Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands.
Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands.
Int J Health Policy Manag. 2022 Jul 1;11(7):981-989. doi: 10.34172/ijhpm.2020.249. Epub 2020 Dec 13.
Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach.
A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model.
The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or 'resistors to change:' recurrent costs, income lost, staff stress, and brain drain.
This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of 'quick fixes' that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.
如果要实现坦桑尼亚国家外科、产科和麻醉计划 (NSOAP) 的目标，那么在地区医院扩大手术规模是一个关键挑战。我们的研究旨在通过采用参与式研究方法从动态角度解决这一挑战，关注地区一级的手术扩大规模。
在阿鲁沙地区的三家医院，我们与 18 名专业人员举行了一次小组模型构建 (GMB) 研讨会。他们通过使用名义小组技术的小组讨论，构建了当地外科服务提供系统的图形表示。这导致了因果循环图 (CLD) 的产生，参与者从图中确定了扩大手术规模的要求以及能够满足这些要求的利益相关者。在 GMB 会议之后，我们使用归纳主题分析和驱动模型的主要反馈循环来确定相关变量的聚类。
CLD 由 57 个变量组成。这些变量包括通过名义小组技术获得的 48 个变量和参与者后来添加的变量。我们确定了 6 个主题：患者受益、手术融资、成本分担、员工激励、沟通和对转诊医院的影响。有 5 个自我强化反馈循环：培训、学习、满足需求、收入和愿意在一家好医院工作。有四个自我修正反馈循环或“变革的阻力”：经常性成本、收入损失、员工压力和人才流失。
这项研究从地区层面提供了一个关于手术扩大规模的系统观点。其结果使人们能够批判性地评估实施 NSOAP 的可行性。我们的研究结果表明，决策者应该警惕只带来短期收益的“权宜之计”。需要长期政策，考虑外科系统的复杂动态，并允许定期评估和调整，以可持续的方式扩大手术规模。
