackman, 2003). Shah et al, (2000) cited in APO, (2002) notes that many projects in the past have been designed and implemented in a ‘top-down’ fashion, with little or no real participation of the supposed ‘beneficiaries’. Even when an element of ‘participation’ is built into projects, it is all too often largely in terms of local investment of labor and not in real decision-making. Beneficiary communities are only informed after plans have been made and that this is done
Despite these developments in the conceptualization and scope of cultural competency, there is no common framework of cultural competency for use across different health contexts either within or between countries (6). The cultural competency litera- ture reveals great variation in interventions that aim to improve cultural competence in health care. One factor contributing to this variation is the level of health-care systems toward which interventions are aimed. A recent review of cultural competency intervention studies has identified that cultural competency interventions are generally implemented on one of four levels across health-care services and systems (7). The first two levels are concerned with the health-care encounter and address the cultural competency of individual health practitioners and professionals. One set of interventions target health students while studying and training, and the other targets health professionals working in the field. In both of these intervention sets, the focus is on teaching the requisite knowledge, attitudes, skills, and behaviors needed to ensure safe and effective health care for diverse patient groups. The next level is concerned with health-care service delivery. In this level, the appropriateness or cultural competence of health programs and services themselves is the focal point. Finally, encompassing all other levels are those interventions concerned with health-care systems. These interventions aim to improve the cultural competence of entire health organizations and systems (see Figure 1 for an illustration of this multileveled approach to understanding cultural competency).
The case study has set out to introduce regional health workforce monitoring as a tool for governance innovation. The illustrative examples reveal how monitoring can make a difference to health workforce governance. The core ele- ments of this model comprise ‘ intelligent ’ data collection through connecting different sources, strong stakeholder involvement and a procedural approach to policy as a ‘ learning system ’ of decision-making. This monitoring model promotes capacity building for integratedhealth workforce monitoring and governance in an otherwise fragmented planning system, which is biased towards medical provider groups, while integration of nurses and other groups are constrained. The case study illustrates how health system deficiencies and governance gaps may be reduced to some degree through bottom-up driven innovation. Next to other German federal states and resource-rich countries, especially with federalist gov- ernance, the monitoring model may also be appealing to low- and middle-come countries, because of its cost-effective nature and easily accessible regional data and governance networks. Systematic transform- ation of the tools to the contexts of resource-poorer health systems may help to establish sustainable health workforce governance and universal healthcare coverage.
staff in new roles , leadership [19, 37], staff stability , a phased roll out approach to implementation , and flexibility and permissiveness of organisational cul- ture . All these factors are similar to those identified by the Department of Health’s national evaluation of 16 integrated care pilots across England . However, the following two themes were not identified by the Depart- ment of Health’s evaluation: Service level and partner- ship agreements and patient engagement. Previous research stresses the importance of patient-level factors (e.g. health-relevant beliefs, personality traits, motiv- ation, and trust) for the implementation of health care interventions . Patient-level factors impact on the outcomes of implementation efforts, as patients are ac- tive agents and consumers of healthcare . Patient- level factors were identified as relevant factors for the implementation of integrated diabetes care in Ireland . As found in this study, service level and partner- ship agreements seem to determine the level of shared understanding of stakeholders’ roles, values, and the in- tervention’s goals, scale, and scope. Hence, partnership and service level agreements may have a direct influence on shared understanding, which was identified as a rele- vant factor for implementation of integrated care pilots in the current and a previous study [19, 36]. In addition to the themes that are relevant to integrated care pilots in general, this study identified a theme that seems to be relevant to SP interventions explicitly: Local infrastruc- ture. Given that SP interventions usually include service providers in the third sector to deliver care to service users, the local infrastructure was identified as a factor influencing the implementation process of SP interven- tions. Finally, two factors that are specific to SP models based in general practice and involving a navigator were identified: Navigator ready surgeries and the involve- ment of primary care practice managers in the develop- ment and implementation of the intervention.
of sexual initiation, correct and consistent condom use, and adherence to the antiretroviral regimen are important strategies to improve adolescents’ health, prevent unintended pregnancies, and prevent HIV transmission to partners. Clinics and physician practices providing primary care for HIV-infected female adolescents need to include comprehensive reproductive health counseling and care and have the capability to provide appropriate contraceptive guidance, delivery, and monitoring. Addressing adolescent reproductive health issues in the medical home and during routine visits, where family planningservices are integrated into care, along with antiretroviral therapy adherence and risk-reduction counseling, may be one of the best ways to address the sexual and reproductive health needs of HIV-infected adolescents.
The results of the studies of service add ons or linkages at a facility level indicate that these interventions probably improve utilisa- tion of services, in particular family planning and HIV counselling and testing. None of these studies, however, provided evidence of improvements in health status outcomes as a result of the add-on services, and none assessed client satisfaction with add-on services. The goals of integration include not only improved utilisation and efficiency of delivery of care but also improved patient satisfaction and health status. The absence of evidence of effect on patient satisfaction and health status suggests that some caution is neces- sary in implementing these interventions as improvements in the ”processes’ of healthcare delivery may not translate automatically into improved patient satisfaction and better health outcomes. The addition of community based interventions for family plan- ning improved family planning uptake, and the addition of com- munity based nutrition and child health interventions improved child nutrition, morbidity and mortality (Taylor 1987). However, the quality of the evidence from the Taylor studies was very low , and the true effect is uncertain. It is also important to note that these additional interventions involved lay health workers provid- ing services in the community, with support from the routine fa- cility based services. Any differences between control and inter- vention sites may therefore be due to the additional community based services as well as the integration across levels of care, as has been demonstrated elsewhere (Baqui 2008; Bhutta 2008).
good practice described in relation to individual workers who listened to people's expressed needs and acted upon them. Again, though, a larger number of accounts suggested that people did not feel listened to, or consulted. A repeated request was for workers who would take time to listen to the concerns of people using their services. The picture portrayed in this study did not conform to the notion of engaged and involved service users, as depicted in the world of 'Patient and Public Involvement'. It seems that much greater effort should be expended by health and social care services to reach out and incorporate the views of service users; as opposed to waiting for people to take the lead in contacting them. Those who make greatest use of health and social care services are likely to be those who find it the most difficult to express their views through conventional channels. If health and social care is ever to be wholly integrated it is imperative that users of services are consulted in a meaningful fashion. It was not at all evident from this study that
Bridges are not merely a major, long term investment but they are the flagship or in fact, vital link in highway transportation network. Inspection and evaluation of the structural health of bridge structures has been traditionally based on “hands-on” visual inspection by experienced personnel. The US Federal Highway Administration’s (FHWA) Nondestructive Evaluation Validation Center recently completed the first comprehensive and quantitative study of reliability of visual inspection and the US National Bridge Inspection Program (NBI) condition rating system . The study reported that a range of condition ratings of 3 or 4 categories can be expected routinely with different inspectors reporting results for same bridge in the same condition. Coupled with this variability is the inherent limitation of visual inspection that fails to detect invisible deterioration, damage or distress. Many of the aforementioned are difficult or impossible to detect visually unless they are severe.
Table 1.0 apportions responsibility for implementing the recommendations identified within the literature review. Each recommendation is assigned to one of three categories: HEI/FEC educational curricula, In-service educational curricula or Policy, planning and process. For example, the recommendation 'Ensure service users of integratedservices are integral to developing communication networks and language' is seen as the responsibility primarily of Policy, planning and process, as the extent to which service users should be included in operational activities is first and foremost a policy decision. In the context of this exercise, the Course Finder seeks to cover only those recommendations that are currently the responsibility of HEI/FEC educational curricula.
Summative quantitative evaluation (H1a, H1b, H2) Subject-level measures will be collected in a repeated mea- sures design via telephone interview, at the beginning of implementation and at 6 and 12 months of implementa- tion. Primary quantitative health status outcomes include the Patient Assessment of Chronic Illness Care (PACIC)  (H1a), site- and veteran-level indices of BHIP clinical fidelity measures (H1b), and the veteran-level mental com- ponent score (MCS) and physical component score (PCS) of the VR-12  (H2). The evaluation is quantitatively powered for H2, specifically the VR-12 MCS (90 % power, alpha = 0.05, effect size = 0.20 ). We will also collect pa- tient satisfaction data using the Satisfaction Index  and the recovery-oriented Quality of Life Enjoyment and Satis- faction Questionnaire  as secondary measures. Note that the sample size accommodates “early looks” at the data at the end of each wave, in order to inform oper- ational partners of emerging results in an operationally relevant time frame.
Gbanko has a Chief who is involved with community development efforts and have initiated programs in the community as well as contributed to CHPS infrastructure. Additionally, there is a district assembly member who is focused on mobilization in the community. The presence of these figures who are highly regarded appears to make an important contribution to the community dynamic. Gbanko is close the main road which is paved, and the CHPS compound is right off the main road. Access to roads in good condition are beneficial to rural communities in the region. The nearest health facility is approximately 7 km away; given the road conditions and distance, the health facility is more accessible than to some other communities. Still, the community demonstrates high level of sustainability with well-functioning CETS. In its favour is that the Gbanko CHPS compound serves two communities in its catchment whereas others serve 6, and the community has the smallest population of the six study communities. A smaller community may be easier to mobilize, and compound resources are not spread as thinly.
For the community dialogue meetings, women were recruited by open invitation (using word of mouth and posted messages) in a convenience sampling approach. Women were asked to notify the local clinic at least 2 days prior to the intended session in order to allow planning for seating and refreshments. The clinics were asked to limit the number of women to 25 partici- pants with assurance that if that number was exceeded we would offer subsequent dialogue meetings. It was agreed that we would not hold more than two sessions per site due to time limits on completion, and likeli- hood of saturation. The participation by community is shown in Table 1. In no situations was a second ses- sion held; however, in two communities in Ngorongoro, more than 25 women attended the sessions and the decision was made on the ground to proceed. A group consent process was facilitated by the local leader at all sessions.
Similar diagnostic benefits from pathology-radiology integration have been observed with regard to interstitial lung disease. Historically, the diagnosis of interstitial lung disease has been the domain of the pulmonologist, who is required to independently correlate the histopathologic report and radiographic findings to be able to identify prognostically distinct subsets [8,9]. Recently, however, the American Thoracic Society and the European Respiratory Society have issued international consensus statements that call for an integrated, dynamic interaction among clinician, imager and pathologist to better inform the spe- cific biological behavior and prognosis of subsets of inter- stitial lung disease [10-12]. Three reasons motivated this call for change:
needed for economic growth in the climate of global financial uncertainties. For years, this distinct and de- manding phase has been unrecognized by the health systems in many parts of the world, where there are different specialities for childhood and adult healthservices, but no dedicated services for young people . However, this is changing and the need for services specifically tailored for this phase of transition in life is being increasingly recognized [5–9]. Against a back- drop of increasing focus on unique health issues of young people, the growing complexity of their needs, and ever-increasing financial pressures on health systems, there is a need to deliver better care in a more effective, feasible, and acceptable way [10, 11].
This article demonstrates how we generated actionable findings that provided our evaluation client, CMS, learning-support providers, and primary care practices with information about the contexts underlying CPC implementation and how factors in those contexts may have influenced implementation progress. Findings derived using our systematicapproach can inform stake- holders on how to change or improve implementation of an intervention in the current settings or replication of an intervention in different settings . The CFIR can support the design of implementation studies by guiding analysis and reporting to generate findings that go be- yond the documentation of intervention details and address important research questions about how, why, and under what conditions intervention implementation is effective. Our delineation of the multiple CPC pro- gram components, used in conjunction with CFIR constructs, guided our data collection, data analysis, and reporting and could be adapted to other studies evaluat- ing the implementation of complex multicomponent interventions, within health care delivery and beyond.