Chile is a country crossed by economic inequalities. The constitutional process has opened a space to problematize the institutions that reproduce these inequalities. This paper joins into this discussion arguing that a nuanced focus on the right of access to healthcare under international law would fit the future Constitution better. I label this focus ‘nuanced’, in reaction to international law’s limited ability to address justice claims located at the core of Chile’s social and constitutional discontent. I argue that the right to health under international law is unlikely to address the problem of unequal enjoyment of healthcare services. The paper argues that a better approach would be to integrate a solidaristic understanding to this human right. The added value of solidarity translates in a more substantive conceptualization of social rights where they become at the service of the liberty of all. Through a critical discussion about the inception of the right to health under Chile’s current Constitution, the paper shows the limitations of today’s understanding and the underlying reasons for the transformation it proposes.
Background Advances have been made in recent years to characterize facilitators and barriers to implementation of complex health care intervention and to classify the implementation strategies available to address these determinants. We study the implementation of a Hospital at Home (HaH) intervention in a multi-hospital health system to understand the selection and use of implementation strategies in its launch, sustainment, and scaling. Methods We report on the implementation portion of an effectiveness-implementation study of the hybrid type 1 design. First, we retrospectively identified determinants of practice most relevant to the HaH intervention using of the Integrated Checklist of Determinants (TICD) assisted by review of archived documents. We also identified implementation strategies using the listing created by the Expert Recommendations for Implementing Change (ERIC) that could potentially address each determinant. Second, we then identified which of the ERIC strategies were actually employed using a modified Delphi process to obtain consensus among HaH program leaders involved in the program implementation. Program leaders also rated the importance and effort expended on each strategy on 1-9 Likert scales. The most relevant implementation strategies identified through these steps were detailed with respect to actors, targets, dosing and justification, and associated with prospectively collected implementation outcomes. Results The majority of ERIC implementation strategies (57 of 73, 78%) were utilized; 7 strategies (10%) were not used. On the remaining 9 strategies (12%), program leaders did not reach consensus regarding utilization. For used strategies, mean importance was 6.87 and mean effort expended was 6.22. Implementation strategies rated most important by program leaders had a broad target of actions that included clinical staff, patients, leadership, external vendors, health plans, and government officials. The strategies varied in temporality and dosing. Over the course of the implementation, adoption, acceptance, and penetration increased over time, while measures of fidelity remained stable. Conclusions Considerable effort and multiple strategies were required to implement Hospital at Home. While potentially daunting, use of existing implementation frameworks can help focus limited efforts and resources by targeting strategies that address the key barriers and enablers to implementation of complex healthcare interventions.
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