International Journal of Health Policy and Management
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Open Access journal
ISSN (Online) 2322-5939
Published by Kerman University of Medical Sciences [5 journals]
- The Rise of Post-truth Populism in Pluralist Liberal Democracies:
Challenges for Health Policy
Abstract: Recent years have witnessed the rise of populism and populist leaders, movements and policies in many pluralist liberal democracies, with Brexit and the election of Trump the two most recent high profile examples of this backlash against established political elites and the institutions that support them. This new populism is underpinned by a post-truth politics which is using social media as a mouthpiece for ‘fake news’ and ‘alternative facts’ with the intention of inciting fear and hatred of ‘the other’ and thereby helping to justify discriminatory health policies for marginalised groups. In this article, we explore what is meant by populism and highlight some of the challenges for health and health policy posed by the new wave of post-truth populism.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- A Cost Analysis of the Jan Aushadhi Scheme in India
Abstract: Medicines constitute a substantial proportion of out-of-pocket (OOP) expenses in Indian households. In order to address this issue, the Government of India launched the Jan Aushadhi (Medicine for the Masses) Scheme (JAS) to provide cheap generic medicines to the patients (http://janaushadhi.gov.in/about_jan_aushadhi.html). These medicines are provided through the Jan Aushadhi stores established across the country. The objective of this study was to do a quick assessment for policy-makers regarding the objective of the JAS. Implications on cost savings for patients and policy implications of the scheme were analyzed. Secondary data sources were used to obtain prices of medicines under the JAS and prices of branded medicines of the same formulations. A cost analysis design was used. There are substantial differences between the JAS price and the cheapest branded medicine available in the market. However, not all JAS prices are lower than branded medicines. For example, the cheapest branded cefuroxime axetil (500 mg) (antibiotic) in the market is almost three times cheaper than its JAS price. Hence, there are cheaper brands available for some commonly prescribed medicines. From the policy perspective, it raises serious questions regarding the pricing of medicines in the JAS and its overarching goal. Since patients are dependent on physicians for medicine prescriptions and have little knowledge of the price variations among branded and generic medicines, the JAS may not provide the cheapest alternative for the patients. Hence, the government should urgently review the JAS prices to achieve its goal of providing low-cost affordable medicines.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Do Management and Leadership Practices in the Context of Decentralisation
Influence Performance ...
Abstract: Background In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. Methods A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. Results There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. Conclusion This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- A Comparison of Iran and UK EQ-5D-3L Value Sets Based on Visual Analogue
Abstract: Background Preference weights for EQ-5D-3L based on visual analogue scale (VAS) has recently been developed in Iran. The aim of the current study was to compare performance of this value set against the UK VAS-based value set. Methods The mean scores for all possible 243 health states were compared using Student t test. Absolute agreement and consistency were investigated using concordance correlation coefficient (CCC) and Bland-Altman plot. Health gains for 29 403 possible transitions between pairs of EQ-5D-3L health states were compared. Responsiveness to change and discriminative ability across subgroups of health transitions were assessed. Results The mean EQ-5D-3L scores were similar for two value sets (mean = 0.31, P = 1.00). For 36% of health states, the absolute differences were greater than 0.10. There were three pairwise logical inconsistencies in the Iranian value set. The Iranian scores were lower (higher) for severe (mild) health states than the United Kingdom. The CCC (95% CI) was 0.85 (0.81 to 0.88) and Bland-Altman plot showed good agreement. The mean health gain for all possible transitions predicted by the Iranian value set was higher (0.22 vs. 0.20, P < .001) and two value sets predicted opposite transitions in 15% of transitions. The responsiveness of these two value sets were similar with lower discriminative ability for Iranian value set. Conclusion The Iranian value set attribute lower values to most severe health states and higher values to mild health states compared with the UK value set. Such systematic differences might translate into discrepant health gains and cost-effectiveness which should be taking into account for informed decision-making.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Stakeholders Perspectives on the Success Drivers in Ghana’s National
Health Insurance Scheme ...
Abstract: Background Ghana’s National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap. Methods Based on an empirical qualitative case study of stakeholders’ views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs. Results In the study, interviewees referred to both ‘hard and soft’ elements as driving the “success” of the Ghana scheme. The main ‘hard elements’ include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The ‘soft’ elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation. Conclusion Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- The Challenges of Projecting the Public Health Impacts of Marijuana
Legalization in Canada; ...
Abstract: A recent editorial in this journal provides a summary of key economic, social, and public health considerations of the forthcoming legislation to legalize, regulate, and restrict access to marijuana in Canada. As our government plans to implement an evidence-based public health framework for marijuana legalization, we reflect and expand on recent discussions of the public health implications of marijuana legalization, and offer additional points of consideration. We select two commonly cited public concerns of marijuana legalization – adolescent usage and impaired driving – and discuss how the underdeveloped and equivocal body of scientific literature surrounding these issues limits the ability to predict the effects of legalization. Finally, we discuss the potential for some potential public health benefits of marijuana legalization – specifically the potential for marijuana to be used as a substitute to opioids and other risky substance use – that have to date not received adequate attention.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Is It Time to Say Farewell to the ISDS System?; Comment on “The
Trans-Pacific Partnership: Is ...
Abstract: Investor-state dispute settlement (ISDS) continues to plague health-oriented government regulation. This is particularly reflected in recent challenges to tobacco control measures through bilateral investment agreements. There are numerous reform proposals circulating within the public health community. However, I suggest that perhaps it is time for the community to explore a stronger position on ISDS. I draw from mounting evidence on the problematic uses of the ISDS to explore the proposition that ISDS is no longer justified. I tackle the normative question of shouldthe ISDS system persist and point out that the ISDS system is not justifiable from a development perspective and because of its nefarious use, is of no added value to a system that could rely on domestic courts.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Assessing the Health Impact of Trade: A Call for an Expanded Research
Agenda; Comment on “The ...
Abstract: Labonté et al provide an insightful analysis of the Trans-Pacific Partnership (TPP) and its impact on a selection of important health determinants. Their work confirms concerns raised by previous analyses of leaked drafts and offers governments serious and timely reasons to carefully consider provisions of the agreement prior to moving forward with ratification. It also contributes more generally to a growing literature focused on identifying the health impacts of trade. This commentary uses the authors’ analysis as a starting point to reflect on two interrelated issues relevant both for taking seriously one of the article’s main recommendations and future work in the area of trade and health.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Advancing Public Health on the Changing Global Trade and Investment
Agenda; Comment on “The ...
Abstract: Concerns regarding the Trans-Pacific Partnership (TPP) have raised awareness about the negative public health impacts of trade and investment agreements. In the past decade, we have learned much about the implications of trade agreements for public health: reduced equity in access to health services; increased flows of unhealthy commodities; limits on access to medicines; and constrained policy space for health. Getting health on the trade agenda continues to prove challenging, despite some progress in moving towards policy coherence. Recent changes in trade and investment agendas highlight an opportunity for public health researchers and practitioners to engage in highly politicized debates about how future economic policy can protect and support equitable public health outcomes. To fulfil this opportunity, public health attention now needs to turn to strengthening policy coherence between trade and health, and identifying how solutions can be implemented. Key strategies include research agendas that address politics and power, and capacity building for both trade and health officials.
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Defining Integrated Knowledge Translation and Moving Forward: A Response
to Recent Commentaries
PubDate: Sun, 30 Apr 2017 19:30:00 +010
- Should Employers Be Permitted not to Hire Smokers? A Review of US
Abstract: BackgroundIncreasingly, healthcare and non-healthcare employers prohibit or penalize the use of tobacco products among current and new employees in the United States. Despite this trend, and for a range of different reasons, around half of states currently legally protect employees from being denied positions, or having employment contracts terminated, due to tobacco use. MethodsWe undertook a conceptual analysis of legal provisions in all 50 states. ResultsWe found ethically relevant variations in terms of how tobacco is defined, which employee populations are protected, and to what extent they are protected. Furthermore, the underlying ethical rationales for smoker protection differ, and can be grouped into two main categories: prevention of discrimination and protection of privacy. ConclusionWe critically discuss these rationales and the role of their advocates and argue that enabling equality of opportunity is a more adequate overarching concept for preventing employers from disadvantaging smokers.
PubDate: Tue, 14 Mar 2017 20:30:00 +010
- Evaluating the Implementation and Feasibility of a Web-Based Tool to
Support Timely ...
Abstract: Background Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. Methods This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative’s feasibility and scalability. Methods will be informed by the ‘Implementing the Frailty Portal in Community Primary Care Practice’ logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). Discussion The ‘Frailty Portal’ aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers’ ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports.
PubDate: Mon, 06 Mar 2017 20:30:00 +010
- Does Scale of Public Hospitals Affect Bargaining Power? Evidence From
Abstract: Background Many of public hospitals in Japan have had a deficit for a long time. Japanese local governments have been encouraging public hospitals to use group purchasing of drugs to benefit from the economies of scale, and increase their bargaining power for obtaining discounts in drug purchasing, thus improving their financial situation. In this study, we empirically investigate whether or not the scale of public hospitals actually affects their bargaining power. Methods Using micro-level panel data on public hospitals, we examine the effect of the scale of public hospitals (in terms of the number of occupancy beds) on drug purchasing efficiency (DPE) (the average discount rate in purchasing drugs) as a proxy variable of the bargaining power. Additionally, we evaluate the effect of the presence or absence of management responsibility in public hospital for economic efficiency as the proxy variable of an economic incentive and its interaction with the hospital scales on the bargaining power. In the estimations, we use the fixed effects model to control the heterogeneity of each hospital in order to estimate reliable parameters. Results The scale of public hospitals does not positively correlate with bargaining power, whereas the management responsibility for economic efficiency does. Additionally, scale does not interact with management responsibility. Conclusion Giving management responsibility for economic efficiency to public hospitals is a more reliable way of gaining bargaining power in drug purchasing, rather than promoting the increase in scale of these public hospitals.
PubDate: Mon, 06 Mar 2017 20:30:00 +010
- Bringing Value-Based Perspectives to Care: Including Patient and Family
Members in ...
Abstract: BackgroundRecent evidence shows that patient engagement is an important strategy in achieving a high performing healthcare system. While there is considerable evidence of implementation initiatives in direct care context, there is limited investigation of implementation initiatives in decision-making context as it relates to program planning, service delivery and developing policies. Research has also shown a gap in consistent application of system-level strategies that can effectively translate organizational policies around patient and family engagement into practice. MethodsThe broad objective of this initiative was to develop a system-level implementation strategy to include patient and family advisors (PFAs) at decision-making points in primary healthcare (PHC) based on wellestablished evidence and literature. In this opportunity sponsored by the Canadian Foundation for Healthcare Improvement (CFHI) a co-design methodology, also well-established was applied in identifying and developing a suitable implementation strategy to engage PFAs as members of quality teams in PHC. Diabetes management centres (DMCs) was selected as the pilot site to develop the strategy. Key steps in the process included review of evidence, review of the current state in PHC through engagement of key stakeholders and a co-design approach. ResultsThe project team included a diverse representation of members from the PHC system including patient advisors, DMC team members, system leads, providers, Public Engagement team members and CFHI improvement coaches. Key outcomes of this 18-month long initiative included development of a working definition of patient and family engagement, development of a Patient and Family Engagement Resource Guide and evaluation of the resource guide. ConclusionThis novel initiative provided us an opportunity to develop a supportive system-wide implementation plan and a strategy to include PFAs in decision-making processes in PHC. The well-established co-design methodology further allowed us to include value-based (customer driven quality and experience of care) perspectives of several important stakeholders including patient advisors. The next step will be to implement the strategy within DMCs, spread the strategy PHC, both locally and provincially with a focus on sustainability.
PubDate: Sun, 05 Mar 2017 20:30:00 +010
- Global Alcohol Harm Network: Struggling or Emerging? A Response to
PubDate: Fri, 03 Mar 2017 20:30:00 +010
- Lost in Translation: Piloting a Novel Framework to Assess the Challenges
in Translating ...
Abstract: BackgroundCalls for evidence-informed public health policy, with implicit promises of greater program effectiveness, have intensified recently. The methods to produce such policies are not self-evident, requiring a conciliation of values and norms between policy-makers and evidence producers. In particular, the translation of uncertainty from empirical research findings, particularly issues of statistical variability and generalizability, is a persistent challenge because of the incremental nature of research and the iterative cycle of advancing knowledge and implementation. This paper aims to assess how the concept of uncertainty is considered and acknowledged in World Health Organization (WHO) policy recommendations and guidelines. MethodsWe selected four WHO policy statements published between 2008-2013 regarding maternal and child nutrient supplementation, infant feeding, heat action plans, and malaria control to represent topics with a spectrum of available evidence bases. Each of these four statements was analyzed using a novel framework to assess the treatment of statistical variability and generalizability. ResultsWHO currently provides substantial guidance on addressing statistical variability through GRADE (Grading of Recommendations Assessment, Development, and Evaluation) ratings for precision and consistency in their guideline documents. Accordingly, our analysis showed that policy-informing questions were addressed by systematic reviews and representations of statistical variability (eg, with numeric confidence intervals). In contrast, the presentation of contextual or “background” evidence regarding etiology or disease burden showed little consideration for this variability. Moreover, generalizability or “indirectness” was uniformly neglected, with little explicit consideration of study settings or subgroups. ConclusionIn this paper, we found that non-uniform treatment of statistical variability and generalizability factors that may contribute to uncertainty regarding recommendations were neglected, including the state of evidence informing background questions (prevalence, mechanisms, or burden or distributions of health problems) and little assessment of generalizability, alternate interventions, and additional outcomes not captured by systematic review. These other factors often form a basis for providing policy recommendations, particularly in the absence of a strong evidence base for intervention effects. Consequently, they should also be subject to stringent and systematic evaluation criteria. We suggest that more effort is needed to systematically acknowledge (1) when evidence is missing, conflicting, or equivocal, (2) what normative considerations were also employed, and (3) how additional evidence may be accrued.
PubDate: Tue, 28 Feb 2017 20:30:00 +010
- “Not Everything That Is Faced Can Be Changed, but Nothing Can Be
Changed Until It Is ...
PubDate: Tue, 28 Feb 2017 20:30:00 +010
- Exploring the Functioning of Decision Space: A Review of the Available
Health Systems Literature
Abstract: BackgroundThe concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. MethodsA narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. ResultsThe articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. ConclusionThe literature supports Bossert’s conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.
PubDate: Sun, 26 Feb 2017 20:30:00 +010
- Contextualizing Obesity and Diabetes Policy: Exploring a Nested
Statistical and Constructivist ...
Abstract: BackgroundThis article conducts a comparative national and subnational government analysis of the political, economic, and ideational constructivist contextual factors facilitating the adoption of obesity and diabetes policy. MethodsWe adopt a nested analytical approach to policy analysis, which combines cross-national statistical analysis with subnational case study comparisons to examine theoretical prepositions and discover alternative contextual factors; this was combined with an ideational constructivist approach to policy-making. ResultsContrary to the existing literature, we found that with the exception of cross-national statistical differences in access to healthcare infrastructural resources, the growing burden of obesity and diabetes, rising healthcare costs and increased citizens’ knowledge had no predictive affect on the adoption of obesity and diabetes policy. We then turned to a subnational comparative analysis of the states of Mississippi in the United States and Rio Grande do Norte in Brazil to further assess the importance of infrastructural resources, at two units of analysis: the state governments versus rural municipal governments. Qualitative evidence suggests that differences in subnational healthcare infrastructural resources were insufficient for explaining policy reform processes, highlighting instead other potentially important factors, such as state-civil societal relationships and policy diffusion in Mississippi, federal policy intervention in Rio Grande do Norte, and politicians’ social construction of obesity and the resulting differences in policy roles assigned to the central government. ConclusionWe conclude by underscoring the complexity of subnational policy responses to obesity and diabetes, the importance of combining resource and constructivist analysis for better understanding the context of policy reform, while underscoring the potential lessons that the United States can learn from Brazil.
PubDate: Sun, 26 Feb 2017 20:30:00 +010
- How Should Global Fund Use Value-for-Money Information to Sustain its
Investments in Graduating ...
Abstract: It has been debated whether the Global Fund (GF), which is supporting the implementation of programs on the prevention and control of HIV/AIDS, tuberculosis (TB) and malaria, should consider the value-for-money (VFM) for programs/interventions that they are supporting. In this paper, we critically analyze the uses of economic information for GF programs, not only to ensure accountability to their donors but also to support country governments in continuing investment in cost-effective interventions initiated by the GF despite the discontinuation of financial support after graduation. We demonstrate that VFM is not a static property of interventions and may depend on program start-up cost, economies of scales, the improvement of effectiveness and efficiency of providers once the program develops, and acceptance and adherence of the target population. Interventions that are cost-ineffective in the beginning may become cost-effective in later stages. We consider recent GF commitments towards value for money and recommend that the GF supports interventions with proven cost-effectiveness from program initiation as well as interventions that may be cost-effective afterwards. Thus, the GF and country governments should establish mechanisms to monitor cost-effectiveness of interventions invested over time.
PubDate: Sun, 26 Feb 2017 20:30:00 +010
- To What Extent Is Long-term Care Representative of Elderly Care? A Case
Study of Elderly Care ...
Abstract: The ageing of European population has been rapidly increasing during the last decades, and the problem of elderly care financing has become an issue for policy-makers. Long-term care (LTC) financing is considered a suitable proxy of the resources committed to elderly care by each government, but the preciseness of this approximation depends on the extent to which LTC is representative of elderly care within each country. Since there is a broad heterogeneity in LTC funding, organization and setting among European States, it is difficult to find a common parameter representing the public resources destined to the elderly care. We address these topics employing as a case study an Italian region, Lombardy, which in terms of population, dimension, healthcare organization and economic development could be compared to other European countries. The method we suggest, which consists basically in a careful estimate of all the public resources employed in the provision of services exclusively destined to the elderly, could be applied, with the due differences, to other European countries or regions.
PubDate: Fri, 24 Feb 2017 20:30:00 +010
- On the Social Construction of Overdiagnosis; Comment on
“Medicalisation and Overdiagnosis: ...
Abstract: In an interesting article Wieteke van Dijk and colleagues argue that societal developments and values influence the practice of medicine, and thus can result in both medicalisation and overdiagnosis. They provide a convincing argument that overdiagnosis emerges in a social context and that it has socially constructed implications. However, they fail to show that overdiagnosis per se is socially constructed and how this construction occurs. Moreover, the authors discuss overdiagnosis on a micro level without acknowledging that overdiagnosis cannot be observed in individuals “in the doctor’s office.” We cannot tell whether a diagnosed person is overdiagnosed or not. This is the core of the problem. Despite these shortcomings, Wieteke van Dijk and her colleagues are certainly on to something important, and they should be encouraged to elaborate their perspective. We certainly need to deepen our understanding of the social construction of overdiagnosis.
PubDate: Fri, 24 Feb 2017 20:30:00 +010
- Overdiagnosis: An Important Issue That Demands Rigour and Precision;
Comment on ...
Abstract: Van Dijk and colleagues present three cases to illustrate and discuss the relationship between medicalisation and overdiagnosis. In this commentary, I consider each of the case studies in turn, and in doing so emphasise two main points. The first is that it is not possible to assess whether overdiagnosis is occurring based solely on incidence rates: it is necessary also to have data about the benefits and harms that are produced by diagnosis. The second is that much is at stake in discussions of overdiagnosis in particular, and that it is critical that work in this area is conceptually rigorous, well-reasoned, and empirically sound. van Dijk and colleagues remind us that overdiagnosis and medicalisation are not just matters for individual patients and their clinicians: they also concern health systems, and society and citizens more broadly.
PubDate: Fri, 24 Feb 2017 20:30:00 +010
- The Global Health Crisis of Solidarity: A Response to Recent Commentaries
PubDate: Fri, 24 Feb 2017 20:30:00 +010
- Ineffective Healthcare Technology Management in Benin’s Public Health
Sector: The Perceptions ...
Abstract: BackgroundLow-income countries face many contextual challenges to manage healthcare technologies effectively, as the majority are imported and resources are constrained to a greater extent. Previous healthcare technology management (HTM) policies in Benin have failed to produce better quality of care for the population and costeffectiveness for the government. This study aims to identify and assess the main problems facing HTM in Benin’s public health sector, as well as the ability of key actors within the sector to address these problems. MethodsWe conducted 2 surveys in 117 selected health facilities. The first survey was based on 377 questionnaires and 259 interviews, and the second involved observation and group interviews at health facilities. The Temple-Bird Healthcare Technology Package System (TBHTPS), tailored to the context of Benin’s health system, was used as a conceptual framework. ResultsThe findings of the first survey show that 85% of key actors in Benin’s HTM sector characterized the system as failing in components of the TBHTPS framework. Biomedical, clinical, healthcare technology engineers and technicians perceived problems most severely, followed by users of equipment, managers and hospital directors, international organization officers, local and foreign suppliers, and finally policy-makers, planners and administrators at the Ministry of Health (MoH). The 5 most important challenges to be addressed are policy, strategic management and planning, and technology needs assessment and selection – categorized as major enabling inputs(MEI) in HTM by the TBHTPS framework – and installation and commissioning, training and skill development and procurement, which are import and use activities(IUA). The ability of each key actor to address these problems (the degree of political or administrative power they possess) was inversely proportional to their perception of the severity of the problems. Observational data gathered during site visits described a different set of challenges including maintenance and repair, distribution, installation and commissioning, use and training and personnel skill development. ConclusionThe lack of experiential and technical knowledge in policy development processes could underpin many of the continuing problems in Benin’s HTM system. Before solutions can be devised to these problems, it is necessary to investigate their root causes, and which problems are most amenable to policy development.
PubDate: Sun, 19 Feb 2017 20:30:00 +010
- A Policy Analysis on the Proactive Prevention of Chronic Disease:
Learnings from the Initial ...
Abstract: Mexico, like many low- and middle-income countries (LMICs), faces an epidemic of chronic non-communicable diseases (NCDs), specifically diabetes, hypertension, obesity, and lipid disorders. Many people with these NCDs may not be aware that they have a disease, pointing to the need for broader screening programs. The traditional prevention policy in Mexico was based on screening with a paper-based risk factor questionnaire. However, this was used to screen patients already seeking healthcare services at facilities, and screening goals were set as a function of the number of questionnaires applied, not number of individuals screened. Due to this, Fundación Carlos Slim developed Medición Integrada para la Detección Oportuna (MIDOTM), or Integrated Measurement for Early Detection, an NCD screening and proactive prevention policy. This document is a policy analysis based on early learnings from the initial implementation of MIDO in eight primary healthcare centers in two central Mexican states. MIDO was found to expand screening programs beyond clinic walls, systematize community screening strategies, emphasize the detection of pre-disease phases, incorporate lifestyle counseling, and propose screening goals based on population targets. In collaboration with the Mexican Ministry of Health, MIDO has successfully screened over 500 000 individuals—about 40% of whom would not have been screened under previous policies. Of these more than 500 000 screened individuals, 13.4% had pre-diabetes (fasting glucose between 100 and 125 mg/dL), and 5.8% had undiagnosed diabetes (defined as fasting glucose above 126 mg/dL or random glucose above 200 mg/dL). However, there is still room for improvement in linking positive results from screening with disease confirmation and with patient incorporation into disease management. The experience of implementing MIDO in Mexico suggests that primary and secondary prevention programs in other parts of the world should consider the need for population-based screening targets, a greater focus on pre-disease stages, and the streamlining of the transition between screening, confirmation of diagnosis, and incorporation of patients into the healthcare system.
PubDate: Sun, 19 Feb 2017 20:30:00 +010
- Mistaking the Map for the Territory: What Society Does With Medicine;
Comment on ...
Abstract: Van Dijk et al describe how society’s influence on medicine drives both medicalisation and overdiagnosis, and allege that a major political and ethical concern regarding our increasingly interpreting the world through a biomedical lens is that it serves to individualise and depoliticize social problems. I argue that for medicalisation to serve this purpose, it would have to exclude the possibility of also considering problems in other (social or political) terms; but to think that medical descriptions of the world seek to or are able to do this is to misunderstand the purpose and function of model construction in science in general, and medicine in particular. So, if medicalisation is nonetheless used for the depoliticization described by many critics, we must ask what society does with medicine to give it this exclusive authority. I propose that the problem arises from a tendency to mistake the map for the territory, and think a tool to understand certain aspects of the world gives us the complete picture. To resist this process, I suggest health workers should be more open about the purpose and limitations of medicalisation, and the value of alternative descriptions of different aspects of human experience.
PubDate: Sat, 18 Feb 2017 20:30:00 +010
- Out-of-Pocket and Informal Payment Before and After the Health
Transformation Plan in Iran: ...
Abstract: BackgroundOne of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran. MethodsThis quasi-experimental study used multistage sampling method to select and evaluate 265 patients discharged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples ttest. ResultsThe mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P < .05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase. ConclusionIt seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.
PubDate: Fri, 10 Feb 2017 20:30:00 +010
- A Process Evaluation to Assess Contextual Factors Associated With the
Uptake of a Rapid ...
Abstract: BackgroundAlthough proven feasible, rapid response services (RRSs) to support urgent decision and policymaking are still a fairly new and innovative strategy in several health systems, more especially in low-income countries. There are several information gaps about these RRSs that exist including the factors that make them work in different contexts and in addition what affects their uptake by potential end users. MethodsWe used a case study employing process evaluation methods to determine what contextual factors affect the utilization of a RRS in Uganda. We held in-depth interviews with researchers, knowledge translation (KT) specialists and policy-makers from several research and policy-making institutions in Uganda’s health sector. We analyzed the data using thematic analysis to develop categories and themes about activities and structures under given program components that affected uptake of the service. ResultsWe identified several factors under three themes that have both overlapping relations and also reinforcing loops amplifying each other: Internal factors (those factors that were identified as over which the RRS had full [or almost full] control); external factors (factors over which the service had only partial influence, a second party holds part of this influence); and environmental factors (factors over which the service had no or only remote control if at all). Internal factors were the design of the service and resources available for it, while the external factors were the service’s visibility, integrity and relationships. Environmental factors were political will and health system policy and decision-making infrastructure. ConclusionFor health systems practitioners considering RRSs, knowing what factors will affect uptake and therefore modifying them within their contexts is important to ensure efficient use and successful utilization of the mechanisms.
PubDate: Fri, 03 Feb 2017 20:30:00 +010
- Factors Associated With Unhealthy Snacks Consumption Among Adolescents in
Abstract: BackgroundWell-informed interventions are needed if school-based health promotion is to be effective. Amongother aims, the Iranian Health Promoting School (IHPS) program that was launched in 2011, has an important aimof promoting dietary behaviors of adolescents. The present study, therefore, aimed to investigate the factors affectingunhealthy snacking of adolescents and provide evidence for a more effective IHPS program. MethodsIn a cross-sectional study design, 1320 students from 40 schools in Kerman city were selected using aproportional stratified random sampling method. A modified qualitative Food Frequency Questionnaire (FFQ) wasused to gather data about unhealthy snacking behavior. Data about intrapersonal and environmental factors wereobtained using a validated and reliable questionnaire. A mixed-effects negative-binomial regression model was usedto analyze the data. ResultsTaste and sensory perception (prevalence rate ratio [PRR] = 1.18; 95% CI: 1.09-1.27), being a male (PRR = 1.20;95% CI: 1.05-1.38) and lower nutritional knowledge (PRR = 0.96; 95% CI: 0.91-0.99) were associated with higher weeklyunhealthy snaking. Perceived self-efficacy (PRR = 0.95; 95% CI: 0.91-1.00) negatively influenced the frequency ofunhealthy snaking, with this approaching significance (P< .06). In case of environmental factors, high socio-economicstatus (SES) level (PRR = 1.45; 95% CI: 1.26-1.67), single-parent family (PRR = 1.14; 95% CI: 1.01-1.30), more socialnorms pressure (PRR = 1.08; 95% CI: 1.01-1.17), pocket money allowance (PRR = 1.21; 95% CI: 1.09-1.34), easyaccessibility (PRR = 1.06; 95% CI:1.01-1.11), and less perceived parental control (PRR= 0.96; 95% CI: 0.92-0.99) all hada role in higher consumption of unhealthy snacks. Interestingly, larger school size was associated with less unhealthysnacking (PRR = 0.79; 95% CI: 0.68-0.92). ConclusionUnhealthy snacking behavior is influenced by individual, socio-cultural and physical-environmentalinfluences, namely by factors relating to poor parenting practices, high SES level, family characteristics, improper socialnorms pressure, and less knowledge and self-efficacy of students. This evidence can be used to inform a more evidencebased IHPS program through focusing on supportive strategies at the home, school, and local community levels.
PubDate: Sat, 28 Jan 2017 20:30:00 +010
- Providing Value to New Health Technology: The Early Contribution of
Entrepreneurs, Investors, ...
Abstract: BackgroundNew technologies constitute an important cost-driver in healthcare, but the dynamics that lead to their emergence remains poorly understood from a health policy standpoint. The goal of this paper is to clarify how entrepreneurs, investors, and regulatory agencies influence the value of emerging health technologies. MethodsOur 5-year qualitative research program examined the processes through which new health technologies were envisioned, financed, developed and commercialized by entrepreneurial clinical teams operating in Quebec’s (Canada) publicly funded healthcare system. ResultsEntrepreneurs have a direct influence over a new technology’s value proposition, but investors actively transform this value. Investors support a technology that can find a market, no matter its intrinsic value for clinical practice or healthcare systems. Regulatory agencies reinforce the “double” value of a new technology —as a health intervention and as an economic commodity— and provide economic worth to the venture that is bringing the technology to market. ConclusionPolicy-oriented initiatives such as early health technology assessment (HTA) and coverage with evidence may provide technology developers with useful input regarding the decisions they make at an early stage. But to foster technologies that bring more value to healthcare systems, policy-makers must actively support the consideration of health policy issues in innovation policy.
PubDate: Tue, 24 Jan 2017 20:30:00 +010
- Peruvian Mental Health Reform: A Framework for Scaling-up Mental Health
Abstract: Background Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face. Methods Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up. Results Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru. Conclusion Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services.
PubDate: Mon, 23 Jan 2017 20:30:00 +010
- How Could Private Healthcare Better Contribute to Healthcare Coverage in
Abstract: Private healthcare services in Vietnam are seen as a major part of the solution to the rapid increase in need and demand for healthcare services. Formally recognized over 20 years ago, the private health services coexist with public services and are available all over the country. However, the scale and size of private sector is still small compared to the public sector and public acceptance and reputation still limited. There are substantial concerns with the quality of services and the adequacy of regulation. Human resource for health is currently inadequate to support growth in both public and private sectors. The role of the private sector in achieving Vietnam’s population health objectives is not clear. In this emerging economy, there is significant potential for increased dependency on private healthcare to increase health access inequities. This paper discusses how private healthcare could better contribute to healthcare coverage in Vietnam.
PubDate: Sat, 21 Jan 2017 20:30:00 +010
- Priority Setting for Universal Health Coverage: We Need to Focus Both on
Substance and on ...
Abstract: In an editorial published in this journal, Baltussen et al argue that information on cost-effectiveness is not sufficient for priority setting for universal health coverage (UHC), a claim which is correct as far as it goes. However, their focus on the procedural legitimacy of ‘micro’ priority setting processes (eg, decisions concerning the reimbursement of specific interventions), and their related assumption that values for priority setting are determined only at this level, leads them to ignore the relevance of higher level, ‘macro’ priority setting processes, for example, consultations held by World Health Organization (WHO) Member States and other global stakeholders that have resulted in widespread consensus on the principles of UHC. Priority setting is not merely about discrete choices, nor should the focus be exclusively (or even mainly) on improving the procedural elements of micro priority setting processes. Systemic activities that shape the health system environment, such as strategic planning, as well as the substantive content of global policy instruments, are critical elements for priority setting for UHC.
PubDate: Sat, 21 Jan 2017 20:30:00 +010
- Framing Political Change: Can a Left Populism Disrupt the Rise of the
Reactionary Right?; ...
Abstract: Solomon Benatar offers an important critique of the limited frame that sets the boundaries of much of what is referred to as ‘global health.’ In placing his comments within a criticism of increasing poverty (or certainly income and wealth inequalities) and the decline in our environmental commons, he locates our health inequities within the pathology of our present global economy. In that respect it is a companion piece to an editorial I published around the same time. Both Benatar’s and my paralleling arguments take on a new urgency in the wake of the US presidential election. Although not a uniquely American event (the xenophobic right has been making inroads in many parts of the world), the degree of vitriol expressed by the President-elect of the world’s (still) most powerful and militarized country is being used to further legitimate the policies of right-extremist parties in Europe while providing additional justification for the increasingly autocratic politics of leaders (elected or otherwise) in many other of the world’s nations. To challenge right-populism’s rejection of the predatory inequalities that 4 years of (neo)-liberal globalization have created demands strong and sustained left populism built, in part, on the ecocentric frame advocated by Benatar.
PubDate: Mon, 16 Jan 2017 20:30:00 +010
- Don’t Discount Societal Value in Cost-Effectiveness; Comment on
“Priority Setting for ...
Abstract: As healthcare resources become increasingly scarce due to growing demand and stagnating budgets, the need for effective priority setting and resource allocation will become ever more critical to providing sustainable care to patients. While societal values should certainly play a part in guiding these processes, the methodology used to capture these values need not necessarily be limited to multi-criterion decision analysis (MCDA)-based processes including ‘evidence-informed deliberative processes.’ However, if decision-makers intend to not only incorporates the values of the public they serve into decisions but have the decisions enacted as well, consideration should be given to more direct involvement of stakeholders. Based on the examples provided by Baltussen et al, MCDA-based processes like ‘evidence-informed deliberative processes’ could be one way of achieving this laudable goal.
PubDate: Fri, 13 Jan 2017 20:30:00 +010
- A Qualitative Assessment of the Evidence Utilization for Health
Policy-Making on the Basis of ...
Abstract: BackgroundSUPPORT tools consist of 18 articles addressing the health policy-makers so that they can learn how to make evidence-informed health policies. These tools have been particularly recommended for developing countries. The present study tries to explain the process of evidence utilization for developing policy documents in the Iranian Ministry of Health and Medical Education (MoHME) and to compare the findings with those of SUPPORT tools. MethodsA qualitative research was conducted, using the framework analysis approach. Participants consisted of senior managers and technicians in MoHME. Purposeful sampling was done, with a maximum variety, for the selection of research participants: individuals having at least 5 years of experience in preparing evidence-based policy documents. Face-to-face interviews were conducted for data collection. As a guideline for the interviews, ‘the Utilization of Evidence in Policy Making Organizations’ procedure was used. The data were analyzed through the analysis of the framework method using MAXQDA 10 software. ResultsThe participants acquired the research evidence in a topic-based form, and they were less likely to search on the basis of the evidence pyramid. To assess the quality of evidence, they did not use standard critical tools; to adapt the evidence and interventions with the local setting, they did not use the ideas and experiences of all stakeholders, and in preparing the evidence-based policy documents, they did not take into consideration the window of opportunity, did not refrain from using highly technical terms, did not write user-friendly summaries, and did not present alternative policy options. In order to develop health policies, however, they used the following innovations: attention to the financial burden of policy issues on the agenda, sensitivity analysis of the preferred policy option on the basis of technical, sociopolitical, and economic feasibility, advocacy from other scholars, using the multi-criteria decisionmaking models for the prioritization of policy options, implementation of policy based on the degree of readiness of policy-implementing units, and the classification of policy documents on the basis of different conditions of policymaking (urgent, short-term, and long-term). ConclusionFindings showed that the process of evidence utilization in IR-MoH enjoys some innovations for the support of health policy development. The present study provides IR-MoH with considerable opportunities for the improvement of evidence-informed health policy-making. Moreover, the SUPPORT process and tools are recommended to be used in developing countries.
PubDate: Sat, 07 Jan 2017 20:30:00 +010
- Critical Global Health: Responding to Poverty, Inequality and Climate
Change; Comment on ...
Abstract: A recent article by Sol Benatar calls on the global health community to reassess its approach to twin crises of global poverty and climate change. I build on his article by challenging mainstream narratives that claim satisfactory progress in efforts to reduce poverty and improve health for all, and arguing that any eradication of poverty that is consistent with environmental sustainability will require a more explicit emphasis on the redistribution of power and wealth. I suggest that the global health community has been largely socialised into accepting that progress and future solutions can be attained through more neoliberal development, technological advancement and philanthropic endeavour and that a more critical global health is required. I propose three steps that the global health community should take: first, create more space for the social, political and political sciences within global health; second, be more prepared to act politically and challenge power; and third, do more to bridge the global-local divide in recognition of the fact that progressive change requires mobilisation from the bottom-up in conjunction with top-down policy and legislative change.
PubDate: Mon, 02 Jan 2017 20:30:00 +010
- Clinician Perspectives of Barriers to Effective Implementation of a Rapid
Response System in an ...
Abstract: BackgroundSystemic and structural issues of rapid response system (RRS) models can hinder implementation. This study sought to understand the ways in which acute care clinicians (physicians and nurses) experience and negotiate care for deteriorating patients within the RRS. MethodsPhysicians and nurses working within an Australian academic health centre within a jurisdictional-based model of clinical governance participated in focus group interviews. Verbatim transcripts were analysed using thematic content analysis. ResultsThirty-four participants (21 physicians and 13 registered nurses [RNs]) participated in six focus groups over five weeks in 2014. Implementing the RRS in daily practice was a process of informal communication and negotiation in spite of standardised protocols. Themes highlighted several systems or organisational-level barriers to an effective RRS, including (1) responsibility is inversely proportional to clinical experience; (2) actions around system flexibility contribute to deviation from protocol; (3) misdistribution of resources leads to perceptions of inadequate staffing levels inhibiting full optimisation of the RRS; and (4) poor communication and documentation of RRS increases clinician workloads. ConclusionImplementing a RRS is complex and multifactorial, influenced by various inter- and intra-professional factors, staffing models and organisational culture. The RRS is not a static model; it is both reflexive and iterative, perpetually transforming to meet healthcare consumer and provider demands and local unit contexts and needs. Requiring more than just a strong initial implementation phase, new models of care such as a RRS demand good governance processes, ongoing support and regular evaluation and refinement. Cultural, organizational and professional factors, as well as systems-based processes, require consideration if RRSs are to achieve their intended outcomes in dynamic healthcare settings.
PubDate: Sat, 31 Dec 2016 20:30:00 +010
- Thinking Out of the Box: A Green and Social Climate Fund; Comment on
“Politics, Power, ...
Abstract: Solomon Benatar’s paper “Politics, Power, Poverty and Global Health: Systems and Frames” examines the inequitable state of global health challenging readers to extend the discourse on global health beyond conventional boundaries by addressing the interconnectedness of planetary life. Our response explores existing models of international cooperation, assessing how modifying them may achieve the twin goals of ensuring healthy people and planet. First, we address why the inequality reducing post World War II European welfare model, if implemented stateby-state, is unfit for reducing global inequality and respecting environmental boundaries. Second, we argue that to advance beyond the ‘Westphalian,’ human centric thinking integral to global inequality and climate change requires challenging the logic of global economic integration and exploring the politically infeasible. In conclusion, we propose social policy focused changes to the World Trade Organisation (WTO) and a Green and Social Climate Fund, financed by new global greenhouse gas charges, both of which could advance human and planetary health. Recent global political developments may offer a small window of opportunity for out of the box proposals that could be advanced by concerted and united advocacy by global health activists, environmental activists, human rights activists, and trade unions.
PubDate: Tue, 27 Dec 2016 20:30:00 +010
- Collaboration Between Researchers and Knowledge Users in Health Technology
Assessment: A ...
Abstract: BackgroundCollaboration between researchers and knowledge users is increasingly promoted because it could enhance more evidence-based decision-making and practice. These complex relationships differ in form, in the particular goals they are trying to achieve, and in whom they bring together. Although much is understood about why partnerships form, relatively little is known about how collaboration works: how the collaborative process is shaped through the partners’ interactions, especially in the field of health technology assessment (HTA)? This study aims at addressing this gap in the literature in the specific context of HTA. MethodsWe used a qualitative descriptive design for this exploratory study. Semi-structured interviews with three researchers and two decision-makers were conducted on the practices related to the collaboration. We also performed document analysis, observation of five team meetings, and informal discussion with the participants. We thematically analyzed data using the structuration theory and a collective impact (CI) framework. ResultsThis study showed that three main contextual factors helped shape the collaboration between researchers and knowledge users: the use of concepts related to each field; the use of related expertise; and a lack of clearly defined roles in the project. Previous experiences with the topic of the research project and a partnership based on “a give and take” relationship emerged as factors of success of this collaboration. ConclusionBy shedding light on the structuration of the collaboration between researchers and knowledge users, our findings open the door to a poorly documented field in the area of HTA, and additional studies that build on these early observations are welcome.
PubDate: Fri, 23 Dec 2016 20:30:00 +010
- Global Health in the Anthropocene: Moving Beyond Resilience and
Capitalism; Comment on ...
Abstract: There has been much reflection on the need for a new understanding of global health and the urgency of a paradigm shift to address global health issues. A crucial question is whether this is still possible in current modes of global governance based on capitalist values. Four reflections are provided. (1) Ecological–centered values must become central in any future global health framework. (2) The objectives of ‘sustainability’ and ‘economic growth’ present a profound contradiction. (3) The resilience discourse maintains a gridlock in the functioning of the global health system. (4) The legitimacy of multi-stakeholder governance arrangements in global health requires urgent attention. A dual track approach is suggested. It must be aimed to transform capitalism into something better for global health while in parallel there is an urgent need to imagine a future and pathways to a different world order rooted in the principles of social justice, protecting the commons and a central role for the preservation of ecology.
PubDate: Fri, 23 Dec 2016 20:30:00 +010
- Understanding Internal Accountability in Nigeria’s Routine Immunization
System: Perspectives ...
Abstract: BackgroundRoutine immunization coverage in Nigeria has remained low, and studies have identified a lack of accountability as a barrier to high performance in the immunization system. Accountability lies at the heart of various health systems strengthening efforts recently launched in Nigeria, including those related to immunization. Our aim was to understand the views of health officials on the accountability challenges hindering immunization service delivery at various levels of government. MethodsA semi-structured questionnaire was used to interview immunization and primary healthcare (PHC) officials from national, state, local, and health facility levels in Niger State in north central Nigeria. Individuals were selected to represent a range of roles and responsibilities in the immunization system. The questionnaire explored concepts related to internal accountability using a framework that organizes accountability into three axes based upon how they drive change in the health system. ResultsRespondents highlighted accountability challenges across multiple components of the immunization system, including vaccine availability, financing, logistics, human resources, and data management. A major focus was the lack of clear roles and responsibilities both within institutions and between levels of government. Delays in funding, especially at lower levels of government, disrupted service delivery. Supervision occurred less frequently than necessary, and the limited decision space of managers prevented problems from being resolved. Motivation was affected by the inability of officials to fulfill their responsibilities. Officials posited numerous suggestions to improve accountability, including clarifying roles and responsibilities, ensuring timely release of funding, and formalizing processes for supervision, problem solving, and data reporting. ConclusionWeak accountability presents a significant barrier to performance of the routine immunization system and high immunization coverage in Nigeria. As one stakeholder in ensuring the performance of health systems, routine immunization officials reveal critical areas that need to be prioritized if emerging interventions to improve accountability in routine immunization are to have an effect.
PubDate: Fri, 09 Dec 2016 20:30:00 +010
- The Elephants in the Room: Sex, HIV, and LGBT Populations in MENA. ...
Abstract: In response to this insightful editorial, we wish to provide commentary that seeks to highlight recent successes and illuminate the often unspoken hurdles at the intersections of culture, politics, and taboo. We focus on sexual transmission and draw examples from Lebanon, where the pursuit of data in quality and quantity is teaching us lessons about the way forward and where we are experiencing many of the challenges referenced in the editorial such as discrepancies between national statistics and rates derived via research as well as the impact of protracted political conflict and displacement. Two important points were raised in the editorial about HIV in Middle East and North Africa (MENA) that we would like to expand further: (1) The epidemic is largely driven by drug-related and sexual behavior among key populations; and (2) Several key populations continue to be criminalized and excluded from surveillance programs.
PubDate: Sat, 03 Dec 2016 20:30:00 +010
- Evidence-Informed Deliberative Processes for Universal Health Coverage:
Broadening the Scope; ...
Abstract: Universal health coverage (UHC) is high on the global health agenda, and priority setting is fundamental to the fair and efficient pursuit of this goal. In a recent editorial, Rob Baltussen and colleagues point to the need to go beyond evidence on cost-effectiveness and call for evidence-informed deliberative processes when setting priorities for UHC. Such processes are crucial at every step on the path to UHC, and hopefully we will see intensified efforts to develop and implement processes of this kind in the coming years. However, if this does happen, it will be essential to ensure a sufficiently broad scope in at least two respects. First, the design of evidence-informed priority-setting processes needs to go beyond a simple view on the relationship between evidence and policy and adapt to a diverse set of factors shaping this relationship. Second, these processes should go beyond a focus on clinical services to accommodate also public health interventions. Together, this can help strengthen priority-setting processes and bolster progress towards UHC and the Sustainable Development Goals.
PubDate: Sat, 26 Nov 2016 20:30:00 +010
- Impact of Health Research Systems on Under-5 Mortality Rate: A Trend
Abstract: Background Between 1990 and 2015, under-5 mortality rate (U5MR) declined by 53%, from an estimated rate of 91 deaths per 1000 live births to 43, globally. The aim of this study was to determine the share of health research systems in this decrease alongside other influential factors. Methods We used random effect regression models including the ‘random intercept’ and ‘random intercept and random slope’ models to analyze the panel data from 1990 to 2010. We selected the countries with U5MRs falling between the first and third quartiles in 1990. We used both the total articles (TA) and the number of child-specific articles (CSA) as a proxy of the health research system. In order to account for the impact of other factors, measles vaccination coverage (MVC) (as a proxy of health system performance), gross domestic product (GDP), human development index (HDI), and corruption perception index (CPI) (as proxies of development), were embedded in the model. Results Among all the models, ‘the random intercept and random slope models’ had lower residuals. The same variables of CSA, HDI, and time were significant and the coefficient of CSA was estimated at -0.17; meaning, with the addition of every 100 CSA, the rate of U5MR decreased by 17 per 1000 live births. Conclusion Although the number of CSA has contributed to the reduction of U5MR, the amount of its contribution is negligible compared to the countries’ development. We recommend entering different types of researches into the model separately in future research andincluding the variable of ‘exchange between knowledge generator and user.’
PubDate: Fri, 25 Nov 2016 20:30:00 +010
- Just Say No to the TPP: A Democratic Setback for American and Asian Public
Health; Comment on ...
Abstract: The article by Labonté, Schram, and Ruckert is a significant and timely analysis of the Trans-Pacific Partnership (TPP) policy and the severe threats to public health that it implies for 12 Pacific Rim populations from the Americas and Asia (Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, United States, and Vietnam). With careful and analytic precision the authors convincingly unearth many aspects of this piece of legislation that undermine the public health achievements of most countries involved in the TTP. Our comments complement their policy analysis with the aim of providing a positive heuristic tool to assist in the understanding of the TPP, and other upcoming treaties like the even more encompassing Transatlantic Trade and Investment Partnership (TTIP), and in so doing motivate the public health community to oppose the implementation of the relevant provisions of the agreements. The aims of this commentary on the study of Labonté et al are to show that an understanding of the health effects of the TPP is incomplete without a political analysis of policy formation, and that realist methods can be useful to uncover the mechanisms underlying TPP’s political and policy processes.
PubDate: Sat, 05 Nov 2016 20:30:00 +010
- Forced Migration and Global Responsibility for Health; Comment on
“Defining and Acting on ...
Abstract: Forced migration has become a world-wide phenomenon in the past century, affecting increasing numbers of countries and people. It entails important challenges from a global health perspective. Leppold et al have critically discussed the Japanese interpretation of global responsibility for health in the context of forced migration. This commentary complements their analysis by outlining three priority areas of global health responsibility for European Union (EU) countries. We highlight important stages of the migration phases related to forced migration and propose three arguments. First, the chronic neglect of the large number of internally displaced persons (IDPs) in the discourses on the “refugee crisis” needs to be corrected in order to develop sustainable solutions with a framework of the Sustainable Development Goals (SDGs). Second, protection gaps in the global system of protection need to be effectively closed to resolve conflicts with border management and normative global health frameworks. Third, effective policies need to be developed and implemented to meet the health and humanitarian needs of forced migrants; at the same time, the solidarity crisis within the EU needs to be overcome. These stakes are high. EU countries, being committed to global health, should urgently address these areas.
PubDate: Fri, 04 Nov 2016 20:30:00 +010
- Labonté Identifies Key Issues for Health Promoters in the New World
Order; Comment on ...
Abstract: For over 35 years Ronald Labonté has been critically analyzing the state of health promotion in Canada and the world. In 1981, he identified the shortcomings of the groundbreaking Lalonde Report by warning of the seductive appeal of so-called lifestyle approaches to health. Since then, he has left a trail of critical work identifying the barriers to — and opportunities for —health promotion work. More recently, he has shown how the rise of economic globalization and acceptance of neo-liberal ideology has come to threaten the health of those in both developed and developing nations. In his recent commentary, Labonté shows how the United Nations’ 2015 Sustainable Development Goals (SDGs) can offer a new direction for health promoters in these difficult times.
PubDate: Tue, 01 Nov 2016 20:30:00 +010
- Cost-Effectiveness of Rural Incentive Packages for Graduating Medical
Students in Lao PDR
Abstract: Background The dearth of health workers in rural settings in Lao People’s Democratic Republic (PDR) and other developing countries limits healthcare access and outcomes. In evaluating non-wage financial incentive packages as a potential policy option to attract health workers to rural settings, understanding the expected costs and effects of the various programs ex antecan assist policy-makers in selecting the optimal incentive package. Methods We use discrete choice experiments (DCEs), costing analyses and recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the costeffectiveness of 15 voluntary incentives packages for new physicians in Lao PDR. Our data sources include a DCE survey completed by medical students (n = 329) in May 2011 and secondary cost, economic and health data. Mixed logit regressions provide the basis for estimating how each incentive package influences rural versus urban location choice over time. We estimate the expected rural density of physicians and the cost-effectiveness of 15 separate incentive packages from a societal perspective. In order to generate the cost-effectiveness ratios we relied on the rural uptake probabilities inferred from the DCEs, the costing data and prior World Health Organization (WHO) estimates that relate health outcomes to health worker density. Results Relative to no program, the optimal voluntary incentive package would increase rural physician density by 15% by 2016 and 65% by 2041. After incorporating anticipated health effects, seven (three) of the 15 incentive packages have anticipated average cost-effectiveness ratio less than the WHO threshold (three times gross domestic product [GDP] per capita) over a 5-year (30 year) period. The optimal package’s incremental cost-effectiveness ratio is $1454/QALY (quality-adjusted life year) over 5 years and $2380/QALY over 30 years. Capital intensive components, such as housing or facility improvement, are not efficient. Conclusion Conditional on using voluntary incentives, Lao PDR should emphasize non-capital intensive options such as advanced career promotion, transport subsidies and housing allowances to improve physician distribution and rural health outcomes in a cost-effective manner. Other countries considering voluntary incentive programs can implement health worker/trainee DCEs and costing surveys to determine which incentive bundles improve rural uptake most efficiently but should be aware of methodological caveats.
PubDate: Fri, 28 Oct 2016 20:30:00 +010
- Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine
Application Process ...
Abstract: Background Global health partnerships have grown rapidly in number and scope, yet there has been less emphasis on their evaluation. Gavi, the Vaccine Alliance, is one such public-private partnership; in Gavi-eligible countries partnerships are dynamic networks of immunization actors who work together to support all stages and aspects of Gavi support. This paper describes a conceptual framework – the partnership framework – and analytic approach for evaluating the perceptions of partnerships’ added value as well as the results from an application to one case in Uganda. Methods We used a mixed-methods case study design embedded in the Gavi Full Country Evaluations (FCE) to test the partnership framework on Uganda’s human papillomavirus (HPV) vaccine application partnership. Data from document review, interviews, and social network surveys enabled the testing of the relationships between partnership framework domains (context, structure, practices, performance, and outcomes). Topic guides were based on the framework domains and network surveys identified working together relationships, professional trust, and perceptions of the effectiveness, efficiency, and legitimacy of the partnership’s role in this process. Results Data from seven in-depth interviews, 11 network surveys and document review were analyzed according to the partnership framework, confirming relationships between the framework domains. Trust was an important contributor to the perceived effectiveness of the process. The network was structured around the EPI program, who was considered the leader of this process. While the structure and composition of the network was largely viewed as supporting an effective and legitimate process, the absence of the Ministry of Education (MoE) may have had downstream consequences if this study’s results had not been shared with the Ministry of Health (MoH) and acted upon. The partnership was not perceived to have increased the efficiency of the process, perhaps as a result of unclear or absent guidelines around roles and responsibilities. Conclusion The health and functioning of global health partnerships can be evaluated using the framework and approach presented here. Network theory and methods added value to the conceptual and analytic processes and we recommend applying this approach to other global health partnerships to ensure that they are meeting the complex challenges they were designed to address.
PubDate: Tue, 25 Oct 2016 20:30:00 +010
- The Trans-Pacific Partnership: Should We “Fear the Fear”?; Comment on
“The Trans-Pacific ...
Abstract: RLabonté et al entitle their paper in this issue of the International Journal of Health Policy and Management “The Trans-Pacific Partnership: Is It Everything We Feared for Health?” Tantalisingly, they do not directly answer the question they pose, and in this commentary, we suggest that it is the wrong question; we should not ‘fear’ the Trans-Pacific Partnership (TPP) at all, rather we should ask how we are to respond. The public health community is right to be concerned with the potential implications of trade and investment agreements (TIAs) for health, particularly with shifts from multilateral to regional/bilateral agreements including provisions with greater risk to public health. But it is critical to understand also the potential health benefits, and especially the mitigating policy and governance mechanisms to respond to adverse TIA implications. Given entrenched and divergent sectoral worldviews and perspectives between trade and health communities on these issues, achieving the requisite understanding will also likely require characterisation of these perspectives and identification of areas of common understanding and agreed solutions
PubDate: Tue, 18 Oct 2016 20:30:00 +010
- “Seeing” the Difference: The Importance of Visibility and
Action as a Mark of ...
Abstract: The Rycroft-Malone paper states that co-production relies on ‘authentic’ collaboration as a context for action. Our commentary supports and extends this assertion. We suggest that ‘authentic’ co-production involves processes where participants can ‘see’ the difference that they have made within the project and beyond. We provide examples including: the use of design in health projects which seek to address power issues and make contributions visible through iteration and prototyping; and the development of ‘actionable outputs’ from research that are the physical embodiment of coproduction. Finally, we highlight the elements of the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) architecture that enables the inclusion of such collaborative techniques that demonstrate visible co-production. We reinforce the notion that maintaining collaboration requires time, flexible resources, blurring of knowledge produceruser boundaries, and leaders who promote epistemological tolerance and methodological exploration.
PubDate: Sun, 16 Oct 2016 20:30:00 +010
- How the Spectre of Societal Homogeneity Undermines Equitable Healthcare
for Refugees; Comment ...
Abstract: Recourse to a purported ideal of societal homogeneity has become common in the context of the refugee reception crisis – not only in Japan, as Leppold et al report, but also throughout Europe. Calls for societal homogeneity in Europe originate from populist movements as well as from some governments. Often, they go along with reduced social support for refugees and asylum seekers, for example in healthcare provision. The fundamental right to health is then reduced to a citizens’ right, granted fully only to nationals. Germany, in spite of welcoming many refugees in 2015, is a case in point: entitlement and access to healthcare for asylum seekers are restricted during the first 15 months of their stay. We show that arguments brought forward to defend such restrictions do not hold, particularly not those which relate to maintaining societal homogeneity. European societies are not homogeneous, irrespective of migration. But as migration will continue, societies need to invest in what we call “globalization within.” Removing entitlement restrictions and access barriers to healthcare for refugees and asylum seekers is one important element thereof.
PubDate: Sun, 16 Oct 2016 20:30:00 +010
- The Life Story Experience of “Migrant Dentists” in Australia:
Potential Implications for ...
Abstract: BackgroundThe migration of dentists is a major policy challenge facing both developing and developed countries. Dentists from over 120 countries migrate to Australia, and a large proportion are from developing countries. The aim of the study was to assess the life story experience (LSE) of migrant dentists in Australia, in order to address key policy challenges facing dentist migration. MethodsA national survey of all migrant dentists resident in Australia was conducted in 2013. Migrant experiences were assessed through a suite of LSE scales, developed through a qualitative-quantitative study. Respondents rated experiences using a five-point Likert scale. ResultsA total of 1022 migrant dentists responded to the survey (response rate = 54.5%). LSE1 (health system and general lifestyle concerns in home country), LSE2 (appreciation towards Australian way of life) and LSE3 (settlement concerns in Australia) scales varied by migrant dentist groups, sex, and years since arrival to Australia (chi-square, P < .05). In a logistic regression model, migrants mainly from developing countries (ie, the examination pathway group) faced greater health system and general lifestyle concerns in their home countries (9.32; 3.51-24.72) and greater settlement challenges in Australia (5.39; 3.51-8.28), compared to migrants from well-developed countries, who obtained direct recognition of qualifications. Migrants also are more appreciative towards the Australian way of life if they had lived at least ten years in Australia (1.97; 1.27-3.05), compared to migrants who have lived for less than ten years. ConclusionMigrant dentists, mainly from developing countries, face challenges both in their home countries and in Australia. Our study offers evidence for multi-level health workforce governance and calls for greater consensus towards an international agenda to address dentist migration. Better integration of dentist migration with the mainstream health workforce governance is a viable and opportunistic way forward.
PubDate: Sun, 09 Oct 2016 20:30:00 +010
- An Assessment of National Maternal and Child Health Policy-Makers’
Knowledge and Capacity for ...
Abstract: BackgroundThere is increasing interest globally in the use of more rigorous processes to ensure that maternal, newborn, and child health (MNCH) care recommendations are informed by the best available research evidence use. The purpose of this study was to engage Nigerian MNCH policy-makers and other stakeholders to consider issues around research to policy and practice interface and to assess their existing knowledge and capacity on the use of research evidence for policy-making and practice. MethodsThe study design is a cross-sectional evaluation of MNCH stakeholders’ knowledge as it pertains different dimensions of research to practice. This was undertaken during a national MNCH stakeholders’ engagement event convened under the auspices of the West African Health Organization (WAHO) and the Federal Ministry of Health (FMoH) in Abuja, Nigeria. A questionnaire was administered to participants, which was designed to assess participants’ knowledge, capacity and organizational process of generation, synthesis and utilization of research evidence in policy-making regarding MNCH. ResultsA total of 40 participants signed the informed consent form and completed the questionnaire. The mean ratings (MNRs) of participants’ knowledge of electronic databases and capacity to identify and obtain relevant research evidence from electronic databases ranged from 3.62-3.68 on the scale of 5. The MNRs of participants’ level of understanding of a policy brief, a policy dialogue and the role of researchers in policy-making ranged from 3.50-3.86. The MNRs of participants’ level of understanding of evidence in policy-making context, types and sources of evidence, capacity to identify, select, adapt, and transform relevant evidence into policy ranged from 3.63-4.08. The MNRs of the participants’ organization’s capacity to cover their geographical areas of operation were generally low ranging from 3.32-3.38 in terms of manpower, logistics, facilities, and external support. The lowest MNR of 2.66 was recorded in funding. ConclusionThe outcomes of this study suggest that a stakeholders’ engagement event can serve as an important platform to assess policy-makers’ knowledge and capacity for evidence-informed policy-making and for the promotion of evidence use in the policy process.
PubDate: Fri, 07 Oct 2016 20:30:00 +010