Surgical intervention for umbilical diseases in calves, when indicated, is a complementary and indispensable therapeutic resource for the treatment of umbilical conditions and is commonly performed using celiotomy. However, laparoscopy has demonstrated feasibility in many diagnostic and therapeutic procedures. The aim of this study was to assess the feasibility of the techniques and the surgical time of laparoscopy and celiotomy used in intra-abdominal resection of the umbilical vein and urachus of bovine fetuses (cadavers). Resection of the umbilical vein and urachus using laparoscopy and celiotomy was performed in 26 anatomical specimens . Resection of umbilical structures was feasible with both techniques, but shorter surgical time and minimal tissue damage were achieved using laparoscopy. Laparoscopy requires specialized training and appropriate instruments and is an important tool for diagnostic and therapeutic exploration of the umbilical structures, liver, bladder, and associated/adjacent structures. In many cases, drug therapy alone is not sufficient to treat these conditions, and surgical intervention is a complementary and indispensable therapeutic resource for effective management of these disorders4.Umbilical disorders are often diagnosed in newborn bovine calves, and their etiologies may be associated with infections of the umbilical vessels and urachus, persistent urachus, and umbilical hernias5. Surgical resection of umbilical structures is indicated for the treatment of calves with infected umbilical components and patent urachus and is usually performed using celiotomy7.For the satisfactory and effective treatment of umbilical infections, reduction of bacterial load and removal of infected structures likely to have low antimicrobial penetration are indispensable as they significantly improve the prognosis of these diseases10. In addition, performing laparoscopy requires the surgeon to have specific skills that can only be acquired with specialized training13. Therefore, the advantages of celiotomy make it the most used surgical technique in cases of umbilical conditions requiring surgical treatment7.Surgical resection of umbilical components using celiotomy has been shown to be effective for the treatment of omphalitis in calves, and it is easily performed by the surgeon using conventional surgical instruments, unlike laparoscopy, which requires special equipment and instruments that are usually more expensive than conventional ones, a fact that greatly influences their application in veterinary medicine13. The use of laparoscopy in cattle is promising; there are many potential applications, and, because it is a safe and effective technique, it is an important alternative to conventional methods14.Laparoscopy is a minimally invasive technique and an important alternative to celiotomy that allows, in addition to the observation of abdominal organs and structures, surgical techniques and exploratory procedures to be performed with less pain and better recovery for the patient than conventional techniques17.Surgical indication for the treatment of omphalitis should be preceded by a complete clinical examination, in particular an examination of the umbilical structures, with palpation of the umbilical region associated with ultrasound and/or laparoscopy, thereby allowing the surgeon to determine the severity of the abnormality and establish an appropriate surgical plan for the management of the specific caseData on the feasibility of the techniques and surgical time of procedures performed for anatomical specimens provide important information for the execution of these procedures in live animals. Thus, the objective of the present study was to assess the feasibility and the surgical time of laparoscopy and celiotomy for intra-abdominal resection of the umbilical vein and urachus of bovine fetuses (cadavers).This study was carried out in accordance with the recommendations of the National Council for Experimentation Control in Brazil (CONCEA). This research was approved by the Animal Ethics and Welfare Committee of the Federal University of Pará (protocol N ° 4848261017). As the study corresponds to a new experimental technique, all surgical procedures were performed on cadavers from a local slaughterhouse in accordance with inspection requirements. Thus, the procedures did not cause pain or suffering in animals, as they were performed on bovine fetuses from the slaughtered of pregnant cows.The experiment was conducted at the Institute of Veterinary Medicine (IMV) in Campus II of the Federal University of Pará (UFPA), located in the municipality of Castanhal, Pará, Brazil, and involved the resection of the umbilical vein and urachus using laparoscopy and celiotomy in 26 anatomical specimens  and the other group with 13 anatomical specimens that underwent resection of the umbilical vein and urachus using celiotomy, i.e., open surgery .All the steps of the procedures in both groups were performed by the same surgeon in a standardized and systematic manner throughout the study.The feasibility of the techniques and the surgical time  were analyzed in all the anatomical specimens in both groups. A descriptive comparison of both techniques was performed, in which the feasibility of performing the surgical procedures was assessed.The experimental simulation of the surgical procedures took into consideration all the surgical principles applicable to laparoscopy and conventional open surgery, and the necessary equipment and instruments were used to perform the techniques. We used a 10-mm laparoscope, 10-mm or 5-mm Babcock forceps, 5-mm laparoscopic scissors, a set of gas insufflator/light source/monitor, and basic surgical instruments for conventional surgery.The anatomical specimens of the LG group were placed in the left lateral recumbency position and underwent laparoscopy using three laparoscopic access ports in the right flank, with two 10-mm cannulas in the first and second access ports and a 5-mm cannula in the third port for access to the umbilical vein and allantoic duct, or urachus. The access ports were established in the right flank near the paralumbar fossa, caudal to the ribs, using the modified hasson technique -induced pneumoperitoneum of 8 mmHg was established, and the abdominal cavity was inspected by viewing the image on the monitor. The inspected elements included the umbilical vein from the umbilical ring to its insertion in the liver, the umbilical arteries from the umbilical ring to the vicinity of the bladder, and the urachus from the umbilical ring to the bladder.The first 10-mm laparoscopic access port with an insufflation valve was inserted, through which a carbon dioxide  using 0.6-mm polyamide thread.Access to the umbilical vein and urachus using celiotomy (open surgery grup—OG).7 adapted, working with the anatomical examples in the dolsal recumbency position, making elliptical access at the umbilical base, accessing as structures that make up the umbilical cord. After access was established, an umbilical vein was inspected, connected with a Miller knot in the region adjacent to the liver, without marsupialization maneuver. The tissues between the urachus and the artery were separated for better bladder identification inspection. Two block ligatures were made in the region close to the bladder using the Miller knots. Subsequently, the entire region of the umbilical ring was removed and the access reversed. Myorrhaphy was performed with superimposed suture, reduction of the subcutaneous space in a continuous suture and demorraphy using U suture.OG procedures were performed according to Marchionatti et al.The Shapiro–Wilk test was used to confirm that surgical time data were distributed normally. Data on total surgical time and duration of each surgical step were grouped for the GV and GA groups. Student's t-test was used to compare normally distributed data on surgical time, and the Mann–Whitney test (Wilcoxon) was used for non-normally distributed data.Descriptive statistics were processed using the R statistical program, version 3.0.2. The confidence interval was 0.95, and when p ≤ 0.05, the difference was considered significant and the null hypothesis was rejected.All fetuses of bovine calves in the final third of gestation had well defined umbilical structures, including the components of interest, i.e., the umbilical vein and the allantoic duct, or urachus. These components had a cylindrical shape, defined walls, and flaccid texture, and it was possible to distinguish the umbilical veins and arteries as separate units. The liver and bladder were also well formed and defined. The bladder was empty, and the allantoic duct was cranially inserted in the anterior apex.In the LG, with the fetuses positioned in left lateral recumbency, it was possible to perform resection of the umbilical vein and urachus using laparoscopy with three access ports established in the right flank, in the paralumbar fossa region Fig. A,B. In tThe pneumoperitoneum established using an intra-abdominal pressure of 8 mmHg allowed satisfactory separation of the abdominal wall from the visceral structures, as well as excellent intra-abdominal visualization of the umbilical structures and associated/adjacent organs such as the liver and bladder.Access to the abdominal cavity and target structures to perform the procedures was achieved through three laparoscopic ports in laparoscopy and through a paramedian and circumscribed incision in the abdominal wall  in celiotomy Figs. B and 2. During access to the abdominal cavity using laparoscopy with three ports, the umbilical vein was the first component inspected because the laparoscope focused directly on the structure, thereby enabling its complete inspection Fig. A. It wasWith regard to the urachus, it was possible to simulate clipping with the Babcock forceps and perform its resection using laparoscopy Fig. E. ResectIn the LG group, closure of the abdominal cavity was performed by placing a stitch on the skin (U suture) that created a post-surgical wound of approximately 5 mm in length. In the OG group, peritoneum/muscle dieresis was performed with overlapping suture, subcutaneous tissue dieresis was performed with simple continuous suture, and dead space was reduced by anchoring the subcutaneous tissue to the musculature. Skin closure was performed with a U suture that created a post-surgical wound ranging from 10 to 20 cm, with an average of 13.6 cm  and 39.44 (± 8.46) min, respectively . The removal of intra-abdominal structures is common in laparoscopic procedures, requiring small extensions in the portal access or the use of laparoscopic specimen retrieval bags27.The difference in the surgical times of umbilical vein resection (second step) between the LG and OG groups was not statistically significant. In laparoscopy, the time required for simulation of the clipping and umbilical vein resection was shorter than that for the execution of Miller’s knot followed by vein resection in conventional open surgery; however, the surgeon's skill may have been a factor that influenced the surgical time of this step. A surgeon's skill is directly related to specialized training that ensures the ability to perform procedures quickly and efficiently28.The surgical time for urachal resection in laparoscopy was longer than that in conventional open surgery because access to the urachus in laparoscopy was not direct, similar to the access to the umbilical vein. The urachus lies in the ventral region of the abdomen, between the umbilical arteries, and is enveloped by tissues that make its identification and manipulation difficult . For satisfactory intervention in the urachus, it is important to perform tissue divulsion around the duct, a procedure that requires a skilled laparoscopist and may have influenced the surgical time of this stage, although not greatly and not affecting the final surgical time. In general, urachal resection was achieved in all the animals in laparoscopy, which was shown to be an efficient technique for urachal interventions, both from a therapeutic and a diagnostic perspective. Considerable advances have already been achieved in the use of laparoscopy in urachal conditions30.In convencional open surgery, the umbilical artery is seccioned and disconected from the abdominal wall. The same procedure could be performed in the laparoscopy. However, the authors believe that the techinique connecting the urachus to the bladder could be the best option. This procedure avoids potential trauma to adjacent structures, minimizing the formation of intra-abdominal adhesions, besides considering that the umbilical artery atrophy with the development of the calf19.In the final step, i.e., closure of the abdominal cavity, the surgical time in the GA group was longer than that in the GV group. This was expected because the opening of the abdominal wall in conventional open surgery was multiple times larger than that in laparoscopy, and additional time was required to perform abdominal tissue closure. In laparoscopy, a simple stitch ensured closure of the cavity, whereas in conventional open surgery, several stitches were required to perform peritoneum/muscle and subcutaneous dieresis and skin closure. Abdominal tissue closure in laparoscopy is satisfactorily performed with one or two simple stitches in each created wound and has lower rates of complications compared with abdominal tissue closure performed in conventional open surgeries31.The total surgical time of laparoscopy was significantly shorter than that of conventional open surgery (exactly 15.81 ± 3.26 min), which shows that resection using endosurgery of the umbilical vein and urachus is faster than resection using conventional open surgery. The step of abdominal cavity closure in conventional open surgery significantly affected the total surgical time in the GA group because access wounds in the abdominal wall were significantly larger than those caused by laparoscopy. This increased the time of abdominal cavity closure and, consequently, the total surgical time of conventional open surgery. The total surgical time of laparoscopy in the present study was significantly shorter than that in other similar studies in which the laparoscopy technique was used in diagnostic and surgical interventions of umbilical structures with times ranging from 36 to 160 min15. Other studies have shown that laparoscopic techniques are less traumatic than conventional open techniques35.Abdominal wall injuries were less common in laparoscopy than in conventional open surgery; laparoscopy caused only three lesions of approximately 10 mm, as well as less tissue damage. This allows us to infer that laparoscopy causes less surgical trauma in living patients and provides better postoperative recovery of newborn calves. Because it is a minimally invasive technique, it is important to determine whether it is possible to perform it under regional anesthesia and sedation, a suitable alternative for treating calves with umbilical disorders associated with concomitant diseases and with reduced ability to adapt to general anesthesia36. The use of laparoscopy in production animals is still incipient, but its use provides better results in semiological and clinical/surgical procedures in bovine veterinary medicine, with advances in sanitary/production methods and animal welfare39.The results of laparoscopy allowed the identification of additional benefits of its use in production animals because the technique enabled a large visual field for the diagnostic exploration of the abdominal cavity, thereby providing diagnostic advantages from a macroscopic and morphological perspective, including the accurate detection of macroscopic disorders in the umbilical structures, liver, bladder, and other adjacent structures, with results that can be correlated with ultrasound and laparatomy. Laparoscopy is a potentially viable diagnostic alternative that allows diagnosing multifocal abscesses in the liver, changes in umbilical arteries near their branching from the internal iliac artery, and focal thickenings and adhesionsThe laparoscopic technique proposed in our study allowed to perform the ressection of the umbilical vein and urachus. The effectiveness in the evaluation of the structures is highlighted, allowing an excellent diagnosis.Even though this research was performed in an experimental model, the study supports the attempt to perform the technique in patients in vivo, based on its minimally invasive quality and the short surgical time in the proposed assessment.More studies in the clinical routine are required to verify each operative step in the face of altered structures, however, the team allows few adaptations in live animals.


To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder’s revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms. Key MessagesThe implementation of the user fee exemption policy for caesarean section may result in mixed outcomes at hospital level within the same country because of contextual factors such as the ownership of the facility, the organizational objectives of the facility, the commitment of managers, the management of health providers, the existence of channels for community voice and of means for exercising that voice.The implementation outcome of such policies may be generated by different mechanisms, including trust, perceived coercion, intrinsic adherence to the goals and values of the policy, perceived individual or organizational financial gains provided by the policy and the perceived fairness in the resources allocation.The policymakers should consider strategically which mix of mechanisms they need to trigger in which contexts for a successful implementation of user fee exemption policies or other similar health-financing reforms for universal health coverage. Since more than a decade, universal health coverage (UHC) is a priority on the global health agenda . World HSeveral African countries introduced user fee exemption policies for various health services since 2000 . Also thGovernment of Benin introduced the user fee exemption policy for caesarean section on 22 December 2008, targeting all pregnant women requiring a caesarean section. It came officially into effect on 1 April 2009 and covered an intravenous infusion before referral, referral within the health district, consultation, hospitalization, surgery, drugs, supplies and post-surgery check-up. A national agency (the implementing agency) was created to manage the implementation process. In 2013, 30 state-owned hospitals and 18 non-state-owned hospitals were accredited for reimbursement under the policy. Criteria for the accreditation of hospitals included the not-for-profit status and the capacity to provide caesarean section. The state-owned hospitals included all the hospitals, operating under the administrative and technical supervision of the Ministry of Health . The nonThe FEMHealth research programme ran from January 2011 to December 2013 and was funded under the Seventh Framework Programme of the European Commission. It aimed at evaluating user fee exemption policies for maternal health services in Mali, Burkina Faso, Morocco and Benin. In Benin, FEMHealth focused on the user fee exemption policies for caesarean section and demonstrated variable implementation outcomes across seven hospitals. Some hospitals provided five out of the eight items covered by the policy for free, whereas other facilities provided only one. The median fees charged for a caesarean section varied between US$0 and US$52 , context, actors, mechanisms and outcomes, using the Intervention-Context-Actor-Mechanism-Outcome (ICAMO) heuristic to identify the configurations that explain the reported outcomes at each level  and alignment of the policy goals with local needs. Programmes are actually or symbolically adopted by district health authorities and hospital managers.Phase 3: This phase concerns the implementation of the programme by service providers, who act as street-level bureaucrats. Berman calls this ‘micro-implementation’ and considers this ‘may be the most pivotal step because a social policy’s outcome depends on local delivery’ , p. 21. If the three papers provided an overarching architecture for a multi-level analysis of policy implementation, they did not present mechanisms. Our berry-picking approach led to the ‘carrots, sticks and sermons’ typology of policy instruments . CarrotsWe adopted the multiple embedded case study design , which iRealist evaluation is method-neutral: the data collection methods should allow to gather data needed to test the initial programme theory. We collected both quantitative and qualitative data to describe the case and its units of analysis. We transcribed verbatim the recordings of the interviews and entered the transcripts in QSR NVIVO 10, converted later to QSR NVIVO 12. In a first phase, we adopted thematic analysis principles , wherebyin casu policy), context, actors, mechanisms and outcomes, and identified the configurations that explain the reported outcomes at each level. We mapped the causal configuration looking for causal links between the actually implemented intervention, relevant contextual elements, the mechanisms that were triggered for specific groups of actors and the observed outcomes. Mechanisms are key components in this heuristic and we defined them as the reasoning of the actors in response to the resources or opportunities and changes in the context introduced by the intervention  in 2012, and the respective research ethics committee of the authors’ institutes approved this study. We obtained a written authorization to conduct the study from the Ministry of Health of Benin but also written consent from the managers of each unit of analysis. All the interviewees signed an informed consent form before the interviews. All the materials are stored for confidentiality and the findings are reported anonymously.In this section, we present the results of the two hospitals, describing the implementation outcome and the respective responses of the actors: the adoption of the policy by the managers, the response of the providers and the perceptions of the community. We present a synthesis of the ICAMO of both hospitals.In the faith-based hospital, the median fee paid by users for a caesarean section amounted to US$53 . Out of the eight items of the policy package, only the post-surgery check-up was fully exempted.This hospital was accredited as an implementing facility in December 2008. Six weeks after the official launch of the policy on 1 April 2009, the hospital managers started implementing it. We found that managers of this facility felt they were not properly engaged in the policy design process and that their concerns were not properly addressed. Managers also reported that they did not trust government to timely reimburse the US$196 for each caesarean section as stated in the official policy documents. Managers justified this mistrust by previous experience with government:We used to exempt some user fees for civil servants affiliated to the national health insurance scheme, but the state never reimbursed us. So, when we received the information [to implement the fee exemption policy], we were a little bit hesitant. We waited for other facilities to start. We started after seeing that the reimbursement was effectively following .Our financial flow tracking study showed that up to December 2011, this facility was reimbursed US$205 800, corresponding to 1050 caesarean sections. Our respondents declared that it took between a few days and 3 months after submitting the claims to receive the reimbursements.Several reasons were given for not fully adopting the policy. The managers perceived the fixed amount of US$196 insufficient and unfair. Yet, the analysis of the costing data showed that the median production cost of a caesarean section  was US$50 . User fee charged in this hospital before the policy was US$180. Managers argued that their reimbursement rate should be higher than that for the state-owned facilities where public subsidies cover some recurrent expenditure. They, therefore, decided to systematically charge patients an additional fee of US$39. Non-exemption of consultation fees was explained as follows:Even when a pregnant woman later undergoes a caesarean section in the facility, she has to pay the consultation fee before being admitted to the hospital. (…) since you cannot predict if the woman will undergo a caesarean section or not, and thus if she has to be exempted for the consultation fee or not. Gynaecologists are very strict on this point, because their income depends on this .In this hospital, gynaecologists receive 5–10% of the fee of each caesarean section they perform. To receive this fee, they have to present a proof of payment of the additional US$39 fee to the administration. Gynaecologist declared they have to ask actively women to pay the fee and collect the proofs they can show to the administration. Users declared they feel constant pressure from health workers to pay the additional fee.In addition to the reimbursements, the Ministry of Health provided free kits of drugs and consumables during the first year of the policy. Kits were issued to the maternity, where they were used for patients who paid the additional fee. The managers interpreted the provision of kits as a permanent measure. When it ended in March 2010, they considered this an important loss of resources and they started charging users all the post-operative care, on top of the additional US$39 additional fee. They reported this change to the implementing agency during a supervision visit. The agency expressed its dissatisfaction and issued an injunction to start implementing the policy as requested.There are pre-anaesthesia consultations that we charge the patients for and that was noticed by the implementing agency when they visited the hospital. They were angry, they really shouted, even in front of patients .The managers, however, did not adhere to the injunction. We found that the managers as well as the providers perceived the hierarchical power of the Ministry of Health as weaker than that of the religious organization owning this hospital. We found that the latter controls the management of the hospital through the appointment of the managers, the recruitment of the staff and the validation of the budget.The providers reported that they adopted the package of the policy only partially. It emerged from the interviews that communication between managers and providers was limited. Providers expressed their feeling that their managers had a laisser-faire attitude about the policy. Providers said they received little organizational or supervision support as illustrated by the following quote:, the managers did not support us. The gynaecologist who was supposed to be responsible of everything related to caesarean sections was blamed for all that went wrong .The supervision visits from the implementing agency were irregular and health providers perceived these visits merely as a control of prescription of drugs and consumables. They felt the visits did not help them in finding solutions to the problems they faced in implementation.Some policy beneficiaries reported in interviews that providers charged them for certain services related to caesarean sections without bill. Providers also reported that they had margins of freedom in the policy implementation that allowed them for instance to prescribe drugs or consumables that were out-of-stock or missing in the kit. As a result, patients had to purchase these items either outside of the facility in private pharmacies or inside the facility  as reported in the following quote:We sell our products. We prescribe certain drugs. When users buy them, (…) we use them. When they don’t find them, we help them. Usually this applies to hyperbaric bupivacaine or spinal needles. In the last three months, there was no ephedrine at the Essential Drugs Purchasing Centre, nor on the market, but we have our own supply chains .We found that there was little if any contestation of these practices by patients.Comité de Santé) reported in interviews that they had little knowledge about the policy and were not much engaged in it. The committee is supposed to ensure participation of all stakeholders in local health governance as prescribed by decree N° 2005-611 of 28-09-2005 .Managers of this hospital applied the policy on 3 April 2009, 2 days after its official launch. The hospital director was involved in the technical workshops organiszed during the development phase of the policy. He perceived the policy as supporting his vision to increase financial accessibility of the hospital. He took active measures to facilitate its implementation, as explained by a manager of this facility:We have sensitized healthcare providers and the community. (…) We started exploring what to put in place to prevent the failure of the policy, for instance, by ensuring a sufficient stock of rehydration fluids for a minimum of six months (…) Our vision was that if the government is out of breath, we should be able to continue .The managers used radio programmes as well as informal communication channels to inform the community about the policy. They simplified the message to facilitate the communication: ‘Caesarean sections are fully free’.In this facility, managers are civil servants who are recruited, appointed and paid by government. They expressed how the power of the hierarchy within the Ministry of Health made them implement the policy. The perceived power of the community added to this pressure:The population has been widely informed that the caesarean section is free and it is difficult to say now “Me, I will not start implementing the policy”. (…) Since the Provincial Health Director knows that the caesarean section is free, if a woman complains that the facility asked her to pay, as a manager, you will have to explain why .The managers considered the guidelines of the implementing agency regarding reimbursement as useful. Managers felt effectively supported by the implementing agency and this helped in accelerating the reimbursement. Our financial flow tracking study showed that up to December 2011, this facility was reimbursed US$134 652 for the 687 caesarean sections it performed.In the interviews, providers declared that the hospital management team effectively supported them in the implementation of the policy, for instance with the regular supply of the maternity unit with the caesarean section kits. Managers reported that when they anticipate a shortage of key products of the kits, they give priority to the free caesarean section policy and stop supplying other wards. Women reported that usually they did not have to buy drug in private pharmacies, except when presenting with complications. For instance, in case of meconium-stained amniotic fluid, providers reported that the staff ask families to buy an infusion of metronidazole and ceftriaxone. We found that some non-official fees were charged in the operating theatre and in the post-operative room. For instance, providers proposed selling pain-relieving drugs to women suffering from post-operative pain.When the effect of anaesthesia waned, we started feeling uncomfortable and women started crying from everywhere. We were obliged to call the midwives and beg them and ask if they would not have a drug that can reduce our pain. They replied [the managers] said caesarean section is free, and if we want a pain relief, we must pay for it. Then we begged them to put something in our infusion .Both managers and providers reported that the management team did not tolerate such practices. Managers reported that they applied two measures when they found out: the confiscation of drug stocks belonging to staff and the reimbursement of the users who complained. The implementing agency’s team, which conducts supervision visits, sometimes participated in seizing drugs from staff.The district health committee includes community representatives who play a leadership role in the management of the hospital, which is considered by the local communities as ‘our hospital’. The committee meets at least three times per year. In interviews, members of this committee reported the policy was a major event for them: they were informed about the policy and closely communicated with the community to inform them.Managers, providers and users reported the perceived financial gain from the policy was very important, and the population had high expectations of the policy. Managers explained that living in a semi-rural area, the population had few choices in terms of care providers. As their capacity to pay was low, the high financial burden of a caesarean section and the consequences were important, and the perceived gain from the exemption was very important for them.Not only users and community representatives but also managers mentioned there were multiple opportunities to express complaints. In constituency meetings with local politicians, they could express their (dis)satisfaction by giving a mark to the public health facilities. Local radio stations provided space for complaints through anonymous phone calls. However, women found it difficult to lodge complaints against staff as long as they were hospitalized, as they feared retaliation.In this public hospital, patients undergoing a caesarean section still paid formal and informal fees but far less than in the non-state-owned hospital. Managers adopted five out of the eight items of the policy package. They were motivated by their involvement in the development of the policy and by the alignment with their values and principles, but as civil servants, they also felt forced to implement the policy. They actively informed the public and made efforts to support their providers in the implementation. As a result, they adhered to the policy goals. The providers, as civil servants, complied with the policy, and felt actively supported by their managers. The community and users had high expectations of the policy and had channels to raise complaints, exerting bottom-up pressure on providers and managers. With this study, we aimed to explain the diverging outcomes in two hospitals where the policy was implemented. We focused on the meso- and micro-level of implementation. Several factors were at play in the adoption of the policy, including alignment with personal and organizational goals and values, financial motivation and enforcement. We found new elements not included in our initial programme theory: trust and perceived fairness of the resource allocation. A somehow surprising finding was that the faith-based hospital did not correctly implement the policy, to the detriment of the patients and against the generally assumed value set of such organizations  and using that voice (actively expressing voice). The sensitivity of managers and providers to such enforcement depends on their perception on how accountable they have to be towards their hierarchy (upwards accountability) and citizens (downwards accountability) and thus on the degree of pressure exerted on them. Enforcement can be counteracted by perceptions of threats to vested interests, such as institutional survival or informal generation of revenue.Extrinsic motivation can drive both adoption and micro-implementation. It may be generated by financial incentives. Policies that increase personal or institutional financial gains are more likely to be adopted, but perceived fairness in the allocation of the resources between the parties beyond the net personal financial gains can play a role, too. The perceived financial gains will more likely operate in organizations with lower financial margins and depend on the trust the implementer has in the policy promotor.Persuasion is effective when the implementers adhere to the policy goals because they became policy champions. The latter will more likely adapt both the policy and the context for an optimal policy implementation. Participation of implementers in the policymaking process can contribute to persuade them, enhance coherence of the policy with their actual needs and increase ownership of the policy.Effective implementation needs the required resources, including drugs, supplies and information, to be timely available at the point of delivery and a general conducive work setting. These measures, if they are implemented consistently, reinforce trust and enhance the self-efficacy of implementers.In Benin, the user fee exemption policy had different implementation outcomes. In the hospitals we studied, contextual factors, including ownership of the facility, organizational objectives, commitment of managers, the management of health providers and the existence of channels for community voice and for exercising that voice transformed the same inputs into contrasting outcomes. In LMICs, trust, perceived coercion, adherence to the policy goals, perceived financial incentives and fairness in their allocation need to be tactically used for a successful implementation of user fee exemption policies—or similar health-financing reforms for UHC—in mixed (state-owned and non-state-owned) delivery platforms.


Over the last decade, the government of Ghana has implemented several interventions aimed at increasing access to skilled birth-care services from trained professionals. Despite these efforts, there is a wide gap between antenatal care attendance and skilled delivery attendance, particularly in rural areas. Evidence shows that many women in rural and deprived communities in Ghana rely on traditional birth attendant (TBA) delivery services. This has created a gap where antenatal attendance is high while skilled delivery is relatively low. The purpose of this study is to identify and analyse the sociodemographic characteristics of women who use the services of TBAs in Bongo District, Ghana.Using a descriptive study design, a survey was conducted involving 330 mothers randomly selected from 1685 mothers who delivered at home by 2014 in Bongo District. The questionnaire for mothers who delivered at home by a TBA comprised 28 questions.The results show that women who used TBA were older, without formal education, married, predominantly farmers, married to spouses who were farmers without formal education. Most of the sampled women were co-currently covered by the national health insurance.This study describes the demographic characteristics of women who use a TBA. Therefore, ongoing efforts aimed at increasing access to and use of professional antenatal services should incorporate sociodemographic factors in the rural context. Home births supervised by TBAs have long been associated with factors such as cultural norms and religious beliefs, cost, and accessibility of services. For instance, in Sub-Saharan Africa, the shortage of medical professionals for maternal health services compelled women to patronise maternal services provided by TBAs4.Globally, traditional birth attendants (TBAs) handle 60–80% of all deliveries in the rural settings of developing countries5 defined a TBA as one (mainly a woman) who acquired her skills of delivering babies by herself, or working with other TBAs, and assists mothers during childbirth. TBAs are mostly initiated through internship with family and non-family TBAs and from dreams and revelations6. Their practice is associated with the exercise of spiritual and physical approaches involving the use of artefacts, herbs, as well as physical examination6.The WHO10. For instance, TBAs in some jurisdictions now play advocacy, sensitisation and referral roles instead of handling direct delivery cases10.Studies suggest that the role of TBAs is changing over time due to attempts by governments, health directorates and international organisations to limit, control, mainstream and in some cases outlaw their activities11. However, recent studies in Sub-Saharan Africa and Ghana show that the practice of TBAs is still widespread and government policy of curtailing their services may not be successful as rural women still prefer the services of TBAs13 due to multiple factors militating against access to professional maternal care14. In rural settings, TBAs are known to offer affordable15 and accessible services as well as conduct delivery in an environment familiar to the woman17. Also, the preference for TBA services is due to their respect for the religious beliefs of clients18. In particular, women still use TBA services, especially those from rural and deprived communities12 such as the Bongo District in the northern part of Ghana. The situation has led to a wide gap between antenatal care attendance and skilled delivery attendance in Bongo District. For instance, in 2009, antenatal care attendance in Bongo District was 90.2% whereas skilled delivery performance was only 47.6%19. In 2010, antenatal care attendance increased to 96.5% whereas skilled delivery attendance increased marginally to 54.6%19. What one can infer from this high antenatal coverage and low skilled attendance at delivery is that most of the women attended antenatal care, but when it came to delivery, they delivered at home, probably through a TBA (relatives or friends). This implies that TBAs continue to play an important role in deliveries at home, especially in rural areas.In Ghana, efforts have been made in recent times to limit the activities of TBAs in some areas to sensitisation and awareness-raising. Also, the introduction of free maternal health services for pregnant women and the introduction of the National Health Insurance (NHIS) in Ghana are expected to reduce the financial burden on pregnant women in order to increase access to skilled birth-care services provided by professionalsTo date, there is a paucity of literature concerning the use of TBA services in the Bongo District of Ghana. This study, therefore, assesses the sociodemographic characteristics of women that influence their use of TBA services from the perspectives of women from Bongo District. The paper argues that the sociodemographic characteristics of women are important in explaining mothers’ choice of antenatal services. Consequently, this study seeks to widen the debate about the use of TBAs in Ghana.20. The district lies between longitudes 0.45'W and latitudes 10°50'N to 11°9'N, with an area of 459.5 km2. It is located within the onchocerciasis-free zone of Ghana. Bongo District is bounded to the North and East by Burkina Faso, to the West by Kassena-Nankana Municipality and Kassena-Nankana West District and to the South by Bolgatanga Municipality.Bongo District was selected for the study because it recorded the lowest performance of skilled delivery services from 2008 to 2010 in the Upper East Region. This situation led to reported cases of four maternal deaths in 2008, five in 2009 and three in 201021. The district is predominantly rural, with over 80% of the inhabitants living in areas classified as rural. It is fairly homogeneous with the Boosi and Gurusi ethnic groups forming about 80% of the population21.The population of the district is about 84545, with 40084 males and 44461 femalesThe modern healthcare system of the Bongo District is consists of one hospital in Bongo, the District capital, four health centres, thirteen completed Community-based Health Planning and Services (CHPS), sixty-two outreach stations, ten feeding/nutrition centres and one rehabilitation centre. The District Health Management Team (DHMT) headed by District Director of Health Services (DDHS) superintends the District Health Administration. The DHMT is supported by sub-district health management team (SDHMT) in all the six sub-districts with twenty-three midwives. Increase awareness creation on health promotion and protection was undertaken by community health nurses, community health officers, midwives and the Public Health Unit of the hospital, at the various health facilities, outreach points, schools and community durbars. Topics include environmental and personal hygiene, hand washing, good nutrition, seeking early treatment, know your HIV status, childcare, early initiation of antenatal care to women, free registration of pregnant women with NHIS, free maternity services for women, and many others.22. According to Glass and Stanley23 descriptive design is used when the researcher intends to accurately show the status of one or more variables, or to specify a phenomenon of human experience. The design has been adopted in this study in order to answer the questions: ‘what exists?’ or ‘how do the phenomena appear?’. The design is flexible and allows the researcher to choose quantitative or qualitative methods to answer the questions24. The descriptive study design was relevant to the study as the main objective was to identify factors influencing the use of TBAs.The study adopted a cross-sectional descriptive design. Descriptive research design helps assist the researcher in exploring and explaining a situation in its natural environment. Additionally, it permits the researcher to describe the characteristics of persons, situations and the occurrence of phenomena24 formula  at 95% confidence level (CI) and 5% margin of error.The study populations included women who gave birth, within one year before the survey, in the study area. Out of a total of 1685 mothers who delivered at home by 2014, a sample of 330 was derived using the Yamane25 was employed to select 330 mothers who delivered at home by TBA in Bongo District for the study sample. The sample frame was obtained from the names and addresses of mothers available in child welfare clinics’ registers.A simple random sampling technique (lottery method with replacement)Data were gathered from participants with the use of both closed and open-ended interview questions. Questionnaires for mothers who delivered at home by a traditional birth attendant (TBA) were administered.The questionnaire for mothers who delivered at home by TBA comprised 28 questions on demographic characteristics of the respondents. This set of questions was mainly close-ended. The questionnaire was pre-tested on 25 mothers attending a child welfare clinic in Bongo District hospital. Each mother was interviewed after the purpose of the study was explained. The purpose of pre-testing the instrument was to obtain clarity and to find out its appropriateness to the main study. There were no difficulties encountered with the questionnaire. However, the pre-test helped to modify some questions.Data quality control was guaranteed throughout the process of data collection, coding, entry and analysis. Training exercises were conducted for all data collectors, and their work in the field supervised strictly for adherence. Supervision of data collectors included observation of how they were administering questions. Codes were assigned to questions in the questionnaires for easy detection and correction of errors. The completed questionnaires were checked for completeness by data collectors daily. Consequently, problems encountered were discussed among the survey team and addressed immediately.26. In order to satisfy the ethical requirement of the study, a research proposal was submitted by the researchers to the School of Allied Health Sciences, University for Development Studies for appraisal and approval. Following the approval by the University, further approvals were sought from the Regional Health Directorate of Upper East Region and Bongo District Health Directorate to use the district as the setting for the study.Ethics constitute values that determine the degree to which research procedures adhere to professional, legal and social requirements about the studyAt the community level, verbal informed consent was sought from participants to conduct interviews. Each respondent was made aware that participation in the study was optional – a respondent had the right to decide whether to participate in the study or not, and to withdraw from the study at any time if she so wished. Respondents were assured that information they provided would remain confidential and their identity kept anonymous. Consequently, respondents were asked to desist from writing their names on the questionnaire. Finally, each questionnaire was accompanied by a cover letter that explained the aims of the study as well as the rights and obligations of the research participant as well as the researcher. The research assistants used the local dialect to facilitate understanding and to seek participation, for those participants who could not read and write English.The completed questionnaires were checked for completeness and consistency of responses. The Statistical Package for Social Sciences (SPSS) computer software package (Version 16.0) was the tool used to analyse the data, organised mainly into frequency tables. Reasons that accounted for the use of and challenges associated with using a TBA were computed and presented in tables in a ranked order. Chi-squared test by cross-tabulation was also employed to measure how utilisation of TBA services relate to sociodemographic variables and other service characteristics. The study considered p-values <0.05 as significant.The study identified the demographic characteristics of women that reported use of TBA, shown in Women’s occupation was also observed to be significantly associated (p<0.001) with TBA use . Within Finally, the chi-squared test showed a statistically significant relationship (p<0.001) between membership of the health insurance scheme and use of a TBA.27 and Siajabu28 in Tanzania have revealed that older women are more likely to access the services of TBAs than younger women.The results from this study give the characteristics of rural women in Ghana that rely on the services of TBAs, despite government efforts to increase access to trained maternal services. The patronage of TBAs is significantly influenced by the sociodemographic characteristics of women. The findings indicate that older women prefer to deliver at home by TBAs than younger women. Studies on the association of a woman’s age and utilisation of TBAs have produced mixed results. Mwifadhi et al.29 has argued that the age of the mother does not affect her choice of delivery service. Another perspective is presented by Constanze and Rosemarie30 in Tanzania and Ogolla31 in Kenya that suggests that younger mothers use the services of TBAs more than older women. These divergent views about the relationship between age of a mother and the use of TBAs can be explained by several factors inter alia, cultural, attitude of service providers, the perception about the quality of services and financial constraints. For instance, a study in Nigeria revealed that teenage mothers lack the financial resources to access services from professionals and therefore rely more on relatives or TBA services, which are relatively cheaper1.In contrast, using empirical evidence from Kenya, Carter13. This finding has several implications for maternal health, safe motherhood, and delivery. It implies that current efforts by the government through the Ministry of Health to expand the services of trained midwives cannot be achieved without sensitising rural women about the advantages of accessing services from professionals.Similarly, in Sub-Saharan Africa, TBA services are embedded in the cultural and traditional norms of the people and are therefore more acceptable to rural women than professional services from trained midwives27, Henry and Tukur32 in Tanzania and Seter et al.33 in Iraq, whose studies suggest that women without formal education are more likely to access the services of TBAs than women with a formal education. In contrast, the Siajabu study from Tanzania proves the opposite. Again, these differences in health-seeking behaviour can be attributed to cultural, financial, and other factors28.The study also reveals the importance of education in the health-seeking behaviour of rural women. Majority of mothers without formal education access the services of TBAs. This finding is consistent with Mwinfadhi et al.28 and Ogolla31, report similar situations in Tanzania and Kenya, respectively. The occupation of rural women also significantly affects their use of health facilities. The findings show that farmers and housewives tend to use the services of TBAs more than traders, civil servants, and hairdressers. This situation may stem from the fact that farming is embedded in the culture of local people, and therefore relates to the activities of TBAs. This is further supported by the finding that the majority of women who practice Traditional Religion use the services of TBAs. The importance of religion as a determinant of maternal healthcare utilisation has been emphasised by Addai34, Bazant and Koenig35, and Carter29. For instance, Addai34 has revealed that Christian women, particularly Roman Catholics, are more likely to seek antenatal care and skilled delivery care compared to mothers of Islamic and Traditional religions.It has been revealed in this study that, the marital status of women also affects their utilization of TBAs. While married women are more likely to access the services of health professionals, single women prefer to deliver at home under the care of TBAs. Siajabu37. These studies suggest that women who are active card holders of the National Health Insurance Scheme (NHIS) are more likely to use professional medical care than those without insurance. Contrary to this view, this study revealed that the majority of rural women use the services of a TBA regardless of health insurance status. The results show that over 93 per cent of women who are on the National Health Insurance Scheme use the services of a TBA. This implies that the utilisation of TBAs goes beyond the issues of affordability of professional care as earlier studies suggest.Several studies have shown that health insurance affects the use of TBA services38 who studied factors influencing the utilisation of skilled delivery services in the Ofinso South District in Ghana, by Adjei39 who assessed factors contributing to low utilisation of skilled delivery services in Ahafo-Ano South District in Ghana, Amankwa37 who assessed the determinants of skilled birth attendance in the city of Bolgatanga Ghana, as well as Mengsteab40 who studied skilled attendance in Zona in South Africa. Their findings show that low parity women prefer the services of skilled professionals. The finding, however, confirms Ogolla31 whose study had revealed that first-time mothers were five times more likely to give birth at home compared to those who had two or more children. Attitudinal differences have sometimes been cited to explain the higher utilisation of health services by young, primipara women compared to older, multipara women. For instance, in the Ogolla31 study in Kenya, the reason for the teenage girls delivering at home was due to lack of awareness of the date of delivery, and their failure to inform their parents about their pregnancy, among others.The results also show that the parity of a woman influences her choice of TBAs for delivery. Low parity women had a higher tendency to use the services of TBAs than the high parity women. This finding opposes the notion by ObengThis study is cross-sectional and may not be generalizable to the entire childbearing population. While the study did not include a non TBA birth group, it is not possible to compare the demographical characteristics of the population that used a TBA versus the population that did not. Nevertheless, this study gives the demographic characteristics of those who used a TBA in Ghana, and area in which there is limited information available.This study in Bongo District gives the characteristics of rural women in Ghana that rely on the services of a TBA, despite government efforts to increase access to trained maternal services. The use of a TBA in rural Ghana is influenced by the sociodemographic characteristics of women. Taking these factors into consideration, a singular focus on increasing the availability of skilled birth attendants in rural areas does not appear to be a practical strategy at the moment; a more holistic approach is needed to deal with the issue. Furthermore, phasing out TBA training will be detrimental at this time, when most communities are without health facilities. Also, policies targeting increases in skilled attendance must work with the local cultures to create incentives for women. Noting that TBAs are an important source of delivery care, policy makers need to make the best use of them while simultaneously planning for their replacement with skilled birth attendants, since women are patronizing their services in rural areas.Click here for additional data file.


Chronic Obstructive Pulmonary Disease (COPD) is a complex disease defined by airflow limitation and characterized by a spectrum of treatable and untreatable pulmonary and extra-pulmonary disease characteristics. Nonpharmacological management related to physical activity, physical capacity, body composition, breathing and energy-saving techniques, coping strategies, and self-management is as important as its pharmacological management. Most patients with COPD carry other chronic diagnoses and this poses a key challenge, as it lowers the quality of life, increases mortality, and impacts healthcare consumption. A personalized, multi-, and interprofessional approach is key. Today, healthcare is poorly organized to meet this complexity with the isolation between care levels, logic silos of the different healthcare professions, and lack of continuity of care along the patient’s journey with the healthcare system. In order to meet the criteria for integrated, personalized care for COPD, the structural capabilities of healthcare to support a comprehensive approach and continuity of care needs improvement. COPD is preeminently a disease that requires a transition from a reactive single-specialty approach to a proactive interprofessional approach. In this study, we discuss the issues that need to be addressed when moving from current health care practice to a person-centered model where the care processes and information are aligned to the individual personal needs of the patient. Chronic Obstructive Pulmonary Disease (COPD) is a complex disease defined by persistent airflow limitation and characterized by a spectrum of treatable and untreatable pulmonary and extra-pulmonary disease manifestations ,2,3. NonThe concept of personalized medicine (PM) in chronic care focuses on the ability to continuously adapt all health care efforts along the health trajectory to cure/meet the symptoms and support health and individual autonomy ,9. PM reIn this article, we discuss the concept of PM in COPD where patients have different needs and commonly carry more than one diagnosis. Whereas not all promises of PM may be realized in COPD, we demonstrate a model that allows focus on individual treatable traits, secondary prevention, improvement of quality of life, patient autonomy, and compliance to clinical guidelines/recommendations .Standard care pathways (care plans) have been suggested as a means to reduce variability in healthcare practice . There iCOPD is defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as “a common, preventable and treatable disease characterized by persistent respiratory symptoms and chronic airflow limitation due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung function development.” Significant comorbidities may have an impact on morbidity and mortality . COPD isExacerbations, or sudden flare-ups of the disease, may be present with a major impact on the clinical course of the disease ,21. The COPD is considered a complex, heterogeneous disease , diagnosIn chronic complex care, it is of importance to organize care according to the biopsychosocial model of disease . This moThe WHO definition of “health” reads “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” When this definition was coined in 1948, infectious diseases were the main problem. Today, however, chronic and lifestyle diseases are much more prevalent, particularly in the Western world, and 95% of the present healthcare budget is spent on medication and intervention in spite of early understanding that prevention is a core task in medicine . Newer dThe application of personalized medicine (PM) in COPD needs to address dimensions such as decreased quality of life, shortened life expectancy, and increased healthcare consumption. A key objective should be stratification of treatment to meet the challenge via addressing of identifiable treatable traits and secondary prevention strategies, i.e., a number of dimensions that are not fully independent of one another ,31,32. TCOPD is a chronic condition in which correct spirometry and flow-volume measurements base the proper diagnosis and classification of the severity of the airway obstruction. However, these measures poorly reflect the individual burden of disease and quality of life and therefore provide an insufficient basis for personalized care . As statWhen the complexity and heterogeneity of patients with COPD is incorporated in regular care, it invokes a paradigmatic shift in which COPD care is transformed from a biomedical reductionist approach, i.e., mainly directed at the airway obstruction, which can be provided by a single healthcare professional. Instead, a holistic model emerges with a multidimensional biopsychosocial approach in both assessment and the (chronic) management, which requires teamwork in the involvement of multiple and different healthcare professionals (HCPs). Many and important treatable traits in patients with COPD are best met with non-pharmacological interventions delivered monodisciplinary by a dietician, physiotherapist, occupational therapist, psychologist, social worker and specialist nurse, together the minimum recommended personnel for the multidisciplinary team and necessary to address the complexities associated with the disease ,39,40 F. EngaginMany decisions that are made in the clinic with or on behalf of the patient are sometimes taken without an explicit basis for the decision. It is actually a minority of decisions and recommendations/guidelines that have a top-level evidence base . The shaThe agreed measures for continuous classification of impact of disease is embedded in the interprofessional team. An interprofessional understanding of the concept of COPD disease characterization is important for the coordination of intensity of interventions from different healthcare professionals. The steps toward secondary prevention and general lifestyle support vary markedly across the different stages. The interprofessionally shared understanding of the current disease state is essential as to maintain all advice adjusted to the disease stage and the patient individual traits and preferences.In chronic disease, and specifically in multimorbidity, a patient’s healthcare trajectory is complex and entails frequent patient visits to many corners of healthcare. Thus, it is a challenge to share the relevant knowledge across all these different instances.A shared access to a common electronic medical record (EMR) is only a partial solution, as the EMR holds sparse and unstructured information to lead the common plans for the patient. A modern solution should entail the sharing of personalized care pathways where the intention of the team effort to improve the health status of the patient is operationalized . HistoriThe patient with advanced COPD is typically managed in both primary and secondary care, and, in secondary care, the patient is managed in both inpatient and outpatient care. The patient relies on inpatient care for the management of severe exacerbations and on primary care for management of unscheduled non-severe exacerbations. The multimorbid COPD patient have multiple caregivers that require coordination. As the clinical burden of COPD is heavily related to comorbidities, the capability to handle such complexity in COPD in the trans-professional team setting is of great importance . This reIT solutions should have the potential to support and reinforce the deployment of an innovative healthcare model for patients with COPD, which is scalable to include other chronic noncommunicable diseases, as well as information from other healthcare levels and providers. The IT solution needs to support the clinical approach that considers a structured and comprehensive assessment, a patient-tailored integrated care plan, involving the empowered patient and connecting professions and healthcare segments. This care plan and all other patient information should travel with the patient along the care trajectory . This meAlong this manuscript, we highlight some limitations in relation to the multidisciplinary structural assessment and management of the patient, the concept of the patient in charge of his own disease trajectory, the sharing of treatment plans across healthcare professionals, and the role of IT in all these developments. In this paragraph, we aim to summarize these and elaborate on limitations and shortcomings as of today.Moving away from the traditional single point of decision (the expert model) to the model with shared decision-making in an interprofessional team is a nontrivial step that requires an organizational revolution. The interprofessional model risks adding complexity and thereby adding costs for healthcare. Without a proper adjusted work organization, coordination efforts become a serious burden and lower the efficiency of the healthcare unit. The planning step that involves all professions is a key to find the most efficient local solution for the work.Although we pin huge hope on IT solutions for communication and coordination between therapist(s) and the patient, it could seem to paradoxically have the danger in itself of atomizing care with no one obviously in charge. However, the IT solutions are thought to build support with the multi-professional organization in order to handle individually tailored support. Without such an upgrade, there is a high risk that, with increasing complexity, each visit of the patient becomes burdened with the need for a detailed analysis and a detailed description of treatments and recommendations. Importantly, the priority of decisions and priority of recommendations must remain unambiguous or confusion may occur. A multi-professional work organization must therefore prioritize planning, including the pathway for decisions, in order to provide a united view. Increased patient engagement and participation in the decision making emphasizes this need for care coordination.The transition to an interprofessional model with the “autonomous” patient as the driver might be criticized as an ideology. This might indeed be difficult to reach with current EMR technologies. A reformed ICT support includes the ability to plan the standard clinical pathway where decision points are identified, to individualize the pathway according to the patient needs, and to allow real-time access to all planning information for all professionals to enable them to supply information to patients a practical way. Whereas many of the dominating EMR vendors have identified these needs, most of them have a long way to go before they can provide the needed support for the proposed model.The issue of integrity of sensitive health data must be guarded in the design of the information support. The proposed model for information sharing along the patient trajectory supports the autonomy of the patient and has the potential to improve quality and efficient resource use in healthcare. Therefore, as long as the data that is collected and shared is technically protected, the GDPR and similar legislations do not preclude the information tools that we envision here.COPD is a complex and heterogeneous disease from both the patient and from the healthcare organizational side. A patient with COPD is commonly a multimorbid elderly subject that requires a holistic, comprehensive approach with specialized and individualized treatments from different medical and paramedical specialties, as well as a management approach that commonly lies across the classic healthcare silos. The complexity of the causes of the impaired health status, that is, the number and severity of treatable traits, should be prioritized when making choices with regard to which care provider, where and when, and to which patients to provide intervention. Interprofessional and trans-organizational patient-centric care with common treatment plans is the key. The current care information systems, which are site-centric, single health profession-centric, and focused on the documentation of past events and observations, provide a hindrance to the development of person-centered care. Breaking the silos rests on a commitment from professionals, healthcare providers, and payers. Trans-professional work models depend of qualified support from healthcare information systems, and in the absence of qualified support, such models become economically unsustainable and inefficient because of all the verbal information that is needed to sustain individual care plans. This leads to imprecise decision-making and imprecise communication with the patient. With correct information sharing, the goal can be reached of seeing the patient as a primary asset in the multi-professional team that can together create continuity of care decisions and care interventions. In this way, complexities in chronic complex care of COPD can be managed, moving away from a reductionistic airway-centered approach to a holistic, multi-professional personalized, and patient-related outcome approach. In the end, this should lead to an improved quality of care with better adherence to clinical guidelines and recommendations and to an improved quality of life for the patient with reductions in both burden of disease and burden of care.


The loss of a hand can significantly affect one’s work and social life. For many patients, an artificial limb can improve their mobility and ability to manage everyday activities, as well as provide the means to remain independent. This paper provides an extensive review of available biosensing methods to implement the control system for transradial prostheses based on the measured activity in remnant muscles. Covered techniques include electromyography, magnetomyography, electrical impedance tomography, capacitance sensing, near-infrared spectroscopy, sonomyography, optical myography, force myography, phonomyography, myokinetic control, and modern approaches to cineplasty. The paper also covers combinations of these approaches, which, in many cases, achieve better accuracy while mitigating the weaknesses of individual methods. The work is focused on the practical applicability of the approaches, and analyses present challenges associated with each technique along with their relationship with proprioceptive feedback, which is an important factor for intuitive control over the prosthetic device, especially for high dexterity prosthetic hands. Even though prosthetics as a field of medicine originated many centuries ago, it is still an area that is developing and largely dependent on the research of new technologies. In the field of prosthetics, there has been significant progress in recent decades due to the development of biomechanics, neurology, new materials, and approaches. However, even the most modern innovations and discoveries in this area cannot provide an ideal replacement for lost limb functions.Multiple control topologies have been developed over the past seventy years with electromyography (EMG) being the most commonly used technology these days. However, there are other less-known and yet unproven techniques available, which may potentially represent a number of advantages such as simultaneous proportional control over multiple degrees of freedom (DOFs) and the possibility of enabling intuitive proprioceptive feedback.This paper represents an extensive review covering existing biosensing approaches for the implementation of control for transradial prostheses, focusing on their applicability and discusses possible implementations of hybrid techniques. The goal is to provide indications for the development of future prosthetic technologies and to facilitate future research in this area. The work is focused on the control methods based on the monitoring of physiological changes in residual muscles during their contraction. It also analyses their relationship with an important factor for intuitive control of prosthetic devices: proprioceptive feedback. The expected value additions from this work are to give information about currently existing standard and promising techniques, by analyzing some of the available results and pointing out key aspects.The paper is organized as follows: This section will present a brief background of the related topics of amputation, proprioception, and upper limb prosthetic control.Depending on the amputation level, upper extremity amputation can be classified into partial hand amputation, wrist disarticulation, transradial, elbow disarticulation, transhumeral, shoulder disarticulation, and forequarter amputations. The choice of applicable control topology for a prosthesis depends on the level of amputation. This paper focuses on the section of transradial prostheses. Transradial  amputation occurs through the radius and ulna of the lower arm. After an amputation of this level, finger flexors and wrist flexors  located in the forearm are often available and represent possible sites to be used to get control signals for a hand prosthesis. In cases when the amputation is very proximal, the muscles of the amputated region are lost, complicating the application of biosensing techniques based on the monitoring of activity in the residual muscles. Separate surgical operations such as Targeted Muscle Reinnervation TMR, a 1,2] a,2 a1,2] An alternative to surgery would be to measure the activity in the muscles other than the ones used to control the limb initially, and, if the signals are strong enough, use them to control the prosthesis. However, both in case of surgery and while using the other muscles to get the control signals, it is not yet possible to establish a fully intuitive control over the prosthesis and the patient has to adapt to new associations. The adaptation process takes time, and the patient must regularly perform rehabilitation exercises to prevent muscle atrophy .Important aspects affecting the ease of use of prostheses are the intuitiveness of operation and the feedback system for the coordination of movements ,13. The Proprioception, kinaesthesia, and neuromuscular control are terms that are often used interchangeably in literature; however, these terms have distinctive definitions. Proprioception is the awareness of joint position, whereas kinaesthesia is the awareness of joint movement . NeuromuProprioceptive sensory signals are generated by various mechanoreceptors (proprioceptors) located in muscles, joint capsules, and ligaments, which together provide sensory input to the central nervous system . Golgi tDynamic relationships within agonist–antagonist muscle pairs in a limb are also fundamental for creating a natural sensation of joint movement  since thMultiple studies ,28,29,30Depending on the interaction between the user and the device, the hand prostheses currently available in the market can be divided into two types, passive and active prostheses. The passive prostheses are designed only for aesthetic purposes and can be used for a very limited range of tasks. The active prosthetic devices can be further divided into body-powered and externally powered. Since body-powered prostheses offer only minimal control over the movement, the electronic prostheses are a common option for patients willing to use a prosthesis . A poorlControl strategies for prosthetic devices define how the muscle activation signals obtained from sensing techniques are utilized to control the prosthesis and drastically influence the ease of use of the prosthetic device . TypicalMost of the biosensing control techniques that are discussed further in the paper can enable sensing at multiple target sites (multiple muscles). For proportional control strategy, each target site may be responsible for actuating its own DOF of the prosthesis. In the case of pattern-based control, the synergy of the signals from different sites may be used for identification of a specific muscle activation pattern. For instance, a series of prosthetic hands i-Limb  from ÖssThe biosensing-based control approaches can be categorized into invasive and non-invasive approaches. Invasive approaches imply surgical procedure to implant electrodes or otherwise change the physiological characteristics of the stump. Non-invasive approaches, on the other hand, utilize technologies enabling indirect measurements of physiological parameters without an actual contact of the device with the monitored muscle or nerve ending. Considering that the alternative is a surgery, the non-invasive methods are preferred by most users  even thoThe control techniques briefly presented in this review will be separated into two sections depending on their testing in the prosthetic applications and the physical basis of their implementation. This part will cover biosensing techniques proven to be applicable for establishing control over an externally powered prosthetic device. Each method has its limitations, and their applicability depends on physiological parameters of the patient’s stump. None of the methods presented in this section provides proprioceptive feedback to the user.Although multiple control methods have been developed in recent years, standard hand prostheses commonly use electromyography (EMG)–an approach based on measuring electric potentials generated by muscles during contractions. The EMG signal’s amplitude lies in between 1–10 mV with the frequency range up to 500 Hz and most signal energy in between 50–150 Hz —in case Monopolar configuration acquiring a signal using a single electrode with respect to a reference (ground) electrode usually placed on an electrically neutral tissue (in the vicinity of a bone).Bipolar configuration—the signal is acquired using two active electrodes (placed 1–2 cm from each other) with the help of a reference electrode. The signals from the two measuring sites are collected with respect to a common ground provided by the reference electrode and then amplified. This helps in the mitigation of ambient electromagnetic noise.Multipolar configurations—similar to the bipolar configuration but uses more than two active electrodes. This configuration further reduces crosstalk and noise.Depending on the number of measurement sites, possible EMG signal acquisition configurations include :MonopolaComprehensive practical recommendations for EMG signal acquisition and processing are provided by the work of De Luca .For EMG, the overall accuracy of gesture prediction depends on the number of sensors, which was shown in the works of Muceli et al.  and AmmaElectrical Impedance Tomography (EIT) ,54 is a Due to the non-invasive nature of the method, it has been widely used in clinical applications such as sensing changes in lung ventilation, brain function, and blood flow. For hand gesture recognition, the electrodes are typically wrapped around the forearm near to the wrist; however, any position along forearm is acceptable , which is commonly used for heart rate detection in wearable devices (smartwatches). PPG differs from NIRS by the type of LED used and has also been proven as a feasible method for hand gesture recognition as it allowed for an average accuracy of 89% while predicting nine different gestures . The weaIt is possible to control the depth of the detectable NIRS signal by changing the distance between the light source and the detector. In a series of experiments it was shown that the region monitored under the skin is approximately half of the source-detector distance . Thus, tOne of the side-effects to be considered is heating of the tissue caused by the infrared LED. To minimize this effect and to prevent injuries, a trapezoidal-shaped activation signal can be used to create periodic pulses with the light source . The refAn early attempt of NIRS-based control for a prosthetic hand was demonstrated by Bianchi et al. ; howeverSonomyography  (SMG) isIn most papers covering ultrasound-based control, researchers use linear ultrasound probes consisting of linear arrays of ultrasound transducers  to capture the 2D images of the internal body structures. This type of measurement is called B-mode scanning, where the brightness of each pixel represents the tissue density in that point of the body. This approach offers high spatial resolution (depending on the number of ultrasound transducers within the probe); however, probes with multiple transducers are usually expensive, bulky, and complicated. Single-element transducers utilizing amplitude A-mode measurement can be a simple, lightweight and energy-efficient alternative for obtaining a control signal. Sikdar et al. presented  a fingerThe method shows a comparable or higher spatial resolution when compared ,86,87,88Due to a large difference in acoustic properties of skin and air, to obtain ultrasound images, a conductive medium should be used to eliminate the layer of air between the ultrasound probe and skin. A commonly used solution is to use ultrasound gel which is often uncomfortable in handling and dries quickly upon exposure to air. This can be partially resolved using hydrogel pads, which, however, also tend to dry. Combination of sonomyography with other myographic methods can lead to increased precision of gesture recognition. For example, surface electromyography (can reflect the degree of muscle tension) and ultrasound imaging  are both non-invasive techniques. Together, they can provide more comprehensive information about movements. Xia et al.  implemenThe force myography (FMG) approach consists of placing force sensors on the limb surface and utilizing them for detecting the volumetric changes of the superficial muscle groups. It is also possible to detect the volumetric changes caused by the movement of tendons under the skin surface ,94. The There have been numerous studies that investigated the feasibility and accuracy of the approach ,104,105.The FMG method has inherent drawbacks, such as poor spatial resolution caused by adjacent muscle crosstalk and susceptibility to muscle fatigue. Jiang et al.  proposedPhonomyography  is a non-invasive method of detecting muscle activity based on the measurement of low-frequency oscillations caused by morphological changes in muscle fibres during their contraction. During the start of the muscle movement, the low-frequency peaks are caused by large changes in the muscle shape. The subsequent vibrations are caused by the oscillations of the muscle fibres at the muscle’s resonant frequency . These vOne of the first examples of an implementation of a practical PMG-based detection system of muscle contractions for prosthesis control was presented by Silva et al. ,116. TheSince the signals measured by EMG and PMG do not interfere with each other, a fusion of these methods represents another hybrid approach which can provide complementary information about muscle activity . GregoriThis section covers promising approaches which represent potential solutions for prosthetic control, although they have not been tested for this task yet. They are separated into two groups according to the provided proprioceptive feedback to the user. The first group does not provide proprioceptive feedback and can be implemented non-invasively. Methods enabling proprioceptive feedback utilize mechanoreceptors in the patient’s residual limb and are potentially capable of invoking a natural sense of movement. However, these methods require surgical procedures.The methods presented in this subsection are non-invasive, and they do not provide any sensory feedback to the user. Capacitance sensing is similar to the EIT technique for measuring distances of nearby conductive objects by measuring the capacitance between the sensor and the object and uses a pair of electrodes (transmitter and receivers). The difference between EIT and capacitive sensing lies in the type of measured signal, the way of connecting the sensors to the human body, and the way the obtained data is processed. When the transmitter electrode is excited by a sine wave signal at a fixed frequency , the receiver electrode is used to measure this wave . The magnitude of the received signal is proportional to the frequency and voltage of the transmitted signal, as well as the capacitance between the electrodes (which work as capacitor plates), which in turn depends on the position of the conductive objects between electrodes. The function of the electrodes is fixed, one provides excitation, and the others perform the measurement. The method requires a non-conductive connection between the electrodes and the part of the user’s body. Since the capacitance may be measured for opened gaps, the contact of the skin with the electrode surface is not required. However, the assumption is that there is no significant movement of the measured object in the space between the electrodes.The primary sensitivity of the gesture recognition devices based on capacitance measurement is to the deformation of the electrodes during movements . HoweverA similar system consisting of an armband with four integrated electrodes developed by Cheng et al. ,124 showNissler et al. studied the potential use of an optical myography (OMG) approach for hand gesture recognition, in which a single low-resolution camera (1280 × 720 pixels) monitors the forearm skin surface deformation caused by the underlying muscle contraction using fiducial marker-based tracking methods ,126. TheAlthough the conducted studies ,128 haveMagnetomyography  (MMG) isBiomagnetic signals are typically very weak and thus are prone to pollution from environmental magnetic noise. Hence, MMG measurements are mostly performed using Superconducting Quantum Interference Devices ,134 . The approach was first fully described and applied by Vanghetti and later by Sauerbruch at the beginning of the 19th century . While nMore modern experimental approaches based on cineplasty imply electromechanical amplification of the force produced by the attached muscle of the residual limb. The basic idea of direct coupling of a residual intact joint motion (or the remnant muscles) to a prosthetic component and enabling natural proprioceptive feedback was described by Simpson in the concept of Extended Physiological Proprioception ,142  is a concept proposed by Tarantino et al.  as part Localizing the position of the magnet is equivalent to measuring the morphological changes of the muscle in which it is implanted: as the magnet moves with the muscle, it gives compound information about the position of the joint and the force applied by the muscle. When the muscle is blocked from movement (for example by an object held by the hand), it performs an isometric contraction, which manifests mainly as radial deformations (changes of muscle’s thickness). During unblocked movements (isotonic contractions), the morphological changes in the muscles are mostly observed in the axial direction (change of muscle’s length). By monitoring both radial and axial deformations of the muscles, it is possible to retrieve information about the force exerted by the muscle and use it to control a prosthesis joint. The magnetic fields generated by the magnetic markers are detected by external three-axis magnetic field sensors placed around the residual limb in the prosthesis socket. The technique is similar to MMG; however, in the case of MYKI, the magnitude of the magnetic field is defined by the chosen material of the markers. For initial testing of the approach, the researchers developed a forearm mock-up with simulated extrinsic muscles of the hand and experimentally assessed the performance of six three-axis sensor localisers tracking positions of four markers implanted in the mock-up muscles.The goal of the MYKI research project  is to deIn the following works ,151, resThe absence of proprioceptive feedback, along with the absence of touch sensations is one of the most critical inconveniences of modern prostheses . In mostVariety of developing techniques enabling brain–machine interface and connection to the neural periphery appear to be the most promising in terms of the long-term development of prosthetics. These approaches ,152 poteAgonist–antagonist Myoneural Interface  AMI, se represenThe concept of AMI was proposed by Clites et al. —primarilThe results showed that enabling proprioceptive feedback significantly improved performance during torque control tasks. Moreover, the patients noted an improved feeling of the embodiment of the prosthesis due to improved control over the DOFs. In further work, the researchers showed that the approach is also applicable for higher levels of amputations, such as transfemoral amputation, by surgically creating agonist–antagonist groups with linked reinnervated muscle grafts (RPNI) and applying the AMI control–feedback topology over them. In addition, it was noted that the approach might also improve performance to some extent during torque-control tasks for patients with traditional amputation (without constructed agonist–antagonist pairs). However, stimulating muscles that are fixed isometrically would result in less effective and less intuitive proprioceptive feedback. Since the stimulation impulses generated by a FES may lead to crosstalk and complicate the processing of data from EMG sensors, there is an opportunity to take advantage of other approaches that are immune to electric noise, such as SMG, FMG, NIRS, and PMG.Another approach to enabling feedback is the physiological phenomenon of kinaesthetic illusion—a vibration-induced illusory sense of movement of the limb. Goodwin et al. demonstrated  that vibExtensive work in this direction was performed by Marasco et al. . In a seResearchers noted that, in in the future, they plan to investigate the inclusion of additional feedback from multiple limb joints along with the possibility of simultaneous integration of multi-modal sensory feedback.In this section, we will discuss the presented control techniques for prostheses as well as the challenges and potential directions of future research on the topic.The described control approaches and concepts represent the latest advances and promising techniques for implementing prosthesis control based on measuring the activity of remaining muscles in the patient’s stump. Despite all the advances in this field, the prosthetic hand rejection rates are estimated to be as high as 45% , often bFor clarity, we summarized important aspects of each control method in an overview table . The tabTechniques representing a fusion of multiple approaches represent particular interest for future research as they can be a synergy of the strengths of each of the methods and may compensate for their individual weaknesses. Currently, most of the research investigating the possibilities of hybrid sensing techniques concentrates on combining EMG with approaches of different sensing modalities. It can be anticipated that not all the methods covered in this review could be combined for simultaneous measurement. For instance, measurement sequences of EIT and capacitance sensing are anticipated to produce high noise for EMG (both surface and intramuscular) as well as for MMG or even represent a danger for the user in case of combining it with MYKI, due to the excitation signal produced by the sensors. Electric inference excited by an EIT device during EMG measurement may be avoided by utilizing signal filters or performing the measurements in sequences. The possibility of combining SMG with PMG methods depends on the sensitivity of the utilized vibrometers. Combining ideas of SMG and myokinetic control approaches may be envisioned as muscle-implantable markers (with high acoustic impedance), which may greatly simplify image processing and feature extraction for SMG allowing for more clearly distinguishing individual muscle movements. Generally, the feasibility of the hybrid approaches will also depend on the actual size of the sensors, the available space, and residual structures of the residual limb. In order to provide a compact solution, the systems have to be developed as a single device instead of separate units.Considering that a vast majority of the abovementioned methods (except for cineplasty) rely on the measurement of physiological parameters of muscles at a particular location, they are susceptible to sensor-shifts between multiple sessions of use and thus require the development of a robust calibration procedure or a continuous shift compensation method in order to retain the accuracy during daily movements. EMG, EIT, MMG, PMG, FMG, NIRS, and MYKI approaches require a calibration procedure that takes into account the position of the sensor with respect to the forearm bones, since the skin might not visually provide a robust estimation about these factors due to possible deformation. Methods capable of mapping tissue distribution in a cross-section plane of the forearm  potentially offer information regarding the position of the ulna and radius, which may be used as a reference for shift compensation. Osseointegration ,160 is aRegarding the approaches of enabling the proprioceptive feedback, AMI seems to be the most intuitive since it more closely resembles a natural interaction of agonist–antagonist: muscles stimulated by FES work as if they were mechanically linked to the prosthetic components . However, currently, no studies are available comparing the actual impacts of these approaches for prosthesis users. In general, it is often considered that further development in the field of the prosthetics should continue in the direction of developing intuitive feedback systems .The goal of this review was to examine the approaches for implementing control over hand prosthesis, describe their weaknesses, important aspects and to discuss areas of exploration for the future. Current research and development efforts in invasive, and non-invasive approaches were explored; however, the focus of the review was limited to the approaches based on the measurement of the activity of remaining muscles in the residual limb.Even though modern prostheses use the latest drive systems and modern materials, it should be borne in mind that the mechanical design aspect of a prosthesis is not the main factor that affects the intuitiveness of its use. A much more essential aspect is a sensory feedback system, which provides the sensation of touch, position, speed of movement and exerted force in the prosthetic limb, with which a person can perform coordinated movements without having to continually monitor the device visually. Only a limited number of control approaches enable intuitive proprioceptive feedback. However, there are techniques, such as agonist–antagonist myoneural interface ,153 and Prosthetics is an ever-evolving field, combining the state-of-the-art knowledge from areas of science such as material science, robotics, neurology, and many others. The development of new, improved prosthetic devices is a matter that significantly affects the lives of people with disabilities. Given the complexity of the human hand as a system, it cannot be expected that the prosthetic limbs will be soon comparable to their biologic analogue. However, researchers have been applying many creative techniques that significantly improve the lives of people using prosthetic devices.