策划事件研究的未来

近25年的现代事件管理探究经验让我比以前更加确信：经过策划的事件（planned events,以下简称＂策划事件＂）是一条必须汇入未来整个研究之河的永恒之流。中国有句古话提醒说,＂凡事留有余地＂（When you wish to test the depth of a stream,donot use both feet）。但现今的事件研究有一种强烈而深刻的趋势,即从个人和职业两方面终其一生地影响到每个人的生活。也许,现在就是这样一个＂不留余地＂地探寻事件研究意义的时代。

Meso-American Nephropathy in El Salvador: Increasing Farmer Participation in MeN Prevention Efforts

Objectives: This paper highlights and discusses major factors affecting Salvadoran farmers’ involvement in National Health System-led efforts to prevent MeN in El Salvador and includes some recommendations to enhance their involvement. Methods: The study, conducted in El Salvador in June 2018, involved 10 life-long farmers residing in five MeN-affected communities in Chalatenango and Usulutan Departments who were either MeN-free or MeN-controlled, to understand through semi-structured, qualitative interviews their experience of participation in broader epidemic control efforts. Complementary interviews held with two nephrology teams and a senior representative of the grassroots-level National Health Forum operating in the same area, provided necessary contrast. Interview questions were informed by reference to the Adaptation and Development after Persecution and Trauma (ADAPT) model [1] as applicable in post-conflict environments like El Salvador to analyze contextual factors influencing community participation. Findings: Farmers are scarcely involved in wider MeN prevention efforts in El Salvador despite greater National Health System emphasis on encouraging community participation since the approval of the 2009 Health Reform [2]. This study found that widespread insecurity due to gang warfare, declining family and social networks due to high murder rates and international migration, and unresolved sense of injustice over unremitting poverty are among major factors with potential destructive effect on farmer participation. Conclusions: Health system-led MeN prevention responses need to encompass attention to persisting social vulnerabilities in economically and socially marginalized communities in order to enhance farmer participation in this effort. This paper concludes with some recommendations on how this can be done.

Sex-Role Orientation in Men Is Related to Salivary Testosterone Levels

Previous research has implicated the involvement of androgens in sex-role orientation in males, from studies of 2nd to 4th digit ratio (a purported marker of prenatal testosterone). The present pilot study investigates the relationship between salivary testosterone levels and sex-role orientation using Bem Sex Role Inventory (BSRI) scores in adult males. Twenty-one males (aged 18-24) completed the BSRI and provided saliva samples for assay. BSRI Femininity scores were significantly negatively correlated with testosterone levels;the higher the Femininity scores, the lower the testosterone levels. There was no relation of BSRI Masculinity scores with testosterone levels. Our preliminary results add to the research suggesting that sex-role orientation in males may be partially related to underlying hormone levels.

(How)does RBF strengthen strategic purchasing of health care?Comparing the experience of Uganda,Zimbabwe and the Democratic Republic of the Congo

Background:Results-Based Financing(RBF)has proliferated in health sectors of low and middle income countries,especially fragile and conflict-affected ones,and has been presented as a way of reforming and strengthening strategic purchasing.However,few studies have empirically examined how RBF impacts on health care purchasing in these settings.This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings:Uganda,Zimbabwe and the Democratic Republic of Congo(DRC)over the past decade.Methods:The article is based on a documentary review,including 110 documents from 2004 to 2018,and 98 key informant(KI)interviews conducted with international,national and district level stakeholders in early 2018 in the selected districts of the three countries.Interviews and analysis followed an adapted framework for strategic purchasing,which was also used to compare across the case studies.Results:Across the cases,at the government level,we find little change to the accountability of purchasers,but RBF does mobilise additional resources to support entitlements.In relation to the population,RBF appears to bring in improvements in specifying and informing about entitlements for some services.However,the engagement and consultation with the population on their needs was found to be limited.In relation to providers,RBF did not impact in any major way on provider accreditation and selection,or on treatment guidelines.However,it did introduce a more contractual relationship for some providers and bring about(at least partial)improvements in provider payment systems,data quality,increased financial autonomy for primary providers and enforcing equitable strategies.More generally,RBF has been a source of much-needed revenue at primary care level in under-funded health systems.The context-particularly the degree of stability and authority of government-,the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.Conclusions:Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced,while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation,towards which two of the three case study countries are working.

Delivering reproductive health services through non-state providers in Pakistan:understanding the value for money of different approaches

Background:Delivering Reproductive Health Results(DRHR)programme used social franchising(SF)and social marketing(SM)approaches to increase the supply of high quality family planning services in underserved areas of Pakistan.We assessed the costs,cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.Methods:Financial and economic programme costs were calculated.Costs to individual users were captured in a pre-post survey.The cost per couple years of protection(CYP)and cost per new user were estimated as indicators of cost efficiency.For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year(DALY)averted.Results:Approximately£20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs.Based on programme data,the cumulative cost-efficiency of the entire DRHR programme was£4.8 per CYP.DRHR activities would avert one DALY at the cost of£20.Financial access indicators generally improved in programme areas,but the magnitude of progress varies across indicators.Conclusions:The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes.This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low-and middle-income settings.Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.

The political economy of results-based financing:the experience of the health system in Zimbabwe

Background:Since 2000,results based financing(RBF)has proliferated in health sectors in Africa in particular,including in fragile and conflict affected settings(FCAS)and there is a growing but still contested literature about its relevance and effectiveness.Less examined are the political economy factors behind the adoption of the RBF policy,as well as the shifts in influence and resources which RBF may bring about.In this article,we examine these two topics,focusing on Zimbabwe,which has rolled out RBF nationwide in the health system since 2011,with external support.Methods:The study uses an adapted political economy framework,integrating data from 40 semi-structured interviews with local,national and international experts in 2018 and thematic analysis of 60 policy documents covering the decade between 2008 and 2018.Results:Our findings highlight the role of donors in initiating the RBF policy,but also how the Zimbabwe health system was able to adapt the model to suit its particular circumstances-seeking to maintain a systemic approach,and avoiding fragmentation.Although Zimbabwe was highly resource dependent after the political-economic crisis of the 2000s,it retained managerial and professional capacity,which distinguishes it from many other FCAS settings.This active adaptation has engendered national ownership over time,despite initial resistance to the RBF model and despite the complexity of RBF,which creates dependence on external technical support.Adoption was also aided by ideological retro-fitting into an earlier government performance management policy.The main beneficiaries of RBF were frontline providers,who gained small but critical additional resources,but subject to high degrees of control and sanctions.Conclusions:This study highlights resource-seeking motivations for adopting RBF in some low and middle income settings,especially fragile ones,but also the potential for local health system actors to shape and adapt RBF to suit their needs in some circumstances.This means less structural disruption in the health system and it increases the likelihood of an integrated approach and sustainability.We highlight the mix of autonomy and control which RBF can bring for frontline providers and argue for clearer understanding of the role that RBF commonly plays in these settings.

在全民健康覆盖体系内采用基于就业的健康筹资无助于性别平等

Lavanya Vijayasingham及同事认为,与就业挂钩的健康筹资和福利体系可能会使女性处于不利地位。国际社会已多次承诺改善女性获取医疗卫生服务的权利。最近的承诺发布于《可持续发展目标》和《2019年全民健康政治宣言》。这些承诺呼应了1995年《北京宣言》的愿景,即确保女性一生中可获得公平、适当、可负担和高质量的医疗卫生服务。然而,25年过去了,女性仍得不到充分的医疗卫生服务,她们的基本健康需求也仍未得到满足。

Tuberculosis infection prevention and control:why we need a whole systems approach

Infection prevention and control(IPC)measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis(TB)in health facilities are well described but poorly implemented.The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative,environmental,and personal protective measures as discrete entities.We present an on-going project entitled Umoya omuhle(“good air”),conducted in two provinces of South Africa,that adopts an interdisciplinary,‘whole systems’approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis(Mtb)through improved IPC.We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines,health facility space,infrastructure,organisation of care,and management culture.Methods drawn from epidemiology,anthropology,and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs,as well as opportunities to address the problem holistically.A‘whole systems’approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission.