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Patient Satisfaction, Rehabilitation Hospital, Cluj-Napoca, Romania
2018
by 

Ngadiuba Alina

Patient satisfaction regarding the quality of the medical services received is one of the indicators that reflect the true performance of a hospital (Observatorul Român de Sănătate, 2018).

According to the report developed by the Romanian Health Observatory, the Clinical Hospital of Rehabilitation is on the second place in terms of patient satisfaction (Observatorul Român de Sănătate, 2018).

 

The healthcare service is confronted with many challenges and competition in the development of the private medical providers. The patients have become more informed of the various options of treatment through online platforms. This results in high expectations of patients towards physicians to being able to provide the necessary information on their condition, politeness, empathy and attention from their doctors, which brings them very close to the traditional meaning of consumer profile (Coțiu and Sabou, 2017).

 

Gradually, the healthcare system undergoes pressures (financial, demographic and technological) in order to deliver good quality services to the patients. As a consequence, the protection of patients’ rights has evolved within the key aspect in the agenda of the new global health (Ahoobim et al., 2012). The national public health organizations, health promotion agencies, health service providers, scientific research institutions and consumers association have put significant efforts to promote and support the patients’ rights protection around the world. In the last decades, researchers have conducted analysis on the rights of patients, their protection and its direct/indirect link with the healthcare quality and its improvement (Green et al., 2012).

 

There are studies that indicate the importance of customer expectations from the healthcare system. This is described as a means of desires to seek for the assistance from the doctor, demands or wants and preferences. Patients’ expectations are important because it implies their involvement and creates the possibilities to better access health services. These expectations from the Romanian healthcare providers are based on the model on active passivity, which describes the physician-patient relationship in Romania. Within years of passivity, the Romanian system has moved to a more democratic approach. This is a new approach that focuses on the call for more client-centred orientation in the healthcare services. Therefore, the knowledge and awareness are expected to meet the needs of the patients (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).

 

Secondly, patients measure their expectations based on their level of satisfaction with the healthcare services. This is mostly used as an indicator of the medical care outcome (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).

 

Thirdly, the first step to prevent dissatisfied patients is through the knowledge of the patients’ needs, because this may result to discontinuity of care and cost ineffectiveness of the healthcare (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).

 

Patients’ satisfaction is an important part of quality assessment of the healthcare system (Williams et al., 1995). There are two dimensions used to improve the patient satisfaction:

·         The procedural dimension of the quality of the provided services (such as the time spent at the waiting reception before getting the required medical attention), the condition of the accommodation provided according to the needs of the patient, and the doctor or physicians anticipated with the patient’s needs 

·         The personal dimension of the provided service quality-that is, the physical aspect of cleanness, maintenance of the facility, the attitude of the practitioner towards the patients, the demonstration of the body language between the physician and the patient and the voice tone used to address the patients (Agheorghiesei and Copoeru, 2013).

 

The most used instrument in measuring patient satisfaction is a questionnaire (Popa et al., 2017). This is most of the time implemented during or after the patients are being discharged from the sanitary units.  Studies have shown that the method of assessing the patient satisfaction uses broad and vague terms that result in short term, superficial, and positive answers without any true meaning (Popa et al., 2017).

 

There are numerous researchers that have brought to attention the term of “patient satisfaction”. Although this term is commonly used in evaluating and guiding the delivery of healthcare services, it is likely to be related to the quality of services rather than the quality of care provided. According to Pomerantz, several changes have occurred within the recent years in the way healthcare service users perceive the quality of care. He suggested that “an increased focus on the patients’ needs and preferences may help better orient medical care, compared to the focus on the adherence to care standards” (Popa et al., 2017).

 

The most frequent aspect of satisfaction and dissatisfaction in the healthcare services is professionalism among the providers. Professionalism is an area that includes various subcategories such as:

·         advancement in medical knowledge,

·         improved level of development in clinical competence,

·         strong ethical morals and standards,

·         sharing of honesty and respect as values,

·         showing empathy, courtesy and kind attitude towards the patients.

In economically developed countries such as the Western European countries and USA, the medical orientation act changed from a “predominantly doctor-oriented approach to a patient centred culture”. This cannot be expressed in Eastern Europe, which is influenced by corruption, informal payments and in-need of a new reform. Since the 1970s, Eastern European countries are slagging behind Western European countries in terms of healthcare quality because of its communist policy throughout the region. Romanian has the lowest level of patient satisfaction in Europe. Romania is faced with other challenges that is related to the lack of access to health services among the less privileged communities.  The general dissatisfaction and cynicism in Romania is owed by the country’s poor economic performance, which limits the freedom of individual to explain a greater degree in behavioural and environmental factors (Popa et al., 2017).

 

The Romanian healthcare system is functioning based on the same principles in the last 30 years. It is built around the central administration and subsidiary, the medical staff, while the patients or their representatives do not have any control over the decision-making process in order to influence the system which they finance and access (Comisia Prezidențială pentru analiza și elaborarea politicilor din  domeniul sănătății publice din România, 2008).

 

The only major modification in the system was the introduction of the healthcare insurance system, with the scope of strengthening the responsibility role of the main customer of healthcare services – the National Health Insurance House, through direct election of the leading structures at a local level (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008)

 

This brought a larger level of autonomy for the local structures in terms of collecting and managing the insurance funds, which means that the structure gained more legitimacy and direct responsibility in front of the citizens. Although it could have been a significant change, the initiative was not politically accepted and after being approved in the Parliament. The law was significantly modified, leading to the centralization of the National Insurance House, politically controlled by the Ministry of Health and the Ministry of Finances, with a low degree of autonomy and difficulties of separating roles from other institutions.

 

Inside the healthcare system, the central authority, the Ministry of Health is keeping an organizational structure, central and local, which does not have a real overview over the healthcare needs of the population. Essential areas for an effective functioning of a modern healthcare system are not developed at all in none of the Ministry of Health structures. Systems of quality assurance, patient safety and the risk management are areas which do not have any type of representativity at the level of decision-making structures, although the quality of the medical services provided and patient safety are the areas that sanitary authorities  should constantly monitor (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

Another important responsibility area is the resource allocation, which practically functions based on the same methods that are not changed for decades. The decisions in these areas are taken without having accepted criteria, both at a national and international level. The allocation of the public resources in the healthcare system must take into consideration the available evidence on statistical data (qualitative and quantitative), prevalence studies and different pathology trends etc, nationally and internationally (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

An informational system would be required in order to make appropriate decisions. This would allow the identification of the healthcare priorities and would evaluate the method of way resources are used in different levels of the system, in a way that would allow the effective feedback of the decision-making factors (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

For that, healthcare information systems are required. These would offer the appropriate information in a decent amount of time about various domains such as:

the utilization of the healthcare resources, work productivity, the social and economical impact of the determinants of health and different types of interventions, the coverage rate and accessibility to different healthcare services, etc.  At the current time, Romania does not have a coherent policy in terms  of healthcare information. Because of that, all of the attempts to build an effective informational system in healthcare, based on informational technologies and and modern communication methods did not succeed, even though high amounts of money were invested (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

Another area of improvement is the incomplete or even confusing legislative and normative framework, in which the roles and responsibilities are not clearly defined or they present similar attributions with other institutions or organizational structures. This problem exists due to the continuous changes of direction as far as the structure and the role of the healthcare system is concerned, but also due to the lack of qualified resources on different decision-making levels (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

Moreover, an appropriate inter-sectorial approach would be required in order to ensure and maintain good quality of life for the general population. This is because of the fact that numerous of the major determinants of health can not be influence only by the healthcare sector. From this point of view, the capacity of the Ministry of Health to get involved in influencing other sectors to respect the insurance of a healthy living environment is low. There is no official written document to state this role of the Ministry of Health in this direction, matching the recommendations of the European Union which mentions the fact that policy and program evaluation or any other intervention is mandatory.

 

RECOMMENDATIONS

One of  the recommendations to the stated problems would be to develop a quality assurance mechanism in the Romanian healthcare system. The system highly requires a program of upgrading the quality of the healthcare services, which would provide information related to the quality of the delivered services and would follow the constant progress of the quality of the services. The system will evaluate and improve the quality of the medical services, it will maintain and raise the level of patient satisfaction and will demonstrate the effectiveness of the financial resources invested in the healthcare system (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).

 

In terms of patient satisfaction and patient experience, measuring the level of satisfaction is necessary, due to the fact that it presents a realistic overview on the patient’s experience and it represents a starting point in improving the services provided, meeting the patients’ expectations or observe the performance of the medical staff (Sherri L. LaVela, 2014).

Patient satisfaction represents the analysis made by the patient alone, persuaded by external and internal factors, based on their opinion on how the services provided made them feel (Sherri L. LaVela, 2014).

In a pilot study realized in an interdisciplinary feeding team clinic, a survey was developed for the patients and their families in order to explore the areas that require improvement and analyze the level of satisfaction as far as the care coordination is concerned. The hospital from the study (Cincinnati Children’s Hospital Medical Center – CCHMC) has its own system for analyzing the patient satisfaction, developed for the individual services provided. The method used by the hospital consisted in applying telephone interviews on a weekly basis, by two marketing research organizations which are oriented in the healthcare domain. The questions that were asked were:

·         Were you able to get an appointment as soon as you wanted?

·         Did the health care provider give you a chance to explain the reasons for your child’s visit? Did they listen to what you had to say about your child?

·         Were you involved in decisions about your child’s care as much as you wanted?

·         When you asked questions, did you get answers you could understand?

 (Claire K. Miller, 2016).

The survey used in the pilot study added three questions to the existing one, using a five-point Likert scale to measure the level of satisfaction between the patient and the healthcare provider. The questions concerned the scheduling appointment, if the healthcare providers understood the concerns and the usefulness of the advices received from the medical staff, rating them from strongly agree to strongly disagree. Moreover, the pilot study included two more open-ended questions related to what could have been better regarding the services received and to detail the positive aspects of patients’ experience.

 

The surveys were completed at the end of the staying, introduced in an Excel database and further analyzed using descriptive summary statistical methods (Claire K. Miller, 2016).

Even though the setting is different, in order to collect as much relevant data as possible, the telephone interview can be a relevant method of analyzing patient satisfaction, if the necessary resources would be invested (the contract with a marketing company focused on healthcare that would do the interviews).

In order to be applicable at the Rehabilitation Hospital in Cluj Napoca the data with the information of the patients should be introduced in online registers.

 

In 2015, The Ministry of health introduced the feedback mechanism for the patient satisfaction in the public sanitary units from the Romanian healthcare system (Ministerul Sănătății, 2015).

 “The feedback mechanism of the patient represents all of the measures and procedures which have as objective raising the trust level of the patients in the medical services offered by the public hospitals, through feedback analysis regarding the quality of the services received, the degree of respecting the rights and obligations both by the patients and the medical staff. The mechanism also includes a component of managing the ethical complaints that happened in the sanitary unit, through the Ethics Committee” (Ministerul Sănătății, 2015).

 

The mechanism offers the patient the opportunity to fill in a questionnaire at the moment of the discharge by receiving a text message on the mobile phone with a link to fill it online, and all of the public sanitary units must apply the methodology of the feedback mechanism of the patient (Ministerul Sănătății, 2015).

 

We have observed that there is an internal questionnaire about patient satisfaction on the website of the Rehabilitation Hospital. After reading the law regarding the patient satisfaction mechanism developed by the Ministry of Health, the standard questionnaire of patient satisfaction must be implemented by all public hospitals.

 

Even though the Rehabilitation Hospital was ranked on the second place at patient satisfaction level, according to the Romanian Health Observatory, the response rate was low (5,9%), meaning that there were 630 responses out of 11983 discharges. The low response rate means that the conditions might not be as satisfying as they were presented.

 

Improvements for the Rehabilitation Hospital:

·         Promoting and insisting on the feedback mechanism developed by the Ministry of Health, so that the rate of responses will increase. Having two questionnaires might lead to having biased results (due to the fact that some patients might complete it twice, they might even give different answers/opinions, etc);

·         In the case of keeping the current questionnaire, we suggest some modifications on the response options: we noticed the fact that, at some questions there is one negative option and two positive. This might influence the patients in choosing a positive answer, even though it would not necessarily reflect the reality.  One alternative way for having the options can be ”Highly unsatisfied”, ”Unsatisfied”, ”Neither unsatisfied or satisfied”, ”Satisfied”, ”Very satisfied”;

·         As there might be the risk that some of the patients do not complete the online surveys because they are not internet users (for example the elderly or people with a low educational background), a survey in a physical format could be necessary. This would be filled in by the patients at the moment of the discharge, being introduced afterwards in the Ministry’s online database by the person in charge to introduce patient’s data from the hospital;

·         Awareness through word-of-mouth promotion of the survey could also increase the response rates, if it would be done by the hospital staff, or only at the reception of the hospital, both in the moment of admission and the moment of discharge.

 

Implementing Staff Training:

Most hospital staff such as the physician or the healthcare organizers have expressed their concern to ask patients personal questions that includes their race, ethnicity and language. They believe that it may offend the patient. In addition, most physicians may be time-sensitive towards the modern nature of clinical practice and want to ensure the effectiveness of asking questions. For data to be accurate and consistent, healthcare organizations are required to invest in clinical training among all staff levels (health professionals, administrative staff, hospitals and health plan leadership), which includes integrating the significance of the data for detecting and addressing health care needs. For instance, those assigned to the task of asking questions directly to the patients, enrollers can receive a front-line training on the importance of collecting the information, how to use the information and the means of collecting the data, and how to address the concerns of the patients and other members (Agency for Healthcare Research and Quality, 2014).

 

The training exercise should be based on the context and the methods of collecting and utilizing the data. For example, health plan staff who do not have face-to-face communication with the enrollers can obtain the demographic information through telephone encounters. Therefore, there should be a training for “telephone means of collecting data” because pre-registration by telephone can occur before hospital admission or ambulatory care appointments.  Before establishing a formal training session with the medical staff, an assessment should be conducted based on the practices and determine what is currently happening and identify the necessary changes. These changes will be clearly communicated among the staff members during the training session (Agency for Healthcare Research and Quality, 2014).

 

Sharing and Collecting of Data Across the Healthcare System:

The health system is a diverse set of public and private entity that contribute to the collection of data including health surveys, administrative enrolment, billing records and medical records used by different medical department such as the hospitals, CHCs, physicians and health plan management. The data collected on the patient’s race, language and ethnicity are extended to these entities suggesting that each can collaborate to obtain and sustain the patient’s medical record.  No one of the entities can individually gather the necessary information regarding the population of patients, neither can they collect the health data on an individual patient.  Therefore, it is important to increase the integration of data from other sources within and across the healthcare system (Agency for Healthcare Research and Quality, 2014).

 

CONCLUSION

All in all, the information stated above presents how the functioning of the healthcare system in Romania affects the sanitary system at a hospital level, directly influencing patient satisfaction. In this sense, measures have been taken, but there is still a lot to pursue in order to have clear and accurate data on the patient satisfaction level and how it can be improved. The suggestions presented are a small step that can be taken to develop the process of collecting data, based on a realistic national approach.

 

REFERENCES:

Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008. Un sistem sanitar centrat pe nevoile cetățeanului, București: s.n.

Sherri L. LaVela, A. S. G., 2014. Evaluation and measurement of patient experience. Patient Experience Journal , 4.Volume 1.

Claire K. Miller, S. P., 2016. Exploring patient satisfaction with interdisciplinary care of complex feeding problems. Patient Experience Journal, Volume 3.

Ministerul Sănătății, 2015. [Online] 
Available at: http://sanatoriulbrad.ro/documente/20150427154315.pdf
[Accessed 9 5 2018].

World Health Organization, 2014. Strengthening people-centred health services delivery in the WHO European Region, s.l.: s.n.

Observatorul Român de Sănătate, 2018. Cât de mulțumiți au fost pacienții români de spitalele publice în 2017, s.l.: s.n.

Agency for Healthcare Research and Quality (2014) Improving Data Collection across the Health Care System | Agency for Healthcare Research & QualityU.S Department of Health and Human Services. Available at: https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata5.html  (Accessed: 27 April 2018).

Agheorghiesei, D.-T. and Copoeru, I. (2013) ‘Evaluating Patient Satisfaction – A Matter of Ethics in the Context of the Accreditation Process of the Romanian Hospitals’, Procedia -Social and Behavioral Sciences World Conference on Psychology and Sociology, 82, pp. 404–410. doi: 10.1016/j.sbspro.2013.06.283.

Ahoobim, O. et al. (2012) ‘Council on Foreign Relations The New Global Health Agenda’. Available at: www.cfr.org (Accessed: 20 April 2018).

Azevedo, M. J. and Johnson, B. H. (2011) ‘The Impact of Globalization Determinants and the Health of the World’s Population’, INTECH. Available at: https://pdfs.semanticscholar.org/ae18/3b3f24372b20b0c286ba2b563561a8567086.pdf (Accessed: 20 April 2018).

Burcea, M., Toma, S.-G. and Papuc, R.-M. (2014) ‘PATIENTS’ SATISFACTION WITH THE HEALTH CARE SYSTEM IN THE AGE OF GLOBALIZATION: THE CASE OF ROMANIA* Marin  BURCEA Sorin-George TOMA Răzvan-Mihail PAPUC’, Transylvanian Review of Administrative Sciences, Special Issue, pp. 5–20. Available at: http://rtsa.ro/tras/index.php/tras/article/viewFile/410/400 (Accessed: 18 April 2018).

Coțiu, M. A. and Sabou, A. (2017) ‘Patient Satisfaction with Diabetes Care in Romania – An Importance-performance Analysis’, in. Springer, Cham, pp. 297–302. doi: 10.1007/978-3-319-52875-5_62.

Green, S. et al. (2012) ‘Aligning quality improvement to population health’, International Journal for Quality in Health Care, 24(5), pp. 441–442. doi: 10.1093/intqhc/mzs049.

Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, J. M. (200AD) ‘The Romanian health care system in transition from the users’ perspective’, Ionilã, Ana-Claudia. Available at: https://www.rug.nl/research/portal/files/2994141/c6.pdf (Accessed: 27 April 2018).

Williams, S. et al. (1995) ‘Patient expectations: What do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction?’, Family Practice. Oxford University Press, 12(2), pp. 193–201. doi: 10.1093/fampra/12.2.193.

Popa, D. et al. (2017) ‘Patients’ perceptions of healthcare professionalism - A Romanian experience’, BMC Health Services Research, 17(1). doi: 10.1186/s12913-017-2412-z.

 

  STRATEGIC MANAGEMENT AND PLANNING OF POWER SUPPLY SECTOR IN NIGERIA
By Ngadiuba_Alina:
INTRODUCTION:
An estimate of 620 million Africans does not benefit from electricity connection in their homes. Both the quality of life and businesses are affected because of unreliable distribution of electric power. The International Energy Agency (IEA) indicated that Africa needs an investment of over $60 million per year to improve universal coverage to electricity by 2040. IEA has identified 12 countries in Africa with poor investment in their energy sector-among them, there are two countries that are on the top two list of inadequate supply of electricity, Ethiopia which has 68% of their population (64 million) with access to electricity and Nigeria, 47% of the population (82 million from 180 million) are connected with electricity supply(Nigerian finance minister Ngozi Okonjo-Iweala, 2008).
For example, in the case of Eastern African (Kenya and Uganda), the amended electricity acts are not sufficient to address the issues of the statement “100%”, as few individuals with incomes as low as $2/day constitute a total of the electrification among the poor people (e.g. proposing new and innovative actions, increasing the level of electricity of the poor). Secondly, the ministry of energy and regulatory bodies, and the utilities, made no effort to track electrification among the poor, while the measurement sequence of the power sector reform seemed to have been detrimental to electrification of the low-income population. In both countries, the electrification in the rural areas were only addressed at the final process of the reform. Finally also, the reforms failed to link the rural electrification to the overall strategy of improving the performance of the power supply industry (Karekezi and Kimani, 2000).
Industrialization operates on the supply of electric power that improves the communication system, contributes to the innovation in science and technology, provides quality healthcare delivery and improve the living condition of the citizens. Electric power, a source that drives industrialization is required to sustain power supply and management as a key factor for Nigeria to become one of the top 20 developed economic country in the world as well as to meet their MDGs targets. Unfortunately, this is the biggest challenge Nigeria is faced with today(Samuel T. Wara, 2012).
Less than half of the population in Nigeria have access to grid connected electricity. In 2015, the estimated average power supply in Nigeria was 3.1 GW which was one third of the country’s minimum demand of the population of 180 million. Commuters are forced to adapt to dim and sparse street lighting, power losses have impacted the functions of businesses, and residence are remained with the struggle to receive inadequate power supply in respective, per capita, Nigeria consumes only 151 kWh in a year (Pedro Omontuemhen, 2016).
Poor implementation of clean energy policies has resulted to lack of coordination between significant agencies in the government that has contributed to the difficulty in developing proper management of clean energy. The conflict between inter-ministerial agencies frequently give the wrong signals to potential investors by overlapping the mandates and, outright the protection of space. Compared to smaller countries such as Kenya, the Nigeria’s renewable energy market is defaulted by unclear political vision and leadership, poor regulatory institutions and insufficient human capacity as well as limited government funds. The presidency has the power to increase the synergies of the proposed climate change commission across the ministries and government agencies at the federal, state and local levels, but the bill to establish the commission remains unsigned by the president (Emodi and Yusuf, 2015).
The electricity grid network in Nigeria is faced with different challenges. The state-owned electric monopoly, NEPA (National Electric Power Agency) is characterized by poor performance operation stated from the fact that from 774 local government areas (LGA) in Nigeria, about 426 are connected to the utility grid(CENTRAL BANK OF NIGERIA, 2010). As a result, the cost of doing a business in Nigeria is high compared to other African countries. For example; the South African phone company MTN which operates the largest mobile phone companies in Nigeria has an estimate of 6,000 installed generators to provide power supply in their operating stations for 19 hours per day. This increases the cost of diesel to $5.5 million/month(Emodi and Boo, 2015).
In developing countries such as Nigeria, there has been lack of improvement in electricity supply, which has led to a high demand of power supply in the homes. The Nigerian government has shut down power projects in the last years due to lack of financial funds (Olawoyin Oladeinde and Adedigba Azeezat, 2018). This has increased the use of back-up generators in homes.  Chairman of Manufacturers Association of Nigeria (MAN), Imo, Abia state Branch, Dr. Frank S.U. Jacobs reported an estimate of 60 million residents using various sizes of power generators in their households. In the past years, compared to other countries such as the EU member state which had a net level of electricity supply of 3.22 Million Euros per GWh in 2015  (EUROSTAT, 2017), the average expenditure spent on fueling power generators in residential areas significantly increased with an estimate of N1.56 trillion ($13.35 billion) per annum  (Obinna F. Muoh, 2016). Nigeria has experienced the worst electricity crisis among other West African countries, which highlights the terrible generation, distribution and supply of power at the national level (Etu, Ahmed and Jack, 2015).

METHODOLOGY:
I consulted the literature to identify the problems of power supply in both Nigeria and other African countries. I conducted a documentation analysis to determine how other countries in Africa tackled the problem of poor electric power supply and I did a comparison of the problem between the countries in Africa and Nigeria and establish a policy proposal that might be suitable to improve the power reform in Nigeria. Furthermore, I developed a policy proposal/recommendation to improve the power supply in Nigeria based on the comparative analysis.
Research Question:
What strategies can be implemented for better management and efficiency in the power sector to provide adequate electricity in Nigeria?
Objectives:
To identify the weakness of the constitutional law that is responsible for the supply of electricity in the country.
To propose a policy that can contribute to the improvement of the electric power supply in Nigeria.

COMPARATIVE ANALYSIS:
BARRIERS IN IMPROVING THE SUPPLY OF ELECTRICAL POWER IN NIGERIAN HOMES(Nicholas Nhede, 2017):
Regulatory barriers
Lack of institutional arrangement
Financial investment ‘
Lack of transmission and distribution network

WHAT HAS BEEN DONE(Yemi Oke, 2017)?
Privatization of public organizations that are authorized to distribute power supply within the country(THE ECONOMIST, 2016).
Decentralization
Involvement of the State electricity regulatory commissions that will oversee giving license to private companies that will be involved in the off-grid electricity generation, transmission and distribution.
Introducing stakeholders including the Federal Government as key investor in the infrastructure such as gas pipelines, equipment used in the distribution, generation and transmission of electricity and other facilities. For example, the involvement of power distribution companies (DisCos) to adequately supply power to the consumers through transformers, feeders and sub-stations (AKINOLA AJIBADE, 2017).

WHY IS THE LACK OF ELECTRICITY STILL A PROBLEM IN NIGERIA-WHAT DID NOT WORK?
The constitution in Nigeria established a decentralized electricity regulation to give the Federal and state government the authority to make laws to improve the supply of electric power. This is not happening or working because of the rivalries between the constitution and the provision in the act. Although the constitution is clear (granting both the state and federal government regulatory authorization in the electric power sector), “at the federal level, the Constitution charges the National Assembly with the responsibility to make the laws”. This simply means that the National Assembly may implement laws to justify the entire federation or any of it constituent stakeholders with respect to the establishment of electric power stations, and the generation and transmission of electricity in or to any part of the federation and from one state to another. Meanwhile, at the state level, the constitution charges the State House of Assembly with the responsibility of making laws to regulate the electricity grid. That is to say, each state will be responsible for their policy actions in respect to the establishment of electric power stations per state, the generation, transmission and distribution of electricity to uncovered areas of the National grid system within a state, and the establishment within a state of any authority will promote and manage the electric power station that is built within that state. The Act provides room for the establishment of the Rural Electrification Agency to administer funds used to provide, promote and support the rural electrification programs but the roles played by the agency and the funds, clashes with the constitution because the constitution assigns these roles to the state, which has the power to regulate off-grid electricity supply and the rural electricity is an off-grid power(Yemi Oke, 2017).

WHAT WAS DONE IN OTHER AFRICAN COUNTRIES:
The following is an example of a study that illustrated changes done in other African countries: the study focuses on the structural/market preconditions to meet the efficiency benefits. “According to Allexon Chiwaya, Ikhupuleng Dube, Stephen Karekezi, Edward Marandu, John Mugyenzi and Donella Mutiso -Reforming the power sector in Africa (edited by M R Bhagavan) the review in performance of the power sector in Malawi, Tanzania, Uganda and Zimbabwe” illustrates the difficulties to undertake the challenges the power sector is facing without substantially reducing the role of the state. There is a requirement for the overall thrust of the reform process to be distant from the power sector and the concerns, and interests of the political class and state bureaucracy. Therefore, one must introduce and institutionalize incentives to both the managers and the workers in order to produce more efficient electrical services to the consumers. This direction was supported by the change of power utility to an independent and self-contained corporation that remained formally on the authority of the state. At the cultural level of corporation, the management adapts in taking and implementing its own decisions without constantly having to look over its shoulders by the government. Hence, commercialization was introduced, which created a form of discipline in the commercial law and was responsible for the market expectations and tolerance (Mkhwanazi and Xolani Mkhwanazi, 2003).
South Africa developed a renewable energy independent power producer program (Renewable Energy Independent Power Producer Procurement Program-REIPPPP) within the years which has proven successful as well as implemented projects for commercial operations(international Trade Administration, 2017).


CONCLUSION:
POLICY PROPOSAL:
Introducing Expanded and Strengthened Nation Grid for Improving the Distribution System:
There is a necessity to expand the source of energy from gas and large hydro to gas, hydro, solar energy, wind energy, biomass/biofuels, coal and nuclear source. Building new power plants in partnership with the public and the private sector will be established. The involvement of the government will be limited as the private organizations handle the generation and distribution system. There will be collaboration with the 3rd world countries along with the International Renewable Energy Agency and the Energy Commission of Nigeria that will assist in developing a large-scale renewable energy-based powerplants. The Ministry of Mines and Steel Development will contribute in the development of clean coal power plants, while the international Atomic Energy Agency and The Nigeria Atomic Energy Agency will foresee the development of the nuclear powerplants(Abubakar Sani Sambo, 2013).

Integrating Smart grid Technologies for Managing Complex Power System:
There are new devices and communications and control system (also known as smart grid) that are used to improve the monitoring and managing system of electric transmission and distribution. This device is manufactured solely as a Phasor Measurement unit (PMU) for transmission, automated capacitor banks and feeder that switches for distribution and advanced metering infrastructure for customers to provide innovative capabilities(Department of Energy, 2015).



 REFERENCES:

 Abubakar Sani Sambo (2013) The Way Forward for Electricity Supply in Nigeria – National Geographic BlogWorld Energy Council. Available at: https://blog.nationalgeographic.org/2015/10/20/the-way-forward-for-electricity-supply-in-nigeria/ (Accessed: 6 May 2018).
AKINOLA AJIBADE (2017) ‘How Nigeria can fix power sector’ - The Nation Nigeria. Available at: http://thenationonlineng.net/nigeria-can-fix-power-sector/ (Accessed: 5 May 2018).
CENTRAL BANK OF NIGERIA (2010) ‘CENTRAL BANK OF NIGERIA ANNUAL REPORT FOR THE YEAR ENDED 31st DECEMBER 2010 SUMMARY CORPORATE ACTIVITIES’. Available at: https://www.cbn.gov.ng/OUT/2011/PUBLICATIONS/REPORTS/RSD/AR2010/Link Files/SUMMARY.pdf (Accessed: 6 May 2018).
Department of Energy, U. (2015) ‘AN ASSESSMENT OF ENERGY TECHNOLOGIES AND RESEARCH OPPORTUNITIES’. Available at: https://www.energy.gov/sites/prod/files/2017/03/f34/qtr-2015-chapter3.pdf (Accessed: 6 May 2018).
Emodi, N. V. and Boo, K.-J. (2015) ‘International Journal of Energy Economics and Policy Sustainable Energy Development in Nigeria: Overcoming Energy Poverty 1’, International Journal of Energy Economics and Policy, 5(52), pp. 580–597. Available at: http: (Accessed: 6 May 2018).
Emodi, N. V. and Yusuf, S. D. (2015) ‘Improving Electricity Access in Nigeria: Obstacles and the Way Forward’, International Journal of Energy Economics and Policy, 5(1), pp. 335–351. Available at: www.econjournals.com (Accessed: 5 May 2018).
Etu, I. A., Ahmed, E. A. and Jack, K. E. (2015) ‘Assessment of Nigeria’s Power Situation and the Way Forward’, International Journal of Latest Research in Engineering and Technology, pp. 2454–5031. Available at: http://www.ijlret.com/Papers/Vol-1-issue-4/4-A090.pdf (Accessed: 5 December 2017).
EUROSTAT (2017) Electricity production, consumption and market overview - Statistics Explained. Available at: http://ec.europa.eu/eurostat/statistics-explained/index.php/Electricity_production,_consumption_and_market_overview (Accessed: 19 January 2018).
international Trade Administration (2017) South Africa - Electrical Power Systems | export.gov. Available at: https://www.export.gov/article?id=South-Africa-electrical-power (Accessed: 6 May 2018).
Karekezi, S. and Kimani, J. (2000) ‘Have Power Sector Reforms Increased Access to Electricity Among the Poor in East Africa?’ Available at: https://pdfs.semanticscholar.org/9377/fb448ed437176f98f8dc3c8f6c1c3025777c.pdf (Accessed: 5 May 2018).
Mkhwanazi, X. and Xolani Mkhwanazi, B. (2003) ‘POWER SECTOR DEVELOPMENT IN AFRICA The Workshop for African Energy Experts on Operationalizing the NGPAD Energy Initiative’. Available at: https://sustainabledevelopment.un.org/content/documents/nepadmkhwanazi.pdf (Accessed: 5 May 2018).
Nicholas Nhede (2017) Power sector: NIGERIA’S POWER SECTOR RECOVERY PROGRAMME. Available at: https://www.metering.com/magazine-article/power-sector-reforms-nigeria/ (Accessed: 6 May 2018).
Nigerian finance minister Ngozi Okonjo-Iweala (2008) ‘Table 1: Energy sector development in Africa (Level 1)’. Available at: https://www.afdb.org/fileadmin/uploads/afdb/Documents/Development_Effectiveness_Review_Energy_2014/Level_1.pdf (Accessed: 5 May 2018).
Obinna F. Muoh (2016) 95 million Nigerians are living without electricity — and something needs to change - Business Insider. Available at: http://www.businessinsider.com/95-million-nigerians-are-living-without-electricity-and-something-needs-to-change-2016-7 (Accessed: 5 December 2017).
Olawoyin Oladeinde and Adedigba Azeezat (2018) Why electricity supply across Nigeria was limited on New Year day - Report - Premium Times Nigeria. Available at: https://www.premiumtimesng.com/news/headlines/254322-why-electricity-supply-across-nigeria-was-limited-on-new-year-day-report.html (Accessed: 19 January 2018).
Pedro Omontuemhen (2016) ‘Powering Nigeria for the Future’. Available at: https://www.pwc.com/gx/en/growth-markets-centre/assets/pdf/powering-nigeria-future.pdf (Accessed: 25 April 2018).
Samuel T. Wara, P. . (2012) ‘Electricity Provision And Manageme1 In Nigeria: Challenges And Prospects’, Department Of Electrical & Electronics Engineering, Federal University Of Agriculture, Abeokuta. Available at: https://www.researchgate.net/profile/Samuel_Wara_Tita/publication/298166102_Electricity_Provision_And_Manageme1_In_Nigeria_Challenges_And_Prospects/links/5a393ae8a6fdcc4d69a6f560/Electricity-Provision-And-Manageme1-In-Nigeria-Challenges-And-Prospects.pdf (Accessed: 25 April 2018).
THE ECONOMIST (2016) Powerless - Electricity in Nigeria. Available at: https://www.economist.com/news/middle-east-and-africa/21693971-nigeria-has-about-much-electricity-edinburgh-problem-powerless (Accessed: 5 May 2018).
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INTERVENTION PROPOSAL

IMPROVING CHILD HEALTH THROUGH GAME ACTIVITIES IN SCHOOL IN CLUJ- NAPOCA, ROMANIA-BY NGADIUBA_ALINA:

CHILD AND DEVELOPMENT AND DEVELOPMENTAL MILESTONES:
A child’s growth is a non-uniform process that progresses along side with its own rate. In
particular stages, the entry and exist point of a child’s development varies in the age which,
often explains how a child expresses him/her self. Although, the age of child may only define the clue of the stage of development, it does not determine its level. Children tend to grow at their own speed and it is the task and skills they obtain within time that can identify the stage of growth. Most times, children are more likely to build new skills on top of the old skills and develop them in accordance to their age level over a period. These development stages are referred to as “Milestones” (Angela Oswalt, 2018) .

Developmental milestones are defined as “a set of functional skills or age-specific tasks that
most children can do at a certain age range” (Layla Mohammed MD, 2017) . The growth of
children is encompassed with that of their peers. Growth is composed of 95% CI for a certain
population (Rogol, Clark, & Roemmich, 2000) . About 200 million children in the world under the age of 5 are limited to reaching their potential in cognitive and social development because of poverty, poor health, malnutrition and deficit care (D, 2016) .
The biological aspects of the body develop from infancy through adolescence and its functions is normally determined by the environment. During the up bringing of a child, if the child is brought up in fear or under any extreme conditions, the immune system and the stress response system of the body will have an abnormal development. Even though the child or adult is exposed the ordinary level of stress, the system may automatically respond to the event as being over stressed. For instance, the child may suffer from great physiological reactivity such as rapid breathing or heart beat or it may eventually result to a “shut down mode” when undergoing stressful situations. Environmental stressors can impair a child from developing the brain and the nervous system. Any absence of mental stimulation in a neglected environment may affect the brain from having its potential development. Children who have traumatic past are more prone to develop chronic or recurrent physical complaints such as headaches or tummy aches, while young adults with past traumatic life during their childhood have indicated the likelihood of chronic physical conditions and problems, which may encourage or push them to engage in risky behaviors (e.g. smoking, substance abuse, diet, and lack of physical exercise) (NATIONAL CHILD TRAUMATIC STRESSORS, 2015) .

HEALTH PROBLEMS DURING CHILDHOOD AND ADOLESCENCE:
Good nutrition is essential in the development of childhood and adolescence. It improves their health and well-being during their growth and it prevents further complications such as chronic diseases. Children are required to have adequate energy, protein and other nutrients necessary for their growth and the maintenance of the body function. Growth retains a fixed rate during childhood before it ascends when the children become adolescence, increasing the level of nutrient needed to support the fast growth rate (high lean body mass and size). In the stage of puberty, adolescents acquire the last 15-20% of stature and gain 50% of adult weight, which accumulates about 40% of skeletal mass. Insufficient intake of energy, protein or other micro-nutrients may lead to a slow growth rate, thereby, delaying the sexual maturation, lack of bone mass, and low ability to reserve micro-nutrient in the body. Nutritional diet plays an important role in the overall health and well-being among children. Lack of dietary practices in children and adolescents increases their vulnerability to experience health risk such as obesity, iron deficiency, and dental caries. Poor nutrition reduces the restrains to infectious diseases that
may have adverse effects on their ability to function at a high mental and physical rate. Obesity in children and adolescents is related to a number of critical health risk which includes; high blood pressure, type 2 diabetes, metabolic syndrome, sleep disturbances, orthopedic problems, and psychosocial problems (SCIENCE, 2007) .

Chronic physical illness has been recognized as a burden because of its effects on the daily
activities of children. It is known to have negative impact on the mental state of children, thereby leaving them on the mercy of others. Recent students have indicated that children suffering from chronic physical illness are likely to undergo emotional and behavioral problems (Ajit Johnson, 2017) .

IMPROVING CHILD AND ADOLESCENT HEALTH IN THE SCHOOL ENVIRONMENT BY PLAYING EDUCATIONAL GAMES:
Over the past 50 years, the WHO provided many reports that identified the problems, increased awareness, indicated the morbidity and mortality data, and implicated policies and guidelines for the government, and other practitioners to use as they address the health in their constituencies which, many of them paid a lot of attention on children and adolescents. During the year of 1950, the WHO introduced an Expert Committee on School Health Services to develop a more comprehensive curricular health activity as a teaching and learning mechanism in schools. The report of the Expert Committee on Health Education of the Public further suggested that there should be an interaction between those who are involved in both the school and non-school sectors in the health education activities during their training (St Leger, 1999) . School health programs has been recognized as three components which includes the school health services, school health education, and school health environment in the early 90s. The society has evolved during the past decades and the health problems changed including the way of living among students. The structural framework of schools also changed. In 1990, infectious agents were known as the leading cause of morbidity and mortality rates, but of recent years, behaviors plays an important role as a major cause (Allensworth & Kolbe, 1987) .

Recently, a meta-analysis on “games promoting health lifestyles” indicated that games have
significant effects on behaviors, stronger effects on the determinants of behaviors also, on the health outcomes. Games are a form of play or recreation, that are considered beneficial to the development of a child. Games are played based on rules, objectives, choices, challenges, points, and criteria for winning or losing when they are simple (amateur level), but there are different variations of games. For example, the digital game which includes “characteristics of traditional games” and “other features such as non-player characters, deep story or narratives, avatar, interactivity, simulation, virtual or online communication with other players”. Research have proven the division of games through the understanding of playing games in different categories “game design (user interface, game mechanics etc.), interactivity between games and players (also known as dynamics and gameplay), the user experience or aesthetics (cognition or emotions), and the positive experience of playing game (fun)” (Baranowski et al., 2016) .

Children can benefit from playing games at a cognitive level because games have been proven to improve attention, focus and reaction time. Games also have motivational advantages as result of encouraging an “incremental” rather than an “entity theory” of intelligence. Games have emotional stimuli among children through the positive mood states. Furthermore, there are evidence to show that games aid in developing adaptive emotion regulation among children. It helps children to build a social environment by enabling them to translate the pro-social skills that is learned from playing in teams (Jordan Shapiro, 2014) .

AIMS:
The aim of this intervention is to improve the daily activities of the children through adapting a physical played game that teaches them healthy behaviors.

OBJECTIVES (Iten & Petko, 2016) :
Children will be willing continue with health behaviors after the use of learning games as an
activity.
Children will gain self-assessed motivation to learn and adapt to healthy behaviors when they are engaged in the learning games which increases their experience of enjoyment.
Children will improve in their daily skills by adapting healthy behavior.

METHODOLOGY:
STUDY POPULATION AND SAMPLE:
The target sample for this study is preschoolers from the age of 4-6 years. We selected this
target group because children are critical at an early age-this is the period of rapid development of the brain. During stage of growth, the brain has a high capacity to change, retain permanent information or actions and it is the foundation which is laid for the health and well-being of the child throughout the life span (“WHO | Early child development,” 2018) . During a child’s first three years, there is a dynamic growth that involves the maturing of the interrelated functions such as cognitive, physical and socio-emotional tendency. Children are required to a proper nutrition, and mental stability to perform and achieve their capabilities to reach their full potential in both terms of quality of life and academics (Ali, 2013) .

This intervention will be conducted in two schools (the Snow-White kindergarten, and the
Helen’s kindergarten), in Cluj-Napoca Romania. Three of classes of preschoolers will be
selected from the two schools. There will be a first surveillance of the school to identify if there will be any special needs for children with certain disability. This is to determine the measures of approaching those children without any exclusion criteria. Before the enrollment of the children in the intervention, the schools will be handed out with informed consent and flyers, which will be distributed among the parents to inform them of the ongoing intervention.

DESCRIPTION OF INTERVENTION:

PHASE A-GAME LEARNING ON NUTRITION (HEALTHY FOOD): 
this activity aims at teaching the children how to eat healthy (HEALTH EATING ADVISORY SERVICE, 2017) .

Rainbow Food Pyramid
There will be a rainbow food pyramid. This pyramid will be with the different colors of the
rainbow. The children will have to match the color of the food, to the color section of the
pyramid. The food items (bread, apple, etc.), and the pyramid sections (vegetable, fruits etc.)
will both be labelled.
My plate:
The children will be grouped into three sections. Each section will have cards of food items, and a plate. The children are required to sort the healthy food from the unhealth food items. The health food items will go into the plate, while the unhealthy food items will remain on the table.

EVALUATION:
Each group will have a different color of plate. This aids at identifying the group with the least healthy food, and the most-unhealthy food, or vice versa.

PHASE B-GAME LEARNING ON PHYSICAL ACTIVITY (“PROMOTING HEALTH IN
SCHOOLS Are there guidelines for health promotion in schools?,” 2015) : the purpose of this is to encourage children to perform physical activity. During this phase, students will be grouped into one. They will perform this activity outside, under the sun where they can sweat and release excess fat from their body. There will be two types of physical exercise during this stage:

The story physical sport:
The teacher of the class will tell story that different forms of physical activity such as jump, bend, turn, twist, hop, touch the toes, swing the arms etc. As the teacher reads the story, the children are to act out the activities. For instance, “when the fairy God mother of Cinderella raised her warned to turn the pumpkin into a carriage, the pumpkin rolled over, and Cinderella jumped to allow the pumpkin to pass through her legs”. The children will jump once they hear “JUMP”.

The move your body physical sport:
Teacher will have pieces of cards containing the body parts. The children will be required to
move that part of the body. For example, when the teacher raises up the card with shake the
“hands”, the children will shake their hands.

EVALUATION:
Each child will be given a colorful sticker. This aids as an identity code for the children to avoid recording their personal names while collecting the data for the evaluation. The intervention will be evaluated based on the willingness of the child to participate in the activity, and if the child completed the exercise curricular. A check list will be used as a data collecting instrument. This data will be analyzed via excel.

STUDY MATERIALS:
Colorful stickers, colorful plates, cut cards with pictures of food items, cut cards with pictures of the body part, check list (for data collection), a story paper, a cross matching pictured food items, and pyramid.

DESCRIPTION OF PRE AND POST TEST DESIGN (Martyn Shuttleworth, 2009) :
After conducting the activities with the children, there will be a final phase of the intervention which will be the “recap session”. The pre-test design of the intervention will be based on a recap of what the children learned during the activities. The children will be split into the same groups (based on the color of the plate they had during the nutrition game). The evaluation will be based on which of the teams had the most correct response.
The post-test of the intervention will be based on evaluating the classes prior to the activities. This is to determine their level of knowledge regarding health eating and physical activities.

EXPECTED RESULTS:
The expected result of this intervention are as follows:
The children are aware of the differences between unhealthy and healthy food items.
The children are aware of the different categories of the food the type using the food pyramid.
Children are physically active to perform the physical exercise that will be implemented during the intervention. 
Children are aware of the forms of physical exercise using the “story sport activity”. 

CONCLUSIONS AND IMPLICATIONS:
The implication of the intervention is for the children to identify healthy behaviors. For instance, matching the food items in accordance to their color on the pyramid helps them to gain more knowledge on the categories of the food, and identifying the differences between healthy and unhealthy food aids in improving their nutritional diet.
These activities aid as a cognitive measure because children tend to repeat what was learned in the classroom and adapt it to their daily activities. During the physical exercise, introducing a new activity will encourage them to perform that event as it occurred in the classroom. The implication of this intervention will improve the actions of the children as carry on with their daily life.

To conclude, children are dependent on the factors that influence their development, such as
nutrition, and physical activity. Furthermore, there are other exposures that may foster the
growth of a child to have a negative impact on the health. Considering the prenatal exposure
which has a significant association to increased risk factors (premature delivery, low birth weight and sudden infant death syndrome). These exposure progresses during the life course of a child, increasing the chances of further health complications such as asthma, allergies, acute lung or ear infections and respiratory diseases (James Heckman, 2004) .

REFERENCES:
1. Ajit Johnson. (2017). Health problems in childhood impacts mental health in adulthood,
new study. Retrieved February 20, 2018, from https://thesurg.com/physical-and-mental-
health-relation-cd6c9f8dde16/
2. Ali, S. S. (2013). A brief review of risk-factors for growth and developmental delay
among preschool children in developing countries. Advanced Biomedical Research, 2,
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3. Allensworth, D. D., & Kolbe, L. J. (1987). The Comprehensive School Health Program:
Exploring an Expanded Concept. Journal of School Health, 57(10), 409–412.
https://doi.org/10.1111/j.1746-1561.1987.tb03183.x
4. Angela Oswalt. (2018). Developmental Stages and Milestones of Child Development -
Child & Adolescent Development: Overview. Retrieved February 19, 2018, from
https://www.gulfbend.org/poc/view_doc.php?type=doc&id=7922&cn=28
5. Baranowski, T., Blumberg, F., Buday, R., DeSmet, A., Fiellin, L. E., Green, C. S., …
Young, K. (2016). Games for Health for Children-Current Status and Needed Research.
Games for Health Journal, 5(1), 1–12. https://doi.org/10.1089/g4h.2015.0026
6. D, P. (2016). Factors Affecting Early Childhood Growth and Development: Golden 1000
Days. Advanced Practices in Nursing, 1(1), 1–4. https://doi.org/10.4172/2573-
0347.1000101
7. HEALTH EATING ADVISORY SERVICE. (2017). The ideas below can be used to
engage children in healthy eating experiences, teach them to recognise different foods
and encourage them to experiment with new foods, tastes, flavours and textures.
Embedding games and activities at your centre will help you address National Quality
Standard, Quality Area 2. Retrieved from
http://heas.health.vic.gov.au/sites/default/files/ECS-healthy-eating-games-activities.pdf
8. Iten, N., & Petko, D. (2016). Learning with serious games: Is fun playing the game a
predictor of learning success? British Journal of Educational Technology, 47(1),
151–163. https://doi.org/10.1111/bjet.12226
9. James Heckman. (2004). Early Childhood Health Problems and Prevention Strategies:
Costs and Benefits Studies Show Lasting Societal Benefits from Investments in the
Health of Young Children. Retrieved from https://www.jhsph.edu/research/centers-and-
institutes/womens-and-childrens-health-policy-center/publications/InvestChildBrief.pdf
10. Jordan Shapiro. (2014). Benefits of Gaming: What Research Shows | The MindShift
Guide to Digital Games and Learning | MindShift | KQED News. Retrieved February 20,
2018, from https://ww2.kqed.org/mindshift/2014/06/13/benefits-of-gaming-what-
research-shows/
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Michigan Medicine. Retrieved February 20, 2018, from
http://www.mottchildren.org/posts/your-child/developmental-milestones
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National Child Traumatic Stress Network - Child Trauma Home. Retrieved February 20,
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trauma
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schools? (2015). Retrieved from
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of Clinical Nutrition, 72(2), 521S–528S. https://doi.org/10.1093/ajcn/72.2.521s
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http://www.who.int/topics/early-child-development/en/


IN COUNTRY RETENTION OF HEALTHCARE PROFESSIONALS IN ROMANIA 
By
Ngadiuba, Alina-Ifunanya-Nicoleta

Romania began its transition from communism in 1989, with an extinct industrial base, and a profitable guide unfitting to the needs of the country. The recession of industrial output, service contracts, and the collapse in investment increased as the trade gap extended for several years. The recent shortcoming of account remained at 5.4% of the GDP in 1998. By 1989-2002, unemployment increased, many large-scale businesses were under government control, yet to tackle the primary issues which empowers the growth of business in a competitive environment (Vlădescu & Scîntee, 2008).
Over the years, according to the world bank, there has been a rise in figures on the Romanian healthcare system, revealing that access to healthcare is biased towards the more privilege classes. In addition, according to Raiffeisen Bank Romania, the ratio of doctors to patients, is two doctors to 1000 of population, below average in Europe. On the account of Romania joining the EU, the availability of medical personnel declined, decreasing access to healthcare services among citizens (Oreste Ross, 2014).  
In 2006, the mass media raised awareness by predicting huge emigration of medical doctors and nurses that would threaten the health system. The emigration rate increased by 2007, 1421 medical doctors left the country which affected the most economical deprived area of Romania more than other regions (Suciu, Popescu, & Buzoianu, 2017).  
By the end of 2009, the economic crisis begun to impact the Romanian society deeply, including the health system. Furthermore, there were additional obstacles introduced in 2010 for the healthcare professionals, as well as a 25% salary discount. As a result, there was shortage of staff, hence, developments regarding the domestic workforce combined with the emigration of healthcare practitioners became a critical problem in Romania (Galan, Olsavszky, & Vladescu, 2006).  
The purpose of these measures is to straight-up a line with the priorities of the strategic partnership. Also, to support the network for the provision of healthcare services (hospitals), increase the services of medical practices increase the availability of primary healthcare at the community level and strengthen governance within the health system. The stakeholder for this responsibility is the World Bank.

LONG TERM MEASURES: -
Strategic Management:
Strategic management an organizational management activities that is used to set priorities, focus energy and resources, strengthen operations, ensure that employees and other stakeholder are working towards common goals and establish agreement around intended outcomes/results access and adjust the organization´s direction in response to a changing environment.
The efforts put in health planning are initiated by either the state or local government agencies (The Ministry of Health), through implemented legislation or private or non-governmental organizations. As a result, a variety of state health policy makers have designed to: enhance the quality of care, provide and control the access of care (through hospital survey), and contain cost (health insurance) (Swayne, Duncan, & Ginter, 2006).

MEDIUM TERM MEASURES: -
Improving Occupational Health in a Workplace:
The working condition of nurses are likely associated to the quality of care provided to patients and patients’ safety. This is also linked with the health and safety outcomes for nurses and other healthcare providers (Geiger-Brown J; Lipscomb J, 2010).
According to the 2005 survey by the National Institute of Statistics, more than half of the people working in Romania reported poor working conditions in the healthcare sector (European Observatory of Working Life, 2006). It has been statistically proven that nurses endanger themselves with the risk of exposure to infectious diseases, physical violence, ergonomic injuries related to the movement and repositioning of patients, exposure to hazardous chemicals and radiologists, and sharp object related injuries. These risk threats could be avoided by the appropriate use of technology, environmental controls, and protective equipment. nurses are revoked in accessing these health cautions. It is upon the ministry of health, and private healthcare facilities to provide adequate workplace safeguards, enforce protective procedures, educate staff regarding the risks, provide protective equipment, utilize safety engineered sharps, and cooperate with research into actual and potential risk (American Nurses Association , 2007).
The code of practice for recruitment of international health personnel by WHO encourages countries to receive emigrant healthcare workers to assist in improving working conditions in developing countries. This has proven efficient mechanism for healthcare institutes. This is an economical advantage for the country as it increases the revenue per capital (Annalee Yassi, 2009).
The government should advocate some support provided for these initiatives, however, there should be collaboration between WHO, the International Labor Organization, the International Commission on Occupational Health, and the International Social Security Association and Public Services International (this is a representative for public sector trade unions) Romania would have a genuine responsibility to reciprocate with their resources as beneficiaries of healthcare worker migration. At university level, researchers and practitioners can contribute to the exchange of knowledge by aligning with their colleagues from other low-income countries (WHO, 2009).
To assure the development of information system, it is significant to promote evidence-based decision making and share information with those who can benefit from it (integration of worker safety and patient safety).  This will aid in sharing jurisdiction. That way, millions of dollars won’t be spent annually to design, implement and maintain different systems that could be distributed and reproduced easily. To achieve this, there has to be an international agreement to reach consensus on data dictionary; establish programming of non-proprietary information system which can be tailored to different mechanical environment made available for easy licensing; train health and safety committees ( focusing on occupational health and infection control) to conduct workplace audits, use the information system and implement appropriate prevention mechanisms; conduct campaign studies to evaluate and refine approaches to improve working conditions among healthcare workers (Weerdta & Baratta, 2005).
Introduction to International Strategy:
The involvement of the state is essential to provide adequate workforce in any situation involving two sides of an equation: demand and supply regarding the workforce of health professionals. There are limitations and opportunities that apply to both aspect (Barriball L, 2015).
The government should be involved in the planning and managing of a healthcare sector because they have the power to sign a treaty among other EU countries (National Rural Health Alliance, 2008). For example, the WHO Assembly adopted the WHO Global Code of Practice on international recruitment of healthcare personnel in May 2010. This sketches a voluntary principle for ethical international recruitment, with the intend for improving the authorized and institutional framework for the enrollment practices (WHO, Managing health workforce migration - The Global Code of Practice, 2010).
As a result, the unilateral contract provides an extra tool for implementing the principles of the Code. Such agreement recognizes the need of the country to monitor the extent of migration and its impact on the country’s economy to ensure sufficient training and strategies for financial support to the health system (Global Health Workforce Alliance, 2008).

SHORT TERM MEASURES
Training of Healthcare Workers:
Hospitals should reintroduce demanding programs to train nurses in their specialties. This contributes in retaining nurses who are seeking for a transfer opportunity as well as recruiting new staff. It also establishes career development path for staff. These training are not inexpensive and nursing governance must be ready to justify the proposed budget. Given the cost of temporary staff, this aids as a logical solution for the organization’s leadership to approve (Watkins, 2005).
Shared Governance and Leadership:
This facilitates a steady condition in a healthcare environment. Reports done on magnet hospitals has proven that organizational characteristics that attract and retain nurses include professional practice models for care delivery with autonomy and responsibility for decision-making (Sebai, 2015).
Hence, effective administrative structure is significant for patient care quality, and investment in professional development of nurses. There must be an involvement of staff in defining and developing the practice of care in the institution due to their closeness with patients; In inclusive with participation in the financial management of their unit (Nevidjon & Erickson, 2001).
Introduction of Emergency Medical Services (EMS)
This is a comprehensive system that provides the arrangements of personnel facilities and equipment for the effective, coordinated and efficient delivery of health and safety services to victims of sudden illness or injury (Moore, 1999). This is essential for providing timely care to patients with life threatening emergencies to avoid unnecessary mortality or long-term morbidity (J & AL., 2002).
EMS is a job opportunity for nurses, as it is a mechanism to decrease the rate of emigration in Romania. Recent studies show that nurses are dissatisfied with the role of coordinating care. It is important that nurses are assigned to positions they are trained to. This prevents them from being overwhelmed with work load (DK, McNeese-Smith, 1999).
Reduction in patients´ length of stay.
The supply of nurses is not adequate to meet the current demand and the shortage is projected to grow more severe as future demand increases and nursing schools are not able to keep up with the increasing educational demand. Example of demand of nurses is the length of patients’ stay. As a result, hospital nurses today take care of patients who are sicker than in the past; therefore, their work is more intensive (Héctor Bueno, Joseph S. Ross, & Yun Wang, 2010). Research studies show that heavy workloads among nurses adversely affect patient safety. Furthermore, it negatively affects nursing job satisfaction, and as a result, contributes to higher turnover, and shortage in nurses (Clarke, 1996).
In addition to the higher patient acuity, work system factors and expectations also contribute to the nurses´ workload. Nurses are expected to perform non-professional tasks such as; delivering and retrieving food trays, housekeeping duties, transporting patients, and ordering, coordinating or performing ancillary services (Patricia W. Stone*, 2004). Certain establishment should be earned to reduce the workload of nurses like; unit level, job level, patient level, and situation level (Stone, Clarke, Cimiotti, & Correa-de-Araujo, 2004).
These measures lead to better communication between nurses and their patients, and also set an organized program for the nurses. Example: in a clinical unit, numerous nursing tasks need to be performed by a group of nurses during a specific shift (unit level workload). The type and amount of workload of nurses is partly determined by the type of unit and specialty. Example: intensive care unit (ICU), nurse versus general floor nurse (job level workload). When nurses perform their job, they encounter situations and patients (National Academy of Sciences, 2004).
Improving Data Collection:
According to Diallo, having reliable and valid data about health workforce is a key to better management and planning. This acknowledges the difficulties in finding accurate data, and he recommends a process of triangulation of different sources to give the most comprehensive overall picture (Diallo K, 2004) .
For example, data can prove the significance of non-financial incentives in other developing countries. Such countries in Africa. This can be adopted by the state in Romania, to improve their law enforcement in the healthcare system. Due to the underinvestment of the countries ‘resources, there has been a decrease in the wages, as well as working conditions (korte et al).
Studies have proven the effectiveness of non-financial incentives which include, training study leave, opportunities to work in teams, support and feedback from supervisors. As result, the performance of our healthcare practitioners will increase due to the enhancement of their job satisfaction (Stilwell B, 2001).
It is important that the country has an auditor who maintains and keeps records of the performance of the healthcare system. This will help in determining the flaws of the actions authorized by the state to improve the healthcare organizations.
EXPECTED RESULTS:
Raising funds for the health system.
Reducing financial barrier to access through prepayment and subsequent pooling of funds in preference to direct out of-pocket.
 Allocating or using funds in a way that promotes efficiency and equity.
Health system stewards must, therefore, seek ways to influence the motivations and behaviors of multiple actors and their diverse agendas, finances and organizational structures forming coherent arrangements for health system accountability. 
There should be adequate supply of Emergency Medical Services (EMS).


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