Subjects -> HEALTH AND SAFETY (Total: 1478 journals)
    - CIVIL DEFENSE (22 journals)
    - DRUG ABUSE AND ALCOHOLISM (87 journals)
    - HEALTH AND SAFETY (700 journals)
    - HEALTH FACILITIES AND ADMINISTRATION (358 journals)
    - OCCUPATIONAL HEALTH AND SAFETY (112 journals)
    - PHYSICAL FITNESS AND HYGIENE (117 journals)
    - WOMEN'S HEALTH (82 journals)

HEALTH AND SAFETY (700 journals)            First | 1 2 3 4     

Showing 201 - 203 of 203 Journals sorted alphabetically
Health Policy OPEN     Open Access  
Health Promotion International     Hybrid Journal   (Followers: 23)
Health Promotion Journal of Australia : Official Journal of Australian Association of Health Promotion Professionals     Full-text available via subscription   (Followers: 7)
Health Promotion Practice     Hybrid Journal   (Followers: 15)
Health Prospect     Open Access  
Health Psychology     Full-text available via subscription   (Followers: 59)
Health Psychology Bulletin     Open Access   (Followers: 1)
Health Psychology Research     Open Access   (Followers: 21)
Health Psychology Review     Hybrid Journal   (Followers: 46)
Health Research Policy and Systems     Open Access   (Followers: 15)
Health SA Gesondheid     Open Access   (Followers: 2)
Health Science Reports     Open Access   (Followers: 1)
Health Sciences and Disease     Open Access   (Followers: 1)
Health Security     Hybrid Journal   (Followers: 1)
Health Services Insights     Open Access   (Followers: 1)
Health Systems     Hybrid Journal   (Followers: 6)
Health Systems & Reform     Open Access   (Followers: 2)
Health Voices     Full-text available via subscription  
Health, Culture and Society     Open Access   (Followers: 13)
Health, Risk & Society     Hybrid Journal   (Followers: 11)
Health, Safety and Environment     Open Access   (Followers: 34)
Healthcare     Open Access   (Followers: 2)
Healthcare Quarterly     Full-text available via subscription   (Followers: 9)
Healthcare Technology Letters     Open Access  
HERD : Health Environments Research & Design Journal     Full-text available via subscription   (Followers: 1)
Highland Medical Research Journal     Full-text available via subscription  
Hispanic Health Care International     Full-text available via subscription  
Histoire, médecine et santé     Open Access   (Followers: 1)
Home Health Care Services Quarterly     Hybrid Journal   (Followers: 5)
Hong Kong Journal of Social Work, The     Hybrid Journal   (Followers: 3)
Horizonte Medico     Open Access  
Horizonte Sanitario     Open Access  
Hua Hin Sook Jai Klai Kangwon Journal     Open Access  
Human Nutrition & Metabolism     Open Access   (Followers: 1)
IEEE Journal of Translational Engineering in Health and Medicine     Open Access   (Followers: 5)
IISE Transactions on Occupational Ergonomics and Human Factors     Hybrid Journal  
IJS Global Health     Open Access  
Implementation Science     Open Access   (Followers: 22)
Implementation Science Communications     Open Access   (Followers: 4)
IMTU Medical Journal     Full-text available via subscription  
Indian Journal of Health Sciences and Biomedical Research KLEU     Open Access   (Followers: 2)
Indian Journal of Youth and Adolescent Health     Open Access  
Indonesian Journal for Health Sciences     Open Access   (Followers: 1)
Indonesian Journal of Public Health     Open Access  
Infodir : Revista de Información científica para la Dirección en Salud     Open Access  
interactive Journal of Medical Research     Open Access  
International Archives of Health Sciences     Open Access  
International Health     Hybrid Journal   (Followers: 5)
International Health Trends and Perspectives     Open Access  
International Journal for Equity in Health     Open Access   (Followers: 10)
International Journal for Quality in Health Care     Hybrid Journal   (Followers: 39)
International Journal of Applied Behavioral Sciences     Open Access   (Followers: 1)
International Journal of Behavioural and Healthcare Research     Hybrid Journal   (Followers: 8)
International Journal of Child Development and Mental Health     Open Access   (Followers: 2)
International Journal of Circumpolar Health     Open Access   (Followers: 2)
International Journal of Community Medicine and Public Health     Open Access   (Followers: 3)
International Journal of E-Health and Medical Communications     Full-text available via subscription   (Followers: 2)
International Journal of Environmental Research and Public Health     Open Access   (Followers: 22)
International Journal of Evidence-Based Healthcare     Hybrid Journal   (Followers: 8)
International Journal of Food Safety, Nutrition and Public Health     Hybrid Journal   (Followers: 20)
International Journal of Growth and Development     Open Access   (Followers: 1)
International Journal of Health & Allied Sciences     Open Access   (Followers: 3)
International Journal of Health Care Quality Assurance     Hybrid Journal   (Followers: 13)
International Journal of Health Economics and Management     Hybrid Journal   (Followers: 10)
International Journal of Health Geographics     Open Access   (Followers: 7)
International Journal of Health Policy and Management     Open Access   (Followers: 11)
International Journal of Health Professions     Open Access   (Followers: 3)
International Journal of Health Promotion and Education     Hybrid Journal   (Followers: 11)
International Journal of Health Research     Open Access   (Followers: 4)
International Journal of Health Sciences     Open Access  
International Journal of Health Sciences Education     Open Access   (Followers: 2)
International Journal of Health Services     Full-text available via subscription   (Followers: 7)
International Journal of Health System and Disaster Management     Open Access   (Followers: 4)
International Journal of Healthcare     Open Access  
International Journal of Healthcare Delivery Reform Initiatives     Full-text available via subscription   (Followers: 1)
International Journal of Healthcare Information Systems and Informatics     Hybrid Journal   (Followers: 6)
International Journal of Healthcare Management     Hybrid Journal   (Followers: 14)
International Journal of Healthcare Policy     Hybrid Journal   (Followers: 1)
International Journal of Hygiene and Environmental Health     Hybrid Journal   (Followers: 7)
International Journal of Indigenous Health     Open Access   (Followers: 5)
International Journal of Kinesiology in Higher Education     Hybrid Journal  
International Journal of MCH and AIDS     Open Access  
International Journal of Medicine and Health Development     Open Access   (Followers: 4)
International Journal of Mens Social and Community Health     Open Access  
International Journal of Mental Health     Full-text available via subscription   (Followers: 24)
International Journal of Practice-based Learning in Health and Social Care     Open Access   (Followers: 1)
International Journal of Prevention and Treatment     Open Access   (Followers: 1)
International Journal of Public Health Research and Management     Hybrid Journal   (Followers: 5)
International Journal of Public Health Science     Open Access   (Followers: 6)
International Journal of Scientific Reports     Open Access   (Followers: 3)
International Journal of Sexual Health     Hybrid Journal   (Followers: 3)
International Journal of Social Welfare     Hybrid Journal   (Followers: 18)
International Journal of Spa and Wellness     Hybrid Journal  
International Journal of Telerehabilitation     Open Access   (Followers: 1)
International Journal of Yoga : Philosophy, Psychology and Parapsychology     Open Access   (Followers: 6)
International Research in Children's Literature     Hybrid Journal   (Followers: 4)
Internationale Revue Fur Soziale Sicherheit     Hybrid Journal   (Followers: 1)
InterScientia     Open Access  
Investigaciones Andina     Open Access  
Iranian Journal of Health and Environment     Open Access  
Iranian Journal of Public Health     Open Access  
Israel Journal of Health Policy Research     Open Access  
İzmir Katip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi     Open Access  
JAMA Health Forum     Open Access  
JBI Evidence Implementation     Full-text available via subscription   (Followers: 4)
JBI Evidence Synthesis     Hybrid Journal   (Followers: 5)
Jeugd en Co     Hybrid Journal  
JGZ Tijdschrift voor jeugdgezondheidszorg     Hybrid Journal   (Followers: 2)
JMIR Human Factors     Open Access   (Followers: 4)
JMIR Public Health and Surveillance     Open Access  
JMIR Serious Games     Open Access   (Followers: 8)
Jornal Brasileiro de TeleSSaúde     Open Access  
Jornal de Ciências da Saúde do Hospital Universitário da Universidade Federal do Piauí     Open Access   (Followers: 3)
Journal Health NPEPS     Open Access  
Journal of Advances in Environmental Health Research     Open Access   (Followers: 2)
Journal Of Allied Health     Full-text available via subscription   (Followers: 7)
Journal of Behavior, Health & Social Issues     Open Access   (Followers: 8)
Journal of Behavioral Addictions     Open Access   (Followers: 5)
Journal of Behavioral Health Services & Research     Hybrid Journal   (Followers: 15)
Journal of Biology, Agriculture and Healthcare     Open Access   (Followers: 2)
Journal of Charoenkrung Pracharak Hospital     Open Access  
Journal of Child Sexual Abuse     Hybrid Journal   (Followers: 61)
Journal of Communication in Healthcare     Hybrid Journal   (Followers: 3)
Journal of Community Health     Hybrid Journal   (Followers: 9)
Journal of Community Medicine and Primary Health Care     Open Access   (Followers: 4)
Journal of Consumer Health on the Internet     Hybrid Journal   (Followers: 4)
Journal of Creativity in Mental Health     Hybrid Journal   (Followers: 13)
Journal of Developing Areas     Full-text available via subscription   (Followers: 5)
Journal of Development Effectiveness     Hybrid Journal   (Followers: 5)
Journal of Dr. NTR University of Health Sciences     Open Access  
Journal of Earth, Environment and Health Sciences     Open Access   (Followers: 2)
Journal of Eating Disorders     Open Access   (Followers: 14)
Journal of Education and Health Promotion     Open Access   (Followers: 4)
Journal of Environment Pollution and Human Health     Open Access   (Followers: 3)
Journal of Epidemiology & Community Health     Hybrid Journal   (Followers: 64)
Journal of Epidemiology and Public Health     Open Access   (Followers: 4)
Journal of Ergonomics     Open Access   (Followers: 8)
Journal of Evolution and Health : An Ancestral Health Society Publication     Open Access  
Journal of Exercise & Organ Cross Talk     Open Access   (Followers: 4)
Journal of Exercise Science & Fitness     Open Access   (Followers: 24)
Journal of Family & Consumer Sciences     Full-text available via subscription  
Journal of Family Medicine and Primary Care     Open Access   (Followers: 11)
Journal of Family Social Work     Hybrid Journal   (Followers: 12)
Journal of Family Strengths     Open Access   (Followers: 3)
Journal of Fasting and Health     Open Access   (Followers: 1)
Journal of Global Health     Open Access   (Followers: 2)
Journal of Health and Social Behavior     Hybrid Journal   (Followers: 27)
Journal of Health Care Chaplaincy     Hybrid Journal   (Followers: 3)
Journal of Health Design     Open Access   (Followers: 1)
Journal of Health Disparities Research and Practice     Open Access   (Followers: 2)
Journal of Health Economics and Outcomes Research     Open Access   (Followers: 2)
Journal of Health Policy and Management     Open Access   (Followers: 2)
Journal of Health Promotion     Open Access   (Followers: 1)
Journal of Health Psychology     Hybrid Journal   (Followers: 57)
Journal of Health Research     Open Access  
Journal of Health Research and Reviews     Open Access  
Journal of Health Science     Open Access   (Followers: 3)
Journal of Health Science and Alternative Medicine     Open Access   (Followers: 1)
Journal of Health Science and Community Public Health     Open Access  
Journal of Health Science and Medical Research     Open Access  
Journal of Health Science and Prevention     Open Access  
Journal of Health Science Research     Open Access  
Journal of health sciences     Open Access  
Journal of Health Sciences     Open Access  
Journal of Health Sciences and Medicine     Open Access  
Journal of Health Sciences and Surveillance System     Open Access  
Journal of Health Sciences Scholarship     Open Access  
Journal of Health Service Psychology     Full-text available via subscription   (Followers: 1)
Journal of Health Services and Education     Open Access  
Journal of Health, Population and Nutrition     Open Access   (Followers: 13)
Journal of Healthcare Informatics Research     Hybrid Journal   (Followers: 2)
Journal of Healthcare Risk Management     Hybrid Journal   (Followers: 10)
Journal of Human Health     Open Access   (Followers: 1)
Journal of Human Trafficking     Open Access   (Followers: 29)
Journal of Ideas in Health     Open Access   (Followers: 1)
Journal of Immigrant and Minority Health     Hybrid Journal   (Followers: 8)
Journal of Industrial Safety Engineering     Full-text available via subscription   (Followers: 6)
Journal of Infection and Public Health     Open Access   (Followers: 4)
Journal of Integrated Care     Hybrid Journal   (Followers: 18)
Journal of Integrated Health Sciences     Open Access   (Followers: 4)
Journal of Interprofessional Education & Practice     Full-text available via subscription   (Followers: 5)
Journal of Law and Health     Open Access   (Followers: 8)
Journal of Manmohan Memorial Institute of Health Sciences     Open Access  
Journal of Medical and Health Studies     Open Access   (Followers: 2)
Journal of Mental Health Counseling     Full-text available via subscription   (Followers: 8)
Journal of Multidisciplinary Healthcare     Open Access   (Followers: 6)
Journal of Multidisciplinary Research in Healthcare     Open Access   (Followers: 2)
Journal of Muslim Mental Health     Open Access   (Followers: 6)
Journal of Nanotheranostics     Open Access  
Journal of Nursing & Interprofessional Leadership in Quality & Safety     Open Access   (Followers: 5)
Journal of Occupational Health     Open Access   (Followers: 1)
Journal of Occupational Health Psychology     Full-text available via subscription   (Followers: 39)
Journal of Occupational Science     Hybrid Journal   (Followers: 27)
Journal of Oral Health and Craniofacial Science     Open Access  
Journal of Patan Academy of Health Sciences     Open Access  
Journal of Prevention and Health Promotion     Full-text available via subscription  
Journal of Preventive Medicine and Public Health     Open Access   (Followers: 1)
Journal of Primary Prevention     Hybrid Journal   (Followers: 7)
Journal of Psychosexual Health     Open Access  
Journal of Public Child Welfare     Hybrid Journal   (Followers: 8)

  First | 1 2 3 4     

Similar Journals
Journal Cover
International Journal of Health Policy and Management
Journal Prestige (SJR): 0.688
Citation Impact (citeScore): 1
Number of Followers: 11  

  This is an Open Access Journal Open Access journal
ISSN (Online) 2322-5939
Published by Kerman University of Medical Sciences Homepage  [5 journals]
  • From Implementation Towards Change Management: A Plea for a
           Multi-Stakeholder View on Innovation Implementation; Comment on “What
           Managers Find Important for Implementation of Innovations in the
           Healthcare Sector – Practice Through Six Management Perspectives”

    • Abstract: In their 2021 paper, Palm and Persson Fischier focus on the enabling factors that can facilitate innovation implementation, specifically the step of moving from idea generation to implementation in a healthcare context. The authors address the lack of concretization of theoretical perspectives related to the implementation of innovations and hence propose to work holistically with six management perspectives. Our commentary provides new interdisciplinary angles to the six perspectives, from management and organization literature to theory of change management. This provides future innovation managers with different viewpoints and inspires creative thinking and reflection. Our commentary also critiques the emphasis on the enablers and hence a constructionist-based approach to change management. We plea that a focus on the ‘good, bad, and ugly’—or rather all moods of change—is warranted in order to support holistic and successful change.
       
  • How to Evaluate Health-In-All-Policies at the Local Level: Methodological
           

    • Abstract: Background  This article proposes a method for analysing the degree of maturity of healthin-all-policies (HiAP) among WHO French Healthy Cities Network (WHO-FHCN) as part of the GREENH-City project. We focused on the creation or enhancement of health-promoting environments, and more specifically, public green spaces. Methods  We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al. mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a Multiple Correspondence Analysis (MCA) and a Hierarchical Ascending Correspondence (HAC).Results  32 criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of  maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies / actions of the sector studied, (2) occasional intersectoral collaboration, i.e. one-off initiatives between the health department and others sectors, (3) the existence of joint projects, i.e. common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.Conclusion  Four dimensionswhich allow to the measurement of the degree of progress in implementing health-all-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.
       
  • Measuring Organizational Culture in Ethiopia’s Primary Care System:
           Validation of a Practical Survey Tool for Managers

    • Abstract: Background  Organizational culture has been widely recognized as predictive of health system performance and improved outcomes across various healthcare settings. Research on organizational culture in healthcare has been largely conducted in high-income settings, and validated scales to measure this concept in primary healthcare systems in low-and middleincome country (LMIC) settings are lacking. Our study aimed to validate a tool to measure organizational culture in the context of the Ethiopian Primary Healthcare Transformation Initiative, a collaborative of the Federal Ministry of Health and the Yale Global Health Leadership Initiative to strengthen primary healthcare system performance in Ethiopia.Methods  Following established survey development and adaptation guidelines, we adapted a 31-item U.S.-based organizational culture scale using (1) cognitive interviewing, (2) testing with 1176 district and zonal health officials from four regions in Ethiopia, and (3) exploratory factor analysis.Results  Based on the results of cognitive interviewing, an adapted 30-item survey was piloted. The factor analyses of 1,034 complete surveys (88% complete responses) identified five constructs of the scale which demonstrated strong validity and internal consistency: learning and problem solving, psychological safety, resistance to change, time for improvement, and commitment to the organization. Of the 30 a priori items, 26 items loaded well on the five constructs (loading values 0.40- 0.86), and 4 items failed to load. Cronbach alpha coefficients were 0.86 for the scale as a whole and ranged from 0.65 to 0.90 for the  subscales. The five-factor solution accounted for 62% of total variance in culture scores across respondents.Conclusion  Through validation and factor analyses, we generated a 26-item scale for measuring organizational culture in public primary healthcare systems in low-and middleincome country settings. This validated tool can be useful for managers, implementers, policymakers, and researchers to assess and improve organizational culture in support of improved primary healthcare system performance.
       
  • Theorising Health System Resilience and the Role of Government
           Policy-Challenges and Future Directions; Comment on “Government Actions
           and Their Relation to Resilience in Healthcare During The COVID-19
           Pandemic in New South Wales, Australia and Ontario, Canada”

    • Abstract: Resilient healthcare emphasises the importance of adaptive capacity to respond to unanticipated crises such as the global Covid-19 pandemic but there are few examples of RHC research focusing on the decisions taken by macro level policy makers. The Smaggus et al paper analyses the actions of two governments in Canada and Australia as described in media releases from a resilience perspective. The paper clearly articulates the need for conceptual clarity when analysing system resilience, and integrates three theoretical perspectives to understand the types of government responses and how they were related to resilience. The paper makes a valuable contribution to the developing RHC evidence base, but challenges remain in identifying conceptual frameworks, researching macro level resilience, including identifying and accessing reliable macro level data sources, analysing interactions between macro, meso and micro system levels, and understanding how resilience manifests at different temporal and spatial scales.
       
  • Applying a Commercial Determinants of Health Lens to Understand, Expose
           and Counter Industry Co-Option, Appeasement and Partnership; Comment on
           ““Part of the Solution:” Food Corporation Strategies for Regulatory
           Capture and Legitimacy”

    • Abstract: Lacy-Nichols and Williams’ examination of the food industry illustrates how it altered its approach from mostly oppositional to regulation to one of appeasement and co-option. This reflection builds upon this by using a commercial determinants of health lens to understand, expose and counter industry co-option, appeasement and partnership strategies that impact public health. Lessons learned from tobacco reveal how tobacco companies maintained public credibility by recruiting scientists to produce industry biased data, co-opting public health groups, gaining access to policy elites and sitting on important government regulatory bodies. Potential counter solutions to food industry appeasement and co-option include i)understanding corporate actions of health harming industries, ii) applying mechanisms to minimize industry engagement, iii) dissecting industry relationship building, and iv) exposing the negative effects of public private partnerships. Such counter-solutions might help to neutralise harmful industry practices, products and policies which currently threaten to undermine healthy food policies.
       
  • Resisting the Effects of Neoliberalism on Public Policy; Comment on
           “Implementing Universal and Targeted Policies for Health Equity: Lessons
           From Australia”

    • Abstract: Fisher and colleagues carefully review the extent to which health equity goals of availability, affordability, and acceptability have been achieved in the areas of national broadband network policy and land-use policy, in addition to the more traditional areas of primary health care and Indigenous health in Australia. They consider the effectiveness of policies identified as either universal, proportionate-universal, targeted or residualist in these areas. In this commentary we suggest future areas of inquiry that can help inform the findings of their excellent study. These include the impacts of Australia being a liberal welfare state and how acceptance of neoliberal approaches to governance makes the achieving of health equity in these four policy areas difficult.
       
  • Exposure to COVID-19 Infection and Mortality Rates Among People With
           Disabilities in South Korea

    • Abstract: Background  With the delayed eradication of coronavirus disease 2019 (COVID-19), people with disabilities, a socially vulnerable class of individuals, face aggravated hardships caused by a pause in support services and lack of care due to stricter social distancing policies combined with the challenges of their disabilities. Given this background, we aim to investigate COVID-19 infection rates and mortality among people with disabilities, who face heightened physical and mental health threats amidst the COVID-19 pandemic.Methods  Gender, age, health insurance premiums, the Charlson Comorbidity Index, the severity of the disability, and the type of disability were compared among people with disabilities who had been infected with or died from COVID-19 using the nationally representative National Health Insurance Service (NHIS)-COVID database (DB).Results  We found that the COVID-19 infection rate was higher among those with low income, those with severe disability, and those with “other” disabilities (i.e., speech disabilities, hepatic dysfunction, respiratory dysfunction, facial disfigurement, intestinal fistular/urinary disability, epilepsy, intellectual disability, autistic disorder, and mental disorders). The mortality rate was markedly higher (i.e., 15.90 times higher, odds ratio [OR]: 15.90, 95%  confidence interval [CI]: 6.16 - 41.06) among people aged 80 years or older as compared with those aged 60 years or younger. The odds for mortality were 2.49 times higher (OR: 2.49, 95% CI: 1.33 - 4.64) among people with severe disabilities as compared with mild disabilities.Conclusions  Among people with disabilities, we found that COVID-19 infection rates differed according to income level, severity of the disability, and disability type, while the COVID-19 mortality rate differed according to age and severity of the disability.
       
  • Lessons for the Implement ability and Sustainability of the SURG-Africa
           Model of Malawi in Colombia; Comment on “Improving Access to Surgery
           Through Surgical Team Mentoring – Policy Lessons From Group Model
           Building With Local Stakeholders in Malawi”

    • Abstract: The development of models that allow improving the quality to achieve person-centered care is a challenge for any health system, especially in low- and middle-income countries, due to the economic difficulties inherent to the countries and to the cost involved in its implementation, which should be assumed by the states, avoiding that the economic burden is assumed by the population, and approaching the goal of universal health coverage. The availability of human talent and efficiency in the use of basic and specialized human talent is a necessity to improve safe access to health services, in this sense, the model proposed by SURG-Africa and whose sustainability in Malawi was evaluated, is an important reference for the establishment and sustainability of these models with other specialties and in other countries. Through this article, the elements of education, care model and financing for the implementation of the strategy in Family Medicine in the Colombian Health System are explored.
       
  • Health Financing Reforms in Uganda: Dispelling the Fears and
           Misconceptions Related to Introduction of a National Health Insurance
           Scheme; Comment on “Health Coverage and Financial Protection in Uganda:
           A Political Economy Perspective”

    • Abstract: Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a national health insurance scheme. This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda’s experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up national health insurance schemes.
       
  • Impact of Regulatory Changes on Innovations in the Medical Device
           Industry; Comment on “Clinical Decision Support and New Regulatory
           Frameworks for Medical Devices: Are We Ready for It' - A Viewpoint
           Paper”

    • Abstract: Economic regulation is an instrument of the state or other institutions to correct market failures, rectify the business environment, or protect consumers. Regulation can be a major driver of innovation, and it has proven to be so in the past. On the other hand, there are also documented cases of ineffective regulation due to information delays or shortcomings in government decision-making. The complexity of the impact of regulatory changes on innovation can currently be observed in the medical device market in Europe. Regulation (EU) 2017/745 whose main idea is to ensure greater safety and health protection for consumers, is a challenge for originator, manufacturer, mostly small and medium-sized enterprises. The regulation is associated with an increase in the cost of developing and maintaining the product on the market. We can now gradually begin to analyze whether it can be ranked among those that have become drivers of innovation.
       
  • Development of Alcohol Control Policy in Vietnam: Transnational Corporate
           Interests at the Policy Table, Global Public Health Largely Absent

    • Abstract: Background  This paper analyses input from global interests in the policy process leading up to the passing of alcohol control legislation in Vietnam in 2019. The global alcohol industry now relies on growth in volume in emerging markets in middle-income countries such as Vietnam, a large, rapidly industrialising country with a youthful population and emerging middle class. The industry’s role in the alcohol policy process is compared with that of global health interests.Methods  Document analysis of letters and English language media coverage was supplemented by and triangulated with data from key informants on changes in the content of draft alcohol legislation and participant observation.Results  The alcohol legislation was negotiated in the context of active engagement from the global alcohol industry and some input from global public health interests. The global alcohol industry established a partnership relationship with politicians using CSR and funded a local employee in Hanoi over the decade prior to the draft legislation being considered. Direct lobbying took place over the content of the legislation, which went through six published drafts. Trade and investment agreements provided a supportive environment and were referred to by both politicians and industry. In contrast public health resource was limited and lacked the support of a normative global policy to counter the economic imperatives. Vietnamese Ministry of Health proposals for cost effective alcohol policy were not enacted. Conclusions  Global commercial interests employed their considerable resources to engage in CSR and build partnerships with policymakers over a long period, contributing significantly to an environment unsupportive of enacting effective alcohol control policy. The absence of structural support from a global health treaty on alcohol and lack of an equivalent level of  long-term sustained input from global health actors contributed to the legislative outcome, which excluded proposed cost-effective policies to reduce alcohol harm.
       
  • The Feedback Loop between the Demand for Voluntary Private Insurance and
           the Burden of Healthcare System: An Explanatory System Dynamics Model of
           Hong Kong

    • Abstract: Background  Many countries with universal healthcare have a parallel private healthcare sector due to the waiting time in the public sector. People purchase individual health insurance to pay for private services. Past studies on the relationship between the public sector’s waiting time and the demand for health insurance have two limitations: not considering the capacity of the private sector, and subsequently, the omission of a feedback loop. These limitations are also present in the health insurance policy discussion in Hong Kong, where the public sector is overstretched. A lack of understanding of market dynamics might lead to unrealistic expectations of public policy. This study highlights these limitations, and tries to answer the research question: whether the historical dynamics between the intersectoral imbalance of burden and the demand for health insurance in Hong Kong could be quantitatively explained.Methods  A system dynamics model was created based on a negative feedback loop. The model’s initial input was the percentage of population with health insurance in 2009, and to simulate the percentage continuously until 2019. Results from 2015 to 2019 were compared with actual figures to examine the model’s explanatory power. Multivariable sensitivity analysis was performed.Results  With initial fluctuation, the simulated result stabilized and was within the acceptable error range from 2015 to 2019. The mean absolute percentage error was 0.94%. At the end  of 2019, the simulated percentage of population with health insurance is 36.6% versus the “real value” of 36.7%. Simulated patient admissions and occupancy rates also approximate the reality. Sensitivity analysis demonstrates the robustness of the model.Conclusion  We can quantitatively explain the feedback loop between health system burden and demand for health insurance. With local parameterization, this model should be transferable to other universal health systems for a better understanding of the system dynamics and more informed policymaking.
       
  • Ensuring Global Health Equity in a Post-Pandemic Economy

    • Abstract: With COVID-19 receding, many countries are pondering what a post-pandemic economy should look like. Some advocate a more inclusive stakeholder model of capitalism. Others caution that this would be insufficient to deal with our pre-pandemic crises of income inequality and climate change. Many countries emphasize a 'green recovery' with improved funding for health and social protection. Progressive tax reform and fiscal policy innovations are needed, but there is concern that the world is already tilting towards a new round of austerity. Fundamentally, the capitalist growth economy rests on levels of material consumption that are unsustainable and inequitable. More radical proposals thus urge 'degrowth' policies to reduce consumption levels while redistributing wealth and income to allow the poorer half of humanity to achieve an ethical life expectancy. We have the policy tools to do so. We need an activist public health movement to ensure there is sufficient political will to adopt them.
       
  • Responding to Food Industry Initiatives to be “Part of the Solution”;
           Comment on ““Part of the Solution:” Food Corporation Strategies for
           Regulatory Capture and Legitimacy”

    • Abstract: In response to growing concerns about chronic diseases, food insecurity, low-wage food labor, and global warming, the food industry has developed new strategies to respond to its critics and pursue its business and political goals. As Lacy-Nicholas and Williams described in a recent review, the food industry has expanded its repertoire from opposition to critics to appeasement, co-option, and partnerships.(1) Defining themselves as “part of the solution”, the food industry seeks to disarm its opponents, shift policy debates to favor its interests, or delay decisions that jeopardize its profits or power. This commentary explores how health professionals, can respond to this changing repertoire. Lessons from previous campaigns to control harmful industry practices,(2) suggest that no single strategy will counter changing food industry efforts to achieve its goals. Thus, advocates must consider a portfolio of approaches that can be deployed in response to changing circumstances, industry tactics, and threats to health.
       
  • Strategic Encounters in Innovation and Regulation: Healthcare
           transformation in the Era of Digital Connectivity; Comment on “What
           Managers Find Important for Implementation of Innovations in the
           Healthcare Sector – Practice Through Six Management Perspectives”

    • Abstract: Healthcare innovations emerge and develop in institutionally dense selective environments. New projects and propositions in healthcare sectoral ecosystems can be understood as product-service compacts, that is, complex solutions that dynamically integrate tangible and intangible elements in close interaction with users’ needs and the evolving regulatory context under uncertainty and ambiguity. We advance the concept of “strategic encounters” to encapsulate, capitalise and extend the contribution by Palm and Fischier’s (2021) on the key enabling managerial factors for healthcare innovation implementation under conditions of imperfect foresight. We intertwine creative assemblages that shape the formation of knowledge-intensive activities at the operators’ level with scope of sectoral level interventions to underscore how the opportunities and constraints can enhance innovation for the common good. We use the case of digital data health regulatory agendas as illustration. We argue that this broader perspective on healthcare transformation is theoretically pertinent and practically useful, for management and policy.
       
  • How to Achieve Universal Health Coverage: A Case Study of Uganda Using the
           Political Process Model; Comment on “Health Coverage and Financial
           Protection in Uganda: A Political Economy Perspective”

    • Abstract: How can resource-deprived countries accelerate progress towards Universal Health Coverage' Here we extend the analysis of Nanini and colleagues to investigate a case-study of Uganda, where despite high-level commitments, health system priority and funding has shrunk over the past two decades. We draw on the Stuckler-McKee adapted Political Process model to evaluate three forces for effecting change: reframing the debate; acting on political windows of opportunity; and mobilising resources. Our analysis proposes a series of pragmatic steps from academics, NGOs, and government officials that can help neutralise the forces that oppose UHC and overcome fragmentation of the pro-UHC movement.
       
  • What Can We Learn From Others to Develop a Regional Centre for Infectious
           Diseases in ASEAN'; Comment on “Operationalising Regional
           Cooperation for Infectious Disease Control: A Scoping Review of Regional
           Disease Control Bodies and Networks”

    • Abstract: The COVID-19 pandemic has brought the need for regional collaboration on disease prevention and control to the fore. The review by Durrance-Bagale et al. offers insights on the enablers, barriers and lessons learned from the experience of various regional initiatives. Translating these lessons into action, however, remains a challenge. The Association of Southeast Asian Nations (ASEAN) planned to establish a regional centre for disease control; however, many factors have slowed the realisation of these efforts. Going forward, regional initiatives should be able to address the complexity of emerging infectious diseases through a One Health approach, assess the social and economic impact of diseases on the region and study the real-world effectiveness of regional collaborations. The initiatives should seek to be inclusive of stakeholders including those from the private sector and should identify innovative  measures for financing. This advancement will enable regions such as ASEAN to effectively prepare for the next pandemic.
       
  • Resilience of Health Systems: Understanding Uncertainty Uses, Intersecting
           Crises and Cross-Level Interactions; Comment on “Government Actions and
           Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in
           New South Wales, Australia and Ontario, Canada”

    • Abstract: The COVID-19 pandemic has created opportunities to study resilience in multiple, interrelated societal systems while considering the institutional, community and individual level. We aim to discuss critical, yet underrepresented, issues in resilience discourses which are fundamental to advance theories, concepts and measurement of health system resilience. These relate to a better understanding of i) how government’s handle and use uncertainties to facilitate or impede change, including the role of negotiation and conflicts, ii) the intersections of health with multiple, cooccurring crises (systemic intersections), and iii) cross-level interactions, i.e. the interrelation between individual-level resilience, the collective resilience of groups and communities, and the resilience of a system as a whole (and vice versa). Analyses of these aspects can help to “contextualize” our understanding of resilience in complex adaptive systems. However, conceptual clarity is needed whether resilience is considered an underlying feature, outcome, or intermediate determinant of a (health) system’s performance.
       
  • Situating Food Industry Influence: Governance Norms and Economic Order;
           Comment on "Part of the Solution: Food Corporation Strategies for
           Regulatory Capture and Legitimacy"

    • Abstract: Lacy-Nichols and Williams provide important new insights into the ongoing contest over policy space and consumer behavior. I attempt to situate these insights in relation to government mandates and governance norms and situate these norms and mandates in the prevailing economic order. This approach is necessary to understand how corporate practices persist and why governments are receptive to the approaches outlined in the analysis conducted by Lacy-Nichols and Williams. This approach can help explain why governments are often receptive to corporations positioning themselves as ‘part of the solution’. Governments want strong economies and big food positions itself as contributor to this end. The point I attempt to articulate is that we often conceive of corporate power as power over, while I suggest that corporate power is rather power within and through a system that is oriented towards profits and economic growth.
       
  • What Might Be Required for Inspections to Be Considered Fair'; Comment
           on “What Lies Behind Successful Regulation' A Qualitative Evaluation
           of Pilot Implementation of Kenya’s Health Facility Inspection Reforms”
           

    • Abstract: Tama et al. offer us an interesting analysis of a piloted regulatory reform that introduced a Joint Health Inspections system in three Kenyan counties. The study highlights key factors facilitating or hindering the implementation of the reform. In this commentary we reflect on the concept of fairness, which is one of the topics that is discussed in the study. We describe four important dimensions of fairness in the context of inspections: expectation clarity, consistency of assessment, consistency of enforcement, and fairness to patients. We argue that all four dimensions are important in the regulatory design, in order for the inspection to be perceived as fair.
       
  • Policy by Pilot' Learning from Demonstration Projects for Integrated
           Care; Comment on “Integration or Fragmentation of Health Care'
           Examining Policies and Politics in a Belgian Case Study”

    • Abstract: Analysis of policy implementation for chronic disease in Belgium highlights the difficulties of launching experiments for integrated care in a health system with fragmented governance. It also entreats us to consider the inherent challenges of piloting integrated care for chronic disease. Sociomedical characteristics of chronic disease –political, social, and economic aspects of improving outcomes – pose distinct problems for pilot projects, particularly because addressing health inequity requires collaboration across health and social sectors and a long-term, life-course perspective on health. Drawing on recent US experience with demonstration projects for health service delivery reform and on chronic disease research, I discuss constraints of and lessons from pilot projects. The policy learning from pilots lies beyond their technical evaluative yield. Pilot projects can evince political and social challenges to achieving integrated chronic disease care, and can illuminate overlooked perspectives, such as those of community-based organizations, thereby potentially extending the terms of policy debate.
       
  • Quality and Performance Measurement in Primary Diabetes Care: A
           Qualitative Study in Urban China

    • Abstract: Background  Quality measurements in primary healthcare have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy makers. We examined stakeholders’ perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation.Methods  In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis.Results  Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors’ work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct “organizational incentives” suggested that current pay-for-performance incentives function as a “double-edged sword”, increasing family doctors’ motivation to excel while creating pressures to “game the system” among some physicians. When considering the CFIR construct “reflecting and evaluating”, policy makers perceived the online evaluation  application – which provides daily reports on family doctors’ work – to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the “network and communication” construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs.Conclusion  The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital–community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving primary healthcare.
       
  • Emergency Department Visits Before, After and During Integrated Home Care:
           A Time Series Analyses in Italy

    • Abstract: Background  Integrated home care (IHC) is one strategy to provide care to people with multiple chronic conditions, and it contributes to the reduction of unnecessary emergency department (ED) use, but there are conflicting results on its effectiveness. In this study, we assessed the frequency and characteristics of ED visits occurring before, during, and after IHC in a large cohort of IHC patients enrolled over 6 years.Methods  The analysis included 39,822 IHC patients identified in Italian administrative databases. Patients were grouped in tertiles according to IHC duration (short, intermediate, and long) and the number of ED visits during IHC was compared to that the 12 months before IHC enrolment and in the 12 months after IHC discharge across IHC duration groups.Results  We observed a reduction in ED visits during IHC. IHC was significantly associated with a reduction in ED visits in the long and short IHC duration groups. A non-significant reduction in ED visits was observed in the intermediate IHC duration group. A 90% reduction in ED visits during IHC and a 45% reduction after IHC was observed in the short IHC duration group. Corresponding reductions were 17% and 64% during and after IHC, respectively, in the long IHC duration group.Conclusion  IHC was effective in reducing ED visits, but expansion of IHC to include additional necessary services could further reduce ED visits. Investment in the creation of a structured, effective network of engaged professionals (including community care services and hospitals) is crucial to achieving this.
       
  • Navigating Dichotomies and Dilemmas; Comment on “Dual Agency in
           Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile
           Dilemmas Between Clinical and Economic

    • Abstract: The complexity within health care typically surfaces in tensions between organizational efficiency and professional values when hospital managers and professionals face dilemmas between economic and clinical considerations. Waitzberg, Gottlieb, Quentin, Busse and Greenberg (2021), based on interviews with managers and physicians working in Israeli and German hospitals, explore strategies to cope with such dilemmas to safeguard both financial sustainability and patient quality. This short commentary provides some follow-up questions in two ways. First, I highlight the importance of nuancing and hybridizing the dichotomies that lead to dilemmas in the hospital context. Second, I discuss how such dilemmas can be highlighted in systematic group reflection which in turn can inform decision-making.
       
  • Beyond ‘Lack of Political Will’: Elaborating Political Economy
           Concepts to Advance ‘Thinking and Working Politically’; Comment on
           “Health Coverage and Financial Protection in Uganda: A Political Economy
           Perspective”

    • Abstract: Political economy analysis (PEA) has been advanced as critical to understanding the political dimensions of policy change processes. However, PE is not a theory on its own but draws on several concepts. Nannini et al., in concert with other scholars, emphasise that politics is characterised by conflict, contestation and negotiation over interests, ideas and power as various agents attempt to influence their context. This commentary reflects how Nannini et al. wrestled with these PEA concepts- summarised in their conceptual framework used for PEA of the Ugandan case study on financial risk protection reforms. The central premise is that a common understanding of the PEA concepts (mainly structure-agency interactions, ideas, interests, institutions and power) forms a basis for strategies to advance thinking and working politically. Consequently, I generate several insights into how we can promote politically informed approaches to designing, implementing and evaluating policy reforms and development efforts.
       
  • Corporations and Health: The Need to Combine Forces to Improve Population
           Health

    • Abstract: The recent concerns raised about commercial determinants of health are not new. Numerous organizations around the world are working on these issues. These groups have emerged in response to specific issues and contexts and bring with them a diversity of interests, worldviews and strategies for change. In creating the ‘Governance, Ethics and Conflicts of Interest in Public Health’ network in 2018, our hope was to broaden our engagement with other actors advocating for change and strengthen our collective efforts. For academics, this requires moving further beyond the collective comfort zone of peerreviewed publications, working with the media and those with political expertise, and learning from and supporting other stakeholders with a common vision.
       
  • Nurses’ and Physicians’ Responses to a New Active Antimicrobial
           Stewardship Program: A Two-Phase Study of Responses and Their Underlying
           Perceptions and Values

    • Abstract: Background  Successful implementation of an antimicrobial stewardship program (ASP) depends on staff members’ response to it. We introduced at the Hadassah Medical Center in Israel a significant change to our long-standing handshake ASP. As before, the new ASP involved a dialogue between the treating physician and the infectious disease physician over the appropriate antibiotic therapy. The main change was that the infectious disease physician’s decision was now integrated into the patient’s electronic medical record. Our purpose in this study was to uncover the concerns and expectations of physicians and nurses towards the new ASP, before and after its implementation, and link these with their basic perceptions of the ASP and their personal values.Methods  We used open-ended questions and Likert-type scales to study staff members’ personal values, basic perceptions of the new system, and attitudes towards it, both before (N=143), and one year after (N=103) the system’s implementation. Relationships of the system’s perceptions and personal values with attitudes toward the system were tested using correlations and multiple regression analyses.Results  Prior to its implementation, physicians and nurses had multiple concerns about the new ASP’s demandingness and inefficiency and its threat to physicians' autonomy and expertise. They also had positive expectations for benefits to the hospital, the patients and society. A year later, following the system’s implementation, concerns dissipated, whereas the perceived benefits remained. Moreover, staff members’ attitudes tended to be more positive among those who value conformity.  Conclusion  Introducing new ASPs is a challenging process. Our findings suggest that hospital staff’s initial concerns about the new ASP were primarily about its ease of use and demandingness. These concerns, which diminished over time, were linked with perceived satisfaction with the system. Conformity values had an indirect effect in predicting satisfaction with the system, mediated by perceptions of the system as straightforward.
       
  • Cost-Utility Analysis of Community Case Management for Malaria Control in
           Burundi

    • Abstract: Background  The community case management (CCM) program for malaria control is a community-based strategy implemented to regulate malaria in children in Burundi. This study compared the cost and utility of implementing the CCM program combined with health facility management (HFM) versus HFM alone for malaria control in children under five in Burundi.Methods  This study constructed a five-year Markov model with one-week cycles to estimate cost-utility and budget impact analysis. The model defined 10 health states, simulating the progression of the disease and the risk of recurrent malaria in children under five years of age. Cost data were empirically collected and presented for 2019. Incremental cost per disability-adjusted life-year (DALY) averted, and a five-year budget was estimated. One-way and probabilistic sensitivity analyses were then performed.Results  From provider and societal perspectives, combining the CCM program with HFM for malaria control in Burundi was more cost-effective than implementing HFM alone. The addition of CCM, using Artesunate Amodiaquine (ASAQ) as the first-line treatment, increased by 1.70 USD, and 1.67 USD per DALY averted from the provider and societal perspectives, respectively. Using Artemether Lumefantrine (AL) as the first-line treatment, adding the CCM program to HFM increased by 1.92 USD, and 1.87 USD per DALY averted from the provider and societal perspectives. At a willingness-to-pay of one GDP/capita, the CCM program remained a 100% chance of being cost-effective. In addition, implementing the program for five years requires a budget of 15,800,486–19,765,117 USD.Conclusions  Implementing the CCM program and HFM is value for money for malaria control in Burundi. The findings can support decision-makers in Burundi in deciding on resource allocation, especially during the program’s scale up.
       
  • “We’re Not Providing the Best Care If We Are Not on the Cutting Edge
           of Research”: A Research Impact Evaluation at a Regional Australian
           Hospital and Health Service

    • Abstract: Background  Research is central to high functioning health services alongside clinical care and health professional training. The impact of embedded research includes delivery of highquality care and improved patient outcomes. Evaluations of research impact help health service leadership ensure investments lead to the greatest healthcare benefits for patients. This study aimed to retrospectively evaluate the impact of research investment from 2008 to 2018 at Townsville Hospital and Health Service (THHS), a regional Hospital and Health Service in Queensland, Australia. The evaluation also sought to identify contextual conditions that enable or hinder intended impacts.Methods  A mixed-methods realist-informed evaluation was conducted using documentation, interviews with 15 staff and available databases to identify and measure research investments, impacts and contextual conditions influencing impact outcomes.Results  Between 2008 and 2018, THHS increased resources for research by funding research projects, employing research personnel, building research-enabling facilities, hosting research events, and providing research education and training. Clinical practice, policy and workforce impacts were successful in isolated pockets, championed by individual researchers and facilitated by their policy and community-of-practice networks. However, there was little organisational-level support for continuity of research and implementation into practice and policy. Availability of research supports varied geographically across THHS, and across disciplines.Conclusion  Definitive steps in the development of THHS as a credible and productive research centre and leading hospital research centre in Northern Australia are evident. Continuing investments should address support for the research continuum through to translation and establish ongoing, systematic processes for evaluating research investment and impact.
       
  • Impact of the Timing of Integrated Home Palliative Care Enrolment on
           Emergency Department Visits

    • Abstract: Background  The association between timing of integrated home palliative care (IHPC) enrolment and emergency department (ED) visits is still under debate, and no studies investigated the effect of the timing of IPHC enrolment on ED visits, according to their level of emergency. This study aimed to investigate the impact of the timing of IHPC enrolment on different acuity ED visits.Methods  A retrospective, pre-/post-intervention study was conducted from 2013 to 2019 in Italy. Analyses were stratified by IHPC duration (short ≤30 days; medium 31-90 days; long >90 days) and triage tags (white/green: low level of emergency visit; yellow/red: mediumto-high level). The impact of the timing of IHPC enrolment was evaluated in two ways: incidence rate ratios (IRR) of ED visits were determined 1) before and after IHPC enrolment in each group and 2) post-IHPC among groups.Results  A cohort of 17983 patients was analysed. Patients enrolled early in the IHPC programme had a significantly lower incidence rate of ED visits than the pre-enrolment period (IRR=0.65). The incidence rates of white/green and yellow/red ED visits were significantly lower post-IHPC enrolment for patients enrolled early (IRR= 0.63 and 0.67, respectively). All results were statistically significant (p<0.001). Comparing the IHPC groups after enrolment versus the short group, medium and long IHPC groups had a significant reduction of ED visits (IRR=0.37, IRR=0.14 respectively), showing a relation between the timing of IHPC enrolment and the incidence of ED visits. A similar trend was observed after accounting for triage tags of ED visits.   Conclusion  The timing of IHPC enrolment is related with a variation of the incidence of ED visits. Early IHPC enrolment is related to a high significant reduction of ED visits when compared to the 90-day pre-IHPC enrolment period and to late IHPC enrolment, accounting for both low-level and medium-to-high level emergency ED visits.
       
  • Why People Forgo Healthcare in France: A National Survey of 164,092
           Individuals to Inform Healthcare Policy-makers

    • Abstract: Background  Even in countries having nearly universal healthcare provision some individuals forgo or postpone healthcare to which they are entitled. Socioeconomic and geographic inequalities can make access to healthcare difficult for some people, such that they fail to seek it, particularly if they deem the type of care as non-essential. The need to pay at the point of care, the complexity and cost of top-up health insurance, and delays or only partial reimbursement can discourage take-up of care. This can affect the general health of the population.Methods  To estimate the rate of forgoing healthcare in the general French population, between 2015 and 2018 we conducted a nationwide cross-sectional survey of individuals visiting French primary healthcare insurance agencies (CPAM). We asked whether the person had foregone or postponed healthcare in the last 12 months, if so the types of healthcare forgone or put-off, and reasons. Individuals were stratified by the type of complementary (top-up) health insurance they had.Results  Out of 164,092 individuals who responded, 158,032 were included in the analysis. Respondents had either private complementary (top-up) insurance (60%), top-up insurance subsidized by the state (29%), or no top-up health insurance (11%). Forgoers (n=40,115; 25.4%) most often lived alone (with or without children), were unemployed, and/or female. Dental care (54%) and consultations with ophthalmologists, gynaecologists and dermatologists (41%) were most commonly forgone. The reasons were: inability to advance payment and/or to pay the uninsured part (69%), time constraints and difficulty in obtaining appointments (26%).Conclusions  We present a snapshot of forgoing healthcare in a developed country, highlighting the need for continuing review by policymakers of payment regimens, insurance cover, availability and accessibility. While initiatives have already emerged from the results, further reforms are needed to address the problem of people forgoing preventative or perceived non-urgent healthcare, particularly for disadvantaged subgroups.
       
  • Rhetoric, Reality and Racism: The Governance of Aboriginal and Torres
           Strait Islander Health Workers in a State Government Health Service in
           Australia

    • Abstract: Background  In northern Australia, Aboriginal and/or Torres Strait Islander Health Workers (A&TSIHWs) are unique members of nominally integrated teams of primary care professionals. Spurred by research documenting ongoing structural violence experienced by Indigenous health providers and more recent challenges to recruitment and retention of A&TSIHWs, this study aimed to explore whether the governance of the A&TSIHW role supports full and meaningful participation.Methods  The qualitative study was co-designed by a team of Aboriginal, Torres Strait Islander and non-Indigenous collaborators. Data collection comprised document review and interviews with A&TSIHWs (n=51), clinicians (n=19) community members (n=8) and administrators (n=5) in a north Queensland health district. We analysed governance at  multiple levels (regulatory, organisational, and socio-cultural) and used critical race theory to deepen exploration of the role of race and racism in shaping it.Results  Governance of the A&TSIHW role occurs within a health system where racism is built into, and amplified by, formal and informal rules at all levels. Racially discriminatory structures such as the previous but long-standing relegation of A&TSIHW into the same career stream as cleaners were mirrored in discriminatory rules and managerial practices such as an absence of career-specific corporate support and limited opportunities to participate in, or represent to, key leadership groups. These interacted with and helped perpetuate workplace norms permissive of disrespect and abuse by non-Indigenous professionals. Ongoing resistance to the structural violence required of, and demonstrated by A&TSIHWs speaks to the gap between rhetoric and reality of governance for A&TSIHWs with race and racism at its core.Conclusion  Strengthening governance to support A&TSIHWs requires critical attention be given to the role of race and racism in regulatory structures, organisational practice, and inter-professional relationships. Addressing all domains will be essential to achieve systemic change that recognises, supports and embeds the unique knowledge, skills and functions of the A&TSIHW role.
       
  • Between Rhetoric and Reality: Learnings From Youth Participation in the
           Adolescent and Youth Health Policy in South Africa

    • Abstract: Background  Youth participation makes an essential contribution to the design of policies and with the appropriate structures, and processes, meaningful engagement leads to healthier, more just, and equal societies. There is a substantial gap between rhetoric and reality in terms of youth participation and there is scant research about this gap, both globally and in South Africa. In this paper we examine youth participation in the Adolescent and Youth Health Policy (AYHP) formulation process to further understand how youth can be included in health policy-making.Methods  A conceptual framework adapted from the literature encompassing Place, Purpose, People, Process and Partnerships guided the case study analysis of the AYHP. Qualitative data was collected via 30 in-depth, semi-structured interviews of policy actors from 2019-2021.Results  Youth participation in the AYHP was a ‘first’ and unique component for health policy in South Africa. It took place in a fragmented policy landscape with multiple actors, where past and present social and structural determinants, as well as contemporary bureaucratic and donor politics, still shape both the health and participation of young people. Youth participation was enabled by leadership from certain government actors and involvement of key academics with a foundation in long standing youth research participatory programs. However, challenges related to when, how and which youth were involved remained. Youth participation was not consistent throughout the health policy formulation process. This is related to broader contextual challenges including the lack of a representative and active  youth citizenry, siloed health programs and policy processes, segmented donor priorities, and the lack of institutional capability for multi-sectoral engagement required for youth health.Conclusion  Youth participation in the AYHP was a step toward including youth in the development of health policy but more needs to be done to bridge the gap between rhetoric and reality.
       
  • How Denmark, England, Estonia, France, Germany, and the USA Pay for
           Variable, Specialized and Low Volume Care: A Cross-Country Comparison of
           In-Patient Payment Systems

    • Abstract: Background  Diagnosis-related Group (DRG-) based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, USA [Medicare]).Methods  Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. Results  Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the USA. Certain areas of care are almost always excluded (e.g. certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers.Conclusion  Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.
       
  • Successful Outcomes for Whom and for What'; Comment on “Government
           Actions and Their Relation to Resilience in Healthcare During the COVID-19
           Pandemic in New South Wales, Australia and Ontario, Canada”

    • Abstract: The COVID-19 pandemic is the case of a complex global crisis that requires resilient performance across all levels of healthcare systems worldwide. The analysis of government actions during the COVID-19 pandemic in Australia and Canada by Smaggus et al1 raises the possibility for a much needed and essential debate on the notion of outcomes in the resilience in healthcare literature. Government actions have downstream effects on stakeholders’ capacity for resilience throughout the healthcare system. Yet, outcomes are fluent, multifaceted and dependant on time, space, and stakeholder perspectives. It is appropriate and timely for the resilience in healthcare field to better grasp the nuances of successful outcomes in complex adaptive systems.
       
  • Mobilising Knowledge in (and About) Academic Health Science Centres:
           Boundary Spanning, Inter-Organisational Governance and Systems Thinking

    •  
  • Exploring Factors Associated With the Work Hours of Attending Physicians
           Working in Hospitals

    • Abstract: Background Long work hours for physicians not only harm the health of physicians, but also endanger patient safety. Compared with resident physicians, attending physicians—especially hospital-employed attending physicians—assume more responsibilities but has not gotten enough attention. The purpose of this study was to explore whether a hospital’s geographic location and emergency care responsibility might influence the number of hours worked.MethodsThe respondents of 2,365 attending physicians from 152 hospitals in the 2018 survey of Taiwan physician work hours were used as the data source. The total work hour per week and its components, the regular scheduled shift and three types of on-call shifts, were used as outcome variables. Hospital geographic location and emergency care responsibility were the independent variables. The multilevel random effect model was employed to examine the study objective after adjusting for clinical specialty, hospital teaching status, and ownership.Results The average number of total working hours was 69.09 hours per week; the regular scheduled shift was account for 75% of total work hours. The results showed the total work hours were only varied by the level of hospital’s emergency care responsibility. However, the results also demonstrated the hours of duty shifts were varied by hospital’s geographic location and emergency care responsibility. The results of the multilevel random effect model revealed that the hospital’s emergency care responsibility was the factor consistently associated with attending physician’s work hour, no matter the total work hours or its composition.ConclusionIn this study, we explored how a hospital’s location and its level of emergency care responsibility were associated with physicians’ work hours for each type of shift. Our findings offer an opportunity to review the rationality of physician workforce allocation, and financial incentives and administrative measures could be the next steps for balancing the work hours of attending physicians.
       
  • The Special Measures for Quality and Challenged Provider Regimes in the
           English NHS: A Rapid Evaluation of a National Improvement Initiative for
           Failing Healthcare Organisations

    • Abstract: Background There is limited knowledge about interventions used for the improvement of low-performing healthcare organisations and their unintended consequences. Our evaluation sought to understand how healthcare organisations in the National Health Service (NHS) in England responded to a national improvement initiative (the Special Measures for Quality (SMQ) and Challenged Provider (CP) regimes) and its perceived impact on achieving quality improvements (QI). Methods Our evaluation included national-level interviews with key stakeholders involved in the delivery of SMQ (n=6);documentary analysis (n=20); and a qualitative study based on interviews (n=60), observations (n=8) and documentary analysis (n=291) in eight NHS case study sites. The analysis was informed by literature on failure, turnaround and QI in organisations in the public sector. Results At the policy level, SMQ/CP regimes were intended to be “support” programmes, but perceptions of the interventions at hospital level were mixed. The SMQ/CP regimes tended to consider failure at an organisational level and turnaround was visualised as a linear process. There was a negative emotional impact reported by staff, especially in the short-term. Key drivers of change included: engaged senior leadership teams, strong clinical input and supportive external partnerships within local health systems. Trusts focused efforts to improve across multiple domains with particular investment in improving overall staff engagement, developing an open, listening organisational culture and better governance to ensure clinical safety and reporting. Conclusions Organisational improvement in health care requires substantial time to embed and requires investment in staff to drive change and cultivate QI capabilities at different tiers. The time this takes may be underestimated by external ‘turn-around’ interventions and performance regimes designed to improve quality in the short-term and which come at an emotional cost for staff. Shifting an improvement focus to the health system or regional level may promote sustainable improvement across multiple organisations over the long-term.
       
  • An Urgent Need for a Common Framework for the Articulation, Design and
           Reporting of Surgical System Strengthening Interventions; Comment on
           “Improving Access to Surgery Through Surgical Team Mentoring – Policy
           Lessons From Group Model Building With Local Stakeholders in Malawi”

    • Abstract: Nearly sixty percent of the world’s inhabitants lack access to timely, safe, and affordable emergency and essential surgical, anesthetic, and obstetric (SAO) services when needed. Although acknowledged as an important step in resolving this disparity, situation analysis informed development of national surgical, obstetric and anesthesia plans (NSOAPs) has not been performed widely. There are even fewer published examples of NSOAP driven SAO system vulnerability resolving policy interventions, potentially hindering broader acceptance and drafting. Thus, there is urgent need for alignment of academic global surgery activities through a common framework for SAO strengthening intervention articulation, design and reporting which can be informed by the Malawian experience and others. This is a logical next step in the evolution of surgical system science as we move towards the articulation of actionable inequity resolving interventions through stakeholder engagement embedded in a plan-do-study-act model for iterative refinement of strengthening policies.
       
  • The Social Media Industry as a Commercial Determinant of Health

    •  
  • Understanding Factors That Support Community Health Worker Motivation, Job
           Satisfaction, and Performance in Three Ugandan Districts: Opportunities
           for Strengthening Uganda’s Community Health Worker Program

    • Abstract: Background  Uganda’s community health worker (CHW) program experiences several challenges related to the appropriate motivation, job satisfaction, and performance of the CHW workforce. This study aims to identify barriers in the effective implementation of financial and non-financial incentives to support CHWs and to strengthen Uganda’s CHW program.Methods  The study was implemented in Uganda’s Lira, Wakiso, and Mayuge districts in May 2019. Ten focus group discussions (FGD) were held with 91 CHWs, 17 in-depth interviews (IDI) were held with CHW supervisors, and 7 IDIs were held with policy-level stakeholders. Participants included stakeholders from both the Ugandan government and non-governmental organizations. Utilizing a thematic approach, themes around motivation, job satisfaction, incentive preferences, and CHW relationships with the community, healthcare facilities, and government were analyzed.Results  CHWs identified a range of factors that contributed to their motivation or demotivation. Non-monetary factors included recognition from the health system and community, access to transportation, methods for identification as a healthcare worker, provision of working tools, and training opportunities. Monetary factors included access to monthly stipends, transportation-related refunds, and timely payment systems to reduce refund delays to CHWs. Additionally, CHWs indicated wanting to be considered for recruitment into the now-halted rollout of a salaried CHW cadre, given the provision of payment.Conclusion  It is imperative to consider how to best support the current CHW program prior to the introduction of new cadres, as it can serve to exacerbate tensions between cadres and further undermine provision of community health. Providing a harmonized, balanced, and uniform combination of both monetary incentives with non-monetary incentives is vital for effective CHW programs.
       
  • Integrating Nutrition Actions in Service Delivery: The Practices of
           Frontline Workers in Uganda

    • Abstract: Background  Integrating nutrition actions into service delivery in different policy sectors is an increasing concern. Nutrition literature recognizes the discrepancies existing between policies as adopted and actual service delivery. This study applies a street-level bureaucracy perspective to understand frontline workers’ practices that enact or impede nutrition integration in services and the conditions galvanizing them.Methods  This qualitative exploratory study assesses the contextual conditions and practices of 45 frontline workers employed by the agriculture, health and community development departments in two Ugandan districts.Results  Frontline workers incur different demands and resources arising at societal, organizational, and individual level. Hence, they adopt nine co-existing practices that ultimately shape nutrition service delivery. Nutrition integration is accomplished through: 1) ritualizing task performance; 2) bundling with established services; 3) scheduling services on a specific day; and 4) piggybacking on services in other domains. Disintegration results from 5) non-involvement and 6) shifting blame to other entities. Other practices display both integrative and disintegrative effects: 7) creaming off citizens; 8) down prioritization by fixating on a few nutrition actions; and 9) following the bureaucratic ‘jobs worth’. Integrative practices are driven mostly by donors.ConclusionUnderstanding frontline workers’ practices is crucial for identifying policy solutions to sustain nutrition improvements. Sustaining services beyond timebound projects necessitates institutionalizing demands and resources within government systems. Interventions to facilitate effective nutrition service delivery should strengthen the integrative capacities of actors across different government levels. This includes investing in integrative leadership, facilitating frontline workers across sectors to provide nutrition services, and adjusting the nutrition monitoring systems to capture cross-sector data and support policy learning.
       
  • Community Participation in Primary Health Care in the South Sudan Boma
           Health Initiative: A Document Analysis

    • Abstract: Background  Community participation is central to primary health care, yet there is little evidence of how this works in conflict settings. In 2016, South Sudan's Ministry of Health launched the Boma Health Initiative to improve primary care services through community participation.Methods  We conducted a document analysis to examine how well the Boma Health Initiative policy addressed community participation in its policy formulation. We reviewed other policy documents and published literature to provide background context and supplementary data. We used a deductive thematic analysis that followed Rifkin and colleagues' community participation framework to assess the Boma Health Initiative policy.Results  The Boma Health Initiative planners included inputs from communities without details on how the needs assessment was conducted at the community level, what needs were considered, and from which community. The intended role of communities was to implement the policy under local leadership. There was no information on how the Initiative might strengthen or expand local women's leadership. Official documents did not contemplate local power relations or address gender imbalance. The policy approached households as consumers of health services.Conclusions  Although the Boma Health Initiative advocated community participation to generate awareness, increase acceptability, access to services and ownership, the policy document did not include community participation during policy cycle.
       
  • Power Dynamics Among Health Professionals in Nigeria: A Case Study of the
           Global Fund Policy Process

    • Abstract: Background  Health workers are central to health policymaking. Given health systems’ complex, dynamic and political nature, various forms of ‘hidden power’ are at play as health workers navigate health systems. This study aims to explore the dynamics of power and its sources, and how this shapes policymaking and implementation within the Nigerian health systems context.Methods  The case study was the Global Fund grant in Nigeria, and results are based on an in-depth qualitative study involving 34 semi-structured key informant interviews, boardmeeting observations, and documentary analysis conducted in 2014 and 2016. Participants held mid to senior-level positions (e.g. Director, Programme Manager) within organisations involved with Global Fund activities, particularly proposal development and implementation. Data were analysed using thematic analysis in order to gain insight into the power dynamics of health professionals in policy processes.Results  Medical professionals maintained dominance and professional monopoly, thereby controlling policy spaces. The structural and productive power of the biomedical discourse in policy making encourages global actors and the local government’s preference for rapid biomedical models that focus on medications, test kits, and the supply of health services, while neglecting aspects that would help us better understand the poor uptake of these services by those in need. The voices of the repressed groups (e.g non-clinical experts, patients and community based organisations) that better understand barriers to uptake of services are relegated. Conclusion  Professional monopoly theories help illustrate how medical professionals occupy and maintain an elite position in the health system of Nigeria. Structural and agential factors specific to the contexts are key in maintaining this professional monopoly while limiting the opportunities for other health occupations’ rise up the social status ladder.
       
  • The Foundations of Corporate Strategies; Comment on “Part of the
           Solution:” Food Corporation Strategies for Regulatory Capture and
           Legitimacy

    • Abstract: The “Part of the Solution” article describes how the food industry has evolved its strategies to respond to critics and government regulation by co-option and appeasement to create a less hostile environment. Rather than focusing research on single industries it would be more efficient and productive to focus on corporate political activities (CPA) that directly influence democratic institutions and processes having authority over laws, policy, rules and regulations that govern industry. The most influential and direct CPA are election campaign donations, lobbying, and the reverse revolving door. In the U.S. those CPA flow from rights of corporations that underlie all industry strategies. The U.S. history of how corporations obtained their rights is described, and research about the affirmative effects of those three CPA is summarized. Health research is needed about those CPA and their effects on health law, policy and regulation in the U.S. and other nations.
       
  • Tools to Reduce Low-Value Care: Lessons From COVID-19 Pandemic; Comment on
           “Key Factors That Promote Low-Value Care: Views of Experts From the
           United States, Canada, and the Netherlands”

    • Abstract: Based on a summary of interviews with 18 experts, Verkerk et al. defined the seven key factors that promoted low-value care, which included system, social, and knowledge factors. During the ongoing COVID-19 pandemic, these key factors have been influential due to the uncertainty of the disease at the beginning of the pandemic. Globally, several measures have been implemented to reduce low-value care practices and promote high-value care for COVID-19 patients. From huge multicenter, non-industry sponsored or multiplatform trials, to the use of social networks sites is an indispensable and effective way to disseminate medical information. Thanks to these measures, we have transformed a scenario of ignorance into an evidence-based medical scenario in less than a year. Verkerk et al.’s proposed key factors are an excellent framework for characterizing and highlighting the lessons that can be learnt from how we have fought against the pandemic and low-value practices.
       
  • Evidence-Driven Policies for Sustainably Scaling up Surgical Task-Sharing
           in Malawi

    • Abstract: This commentary discusses an article by Broekhiuzen et al. which assesses policy options for scaling up the SURG-Africa surgical team mentoring program in Malawi to increase access to surgical care. In modeling these scenarios, the authors assess the cost of scaling up surgical teams mentoring and the impacts of scaling the program on District and Central Hospitals. The additional costs borne by district hospitals when increasing surgical volume remains a significant issue identified by the authors and could ultimately determine the success of the program. The piece indirectly advocates for an increased role for task-shifting. The Ministry of Health of Malawi will have to ensure the appropriate governance and regulatory processes are in place to maintain quality and accountability.
       
  • Dual Goals, Dual Agency: The Perils of Measurement and Control; Comment on
           "Dual Agency in Hospitals: What Strategies Do Managers and Physicians
           Apply to Reconcile Dilemmas Between Clinical and Economic
           Considerations'"

    • Abstract: This commentary to Waitzberg et al. (2021) draws on the research stream on organizational goals in management to examine the findings they report, point out the correspondence of their findings and interpretation with existing theory, including development beyond it. Their work discusses these considerations very well. It also suggests paths to further theoretical development and proposes how their work demonstrate the potential for further research on multiple goals in hospitals. Such research will be important both for health policy and management and for management theory and practice generally.
       
  • How and Why Context Matters: A Personal Reflection; Comment on
           "Stakeholder Perspectives of Attributes and Features of Context Relevant
           to Knowledge Translation in Health Settings: A Multi-Country Analysis"

    • Abstract: This commentary acknowledges that the evidence-based practice (EBP) movement did not automatically or initially understand the impact of context on successful implementation. The subsequent work of research teams, such as the PARIHS team, and the Ottawa team led by Squires, have contributed to the ongoing refinement of the concept. However, still under discussion is whether having a more comprehensive set of contextual attributes will necessarily lead to more implementation success. Just as the strength of the evidence does not automatically lead to implementation success, so having a comprehensive understanding of contextual factors will not necessarily improve implementation uptake.
       
  • Belgium’s Health Care System: The Way Forward to Address the Challenges
           of the 21st Century; Comment on "Integration or Fragmentation of Health
           Care' Examining Policies and Politics in a Belgian Case Study"

    • Abstract: In this paper we have tried, starting from the results of an analysis of the functioning of integrated care in the Belgian Health System by Martens, Danhieux, et al. (2021), to design a strategy that could contribute to better addressing the challenges of the 21st century in Belgium. We proposed health system changes at the macro-, meso- and micro-level. We focused on health policy development and organization of care, emphasizing the importance of a shift from a hospital-centric towards a primary care based approach. Special attention was paid to the need for institutional reforms, in order to facilitate the further development of interprofessional integrated care, that focuses on the achievement of the life-goals of a person.
       
  • Reducing Low-Value Care: Uncertainty as Crucial Cross-Cutting Theme;
           Comment on “Key Factors That Promote Low-Value Care: Views of Experts
           From the United States, Canada, and the Netherlands”

    • Abstract: Low-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al. have identified key factors promoting low-value care on a national level, proposed strategies to address these and create a healthcare system facilitating delivery of high-value care. In this commentary, we reflect on the results of Verkerk et al. and argue that uncertainty has a crucial role when it comes to reducing lowvalue care. This uncertainty is reflected in lack of a shared view between stakeholders, with clear criteria and thresholds on what constitutes low-value care, and a cross-cutting theme related to the key factors identified. We suggest to work on such a shared view of low-value care and - different from implementation efforts - to explicitly address uncertainty and its driving cognitive biases grounded in human decision making psychology, to reduce low-value care.
       
  • Common Features of Selection Processes of Health System Performance
           Indicators in Primary Health Care: A Systematic Review

    • Abstract: Background  Health system performance indicators are widely used to assess primary health care (PHC) performance. Despite the numerous tools and some convergence on indicator criteria, there is not a clear understanding of the common features of indicator selection processes. We aimed to review the literature to identify papers that document indicator selection processes for health system performance indicators in PHC.Methods  We searched the online databases Scopus, Medline and CINAHL, as well as the grey literature, without time restrictions, initially on 31 July 2019 followed by an update 13 November 2020. Empirical studies or reports were included if they described the selection of health system performance indicators or frameworks, that included PHC indicators. A combination of the process focussed research question and qualitative analysis meant a quality appraisal tool or assessment of bias could not meaningfully be applied to assess individual studies. We undertook an inductive analysis based on potential indicator selection processes criteria, drawn from health system performance indicator appraisal tools reported in the literature.Results  We identified 16,503 records of which 28 were included in the review. Most studies used a descriptive case study design. We found no consistent variations between indicator selection processes of health systems of high income and low- or lower-middle income countries. Identified common features of selection processes for indicators in PHC include literature review or adaption of an existing framework as an initial step; a consensus building process with stakeholders; structuring indicators into categories; and indicator criteria  focusing on validity and feasibility. The evidence around field testing with utility and consideration of reporting burden was less clear.Conclusion  Our findings highlight several characteristics of health system indicator selection processes. These features provide the groundwork to better understand how to value indicator selection processes in primary health care.
       
  • Moral Lacunae in the Management of Dual Agency Dilemmas; Comment on "Dual
           Agency in Hospitals: What Strategies Do Managers and Physicians Apply to
           Reconcile Dilemmas Between Clinical and Economic Considerations'"

    • Abstract: Waitzberg et al’s participants articulate a wide range of strategies to manage tensions between clinical and economic obligations. There are, however, three notable absences in the data. First, all strategies described by participants are underpinned by the assumption that clinical (and associated administrative) practices need to either align with economic considerations or be made more compatible with them. Second, the dual agency dilemma was framed exclusively as existing at the level of the health care institution, with little attention paid to obligations to broader health systems. Third, there was no evidence of critical questioning of the priorities of the hospitals in which participants work. These absences do not render the strategies used by Weitzberg et al’s participants morally “wrong,” but they do suggest that people who are deeply embedded in a system might fail to recognise the full range of moral concerns and moral possibilities.
       
  • Universal Health Coverage for Health Equity: From Principle to Practice

    •  
  • Time to See Quality Measurement Differently: Focus on Reflection, Learning
           and Improvement; A Response to The Recent Commentaries

    •  
  • Overcoming Political Fragmentation: The Potential of Meso-Level
           Mechanisms; Comment on “Integration or Fragmentation of Health Care'
           Examining Policies and Politics in a Belgian Case Study.”

    • Abstract: Marten’s et al’s paper “Integration or Fragmentation of Health Care' Examining Policies and Politics in a Belgian Case Study”, offers an in-depth examination of integrated care policy efforts in Belgium. A key finding in this case study was that political fragmentation proved too great an obstacle for integration efforts. In this commentary, I draw on the organizational behaviour and integrated care literatures to suggest how meso-level mechanisms related to sensemaking, distributive leadership, and evaluation could help overcome policy (or macro) level challenges like those experienced in Belgium. The commentary also suggests we need to consider and address both the process and normative challenges in these transformation efforts.
       
  • Competing Values in Global Health: Is Inclusive Governance Valued Higher
           Than the Right to Health' A Response to the Recent Commentaries

    •  
  • Establishment and Application of an Index System for the Risk of Drug
           

    • Abstract: Background  At present, the avoidance of drug shortages mainly relies on expert experience. This study aimed to establish an evaluation index system for the risk of drug shortages in medical institutions in China and to apply the system to guide the graded management of drugs in short supply.Methods  A two-round Delphi process was conducted to determine the indicators in the index system. The weight value of each indicator was calculated using analytic hierarchy process (AHP) methods. The data of drugs in short supply from January 1 to December 31, 2020 in Hunan province were collected and evaluated using this index system. The evaluation scores, which ranged from 0 to 100, were calculated.Results  A three-level index system with four first-level indicators, 11 second-level indicators, and 36 third-level indicators was constructed by the two rounds of the Delphi process. The expert authority coefficient (Cr) of the first and second rounds of consultation were 0.88 and  0.90, respectively. The Kendall’s coefficients of concordance (Kendall’s W) for the two rounds of consultation were 0.44 and 0.50, respectively (P <0.05). For the first-level indicators ‘supply stability’, ‘causes of shortage’, ‘medicine availability in medical institution’ and ‘pharmaceutical properties’, the weight values were 0.3253, 0.2489, 0.2398, and 0.1860, respectively. Based on the risk evaluation score, drugs (dosage strength) at high risk of shortage included sodium thiosulfate (0.64 g), posterior pituitary lobe hormones (1 ml:6 IU), protamine sulfate (5 ml:50 mg), thrombin (500 U), urokinase (10 WU), and rotundine sulfate (2 ml:60 mg).Conclusions  An indexed system for the risk assessment of drug shortages in China was established to guide the graded response to drug shortages in medical institutions and the implementation of differential management strategies to address these shortages.
       
  • Managing Differences Among Pro-nutrition Actors on Corporate Engagement

    •  
  • Tip of The Iceberg' Country- and Company-Level Analysis of Drug
           Company Payments for Research and Development in Europe

    • Abstract: Background  Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interests. We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.Methods  Using documentary sources and a stakeholder survey we identified countryregulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the UK, a country with a major role in Europe’s R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.Results  In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a self-regulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the UK suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available company-level data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D. Conclusion  The lack of full disclosure of R&D payments in countries with industry selfregulation leaves considerable sums of money unaccounted for and potentially many conflicts of interests undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.
       
  • If It Is Complex, Let It Be Complex – Dealing With Institutional
           Complexity In Hospitals; Comment on “Dual Agency in Hospitals: What
           Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between
           Clinical and Economic Considerations'”

    • Abstract: Waitzberg and colleagues identified strategies that managers and physicians in hospitals apply to reconcile dilemmas between clinical and economic considerations. Contributions that actually acknowledge the institutional complexity of hospitals and describe how to deal with it are rare. This comment explains the reason behind the institutional complexity in healthcare organizations and argues that institutional complexity is a good foundation for a wellfunctioning and sustainable healthcare, as long as we are able to deal with this complexity. This point underscores the importance of their contribution. However, even if the identified strategies on how to reconcile and balance different, competing demands are important, they are not easy to apply in practice. First, the strategies require frequent and high-quality interaction between different actors adhering to different institutional logics. Second, even when the strategies are applied successfully, it is difficult to make them sustainable since they rest on a fragile balance between competing logics. However, these are important avenues for future research for researchers who want to follow the route of Waitzberg and colleagues.
       
  • Sustaining Knowledge Translation Practices: A Critical Interpretive
           Synthesis

    • Abstract: Background  The health policy and systems research literature increasingly observes that knowledge translation (KT) practices are difficult to sustain. An important issue is that it remains unclear what sustainability of KT practices means and how it can be improved. The aim of this study was thus to identify and explain those processes, activities, and efforts in the literature that facilitate the sustaining of KT practices in health policymaking processes.Methods  We used a critical interpretive synthesis (CIS) to review the health policy and systems research and Science and Technology Studies (STS) literature. The STS literature was included as to enrich the review with constructivist social scientific perspectives on sustainability and KT. The CIS methodology allowed for creating new theory by critically combining both literatures. We searched the literature by using PubMed, Google Scholar, Web of Science, and qualitative sampling. Searches were guided by pre-set eligibility criteria and all entries were iteratively analysed using thematic synthesis.Results  Eighty documents were included. Our synthesis suggests a shift from sustainability as an end-goal towards sustaining as actors’ relatively mundane work aimed at making and keeping KT practices productive. This ‘sustaining work’ is an interplay of three processes: i) translating, ii) contexting, and iii) institutionalising. Translating refers to activities aimed at constructing and extending networks. Contexting emphasises the activities needed to create contexts that support KT practices. Institutionalising addresses how actors create, maintain, and disrupt institutions with the aim of sustaining KT practices.Conclusion  The ‘sustaining work’ perspective of our CIS emphasises KT actors’ ongoing work directed at sustaining KT practices. We suggest that this perspective can guide empirical study of sustaining work and that these empirical insights, combined with this CIS, can inform training programmes for KT actors, and thereby improve the sustainability of KT practices.
       
  • ‘Attending to History’ in Major System Change in Healthcare in
           England: Specialist Cancer Surgery Service Reconfiguration

    • Abstract: Background  The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric cancer surgery services in a large urban area of England (Greater Manchester), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts.Methods  This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in Greater Manchester. Forty-six interviews with relevant stakeholders were carried out, along with 159 hours of observations  at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of ‘simple rules’ for major system change.Results  Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge.Conclusion  Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about major system change and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.
       
  • In Need of Renewal Rather Than Reconciliation: Why We Cannot Be Satisfied
           With Hospital Management’s Status Quo; Comment on “Dual Agency In
           Hospitals: What Strategies Do Managers And Physicians Apply to Reconcile
           Dilemmas Between Clinical and Economic Considerations'”

    • Abstract: Activity-based payment systems enforce Israeli and German hospital professionals to continuously balance clinical and economic considerations. As argued this status quo is unsatisfactory due to two reasons. First, professional hybridity in hospital management is restricted to the physician versus manager dichotomy rather than a multifaceted-identity framework. Second, by depending mostly on serendipity rather than hospital professionals’ organizational leewayapplied reconciliation strategies seem extremely temporarily and brittle. As concluded, alternative models of hospital funding and organization such as global budgets are urgently needed. In addition, hospital professionals have to be empowered to make effectively us from their hybrid identities.
       
  • Evidence-Informed Policymaking: Are We Doing Enough'; Comment on
           “Commentary: Examining and Contextualizing Approaches to Establish
           Policy Support Organizations – A Mixed Method Study”

    • Abstract: In their study of manifestations of policy support organizations (PSOs), Al Sabahi et al. found that PSOs are united in their goal to support evidence-informed policymaking, albeit with differing approaches. Their article is an important contribution to the body of research on evidence utilization and implementation. The unprecedented evidence climate presented by Covid-19 provides a unique window to motivate EIPM implementation. Research such as Al Sabahi et al.’s must prompt a dialogue regarding how best to address some of the current shortcomings in the field of evidence-informed policymaking. Monitoring and evaluation of best practices in evidence-informed policymaking is scarce. EIPM uptake is unsatisfactory, and the scientific community needs to ask itself why that is and what can be done. And, we should strive to develop a gradient that discerns between the convenient and the essential so countries can evaluate and pursue the policies to best address their greatest pain points through evidence.
       
  • Hospital Professionals as Dual Agents: A Superordinate Identity to Solve
           Interprofessional Conflicts in Hospitals'; Comment on “Dual Agency
           in Hospitals: What Strategies Do Managers and Physicians Apply to
           Reconcile Dilemmas Between Clinical and Economic Considerations'”

    • Abstract: The inherent conflict between economic and clinical considerations, between professionalism and managerialism, and between being a manager or being a clinician is widely acknowledged in the sociology of professions. The original article by Waitzberg and colleagues focused on how hospital professionals reconcile these conflicting demands. In this commentary, we argue that their assumption that the considered hospital professionals (managers, CFOs, chief physicians and practising physicians) are dual agents moves on from the unproductive debates of inherent conflicts to envisage possibilities of reconciling economic and clinical considerations. We conclude that the instrumental use of the term dual agent to include “the other” (the manager or the clinician) in a superlative and inclusive category can be considered a reframing strategy to solve inherent interprofessional conflicts and to implement more collaborative models in healthcare.
       
  • The Use of Evidence-Informed Deliberative Processes for Health Insurance
           Benefit Package Revision in Iran

    • Abstract: Background  Iran considers the revision of its health insurance benefit package (HIBP) as a means to achieve universal health coverage. Yet, its decision-making process has been criticised for being weak in terms of accountability and transparency. This paper reports on the development and implementation of the HIBP revision in Iran in the period 2019-2021, employing evidence informed deliberative processes (EDPs), a framework for benefit package design with the explicit aim of optimising the legitimacy of decisionmaking.Methods  The High Council for Health Insurance (HCHI) is coordinating the HIBP revision: it planned the six steps of the EDP framework with support from World Health Organisation and Radboudumc in 2019, and conducted a pilot project on multiple sclerosis diagnosis and treatment in 2020.Results  Implementation of the MS pilot project concerned the installation of advisory committees (involving some 60 stakeholders in supportive task forces, a technical working group and a national advisory committee), the selection of decision criteria (relating to quality of care, necessity, and sustainability), the inclusion of services for evaluation (nine in total), and the assessment and appraisal of these services.Conclusion  Implementation of the priority setting process for MS diagnosis and treatment services has likely improved the legitimacy of decision-making by involving stakeholders who engaged in deliberation based on available evidence in a stepwise, transparent process. It is expected to improve the quality of care for MS patients as well as its financial accessibility, at a zero net budget impact. The pilot project has served to help Iran’s health system move faster toward universal health coverage for a broader range of essential health services.
       
  • Adaptation, Transformation and Resilience in Healthcare; Comment on
           “Government Actions and Their Relation to Resilience in Healthcare
           During the COVID-19 Pandemic in New South Wales, Australia and Ontario,
           Canada”

    • Abstract: Adaptive capacity is a critical component of building resilience in healthcare. Adaptive capacity comprises the ability of a system to cope with and adapt to disturbances. However, “shocks”, such as the current Covid-19 pandemic, can potentially exceed critical adaptation thresholds and lead to systemic collapse. To effectively manage healthcare systems during periods of crises, both adaptive and transformative changes are necessary. This commentary discusses adaptation and transformation as two complementary, integral components of resilience and applies them to healthcare. We treat resilience as an emergent property of complex systems that accounts for multiple, often disparately distinct regimes in which multiple processes (e.g., adaptation, recovery) are subsumed and operate. We argue that Convergence Mental Health and other transdisciplinary paradigms such as Brain Capital and One Health can facilitate resilience planning and management in healthcare systems.
       
  • Context Matters, So How Do We Get Better at Working with Context in
           Implementation Research and Practice'; Comment on "Stakeholder
           Perspectives of Attributes and Features of Context Relevant to Knowledge
           Translation in Health Settings: A Multi-country Analysis”

    • Abstract: In the field of implementation research, it is widely recognised that ‘context matters’. Attempts to implement innovations, research and new knowledge into practice invariably meet contextual challenges at multiple levels during the process of implementation. The paper by Squires and colleagues provides a detailed insight into the many different features and attributes of context. Yet, as this commentary argues, there are significant challenges ahead if we are to apply our growing understanding about context to improve the practice of implementation in everyday health care. This will require attention to the practicalities of working with context to achieve successful implementation.
       
  • Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in
           Situations of Dual Agency at the Hospital Level; Comment on "Dual Agency
           in Hospitals: What Strategies Do Managers and Physicians Apply to
           Reconcile Dilemmas Between Clinical and Economic Considerations'"

    • Abstract: The article by Waitzberg et al. on dual agency in hospitals reports on three strategies to mitigate dilemmas arising from conflicting clinical and economic considerations. This could be further explored by using systems science methods that allow in-depth analyses of (health) system dynamics, networks, and agent-based modelling, and that take into account local context, incentives and how institutions work. Future studies may also draw on the literature of multi-criteria decision-making and evidence-informed deliberative processes that are increasingly being used to optimise legitimate health benefit package design. Toolkits to assist hospital professionals in improving their decision-making need to be practical, with ample attention for the process of decision-making, including transparency, use of evidence, and opportunities for health professionals (and possibly others stakeholders) to contest or formally appeal against certain decisions. 
       
  • Vaccination Strategies at a COVID-19 Mass Vaccination Site

    •  
  • The Roles of Regional Organisations in Strengthening Health Research
           Systems in Africa: Activities, Gaps, and Future Perspectives

    • Abstract: Background  Regional cooperation on health in Africa is not new. The institutional landscape of regional cooperation for health and health research, however, has seen important changes. Recent health emergencies have focussed regional bodies’ attention on supporting aspects of national health preparedness and response. The state of national health research systems is a key element of capacity to plan and respond to health needs – raising questions about the roles African regional bodies can or should play in strengthening health research systems.Methods  We mapped regional organisations involved in health research across Africa and conducted 18 interviews with informants from 15 regional organisations. We investigated the roles, challenges, and opportunities of these bodies in strengthening health research. We deductively coded interview data using themes from established pillars of health research systems – governance, creating resources, research production and use, and financing. We analysed organisations’ relevant activities in these areas, how they do this work, and where they perceive impact.Results  Regional organisations with technical foci on health or higher education (versus economic or political remits) were involved in all four areas. Most organisations reported activities in governance and research use. Involvement in governance centred mainly around  agenda-setting and policy harmonisation. For organisations involved in creating resources, activities focused on strengthening human resources, but few reported developing research institutions, networks, or infrastructure. Organisations reported more involvement in disseminating than producing research. Generally, few have directly contributed to financing health research. They report gaps in research coordination, infrastructure, and advocacy at regional level. Finally, we found regional bodies’ mandates, authority, and collaborations influence their activities in supporting national health research systems.Conclusion  Continued strengthening of health research on the African continent requires strategic thinking about the roles, comparative advantages, and capability of regional organisations to facilitate capacity and growth of health research systems.
       
  • Understanding the Political Skills and Behaviours for Leading the
           Implementation of Health Services Change: A Qualitative Interview Study

    • Abstract: Background  The implementation of change in health and care services is often complicated by organisational micro-politics. There are calls for those leading change to develop and utilise political skills and behaviours to understand and mediate such politics, but to date only limited research offers a developed empirical conceptualisation of the political skills and behaviours for leading health services change.Methods  A qualitative interview study was undertaken with 66 healthcare leaders from the English National Health Service (NHS). Participants were sampled on the basis of their variable involvement in leading change processes, taking into account anticipated differences in career stage, leadership level and role, care sector, and professional backgrounds. Interpretative data analysis led to the development of five themes.Results  Participants’ accounts highlighted five overarching sets of political skills and behaviours: personal and inter-personal qualities relating to self-belief, resilience and the ability to adapt to different audiences; strategic thinking relating to the ability to understand the wider and local political landscape from which to develop realistic plans for change; communication skills for engaging and influencing stakeholders, especially for understanding and mediating stakeholders’ competing interests; networks and networking in terms of access  to resources, and building connections between stakeholders; and relational tactics for dealing with difficult individuals through more direct forms of negotiation and persuasion.Conclusion  The study offers further empirical insight the existing literature on healthcare organisational politics by describing and conceptualising the political skills and behaviours of implementing health services change.
       
  • Managing Urban Stroke Health Expenditures in China: Role of Payment Method
           and Hospital Level

    • Abstract: Background  Stroke is one of the leading public health issues in China and imposes a heavy financial burden on patients and the health care system. This study assess which payment method provides the lowest hospital costs for China’s health care system and the lowest outof-pocket (OOP) expense for insured patients.Methods  This is a 4-year cross-sectional study. From the China Health Insurance Research Association database, a 5% random sample of urban health insurance claims was obtained.   Descriptive analysis was conducted and a generalized linear model (GLM) with a gamma distribution and a log link was estimated.Results  For outpatients, capitation payment had the lowest hospital cost (RMB180.9/US$28.8) and lowest OOP expenses (RMB75.6/ US$12.0) per patient visit in primary hospitals compared with fee-for-service (FFS) payments. The global budget displayed the lowest total hospital costs (RMB344.7/US$54.8) in secondary hospitals, and was 27.39% (95% CI=-0.320, -0.289) lower than FFS. FFS had the lowest OOP expenses (RMB123.4/US$19.6 vs. RMB151.8/US$24.1) in secondary and tertiary hospitals. For inpatients, FFS had the lowest total hospital costs (RMB5,918.7/US$941.1) per visit and capitation payments had the lowest OOP expenses (RMB876.5/US$139.4, 40.10% lower than FFS, 95% CI=-0.579, -0.147) in primary hospitals. Capitation payment had both the lowest hospital costs (RMB7,342.9/US$1,167.5 vs. RMB17,711.7/US$2,816.2) and the lowest OOP expenses (RMB1,664.2/US$264.6 vs. RMB3,276.3/US$520.9) for both secondary and tertiary hospitals.Conclusion  For outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest OOP expenses for patients and the lowest hospital total costs for hospitals. We recommend that health policymakers prioritize the 2implementation of the payment method with the lowest OOP expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest OOP expenses for patients.
       
  • Insights Gained From a Re-Analysis of Five Improvement Cases in Healthcare
           Integrating System Dynamics into Action Research

    • Abstract: Background  Healthcare is complex with multi-professional staff and a variety of patient care pathways. Time pressure and minimal margins for errors, as well as tension between hierarchical power and the power of the professions, make it challenging to implement new policies or procedures. This paper explores five improvement cases in healthcare integrating System Dynamics (SD) into Action Research (AR), aiming to identify methodological aspects of how this integration supported multi-professional groups to discover workable solutions to work-related challenges.Methods  This re-analysis was conducted by a multi-disciplinary research group using an iterative abductive approach applying qualitative analysis to structure and understand the empirical material. Frameworks for consultancy assignments/client projects were used to  identify case project stages (workflow steps) and socio-analytical questions were used to bridge between the AR and SD perspectives.Results  All studied cases began with an extensive AR-inspired inventory of problems/objectives and ended with an SD-facilitated experimental phase where mutually agreed solutions were tested in silico. Time was primarily divided between facilitated group discussions during meetings and modelling work between meetings. Work principles ensured that the voice of each participant was heard, inspired engagement, interaction, and exploratory mutual learning activities. There was an overall pattern of two major divergent and convergent phases, as each group moved towards a mutually developed point of reference for their problem/objective and solution, a case-specific multi- professional knowledge repository.Conclusion  By integrating SD into AR, more favourable outcomes for the client organization may be achieved than when applying either approach in isolation. We found that SD provided a platform that facilitated experiential learning in the AR process. The identified results were calibrated to local needs and circumstances, and compared to traditional top-down implementation for change processes, improved the likelihood of sustained actualisation.
       
  • Trust, but Verify; Comment on “Part of the Solution:” Food Corporation
           Strategies for Regulatory Capture and Legitimacy

    • Abstract: According to Lacy-Nichols and Williams, the food industry is increasingly forestalling regulation with incremental concessions and co-option of policymaking discourses and processes; bolstering their legitimacy via partnerships with credible stakeholders; and disarming critics by amending their product portfolios whilst maintaining high sales volumes and profits. Their assessment raises a number of fundamental philosophical questions that we must address in order to form an appropriate public health response: is it appropriate to treat every act of corporate citizenship with cynicism' If voluntary action leads to better health outcomes, does it matter whether profits are preserved' How should we balance any shortterm benefits from industry-led reforms against the longer-term risk stemming from corporate capture of policymaking networks' I argue for a nuanced approach, focused on carefully defined health outcomes; allowing corporations the benefit of the doubt, but implementing robust binding measures the moment voluntary actions fail to meet independently set objectives.
       
  • ‘Ahscs as Health Policy Transfer: Some Emergent Evidence From
           Australia’; Comment on "Academic Health Science Centres as Vehicles for
           Knowledge Mobilisation in Australia' A Qualitative Study"

    • Abstract: This commentary discusses Edelman et al 2020’s (1) recent exploratory study of the early development of 4 Academic Health Services Centres (AHSCs) in Australia. AHSCs were originally invented in the USA, but have then diffused to the UK and Canada over the last decade or so and now to Australia so they are a good example of health policy transfer. They are dedicated to advancing more speedy knowledge translation/mobilization (‘from bench to bedside’) and also the more effective commercialization of scientific inventions. The commentary argues some interesting if preliminary findings are identified in their study. Its limitations will also be considered. Finally, suggestions for future research are made, including more cross national and comparative studies.
       
  • Structural and Managerial Risk Factors for COVID-19 Occurrence in French
           Nursing Homes

    • Abstract: Background Nursing home (NH) residents accounted for half of the deaths during the 2020 spring wave of the COVID-19 epidemic in France. Our objective was to identify structural and managerial factors associated with COVID-19 outbreaks in NHs.Methods We conducted in july 2020 a retrospective study by questionnaire addressed to NH directors in the Brittany region of France. The questions related to structural characteristics of the establishment, human resources, and crisis management decisions. The primary endpoint was the occurrence of at least one confirmed case of COVID-19 among residents between 1 March 1 and 31 May 2020. The secondary endpoint was total mortality during this period. We used multivariate regressions to identify factors associated with these outcomes.Results Responses were collected from 231 NHs hosting 20,881 residents, representing a participation rate of 47%. In 24 (10%) NHs, at least one resident presented confirmed COVID-19. NHs often implemented stringent protective measures, with 65% of them choosing to confine residents to their rooms. In multivariate analysis, factors associated with a reduced risk of case occurrence were in-room meal service, early ban of family visits, and daily access to an outdoor space. No association was found between mortality and the factors studied. Our results show an early and strict implementation of lockdown measures, with good epidemiological results in a context of shortage of personal protective equipment and non-vaccination. Nevertheless, it raises ethical questions concerning respect of residents’ wellbeing and rights.Conclusion Cessation of communal dining seems to be the main measure likely to be effective in preventive terms. It does not seem that room lockdown and cessation of group activities should be recommended, particularly if mask wearing is possible.
       
  • Evaluating Public Participation in a Deliberative Dialogue: A Single Case
           Study

    • Abstract: BackgroundDeliberative dialogues (DDs) are used in policy making and healthcare research to enhance knowledge exchange and research implementation strategies. They allow organized dissemination and integration of relevant research, contextual considerations, and input from diverse stakeholder perspectives. Despite recent interest in involving patient and public perspectives in the design and development of healthcare services, DDs typically involve only professional stakeholders. A DD took place in May 2019 that aimed to improve the social environment (e.g., safety, social inclusion) and decrease social isolation in a rent-geared-to-income housing complex in a large urban community. Tenants of the housing complex, public health, primary care, and social service providers participated. This study aimed to determine how including community tenants impacted the planning and execution of a DD, including adjustments made to the traditional DD model to improve accessibility.MethodsA Core Working Group and Steering Committee coordinated with researchers to plan the DD, purposefully recruit participants, and determine appropriate accommodations for tenants. A single mixed-methods case study was used to evaluate the DD process. Meeting minutes, field notes, and researchers’ observations were collected throughout all stages. Stakeholders’ contributions to and perception of the DD were assessed using participant observation, survey responses, and focus groups.Results34 participants attended the DD and 28 (82%) completed the survey. All stakeholder groups rated the overall DD experience positively and valued tenants’ involvement. The tenants heavily influenced the planning and DD process, including decisions about key features. Suggestions to improve the experience for tenants were identified.ConclusionsThese findings demonstrate the viability of and provide recommendations for DDs involving public participants. Like previous DDs, participants found the use of engaged facilitators, issue briefs, and off-the-record deliberations useful. Similarly, professional stakeholders did not highly value consensus as an output, although it was highly valued among tenants, as was actionability.
       
  • A Realist Explanatory Case Study Investigating How Common Goals,
           Leadership, and Committed Staff Facilitate Health in All Policies
           Implementation in the Municipality of Kuopio, Finland

    • Abstract: Background  Health in All Policies (HiAP) encompasses collaboration across government and the consideration of health in various governmental sector’s policies and decisions. Despite increasing advocacy, interest, and uptake in HiAP globally, empirical and evaluative studies are underrepresented in this growing literature, particularly literature on HiAP implementation at the local level. Finland has been a pioneer in and champion for HiAP.Methods  A realist explanatory case study design was used to test hypotheses about how HiAP is implemented in Kuopio, Finland. Semi-structured interviews with ten government employees from various sectors were conducted. Data from interviews and literature were analyzed with the aims of uncovering explanatory mechanisms in the form of Context-Strategy-Mechanism-Outcome configurations related to implementation strategies. Evidence was evaluated for quality based on triangulation of sources and strength of evidence. We hypothesized that having or creating a common goal between sectors and having committed staff and local leadership would facilitate implementation.Results  Strong evidence supports our hypothesis that having or creating a common goal can aid in positive implementation outcomes at the local level. Common goals can be created by the strategies of having a city mandate, engaging in cross-sectoral discussions, and/or by working together. Policy and political elite leadership led to HiAP implementation success because leaders supported HiAP work, thus providing justification for using time to work intersectorally. How and why the wellbeing committee facilitated implementation included by providing opportunities for discussion and learning, which led to understanding of how nonhealth decisions impact community wellbeing, and by acting as a conduit for the communication of wellbeing goals to government employees.Conclusion  At the municipal level, having or creating a common goal, leadership from policy and political elites, and the presence of committed staff can facilitate HiAP implementation. Inclusion of not only strategies for HiAP, but also the explanatory mechanisms, aids in elucidating how and why HiAP is successfully implemented in a local setting.
       
  • Convergence on Coercion: Functional and Political Pressures as Drivers of
           Global Childhood Vaccine Mandates

    • Abstract: Background  Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion – the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle.Methods  To better understand the drivers of enhanced vaccine mandates, a crucial issue during the COVID-19 global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents.Results  The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policymakers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers.ConclusionIn four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.
       
  • Governance of Intersectoral Collaborations for Population Health and to
           Reduce Health Inequalities in High-income Countries: A ComplexityInformed
           Systematic Review

    • Abstract: Background  A ‘Health in All Policies’ (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities.Methods  Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model.Results  Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multicomponent and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement,  leadership that championed collaborations and the identification of ‘win-win’ strategies. External factors such as economic shocks and short political cycles reduced collaborative power.Conclusion  This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.
       
  • Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative
           Interview Study in the United Kingdom, 2019

    • Abstract: Background  The World Health Organization recommends that countries implement fiscal policies to reduce the health impacts of sugary drinks. Few studies have fully examined the responses of industry to these policies, and whether they support or undermine health benefits of sugary drinks taxes. We aimed to explore the changes that sugary drinks companies may make to their marketing, and underlying decision-making processes, in response to such a tax.Methods  Following introduction of the UK Soft Drinks Industry Levy (SDIL) in 2018, we undertook one-to-one semi-structured interviews with UK stakeholders with experience of the strategic decision-making or marketing of soft drink companies. We purposively recruited interviewees using seed and snowball sampling. We conducted telephone interviews with 6 representatives from each of industry, academia and civil society (total n=18), which were transcribed verbatim and thematically analysed. Four transcripts were double-coded, three were excluded from initial coding to allow comparison; and findings were checked by interviewees. Results  Themes were organised into a theoretical framework that reveals a cyclical, iterative and ongoing process of soft drink company marketing decision-making, which was accelerated by the SDIL. Decisions about marketing affect a product’s position, or niche, in the market and were primarily intended to maintain profits. A product’s position is enacted through various marketing activities including reformulation and price variation, and non-marketing activities like lobbying. A soft drink company’s selection of marketing activities appeared to be influenced by their internal context, such as brand strength, and external context, such as consumer trends and policy. For example, a company with low brand strength and an awareness of trends for reducing sugar consumption may be more likely to reformulate to lower-sugar alternatives.Conclusion  The theoretical framework suggests that marketing responses following the SDIL were coordinated and context-dependent, potentially explaining observed heterogeneity in responses across the industry.
       
  • Overview of The Drivers of Low-Value Care; Comment on “Key Factors That
           Promote Low-Value Care: Views of Experts From the United States, Canada,
           and the Netherlands”

    • Abstract: Verkerk and colleagues (2021) explored the key drivers of low-value care from the perspective of 18 policy makers and researchers who had led and evaluated at least one initiative to reduce low-value care or had been responsible for reducing low-value care in an organisation. They identified several drivers of low-value care presented in the 2017 Lancet Right Care Series (e.g. fee for service payment systems, the pharmaceutical and medical device industry, fear of malpractice litigation, issues with research conduct and reporting, a culture of ‘more is better’ and ‘new technology is better’) but did not discuss some other important ones. In this commentary, we aim to extend the work of Verkerk and colleagues (2021) and provide some additional perspectives on the drivers of lowvalue care within the following categories: Economic incentives; Money, finance, and organisation; Knowledge beliefs, assumptions, bias and uncertainty; and Power and human relationships.
       
  • Improving District Hospital Surgical Capacity in Resource Limited
           Settings: Challenges and Lessons From South Africa; Comment on
           “Improving Access to Surgery Through Surgical Team Mentoring – Policy
           Lessons From Group Model Building With Local Stakeholders in Malawi”

    • Abstract: Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings. Surgical team mentoring programmes require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for all.
       
  • Context, Culture, and the Complexity of De-Implementing Low-Value Care;
           Comment on “Key Factors That Promote Low-Value Care: Views of Experts
           From the United States, Canada, and the Netherlands”

    • Abstract: Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk et al.’s recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives.
       
  • An Analysis of Zonal Health Management Capacity and Health System
           Performance: Ethiopia Primary Healthcare Transformation Initiative

    • Abstract: Background  District management is emerging as a lynchpin for primary healthcare system performance. However, delivery of district-level interventions at scale is challenging, and overlooks the potential role of management at other subnational levels. From 2015-2019, Ethiopia’s Primary Healthcare Transformation Initiative (PTI), aimed to build a culture of performance management and accountability at the zonal level. This paper aims to evaluate the longitudinal change in management practice and performance in the 19 zones participating in PTI, which included 315 districts and 1617 health centers.Methods  Using data from PTI intervention (2018 to 2019), we employed quantitative measures of management capacity at health center, district, and zonal levels, and quantified primary healthcare service performance using a summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We used multiple generalized linear regression models accounting for clustering of health centers within zones to quantify (1) change in management and performance during the two-year intervention, (2) associations between the changes in management capacity at the zonal, district, and health facility level.Results  Adherence to management standards at the zonal, district, and health facility level improved significantly over two years (37%, p<0.001; 18%, p<0.001; 18%, p<0.001; respectively), as did the performance summary score (14%, p<0.001). Adherence at the zonal level in year one was associated with district level adherence in year one (p<0.001), and, over the two-year period (p<0.01), and district management mediated the relationship between management practice at zonal and health center levels (p<0.001).Conclusion  Improvements in zonal-level management practice were associated with significant improvements in district-level management and performance in PTI sites. Investments in managerial practices at the zonal level may provide an immediate way to energize primary healthcare system performance at scale in low-income country settings.
       
  • Job Performance of Medical Graduates With Compulsory Services in
           Underserved Rural Areas in China: A Cohort Study

    • Abstract: Background  China started a national program in 2010 to train qualified general practitioners with compulsory services (CSP) in rural and remote areas. While the program has shown positive effects on staffing primary health care in rural areas, very little is known about how well they perform. This study aims to evaluate the job performance of medical graduates from this program and the influence of program design on job performance.Methods  A cohort study was conducted with graduates from CSP and non-CSP (NCSP) from four medical universities in central and western China. Baseline and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements. Multivariable regressions were used to identify factors affecting job performance.Results  2154 medical graduates were included, with 1586 CSP and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=0.153). CSP graduates reported similar job performance with NCSP graduates (CSP, 63.7; NCSP, 64.2); in the multivariable regression, CSP graduates scored 0.32 and 1.36 points lower in the total sample and graduates of 2015-2017, respectively, but not significantly. Having formally funded positions improved the job performance of CSP (β coefficient=4.87, P<0.05). After controlling for Qinghai which adopted a different contracting strategy, “working in hometown” showed significant influence on job performance (β coefficient=1.48, P<0.05).ConclusionCSP graduates have demonstrated as good job performance as NCSP, proving the competency to provide high-quality care for remote and rural areas. The contracted township health centers should provide guidance for CSP graduates, especially in the first few years after graduation. The local government should provide formally funded positions on time and prioritize signing contracts with hometowns or places nearby.
       
  • Policymaking Context Matters, but Can (and Should) It Be
           Operationalised'; Comment on "Stakeholder Perspectives of Attributes
           and Features of Context Relevant to Knowledge Translation in Health
           Settings: A Multi-Country Analysis"

    • Abstract: Squires et al note that too many people use terms like ‘context’ imprecisely. The result (to avoid) is a catch-all term that lacks explanatory value and hinders the efforts of policy designers. Their list of 66 factors is a useful exercise to unpack what people mean when describing context. However, some problems will arise when the authors seek to move from research to practice. First, the list is too long to serve its purpose. Second, in many cases, it categorises rather than operationalises key terms. The result is the replacement of one vague term with a collection of others. Third, many categories describe what policy designers might need, rather than what they can reasonably expect to happen. In that context, wider studies of implementation and complex systems provide cautionary tales in which the outcomes of research become overwhelming rather than practical.
       
  • Legitimacy of Front-of-Pack Nutrition Labels: Controversy Over the
           Deployment of the Nutri-Score in Italy

    • Abstract: Background  Front-of-Pack nutrition Labels (FoPLs) aim at increasing transparency and consumers’ awareness of the nutritional composition of pre-packed food products in order to improve the nutritional quality of their food choices. Nevertheless, the legitimacy of the Nutri-Score - the FoPL officially adopted in France and several other European countries - is subject to both technical and political controversy, particularly in Italy. In this study, we investigated how and by whom the legitimacy of the Nutri-Score, recognized by several institutional authorities, could be deconstructed within a specific system of norms, values and beliefs among Italian stakeholders.Methods  A netnography completed with qualitative interviews with eight Italian and French nutrition and public health experts were carried out to highlight the dimensions (pragmatic, normative and cognitive) in which the Nutri-Score’s legitimacy is being challenged among the stakeholders involved in FoPLs’ implementation in Italy. The degree of influence and the position of these stakeholders on the debate around the Nutri-Score were assessed through the Stakeholder Theory, using their respective level of power, legitimacy and urgency. Furthermore, we compared the Italian and the French contexts on the issue.Results  The direct implication of political parties and media outlets in framing the Italian debate around Nutri-Score as well as the high influence of corporate unions, led to a different political outcome than in France. Results also show that the deconstruction of the legitimacy of the Nutri-Score in Italy pertained mainly to its pragmatic dimension according to the Italian public health experts. Nevertheless, its two other dimensions (normative and cognitive) are also questioned by high-influence stakeholders.Conclusion  Due to the limited mobilization of scientific expertise over the issue, the debate in Italy stayed centered around the “attack” of the Nutri-Score to the Italian way of life, mixing up concepts such as Made in Italy products and the Mediterranean Diet.
       
  • Representations of Ultra-Processed Foods: A Global Analysis of How Dietary
           Guidelines Refer to Levels of Food Processing

    • Abstract: Background  As evidence grows about negative health impacts of ultra-processed foods, nutrient-centred advice is contested, and food-based dietary guidelines are increasingly utilised. Previous analyses of dietary guidelines evaluated their potential impact on health and sustainability, but little research has been conducted to examine how the concept of ultraprocessed foods is reflected in dietary advice for consumers. This paper systematically analyses whether and how ultra-processed foods are represented in dietary guidelines internationally.Methods  Based on a systematic online search, the consumer-targeted key messages of 106 dietary guidelines were identified and a qualitative content analysis was conducted. A coding framework was developed to classify messages as ‘eat more’ or ‘eat less’ according to the language used (e.g. ‘choose’ vs ‘avoid’) and to differentiate between a focus on nutrients or food processing. Specific foods mentioned in ‘eat less’ guidelines were classified according to their level of processing using the NOVA framework.Results  99% of guidelines utilised some type of nutrient-based message, either promoting ‘positive’ nutrients (e.g. vitamins) or discouraging the consumption of ‘negative’ nutrients (mainly salt, sugar and fat). Explicit references to food processing were present in 45% of ‘eat less’ guidelines and 5% of ‘eat more’ guidelines. Implicit references (e.g. promoting ‘raw’ or discouraging ‘packaged’ foods) were found in 43% of ‘eat less’ and 75% of ‘eat more’ guidelines. 53% of the specific foods referred to in ‘eat less’ advice were ultra-processed foods.Conclusion  Overall, nutrient-based messages were more common than messages about processing levels. The majority of discouraged foods were ultra-processed foods, however some minimally processed foods were discouraged, which points to tensions and contradictions between nutrient- and processing-based dietary advice. As dietary guidelines begin to include advice about food processing, it is important to consider both consumer understanding of the terms used and their capacity to act on the advice.
       
  • Utility of the Right to Health for Addressing Skilled Health Worker
           Shortages in Low- and Middle-Income Countries

    • Abstract: Background  As a fundamental human right, the right to health (RTH) can influence state actors' behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low-and-middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and High-Countries (HICs), we sought to answer the question: "how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs'"Methods  We conducted a realist synthesis of evidence identified through a systematic search of peerreviewed articles in Embase, Global Health, Medline (Ovid), ProQuest – Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar.Results  We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors' concerns for their countries' reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors' response include financial cost and sustainability of rights'-based options.Conclusions  State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.
       
  • The Projection of Iran’s Healthcare Expenditures by 2030: Evidence
           of A Time-Series Analysis

    • Abstract: Background  The projection of levels and composition of financial resources for the Healthcare expenditure (HCE) and relevant trends can provide a basis for future health financing reforms. This study aimed to project Iran’s healthcare expenditures by the sources of funds until 2030.Methods  The structural macro-econometric modeling in the Eviews 9 software was employed to simulate and project Iran’s (HCE) by the sources of funds (Government (GHCE), Social Security Organization (SOHCE), Out-of-Pocket Payments (OOP), and Prepaid Private Health Spending (PPHCE)). The behavioral equations were estimated by Autoregressive Distributed Lag (ARDL) approach.Results  If there is a 5%-increase in Iran’s oil revenues, the mean growth rate of GDP is about 2% until 2030. By this scenario, the Total HCE(THCE), GHCE, SOHCE, OOP, and PPHCE increases about 30.5%, 25.9%, 34.4%, 31.2%, and 33.9%, respectively. Therefore, the THCE as a percentage of the GDP(Gross Domestic Product)) will increase from 9.6% in 2016 to 10.7% in 2030. It is predicted that Iran’s THCE will cover 22.2%, 23.3%, 40%, and 14.5% by the government, Social Security Organization, households OOP, and other private sources, respectively, in 2030.Conclusion  Until 2030, Iran’s health expenditures will grow faster than the GDP, government revenues, and non-health spending. Despite the increase in GHCE and total government expenditure, the share of the GHCE from THCE has a decreasing trend. OOP payments remain among the major sources of financing for Iran’s HCE.
       
  • Articulating Concepts Matters! Resilient Actions in the Norwegian
           Governmental Response to the COVID-19 Pandemic; Comment on "Government
           Actions and Their Relation to Resilience in Healthcare During the COVID-19
           Pandemic in New South Wales, Australia and Ontario, Canada"

    • Abstract: The COVID-19 pandemic has challenged our healthcare systems and required collaboration from both centralized and decentralized system levels to adapt to the changes and challenges. This commentary offers a look into the Norwegian governmental healthcare system and response within a resilience in healthcare perspective, by analyzing the situated, structural, and systemic resilience. Such a conceptualization of resilience into three scales of organizational activity may assist our efforts to understand and explain governmental actions throughout the pandemic. Research application of resilience in healthcare to explain and discuss government actions during the COVID-19 pandemic, needs to ensure sensitivity to the overall structural, cultural, and human factor aspects of the relevant healthcare system under scrutiny as well as sensitivity to specific context within the various system levels.
       
  • Hospital Readmission Due to Chronic Obstructive Pulmonary Disease: A
           Longitudinal Study

    • Abstract: ObjectiveTo investigate the prevalence of hospital readmission for chronic obstructive pulmonary disease (COPD) at 30, 90 and 365 days, and to determine demographic and socioeconomic risk factors for 30-day and 90-day readmission and time to COPD-related readmission within 365 days in Tasmania.Methods  Patients ≥40 years admitted for COPD between 2011 and 2015 were identified using administrative data from all major public hospitals in Tasmania, Australia. Factors associated with readmission and time to readmission were identified using logistic and Cox regression, respectively.Results  The rates of COPD-related readmission were 6.7% within 30 days, 12.2% within 90 days and 23.7% within 365 days. Being male (OR 1.49, CI 1.06–2.09), Indigenous (OR 2.47, CI 1.31–4.66) and living in the lower socioeconomic North-West region of Tasmania (OR 1.80, CI 1.20–2.69) were risk factors for 30-day readmission. Increased COPD-related (OR 1.48, CI 1.22–1.80; OR 1.52, CI 1.29–1.78) and non-COPD-related (OR 1.12, CI 1.03–1.23; OR 1.11, CI 1.03–1.21) emergency department (ED) visits in the preceding six months were risk factors for both 30-day and 90-day readmissions. Being Indigenous (HR 1.61, CI 1.10–2.37) and previous COPD-related ED visits (HR 1.30, CI 1.21–1.39) decreased, while a higher Charlson Comorbidity Index (OR 0.91, CI 0.83–0.99) increased the time to readmission within 365 days.Conclusions  Being male, Indigenous, living in the North-West region and previous ED visits were associated with increased risk of COPD readmission in Tasmania. Interventions to improve access to primary healthcare for these groups may reduce COPD-related readmissions. 
       
  • Knowledge About HIV/AIDS and Its Transmission and Misconception Among
           Women in Bangladesh

    • Abstract: BackgroundAsian and pacific region countries are high risk countries for HIV/AIDS. Although the prevalence of HIV/AIDS is low in Bangladesh but women in Bangladesh have been identified as susceptible due to associated socioeconomic exposures. There are various misconceptions associated with HIV/AIDS transmission among the women in low-and middle-income countries including Bangladesh, which lead to a negative attitude towards the HIV/AIDSinfected. The purpose of this study was to assess the overall knowledge, transmission, and misconception about HIV/AIDS among the women in Bangladesh as well as its spatial distribution across the country.MethodsThe study used data from the UNICEF Multiple Indicator Cluster Survey 2019, with a sample of 64,346 women. This was a cross-sectional, population-based survey of Bangladeshi women aged 15–49 conducted using a multistage, cluster sampling technique. Three binary outcome variables considered were knowledge about HIV/AIDS, knowledge about HIV/AIDS transmission and knowledge on myths and misconceptions on HIV/AIDS along with 10 predictors based on past literature. Bivariable analysis using Chi-square tests of association was conducted to examine the unadjusted percentage differences of the outcome variables for each of the predictor variables and their associations. Multiple binary logistic regression models were then fitted to evaluate the association between the outcome variables and the predictors after adjusting for survey cluster, strata, and weights. All analysis was conducted in R software (V 2.5.0).ResultsThe percentage of women who held knowledge about HIV/AIDS, knowledge about HIV/AIDS transmission and knowledge on misconceptions about transmission of HIV were on average 60.3%, 52.2% and 71.7% respectively. The models indicated that women regularly exposed to media were 79%, 18% and 19% significantly more likely (OR (95% CI) = 1.79 (1.70, 1.89); 1.18 (1.10 1.26) and 1.19 (1.11, 1.27)) to have heard about HIV, aware about HIV transmission, and have less misconceptions about HIV respectively compared to those who were not exposed to media. Overall results indicate that women from peripheral districts living far from metropolitan cities were most unaware of HIV and had higher misconceptions about AIDS.ConclusionThe findings of this study should assist policy makers and program implementers to focus on raising awareness to educating women about how HIV/AIDS is transmitted. Furthermore, interventions should be made by targeting the most disadvantaged groups, including younger women with low education living in rural areas, from poor households and limited access to information. Also, education on HIV transmission in Bangladesh should integrate cultural and ethnic considerations of HIV/AIDS.
       
  • Does Direct Benefit Transfer Improve Outcomes Among People With
           Tuberculosis' – A Mixed-Methods Study on the Need for a Review of
           the Cash Transfer Policy in India

    • Abstract: Background  A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program.Methods  We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by indepth interviews of nine patients and eight program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories.Results  Among the 426 patients, nine percent of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit.Conclusion  Direct benefit transfer improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for ‘DBT plus food-kit’ vs. universal cash transfers in India.
       
  • Zero-Covid Strategy: What’s Next'

    •  
  • Donors' Participation in Iran's Health System: Challenges and Solutions

    • Abstract: Background  Philanthropic activities play an important role in health systems. Donors contribute to financing, generating resources, and providing healthcare services in Iranian health system. However, they face many challenges. This study aimed to identify barriers to donors' participation in the Iranian health system and to provide solutions.Methods  This qualitative study was performed using semi-structured interviews with 38 donors and 26 policymakers and managers in the social affairs department of health ministry and medical universities in 2018. In addition, document analysis was performed and the relevant data were extracted. Thematic analysis was used for data analysis. All ethical considerations were followed in this research.Results  Insufficient structures, poor communications, low trust, ineffective working processes, bureaucracy, insufficient senior managers’ support, weak legal support and poor monitoring were the most important challenges for donors’ participation in the Iranian health system. Effective donor participation in the health system requires the creation of an appropriate system including the right structures, processes, culture, and management. The necessary changes must be planned, led and monitored to promote donors’ participation in healthcare. A conceptual model was developed to strengthen donors’ participation in the health system.Conclusion  Iranian donors face structural, procedural, cultural, and managerial challenges when financing the health system, generating resources, and providing health services. Policymakers and managers should tackle these challenges and adopt strategies to reinforce donors' participation in the health system. Planning, organizing, leading, monitoring, evaluation, transparency, accountability, and a commitment to meet donors’ needs are necessary for successful philanthropy initiatives in the health sector. 
       
  • Developing a How-to-Guide for Health Technology Reassessment: “The
           HTR Playbook”

    • Abstract: Background  To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative.Methods  The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (i.e., potential users) at the Health Technology Assessment International 2018 annual meeting.Results  An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology (The Stats and Projections), stakeholders to engage (The Team), potential facilitators and/or barriers within the policy context (The Playing Field), strategic use of different levers and tools (The Offensive Plays), unintended consequences (The Defensive Plays), and metrics and methods for monitoring and evaluation (Winning the Game).Conclusion  The HTR playbook is intended to enhance a user’s ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question.
       
  • Context Matters in Evidence Implementation Globally; Comment on
           “Stakeholder Perspectives of Attributes and Features of Context Relevant
           to Knowledge Translation in Health Settings: A Multi-Country Analysis”

    • Abstract: Context influences the effectiveness of healthcare interventions and should be considered to inform their implementation. However, context remains poorly defined in the knowledge translation (KT) literature. The paper by Squires and colleagues constitutes a valuable contribution to the field of KT as it provides the basis for a comprehensive framework to assess the influence of context on implementation success. In their study, Squires et al. identified 66 context features, grouped into 16 attributes. Their findings highlight a great convergence in the context features mentioned by stakeholders across countries, experience levels and roles in KT. Thus, the proposed framework could eventually transfer to several implementation settings. However, all study participants were from high-income countries. It would therefore be important to replicate this research in low- and middle-income countries. A common understanding of what context means is essential to assessing its influence on the implementation of healthcare interventions globally.
       
  • Operationalising Regional Cooperation for Infectious Disease Control: A
           Scoping Review of Regional Disease Control Bodies and Networks

    • Abstract: Background  The rapid spread of the COVID-19 pandemic demonstrates the value of regional cooperation in infectious disease prevention and control. We explored the literature on regional infectious disease control bodies, to identify lessons, barriers and enablers to inform operationalisation of a regional infectious disease control body or network in southeast Asia.Methods  We conducted a scoping review to examine existing literature on regional infectious disease control bodies and networks, and to identify lessons that can be learned that will be useful for operationalisation of a regional infectious disease control body such as the ASEAN Center for Public Health Emergency and Emerging Diseases.Results  Of the 57 articles included, 53 (93%) were in English, with two (3%) in Spanish and one (2%) each in Dutch and French. Most were commentaries or review articles describing programme initiatives. Sixteen (28%) publications focused on organisations in the Asian continent, with 14 (25%) focused on Africa, and 14 (24%) primarily focused on the European region. Key lessons focused on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability. Enablers and constraints were consistent across regions/organisations. A clear understanding of the regional context, budgets, cultural or language issues, staffing capacity and governmental priorities, is pivotal. An initial workshop inclusive of the various bodies involved in the design, implementation, monitoring or evaluation of programmes is essential. Clear governance structure, with individual responsibilities clear from the beginning, will reduce friction. Secure, long-term funding is also a key aspect of the success of any programme.Conclusion  Operationalisation of regional infectious disease bodies and networks is complicated, but with extensive groundwork, and focus on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability, it is achievable. Ways to promote success are to include as many stakeholders as possible from the beginning, to ensure that context-specific factors are considered, and to encourage employees through capacity building and mentoring, to ensure they feel valued and reduce staff turnover.
       
  • Generating Political Commitment for Regulatory Interventions Targeting
           Dietary Harms and Poor Nutrition: A Case Study on Sugar-Sweetened Beverage
           Taxation in Australia

    • Abstract: Background  Sugar-sweetened beverage (SSB) taxes are an effective public health policy intervention for improving nutrition and public health. Although implemented in over 50 jurisdictions worldwide, this intervention remains vastly underutilised, and in Australia political commitment for such a tax is low. The aim of this study is to understand the politics of SSB taxation in Australia, what factors have constrained political commitment for a tax, and what might enable such commitment in future.Methods  We adopted a case study design, guided by a theoretical framework developed from the political economy of nutrition literature. Data were collected from 16 interviews with informants from multiple sectors, supported by media articles, journal articles, and grey literature. Data were coded and organized by thematic analysis, and synthesised into the final results.Results  Nutrition actors have made significant progress in generating commitment for a SSB tax by producing relevant evidence, raising awareness, advocating for action, employing resonating frames, collaborating with civil society organisations, and forming coalitions increasing their overall cohesion. Nevertheless, political commitment for a SSB tax is low and was found to be impeded by the powerful influence of the food, beverage, and sugar industries, opposition from both major Australian political parties, ideological resistance to regulation, a low quality monitoring and surveillance system for food and nutrition, and limited public advocacy. The influence of nutrition actors was also impeded by weak connections to key policymakers and missed collaborative opportunities with pro-SSB tax organisations.Conclusion  The identification of several impediments provides an explanation for why political commitment for a SSB tax is low in Australia and reveals several opportunities for how it might be generated in the future. Political commitment may come about through, for example, actions to limit the influence of industry in policy decision-making, and by strengthening the existing pro-SSB tax coalition.
       
  • Using Network and Complexity Theories to Understand the Functionality of
           Referral Systems for Surgical Patients in Resource-Limited Settings, the
           Case of Malawi

    • Abstract: Background  A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.Methods  This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period.Results  Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-referral hospital relationships, which could be leveraged to build more collaborative and productive inter- professional relationships in the future.Conclusion  Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.
       
  • Future Directions for Providing Conceptual Clarity Related to Context in
           Implementation; Comment on "Stakeholder Perspectives of Attributes and
           Features of Context Relevant to Knowledge Translation in Health Settings:
           A Multi-Country Analysis"

    • Abstract: In implementation science, contextual inquiry guides the implementation process for successful uptake of evidence- based practices. However, the conceptualization and measurement of context varies across frameworks and stakeholders. To advance implementation science, future efforts to advance the understanding of context should incorporate input from implementation stakeholders through co-creation, elicit stakeholders’ perspectives in low- and middle-income countries to generate a more comprehensive list of determinants, and refine inconsistencies in terminology to promote research synthesis. Greater conceptual clarity and generalizability in contextual inquiry will enable improved communication and collaboration, thus facilitating a shift in focus to development and evaluation of implementation strategies to improve healthcare and health outcomes.
       
  • Donations Made and Received: A Study of Disclosure Practices of
           Pharmaceutical Companies and Patient Groups in Canada

    • Abstract: Given the increasing role of patient groups in pharmaceutical policy making in Canada, this observational study was undertaken to determine whether companies that are members of Innovative Medicines Canada (IMC) list, on their publicly available websites, the names of patient groups that they make donations to and reciprocally, whether patient groups publicly list the names of the companies that they receive donations from. Websites of IMC members were searched for the names of the patient groups receiving donations, value of the donations and year the donations were made. The website of each patient group that was listed as receiving a donation was then searched for information about the name of companies making donations along with the value of the donations, year the donations were made and percent of the patient group’s income represented by the donation. For donations over $50,000, an attempt was made to match donations that companies made to donations that patient groups received. Eleven of 44 IMC members reported making 165 donations to 114 different patient groups. Seventy-nine of these 114 groups reported receiving 373 donations from IMC members. Information about the value of donations, the year that they were given and received and the percent of patient groups’ income that they represented was limited. Donations made and received could not be matched because of the absence of information about the donations. Reporting on websites about donations by both companies and patient groups in Canada is haphazard, inconsistent and incomplete. Reforms are need to both the way that companies and patient groups report donations.
       
  • Irish Media Coverage of COVID-19 Evidence-Based Research Reports From One
           National Agency

    • Abstract: Background  How research findings are presented through domestic news can influence behaviour and risk perceptions, particularly during emergencies such as the COVID-19 pandemic. Monitoring media communications to track misinformation and find information gaps is an important component of emergency risk communication. Therefore, this study investigated the traditional media coverage of nine selected COVID-19 evidence-based research reports and associated press releases published during the initial phases of the pandemic (April to July 2020) by one national agency.Methods  NVivo was used for summative content analysis. ‘Key messages’ from each research report were proposed and 488 broadcast, print, and online media sources were coded at the phrase level. Manifest content was coded and counted to locate patterns in the data (what and how many) while latent content was analysed to further investigate these patterns (why and how). This included the coding of the presence of political and public health actors in coverage.Results  Coverage largely did not misrepresent the results of the reports, however, selective reporting and the variability in the use of quotes from governmental and public health stakeholders changed and contextualised results in different manners than perhaps originally intended in the press release. Reports received varying levels of media attention. Coverage focused on more ‘human-interest’ stories (e.g., spread of COVID-19 by children and excess mortality) as opposed to more technical reports (e.g., focusing on viral load, antibodies, testing, etc.).Conclusion  Our findings provide a case-study of European media coverage of evidence reports produced by a national agency. Results highlighted several strengths and weaknesses of current communication efforts.
       
  • Dropout Analysis of a National Social Health Insurance Program at Pokhara
           Metropolitan City, Kaski, Nepal

    • Abstract: Background  Nepal’s national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9 percent and 38 percent respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with social health insurance program dropout in Pokhara, Nepal.Methods  A cross-sectional household survey of 355 households enrolled for at least one year in the national social health insurance program was conducted. A structured questionnaire was used to conduct face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with social health insurance program dropout were identified using bivariate and multiple logistic regression analyses.Results  The findings of the study revealed a dropout prevalence of 28.2% (95% confidence interval: 23.6%-33.2%). Households having more than five members [adjusted odds ratio (aOR) 2.19, 95% CI: 1.22-3.94], belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95%CI 1.87-10.95), absence of chronic illness in family (aOR 1.95, 95%CI: 1.07-3.59), perceived good health status of the family (aOR 4.21, 95%CI: 1.21-14.65), having private health facility as first contact point (aOR 3.75, 95%CI: 1.93-7.27), poor availability of drugs (aOR 4.75, 95%CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR 3.09, 95%CI: 1.01- 9.49) were statistically significant factors associated with SHI dropout.Conclusion  In Pokhara, more than one-fourth of households have dropped out of the Social Health Insurance Scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members’ reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers’ behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.
       
  • Government Actions and Their Relation to Resilience in Healthcare; What We
           See Is Not Always What We Get; Comment on "Government Actions and Their
           Relation to Resilience in Healthcare During the COVID-19 Pandemic in New
           South Wales, Australia and Ontario, Canada"

    • Abstract: This commentary reviews the publication by Smaggus et al. published in the IJHPM in July 2021 on “Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada” which analysed media releases to identify how governments contributed to Resilience in Healthcare (RiH). We suggest media releases might not be the best data to capture the mechanisms, activities and interactions through which government actions enhance or hinder RiH. RiH recognizes healthcare as a complex sociotechnical system, so studies into fostering capacity for RiH should be designed for complex sociotechnical systems. This means data should be derived from multiple sources to allow for diverse perspectives, and preferably include direct observations to capture the intricacies of backstage interactions.
       
  • Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review
           into Integrated Hospital Strategies

    • Abstract: Background  A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation.Methods  We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospital-wide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies.Results  The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the US. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement, clinical pathways, Lean, Six Sigma and value-based healthcare. Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: 1) strategy, 2) leadership, 3) engagement, 4) reorganization, 5) finances, 6) data and information technology (IT), 7)projects, 8) support, 9) skill development, 10) culture, and 11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection.Conclusion  Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature.
       
  • Neurotrauma Surveillance in National Registries of Low- and Middle-Income
           

    • Abstract: Background  Injury is a major global health problem, causing >5,800,000 deaths annually and widespread disability largely attributable to neurotrauma. 89% of trauma deaths occur in low- and middle-income countries (LMICs), however data on neurotrauma epidemiology in LMICs is lacking. In order to support neurotrauma surveillance efforts, we present a review and analysis of data dictionaries from national registries in LMICs.Methods  We performed a scoping review to identify existing national trauma registries for all LMICs. Inclusion/exclusion criteria included articles published since 1991 describing national registry neurotrauma data capture methods in LMICs. Data sources included PubMed and Google Scholar using the terms “trauma/neurotrauma registry” and country name. Resulting registries were analyzed for neurotrauma-specific data dictionaries. These findings were augmented by data from direct contact of neurotrauma organizations, health ministries, and key informants from a convenience sample. These data were then compared to the WHO minimum dataset for injury (MDI) from the international registry for trauma and emergency care.Results  We identified 15 LMICs with 16 total national trauma registries tracking neurotrauma-specific data elements. Among these, Cameroon had the highest concordance with the MDI, followed by Colombia, Iran, Myanmar and Thailand. The MDI elements least often found in the data dictionaries included helmet use, and alcohol level. Data dictionaries differed significantly among LMICs. Common elements included Glasgow Coma Score, mechanism of injury, anatomical site of injury and injury severity scores. Limitations included low response rate in direct contact methods.Conclusion  Significant heterogeneity was observed between the neurotrauma data dictionaries, as well as a spectrum of concordance or discordance with the MDI. Findings offer a contextually relevant menu of possible neurotrauma data elements that LMICs can consider tracking nationally to enhance neurotrauma surveillance and care systems. Standardization of nationwide neurotrauma data collection can facilitate international comparisons and bidirectional learning among health care governments.
       
  • Changing The Discourse in Ambitions Towards Universal Health Coverage:
           Lessons From Australian Primary Healthcare; Comment on “Universal Health
           Coverage for Non-Communicable Diseases and Health Equity: Lessons From
           Australian Primary Healthcare”

    • Abstract: While Australia’s health system has reached universal health coverage (UHC), recent scholarship points to its strengths and identifies ways it could be more effective and equitable, especially for tackling non-communicable diseases (NCDs). Building on the Australian experience, we add to these perspectives and present pertinent lessons for the quest towards UHC, and for policy makers globally with regard to NCDs. Potential lessons include: the need for i) vigilance – UHC requires ongoing monitoring and evaluation of not only financial risk protection but non-financial barriers and impacts such as forgone care; ii) investment and action now on structural determinants of NCDs and related inequalities to avoid potentially higher (fiscal, social and health) costs in the longer term; and iii) the opportunity for policy makers globally and nationally to revisit their ambitions for UHC to include population health policies/programs beyond essential health services that are required for healthier, more equitable and thriving societies.
       
  • The Effects of Health Sector Fiscal Decentralisation on Availability,
           Accessibility, and Utilisation of Healthcare Services: A Panel Data
           Analysis

    • Abstract: Background  Fiscal Decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality.Methods  This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy.Results  FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients' mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public – rather than private – services, and are more prominent in poorer areas. Conclusion  This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources – as well as the extent of public sector’s retrenchment – coincide with the wealth of the area.
       
  • What Opportunities Exist for Making the Food Supply Nutrition
           Friendly' A Policy Space Analysis in Mexico

    • Abstract: Background  As part of a global policy response for addressing malnutrition, food system actions have been proposed. Within food system interventions, policies directed to supply chains have the potential to increase the availability and affordability of a healthy diet. This qualitative study aimed to identify opportunities to integrate nutrition as a priority into the food supply policy space in Mexico.Methods  Data were collected through analysis of 19 policy documents and 20 semistructured stakeholder interviews. As an analytical framework, we used Policy Space Analysis and embedded the Advocacy Coalition Framework and the steps of the food chain of the conceptual framework of food systems for diets and nutrition.Results  Policy issues relevant to nutrition were viewed differently in the economic and agricultural sectors versus the health sector. Overall, the main policy objective related to nutrition within the economic and agricultural sectors was to contribute to food security in terms of food quantity. Nutrition was an objective in itself only in the health sector, with a focus on food quality. Our policy space analysis reveals an opportunity to promote a new integrated vision with the recent creation of an intersectoral group working on the public agenda for a food system transformation. This newer integrative narrative on food systems presents an opportunity to shift the existing food security narrative from quantity towards considerations of diet quality.Conclusion  The political context and public agenda are favorable to pursue a food system transformation to deliver sustainable healthy diets. Mexico can provide a case study for other low- and middle-income countries for putting nutrition at the center of food policy, despite the ongoing constraints on achieving this.
       
  • The Impact of Drug Trials With Financial Conflict of Interests on the
           Meta-Analyses: A Meta-Epidemiological Study

    • Abstract: Background  Drug trials with potential financial conflict of interests (FCOIs) may influence trial design, drug dosage, comparators, and promising results are more likely to be reported. The objective of this study was to assess the impact of trials with FCOIs on evidence synthesis in meta-analyses (MAs).Methods  A total of 96 MAs from the Cochrane Library about drug trials were investigated. The primary outcomes examined the proportion of conclusions that would change with the exclusion of trials with potential FCOIs. If the proportion of changed conclusions was below the non-inferiority margin of 10%, we considered that it was not inferior to include the trials with potential FCOIs in the MAs.Results  Only 54.17% of MAs reported the funding sources of each included trial, and in 21.88% of MAs, the author-industry- related financial ties of each included trial were reported. When trials with FCOIs were excluded, the changed conclusions of effectiveness and major adverse events were 13.16% and 11.11%, respectively, and the I2 decreased by 13.56% and 10.09%, respectively. For serious adverse events, the exclusion of FCOIs trials did not lead to any change in conclusions; however, the I2 decreased by 24.24%. The impact of trials without reported FCOIs was also examined on evidence synthesis, and the results showed that the changed conclusions of effectiveness and major adverse events were 5.26% and 6.25%, respectively, indicating non-inferiority. However, the I2 increased by 13.60% and 12.37%, respectively.Conclusion  In this meta-epidemiological study, we demonstrated that trials with FCOIs may not only influence the final outcome of MAs but may also increase the heterogeneity of results. It is suggested that all MAs fully report the FCOIs involved in evidence-based research and explore the impact of its FCOIs to better provide a more valuable reference for patients,clinicians, and policy-makers.
       
  • The Politics of Regulating Foods for Infants and Young Children: A Case
           Study on the Framing and Contestation of Codex Standard-Setting Processes
           on Breast-Milk Substitutes

    • Abstract: Background  Breastfeeding is important for the health and development of the child, and for maternal health, in all country contexts. However, global sales of breast-milk substitutes (BMS), including infant, follow-up and toddler formulas, have ‘boomed’ in recent decades. This raises the importance of international food standards established by the Codex Alimentarius Commission (Codex) on the safety, composition and labelling of BMS. Such standards appear to be strongly contested by governments, industry and civil society groups, yet few studies have investigated the politics of Codex standard-setting processes. The aim of this paper is to understand who participates in decision-making, and how actors frame and contest proposals to revise the Codex Standard on Follow-up Formula (FUF).Methods  We adopted a case study design involving two steps. First, we enumerated government, industry, civil society, and international organization stakeholders participating in standard-setting processes of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Second, we conducted a framing analysis of stakeholder inputs during the FUF standard revision in CCNFSDU meetings. Publicly available online meeting reports (2015-2019) were retrieved, analyzed using a theoretical framework, and organized thematically.Results  High-income country (HIC) delegates greatly outnumbered those from other country income categories. Industry representation was higher compared with other observer categories Member state delegations included more industry representation than civil society representation, and were occasionally the only member state delegates. Industry stakeholders framed arguments in terms of trade implications, science, and flexible standards. Civil society groups used public health, science, and pro-breastfeeding frames.Conclusion  Codex BMS standard-setting procedures are dominated by HICs and industry groups. Limited representation of civil society, and of middle- and low-income countries, suggest actions are needed to substantially increase support for their involvement at Codex. Such representation may help to counteract power asymmetries and commercial influences on food standards for infants and young children.
       
  • Strategies to Facilitate Improved Recruitment, Development, and Retention
           of the Rural and Remote Medical Workforce: A Scoping Review

    • Abstract: Background  Medical workforce shortages in rural and remote areas are a global issue. Highincome countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs.Methods  The Arksey and O’Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. PRISMA-P guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates.Results  Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in high-income countries, with only eight studies from low and middle-income countries. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce.Conclusion  This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.
       
  • Implementing Universal and Targeted Policies for Health Equity: Lessons
           From Australia

    • Abstract: Background  Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health-related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.Methods  We synthesised findings across case studies of policy implementation in four policy areas of primary health care, telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access – availability, affordability and acceptability – and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures. Results  Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.Conclusion  While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.
       
  • Evidence-Informed Deliberative Processes for Legitimate Health Benefit
           Package Design − Part I: Conceptual Framework

    • Abstract: Background  Countries around the world are increasingly rethinking the design of their health benefit packages to achieve universal health coverage and health technology assessment (HTA) bodies support governments in these decisions. Coverage decision-making is an intrinsically complex and value-laden political process, but value frameworks currently employed by HTA bodies do not sufficiently account for this complex reality. Methods  Several years ago, evidence-informed deliberative processes (EDPs) were developed to address this issue. An EDP is a practical and stepwise approach for HTA bodies to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, and to interpret available evidence on these values. We further developed the conceptual framework and initial 2019 guidance based on academic knowledge exchange, analysing practices of HTA bodies, surveying HTA bodies and experts around the globe, and implementation of EDPs in several countries around the world.Results  EDPs stem from the general concept of legitimacy, which is translated into four elements – stakeholder involvement ideally operationalised through stakeholder participation with deliberation; evidence-informed evaluation; transparency; and appeal. The 2021 practical guidance distinguishes six practical steps of a HTA process and provides recommendations on how these elements can be implemented in each of these steps. Conclusion  There is an increased attention for legitimacy, deliberative processes for HTA and health benefit package design, but the development of theories and methods for such processes remain behind. The added value of EDPs lies in the operationalisation of the general concept of legitimacy into practical guidance for HTA bodies.
       
  • Evidence-Informed Deliberative Processes for Health Benefit Package Design
           – Part II: A Practical Guide

    • Abstract: Background  Countries around the world are using health technology assessment (HTA) for health benefit package design. Evidence-informed deliberative processes (EDPs) are a practical and stepwise approach to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. This paper reports on the development of practical guidance on EDPs, while the conceptual framework of EDPs is described in a companion paper.Methods  The first guide on EDPs (2019) is further developed based on academic knowledge exchange, surveying 27 HTA bodies and 66 experts around the globe, and the implementation of EDPs in several countries. We present the revised steps of EDPs and how selected HTA bodies (in Australia, Brazil, Canada, France, Germany, Scotland, Thailand and the United Kingdom) organize key issues of legitimacy in their processes. This is based on a review of literature via PubMed and HTA bodies’ websites.Results  HTA bodies around the globe vary considerable in how they address legitimacy (stakeholder involvement ideally through participation with deliberation; evidence-informed evaluation; transparency; and appeal) in their processes. While there is increased attention for improving legitimacy in decision-making processes, we found that the selected HTA bodies are still lacking or just starting to develop activities in this area. We provide recommendations on how HTA bodies can improve on this.Conclusion  The design and implementation of EDPs is in its infancy. We call for a systematic analysis of experiences of a variety of countries, from which general principles on EDPs might subsequently be inferred.
       
  • Epidemics, Lockdown Measures and Vulnerable Populations: A Mixed-Methods
           Systematic Review of the Evidence of Impacts on Mother and Child Health in
           Low- And- Lower Middle-Income Countries

    • Abstract: Background  The aim of this research was to synthetise the existing evidence on the impact of epidemic-related lockdown measures on women and children’s health in low-and-lowermiddle-income countries. Methods  A mixed-methods systematic review was conducted of qualitative, quantitative and mixed-methods evidence. Between November 1st-10th 2021, seven scientific databases were searched. The inclusion criteria were that the paper provided evidence on the impact of lockdown and related measures, focused on low-and-lower-middle-income countries, addressed impacts on women and child’s health, addressed epidemics from 2000-2020, was peer-reviewed, provided original evidence, and was published in English. The Joanne Briggs Institute’s critical appraisal tools were used to assess the quality of the studies, and the PRISMA guidelines for reporting. The evidence from the papers was grouped by type of lockdown measure and categories of impact, using a narrative data-based convergent synthesis design. Results  The review process identified 46 papers meeting the inclusion criteria from 17 countries whichall focussed on the COVID-19 and Ebola epidemics. The evidence on the decrease of utilisation of health services showed plummeting immunisation rates and faltering use of maternal and perinatal services, which was linked to a growth of premature deaths. Impacts on the mental health of children and women is well-established, with lockdowns associated with surges in depression, anxiety and low life satisfaction. Vulnerability may be compounded by lockdowns, as livelihoods are disrupted, and poverty levels increase. Conclusion  Limitations included that searches were conducted in late-2020 as new research was being published, and that some evidence not published in English may have been excluded. Epidemic-related lockdown measures carry consequences for the health of women and children in lower-income settings. Governments will need to weigh the trade-offs of introducing such measures and consider policies to mitigate their impacts on the most vulnerable.
       
  • Creating a Global Legal and Policy Database and Document Repository:
           Challenges and Lessons Learned From the World Health Organization Sexual,
           Reproductive, Maternal, Newborn, Child and Adolescent Health Policy Survey
           

    • Abstract: The World Health Organization (WHO) has collected information on policies on sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) over many years. Creating a global survey that works for every country context is a well-recognized challenge. A comprehensive SRMNCAH policy survey was conducted by WHO from August 2018 through May 2019. WHO regional and country offices coordinated with Ministries of Health and/or national institutions who completed the questionnaire. The survey was completed by 150 of 194 WHO Member States using an online platform that allowed for submission of national source documents. A validation of the responses for selected survey questions against content of the national source documents was conducted for 101 countries (67%) for the first time in the administration of the survey. Data validation draws attention to survey questions that may have been misunderstood or where there was a lot of missing data, but varying methods for validating survey responses against source documents and separate analysis of laws from policies and guidelines may have hindered the overall conclusions of this process. The SRMNCAH policy survey both provided a platform for countries to track their progress in adopting WHO recommendations in national SRMNCAH-related legislation, policies, guidelines and strategies and was used to create a global database and searchable document repository. The outputs of the SRMNCAH policy survey are resources whose importance will be enriched through policy dialogues and wide utilization. Lessons learned from the methodology used for this survey can help to improve future updates and inform similar efforts.
       
  • Measuring the Protective Effect of Health Insurance Coverage on
           Out-of-Pocket Expenditures During the COVID-19 Pandemic in the Peruvian
           Population

    • Abstract: Background  Health insurance coverage is expected to protect individuals from out-ofpocket (OOP) expenditures, potentially preventing them from falling into poverty. However, to date, the effect of health insurance on OOP spending during the COVID-19 pandemic has not been fully explored. This study aimed to estimate differences in the proportion and the amount of OOP expenditures among Peruvians during the pre- and post-mandatory lockdown response to COVID-19 in 2020 according to the health insurance coverage status. Methods  This study utilized repeated cross-sectional data from the National Household Survey on Living and Poverty Conditions from the first quarter of 2017 until the fourth quarter of 2020. The outcomes were i) the proportion of individuals who incurred OOP expenditures and ii) the monetary value of OOP expenditures. An interrupted time series analysis (ITS) and a quasi-experimental difference-in-difference (DID) analysis were performed to examine the outcomes among the control (individuals without health insurance) and treatment groups (individuals with health insurance) after the COVID-19 pandemic. Results  ITS analysis showed that the proportion of individuals reporting OOP expenditures after implementation of mandatory lockdown due to COVID-19 in Peru decreased in both groups, but no difference in the slope trend was found (p=0.916). The average quarterly amount of OOP spending increased in both groups, but no difference in the slope trend was found (p=0.073). Lastly, the DID analysis showed that the mandatory lockdown was associated with a higher amount of OOP, but there was no evidence to indicate that the higher amount was different between the control and treatment groups. Conclusion  The mandatory lockdown in response to the COVID-19 was associated with a higher amount of OOP expenditures and a lower likelihood of incurring OOP expenditures. However, our findings suggest that health insurance coverage does not lower OOP expenditures or reduce the likelihood of incurring OOP expenditures.
       
  • Social Media as a Tool for Consumer Engagement in Hospital Quality
           Improvement and Service Design: Barriers and Enablers for Implementation

    • Abstract: Background  Social media can be used to engage consumers in hospital service design and quality improvement (QI) activities, however its uptake may be limited by a lack of guidance to support implementation. This article presents the perceived barriers and enablers in using social media for consumer engagement derived from an interview study with public hospital stakeholders. Methods  Semi-structured interviews with 26 Australian hospital service providers and consumer representatives. Data were analysed using a deductive content analysis method. Results  Data were collected between October 2019 and April 2020. Facebook was the platform most commonly used for consumer engagement activities. Barriers and enablers to social media-based consumer engagement were identified. The barrier themes were 1) fears and concerns; 2) lack of skills and resources for social media engagement; 3) lack of organisational processes and support; and 4) problems with social media platforms and the changing social media landscape. The enabler themes were: 1) hospitals facilitating access and use; 2) making discussions safe; 3) cultivating a social media community; and 4) building on success.    Conclusion  Using social media to facilitate consumer engagement in hospital service design and QI activities is feasible and acceptable to service providers and consumers. Hospitals and their executives can create a supportive environment for social media-based engagement activities through developing clear governance systems and providing training and support to all users. Consumers need to be involved in co-designing social media-based activities and determining which forms of engagement are accessible and acceptable. For some consumers and service providers, barriers such as a lack of resources and distrust of social media companies might mean that social media-based engagement will be less acceptable for them. Because of this it is important that hospitals provide complementary methods of engagement (e.g., face-to-face) alongside social media-based methods.
       
  • Attributes Underlying Patient Choice for Telerehabilitation Treatment: A
           Mixed-Methods Systematic Review to Support a Discrete Choice Experiment
           Study Design

    • Abstract: Background  Across most healthcare systems, patients are the primary focus. Patient involvements enhance their adherence to treatment, which in return, influences their health. The objective of this study was to determine the characteristics (i.e., attributes) and associated levels (i.e., values of the characteristics) that are the most important for patients regarding telerehabilitation healthcare to support a future discrete choice experiment (DCE) study design. Methods  A mixed-methods systematic review was conducted from January 2005 to the end of July 2020 and the search strategy was applied to five different databases. The initial selection of articles that met the eligibility criteria was independently made by one researcher, two researchers verified the accuracy of the extracted data, and all researchers discussed about relevant variables to include. Reporting of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Mixed Methods Appraisal Tool was used to assess the quality of the study. A qualitative synthesis was used to summarize findings. Results  From a total of 928 articles, 11 [qualitative (n=5), quantitative (n= 3) and mixed-methods (n= 3) design] were included, and 25 attributes were identified and grouped into 13 categories: Accessibility, Distance, Interaction, Technology experience, Treatment mode, Treatment location, Physician contact mode, Physician contact frequency, Cost, Confidence, Ease of use, Feeling safer, and Training session. The attributes levels varied from two to five. The DCE studies identified showed the main stages to undertake these types of studies. Conclusion  This study could guide the development of interview grid for individual interviews and focus groups to support a DCE study design in the telerehabilitation field. By understanding the characteristics that enhance patients’ preferences, health care providers can create or improve telerehabilitation programs that provide high-quality and accessible care. Future research via a DCE is needed to determine the relative importance of the attributes.
       
  • Six Honest Serving Matters, Teaching Us all We Need to Know About Context
           in Knowledge Implementation'; Comment on "Stakeholder Perspectives of
           Attributes and Features of Context Relevant to Knowledge Translation in
           Health Settings: A Multi-Country Analysis"

    • Abstract: While context is a vital factor in any attempt to study knowledge translation or implement evidence in healthcare, there is a need to better understand the attributes and relations that constitute context. A recent study by J. Squires et al. investigates such attributes and definitions, based on 39 stakeholder interviews across Australia, Canada, the UK, and the USA. Sixteen attributes, comprising 30 elements suggested as new findings, are proposed as the basis for a framework. This commentary argues for the need to incorporate more perspectives but also suggests an initial taxonomy rather than a framework, comprising a wider range of stakeholders and an enhanced understanding of how context elements are related at different levels and how this affects implementation processes. Aligning with person- centred care, this must include not only professionals but also patients and their next of kin, as partners in shaping more evidence-based healthcare.
       
  • The Economic Value of Non-Professional: A Europe-Wide Analysis

    • Abstract: Background  This paper had two aims. Firstly, to provide a broader view of the profile of non-professional caregivers in Europe, and secondly, to estimate the economic value of the non-professional caregiving. Methods  The European Quality of Life Survey 2016/17, carried out by Eurofound, was used. The target population of the survey was adults who care for a relative or friend in a total of 33 European countries. The opportunity cost method was used to estimate the economic value of caregiving, in which two of the activities forgone were analysed: paid activities (restricted to caregivers who were employed), for which the average gross wage of each country was used; and unpaid activities, for which the minimum gross wage of each country was used. Results  There were more than 76 million non-professional caregivers in Europe that provides care for a relative or friend. This figure represents 12.7% of the population in Europe. The estimated time devoted to non-professional care in Europe reached 72,301.5 million hours in 2016. Sharp differences were found among countries. The economic value of that time is estimated at 576,000 million of euros, which represented about 3.63% of Europe’s GDP. Conclusion  This study show the very important number of resources dedicated to the non-professional care of dependent people and their economic valuation. These results may be helpful in prospective analyzes estimating future needs on professional and nonprofessional and for designing of long-term care policies in Europe.
       
  • What Managers Find Important for Implementation of Innovations in the
           Healthcare Sector - Practice Through Six Management Perspectives

    • Abstract: Background  There is a growing expectation that many health organisations will implement innovations. One obstacle for innovative ideas to have an impact on the healthcare system in practice seems to be difficulties in the implementation phase. There is a lack of concretization of theoretical perspectives related to implementation of innovations. The research question answered by this article is: Which enabling factors can facilitate the specific step of moving from idea generation to implementation in a healthcare context' Methods  The research was carried out with a qualitative action research methodology where the researchers took part in the innovation implementation project. The authors of this article were part of a collaborative innovation implementation project involving approximately 54 practitioners. The project was run by five stakeholders: 1) the Division of Assistive Technology in the Dalarna County Council Regional Healthcare Administration 2) the Habilitation Division 3) the Division for Home Care and Social Services in the municipality of Leksand 4) Dalarna University and 5) Uppsala University. Through a ‘Pearl growing’ technique six implementation management perspectives were, as a framework, identified and presented for the practitioners. The practitioners worked further to concretize these six perspectives. Data was collected through five workshops and collaborations between the researchers and the practitioners. Data was clustered regarding what the managers want to achieve within these six perspectives (ideal situation) and the main means for reaching this situation.   Results   The study underlying this article generated 35 concrete enabling factors for successful innovation implementation, distributed over the initially presented six theoretical perspectives. Conclusion  Concretizing management principles into enabling factors shows, on the one hand, that the theoretical principles have practical value, but on the other that they must be adopted to the specific circumstances of each organization, and that too abstract principles can hardly be operationalized.
       
  • Conceptualizing Context and Intervention as a System In Implementation
           Science: Learning From Complexity Theory; Comment on "Stakeholder
           Perspectives of Attributes and Features of Context Relevant to Knowledge
           Translation in Health Settings: A Multi-Country Analysis"

    • Abstract: In implementation science, implementation has been widely theorized and assessed. Context, on the other hand, usually played a minor role in the field and was usually conceptualized in a rather positivist way. Despite some promising efforts, there is a strong need to continue building theory on context and operationalizing the concept in implementation practice. I argue for the benefit of integrating complexity theory into our understanding of context in order to further our thinking about context and intervention as a system. This should be reflected by the way in which we build theory as well as apply this theory by employing methods that adequately account for complexity in systems.
       
  • Clinical Decision Support and New Regulatory Frameworks for Medical
           Devices: Are We Ready for It' - A Viewpoint Paper

    •  
  • How to Realize the Benefits of Point-of-Care Testing at the General
           Practice: A Comparison of Four High-Income Countries

    • Abstract: Background  In some countries, such as the Netherlands and Norway, point of care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices (GPs) in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations. Methods  The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country. Results  The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for GPs aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support. Conclusion  Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.
       
  • A Review of the User Fees Policy for Primary Healthcare Consultations in
           

    • Abstract: Background The Government of Botswana introduced user-fees for primary healthcare consultations in 1975. The policy has remained in place since then, although the fee has remained largely unaltered despite rising inflation. Early reviews of the policy pointed to problems in its implementation, but there has been no evaluation in the past 20 years. The aim of this study was to review the policy to assess whether documented issues with its implementation have been addressed. Methods This qualitative study involved interviews with 32 key informants: 18 policy makers and 14 front-line revenue collectors. Data were analysed thematically using a template approach with constructs from an established organizational capacity assessment framework used as predetermined categories to guide data collection and analysis. Results Limited administrative and management capacity has been a major hindrance to effective implementation of the policy. The lack of infrastructure for effective revenue collection led to misappropriation of funds. Lack of clear guidelines for health facilities on how to implement the policy generated interdepartmental conflicts. Study participants believed the current policy was not cost-effective since the cost of collecting fees exceeded the revenue it generated. Conclusion Should the Botswana Government wish to persist with the policy then it needs to improve organizational capacity to collect and manage revenues. However, policy thinking since the turn of the century has turned away from user- harges as they impede the move towards universal access. It is timely therefore to consider alternative financing approaches that are more effective and equitable means of paying for healthcare.
       
  • Developing Framework and Strategies for Capacity Building to Apply
           Evidence-Informed Health Policy-making in Iran: Mixed Methods Study of
           SAHSHA Project

    • Abstract: Background SASHA, which stands for “Evidence-Informed Health Policymaking (EIHP)” in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidence-based and context- aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran. Methods This was a qualitative study, which was informed by a literature review of pull efforts’ capacity building programs (CBPs). Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method. Results  We extracted data from 11 articles. The objectives of CBPs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. CBPs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain underresearched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policymakers incorporates strategies at three levels: CBP, organizational structure, and health system context. Conclusion  To prepare the context of Iranian healthcare organizations for CBPs, the conflict of interests needs to be resolved, decision- makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.
       
  • Management of Conflicts of Interest in WHO’s Consultative Processes
           on Global Alcohol Policy

    • Abstract: Background  The World Health Organization (WHO) has engaged in consultations with the alcohol industry in global alcohol policy development, including currently a draft action plan to strengthen implementation of the Global strategy to reduce the harmful use of alcohol. WHO’s Framework for Engagement with Non-State Actors (FENSA) is an organization-wide policy that aims to manage potential conflicts of interest in WHO’s interactions with private sector entities, non-governmental institutions, philanthropic foundations and academic institutions. Methods  We analysed the alignment of WHO’s consultative processes with non-state actors on “the way forward” for alcohol policy and a global alcohol action plan with FENSA. We referred to publicly accessible WHO documents, including the Alcohol, Drugs and Addictive Behaviours Unit website, records of relevant meetings, and other documents relevant to FENSA. We documented submissions to two web-based consultations held in 2019 and 2020 by type of organization and links to the alcohol industry. Results  WHO’s processes to conduct due diligence, risk assessment and risk management as required by FENSA appeared to be inadequate. Limited information was published on nonstate actors, primarily the alcohol industry, that participated in the consultations, including their potential conflicts of interest. No minutes were published for WHO’s virtual meeting with the alcohol industry, suggesting a lack of transparency. Organizations with known links to the tobacco industry participated in both web-based consultations, despite FENSA’s principle of non-engagement with tobacco industry actors.   Conclusion  WHO’s consultative processes have not been adequate to address conflicts of interest in relation to the alcohol industry, violating the principles of FENSA. Member states must ensure that WHO has the resources to implement and is held accountable for appropriate and consistent safeguards against industry interference in the development of global alcohol policy.
       
  • “A Promise Unfulfilled”: Stakeholder Influence and the 2018 UN
           High-Level Meeting on NCDs; Comment on "Competing Frames in Global Health
           Governance: an Analysis of Stakeholder Influence on the Political
           Declaration on Non-Communicable Diseases

    • Abstract: In recognition of the global burden of noncommunicable diseases (NCDs), the past decade has seen three U.N. High Level Meetings on NCDs. Yet progress in terms of political or financial commitments has been very slow. At the 2018 meeting, a political declaration was approved but featured language that had been watered down in terms of commitments. In "Competing Frames of Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases," Suzuki et al analyze the documents that were submitted by Member States, NGOs and the private sector during the consultation period and conclude that the private sector and several high-income countries appeared to oppose regulatory frameworks for products associated with NCDs , that wealthier countries resisted financing commitments, and that general power asymmetries affected the final document. This comment supports their findings and provides additional considerations for why the NCD response has yet to produce significant commitments.
       
  • Usefulness of Home Screening for Promoting Awareness of Impaired Glycemic
           Status and Utilization of Primary Care in a Low Socio-Economic Setting: A
           Follow-Up Study in Reunion Island

    • Abstract: Background  Low socio-economic settings are characterized by high prevalence of diabetes and difficulty in accessing healthcare. In these contexts, proximity health services could improve healthcare access for diabetes prevention. Our primary objective was to evaluate the usefulness of home screening for promoting awareness of impaired glycemic status and utilization of primary care among adults aged 18-79 in a low socio-economic setting. Methods  This follow-up study was conducted in 2015-2016 in Reunion Island, a French overseas department in the Indian Ocean. Enrollment and screening occurred on the same day at the home of participants (N = 907). Impaired glycemic status was defined as [glycated hemoglobin (HbA1c) ≥5.7%] OR [fasting capillary blood glucose (FCBG) ≥1.10 g/L] OR [HbA1c = 5.5-5.6% and FCBG = 1.00-1.09 g/L]. Medical, socio-cultural, and socio-economic characteristics were collected via a face- to-face questionnaire. A one-month telephone follow-up survey was conducted to determine whether participants had consulted a general practitioner (GP) for confirmation of screening results. A multinomial polytomous logistic regression model was used to identify factors independently associated with non-use of GP consultation for confirmation of screening results and nonresponse to the telephone follow-up survey. Results  Prevalence of glycemic abnormalities was 46.0% (95% CI = 42.7-49.2%). Among participants with impaired glycemic status (N = 417), 77.7% (95% CI = 73.7-81.7%) consulted a GP for confirmation of screening results, 12.5% (95% CI = 9.3-15.6%) did not, and 9.8% failed to respond to the follow-up survey. Factors independently associated with nonuse of GP consultation for confirmation of screening results were self-reported unwillingness to consult a GP (adjusted odds ratio [OR]: 4.86, 95% CI = 1.70-13.84), usual GP consultation frequency of less than once a year (adjusted OR: 4.13, 95% CI = 1.56-10.97), and age 18-39 years (adjusted OR: 3.09, 95% CI = 1.46-6.57). Conclusion  Home screening for glycemic abnormalities is a useful proximity health service for diabetes prevention in low socio- economic settings. Further efforts, including health literacy interventions, are needed to increase utilization of primary care.
       
  • Financing Strategies to Facilitate Access to High-Cost Anticancer Drugs: A
           Systematic Review of the Literature

    • Abstract: Background  Each country manages access to anticancer drugs differently due to variations in the structure and financing of the health system, but a summary of the various strategies used is absent. This study aimed to review and summarize financing strategies implemented across countries to facilitate access to high-cost anticancer drugs. Methods  We conducted a systematic review of articles referenced in PubMed, Embase, and Web of Science through May 12, 2021. Articles published in the English language from 2000 that describe strategies implemented in different countries to facilitate access to high-cost anticancer drugs were included. Letters, news articles, and proposed strategies were excluded. Quality assessment was not performed as we aimed to summarize the strategies. Data were analyzed by thematic analysis. A review protocol was registered at PROSPERO (CRD42018068616). Results  The review included 204 studies from 176 countries. Three themes of financing strategies were identified: 1) Basic pharmaceutical reimbursement and pricing policies, 2) Alternative funding strategies specific to high-cost drugs, and 3) Financial assistance for individual patients. Access in most countries depends mainly on basic pharmaceutical reimbursement policies (165 of 176 countries). Apart from that, high-income countries tended to use funding strategies targeting high-cost drugs (72% of high-income countries vs 0-24% of the rest), such as Managed Entry Agreements or dedicated funds for highcost drugs. In contrast, lower-income countries tended to implement financial assistance programs for cancer patients as a tool to increase access (32% of high-income countries vs 62-79% of the rest).  Conclusion  Many countries have implemented a combination of strategies to increase access to high-cost anticancer drugs. Most low- and middle-income countries utilized placement of anticancer drugs on a national list of essential medicines and patient assistance programs to facilitate access, while many high-income countries implemented a broader range of strategies.
       
  • Bio-Politics and Calculative Technologies in COVID Governance: Reflections
           From England

    • Abstract: Background  Through the extensive use of public media, the government of England was heavily involved in encouraging and instructing people on how to manage their life during COVID-19. This model of health emergency governance replicates the practice of ‘calculative technologies’ and ‘bio-politics’ embedded in population management. Previous research on COVID-19 governance both in the UK and beyond provides varied revelations on broader ‘technologies of government’ and bio-politics by numerous governments. However, rarely have any studies explicitly and distinctively highlighted the unique ‘calculative technologies” mobilised by governments within their bio-politically designed “technologies of government” to compel the populations to manage their lives under their COVID guidance. The paper therefor examines how the UK government deployed “calculative technologies”, as part of its strategies of health governance and governmentality during the first wave of COVID-19 in England. Methods  This study uses document analysis as its data collection method. Its review includes documents, press releases, social media disclosures and health guidance issued by the UK government from March to December, 2020. The data are analysed employing the Foucault’s governmentality and bio-political scholarship. Results  The paper’s findings reveal the UK government’s use of integrated calculative technologies of self-governance in the form of risk calculations and metrices/statistics (e.g. death tolls, infection rates), performance management (e.g. two metre social distancing, and hand washing for twenty seconds) and discipline and control (e.g. fourteen days selfisolation), in addition to a more conventional top-down, managerial decision-making process adopted in the past. By these newly initiated “calculative technologies”, the government has “bio-politically” governed the behaviours and lifestyles of vulnerable community members, health workers and general public at a distance, inculcating selfmanagement and individualisation of responsibility. Conclusion  The newly adopted calculative technologies used by the UK government created a multi-faceted discourse of obligations, entitlements and scale of engagement, and facilitated directions about what people should do to protect themselves and others from the spread of the virus. Overall, the overtly and idiosyncratically used calculative technologies resemble a unique ‘art of government’ and produce a set of ‘bio-political’ interventions enforcing the populations to manage their own wellbeing and governing them at a distance during COVID-19.
       
  • The Effects of Cost Containment and Price Policies on Pharmaceutical
           Expenditure in South Korea

    • Abstract: Background Policymakers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea. Methods We constructed the longitudinal dataset from 2008-2017 for 11,849 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies’ implementation. Results Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The top-spending clinics showed the highest rate of increase in drug costs. Conclusion Future policy interventions can maximize their effects by targeting high-spending providers.
       
  • Powerful Allies and Weak Consensus: Towards a Deeper Understanding of how
           Health-Harming Industries Seek to Influence Global Health Governance;
           Comment on "Competing Frames in Global Health Governance: An Analysis of
           Stakeholder Influence on the Political Declaration on Non-Communicable
           Diseases"

    • Abstract: Suzuki et al. have identified commonalities in the policy positions adopted at a global forum by commercial sector actors and high-income countries, on the one hand, and nongovernmental organizations and low- and middle-income countries, on the other, in ways that may allow commercial sector actors to block or delay evidence-based policies through the creation of political controversy. The ability of industry actors to draw on the support of the most politically and economically powerful countries for their favoured policy agenda is an important contribution to understanding the dynamics of global health governance in the area of non-communicable diseases and beyond. Here we assess the relevance of this paper for the field of corporate actors’ research and the potential avenues this opens up for further study. More specifically we emphasize the need for comparative, cross disciplinary research to examine the power of heath- harming industries and the relevance of these findings for decolonizing global health.
       
  • Reiterating the Importance of Publicly Funded and Provided Primary Health
           Care for Non-Communicable Diseases: The Case of India; Comment on
           “Universal Health Coverage for Non-communicable Diseases and Health
           Equity: Lessons From Australian Primary Healthcare”

    • Abstract: India has established Health and Wellness Centres (HWCs) and appointed Mid-level Healthcare Providers (Community Health Officers) to provide free and comprehensive primary health care, through screening, prevention, control, management and treatment for non-communicable diseases (NCDs), in addition to existing services for communicable diseases, and reproductive and child health. The range of services being provided and the number of people accessing ambulatory care in these government centres have increased, leading to more equitable healthcare access and financial protection. In policy debates, contestations exist prioritising between primary health care or hospital services, and between publicly-provided healthcare or privatised and “purchased” services. Nationally and globally the influence of industries and corporations in health governance has weakened the response against NCDs. Primary health care initiatives for NCDs must be publicly funded and provided, located within communities, and necessitate action on the determinants of health. The experiences from Australia (a High-Income Country) and India (a Low-and Middle-Income Country) amply illustrate this.
       
  • Designing a Healthy Food-Store Intervention; A Co-Creative Process Between
           Interventionists and Supermarket Actors

    • Abstract: BackgroundWithout consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes. Methods  We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis. Results  We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor. Conclusion  Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.
       
  • Prohibit, Protect, Or Adapt' The Changing Role of Volunteers in
           Palliative and Hospice Care Services during the COVID-19 Pandemic. A
           Multinational Survey (Covpall)

    • Abstract: Background  Volunteers are common within palliative care services, and provide support that enhances care quality. The support they provided, and any role changes, during the COVID-19 pandemic are unknown. The aim of this study is to understand volunteer deployment and activities within palliative care services, and to identify what may affect any changes in volunteer service provision, during the COVID-19 pandemic. Methods  Multi-national online survey disseminated via key stakeholders to specialist palliative care services, completed by lead clinicians. Data collected on volunteer roles, deployment, and changes in volunteer engagement. Analysis included descriptive statistics, a multivariable logistic regression, and analysis of free-text comments using a content analysis approach. Results  458 respondents: 277 UK, 85 rest of Europe, and 95 rest of the world. 68.5% indicated volunteer use pre-COVID-19 across a number of roles (from 458): direct patient facing support (58.7%), indirect support (52.0%), back office (48.5%) and fundraising (45.6%). 11% had volunteers with COVID-19. Of those responding to a question on change in volunteer deployment (328 of 458) most (256/328, 78%) indicated less or much less use of volunteers. Less use of volunteers was associated with being an in-patient hospice, (OR=0.15, 95% CI = 0.07-0.3 p<.001). This reduction in volunteers was felt to protect potentially vulnerable volunteers, with policy changes preventing volunteer support. However, adapting was also seen where new roles were created, or existing roles pivoted to provide virtual support. Conclusion  Volunteers were mostly prevented from supporting many forms of palliative care which may have quality and safety implications given their previously central roles. Volunteer re-deployment plans are needed that take a more considered approach, using volunteers more flexibly to enhance care while ensuring safe working practices. Consideration needs to be given to widening the volunteer base away from those who may be considered to be most vulnerable to COVID-19.
       
  • The COVID-19 System Shock Framework: Capturing Health System Innovation
           During The COVID-19 Pandemic

    • Abstract: Background  COVID-19 has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children’s Hospitals Network (SCHN), the largest provider of children’s health services in the Southern hemisphere. Methods  We used ethnographic methods, guided by the COVID-19 System Shock Framework, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the Emergency Operations Centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN’s response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN. Results  The CSSF captured SCHN’s complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN’s response to the pandemic included principles of equity of health care delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN’s resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision. Conclusion  Using the CSSF, we found that SCHN’s ability to innovate was key to ensuring its resilience during the pandemic.
       
  • The Effect of Governmental Health Measures on Public Behaviour during the
           COVID-19 Pandemic Outbreak

    • Abstract: Background  The COVID-19 pandemic resulted in radical changes in many aspects of life. To deal with this, each country has implemented continuous health measures from the beginning of the outbreak. Discovering how governmental actions impacted public behaviour during the outbreak stage is the purpose of this study. Methods  This study uses a hybrid large-scale data visualisation method to analyse public behaviour (epidemic concerns, self- protection, and mobility trends), using the data provided by multiple authorities. Meanwhile, a content analysis method is used to qualitatively code the health measures of three countries with severe early epidemic outbreaks from different continents, namely China, Italy, and the United States. Eight dimensions are coded to rate the mobility restrictions implemented in the above countries. Results  (1) Governmental measures did not immediately persuade the public to change their behaviours during the COVID-19 epidemic. Instead, the public behaviour proceeded in a three-phase rule, which is typically witnessed in an epidemic outbreak, namely the wait-andsee phase, the surge phase and the slow-release phase. (2) The strictness of the mobility restrictions of the three countries can be ranked as follows: Hubei Province in China (with an average score of 8.5 out of 10), Lombardy in Italy (7.125), and New York State in the United States (5.375). Strict mobility restrictions are more likely to cause a surge of population outflow from the epidemic area in the short term, whereas the effect of mobility restrictions is positively related to the stringency of policies in the long term. Conclusion  The public showed generally lawful behaviour during regional epidemic outbreaks and blockades. Meanwhile public behaviour was deeply affected by the actions of local governments, rather than the global pandemic situation. The contextual differences between the various countries are important factors that influence the effects of the different governments’ health measures.
       
  • Commercial Influence on Political Declarations: The Crucial Distinction
           Between Consultation and Negotiation and the Need for Transparency in
           Lobbying; Comment on “Competing Frames in Global Health Governance: An
           Analysis of Stakeholder Influence on the Political Declaration on
           NonCommunicable Diseases”

    • Abstract: Suzuki and colleagues’ rare and elaborate analysis of the political processes behind the 2018 UN Non-communicable Diseases (NCD) Declaration discloses various pathways towards influencing global public health policies. Their study should be a wake-up call for further scientific political scrutiny and analysis, including clearly distinguishing between consultations such as UN multi-stakeholder hearings preceding high-level meetings and the actual negotiating and decision making process. While stakeholder positions at interactive hearings are documented and published and thus made transparent, the negotiating process among member states is not publicly known. The extent to which intergovernmental negotiations are influenced at country or regional levels by commercial interests through direct and indirect lobbying outside of public consultations should be given more attention. Lobby registers should be implemented more stringently and legislative footprints required and applied not only to legally binding but also to internationally important documents such as political declarations.
       
  • New Directions in Global Health: How Sweden Can Advance Healthier
           Populations

    •  
  • People’s Voice and Civil Society Participation as a Core Element of
           Universal Health Coverage Reforms: Review of Experiences in Iran

    • Abstract: Health governance challenges can make or break Universal Health Coverage (UHC) reforms. One of the biggest health governance challenges is ensuring meaningful participation and adequately reflecting people’s voice in health policies and implementation. Recognizing this, Iran’s Health Transformation Plan (HTP) lays out the country’s blueprint for UHC with an explicit emphasis on the ‘socialization of health’. ‘Socialization’ is seen as a key means to contribute to HTP objectives, meaning the systematic and targeted engagement of the population, communities, and civil society in health sector activities. Given its specific cultural and historical context, we sought to discern what notions such as ‘civil society’, ‘non-governmental organization’, etc. mean in practice in Iran, with the aim of offering policy options for strengthening and institutionalizing public participation in health within the context of the HTP. For this, we reviewed the literature and analysed primary qualitative data. We found that it may be more useful to understand Iranian civil society through its actions, i.e. defined by its motivation and activities rather than the prevailing international development understanding of civil society as a structure which is completely independent of the state. We highlight the blurry boundaries between the different types of civil society organizations and government institutions and initiatives, as well as high levels of overlaps and fragmentation. Reducing fragmentation as a policy goal could help channel resources more efficiently towards common HTP objectives. The national health assembly model which was first launched in 2017 offers a unique platform for this coordination role, and could be leveraged accordingly.
       
  • Effect of Health Shocks on Poverty Status in South Korea: Exploring the
           Mechanism of Medical Impoverishment

    • Abstract: Background  South Korea has the highest out-of-pocket burden for medical expenses among the Organisation for Economic Co- operation and Development (OECD) member countries and has no formal sickness benefit system, along with United States and Switzerland, greatly increasing the risk of poverty due to a sudden illness. Methods  We identify the causal effect of health shocks on poverty status and explore the mechanisms of medical impoverishment by analyzing longitudinal data from 13 670 households that participated in the representative Korean Welfare Panel Study (KOWEPS) from 2007 to 2016. In this study, we define a health shock as a case in which no household members were hospitalized in the previous year, but together they had more than 30 days of hospitalization in this year. The propensity score matching method was combined with a mediation analysis in this work. Results  The proportion of households in absolute poverty increased by 4.6–8.0 percentage points among households that experienced a health shock compared with matched controls. The selection effects due to health shock were estimated to be 5.6–8.2 percentage points. On average, a sudden hospitalization reduces annual non-medical expenditures and equivalized disposable income by just over 3.2 million KRW (2500 USD) and 1.2 million KRW (1000 USD), respectively. Health shock induces impoverishment after one year through both the medical expense and work capacity pathways, which explain 12.8% and 12.8% of the total effect, respectively. However, when we decompose the mediation effect of a health shock on poverty status after two years, we find that a health shock leads to poverty mainly through labor force nonparticipation (9.9%). Conclusion  Income stabilizing scheme to protect households that experience a health shock should be introduced as a policy alternative to confront the issue of medical impoverishment.
       
  • Evaluating Cancer Care Networks; A Case Study of a Lung Cancer Care
           Network

    • Abstract: Background  Networks are promoted as an organizational form that enables integrated care as well as enhanced patient outcomes. However, implementing networks is complex. It is therefore important to evaluate the quality and effectiveness of networks to ensure it is worth developing and maintaining them. This article describes the development of an evaluation tool for cancer care networks and the results of a pilot study with a regional lung cancer care network. Methods  This study used a combination of qualitative and quantitative evaluation methods. The qualitative evaluation was based on a framework with 10 standards for the organization of an oncological (tumor-specific) care network. Data for the quantitative evaluation were obtained from the Dutch Cancer Registry. The evaluation was performed at a network of three hospitals collaborating in the field of lung oncology. Results  The qualitative evaluation framework consisted of 10 standards/questions which were divided into 38 subquestions. The evaluation showed that in general patients are satisfied with the collaboration in the network. However, some improvement points were found such as the need for more attention for the implementation and periodic evaluation of a regional care pathway. The start of a regional multidisciplinary meeting has been a major step for improving the collaboration. Conclusion  An evaluation tool for (lung) cancer care networks was successfully developed and piloted within a cancer care network. The tool has proven to be a useful method for evaluating collaboration within an oncological network. It helped network partners to understand what they see as important and allowed them to learn about their program’s dynamics. Improvement opportunities were successfully identified. To keep the tool up to date continuous improvement is needed, following the Plan Do Check Act (PDCA) cycle.
       
  • Cost-Effectiveness of Cost-Effectiveness of Hepatitis B Mass Screening and
           Management in High-Prevalent Rural China: A Model Study From 2020 to 2049B
           Mass Screening and Management in High-prevalent Rural China: A Model Study
           From 2020 to 2049

    • Abstract: Background  Chronic hepatitis B is highly prevalent among adults in rural China and better management of those populations is of vital importance for viral hepatitis elimination. Adult immunization has been the subject of much controversy in previous studies. This study estimates the cost-effectiveness of population-based hepatitis B screening, treatment, and immunization strategy (comprehensive strategy) in rural areas with high prevalence under the national policy of sharpdrop drug prices. Methods  We constructed a Markov model comparing 4 strategies in a 30-year horizon from the healthcare payer perspective: (1) the conventional pattern; (2) screening and treating infected (treatment); (3) screening and immunizing susceptible individuals (immunization); and (4) the comprehensive strategy. Screening intensity ranged from 50% to 100%. Outcomes were measured by costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and clinical outcomes. Results  The costs for the conventional pattern, treatment strategy, immunization strategy, and comprehensive strategy were US$ 341, 351, 318, and 323, respectively. In addition, effects were 17.45, 17.57, 17.46, and 17.58 QALYs, respectively. The ICER of the comprehensive strategy was 35 US$/QALY gained at 50% screening intensity and 420 US$/QALY gained at 100%. The net monetary benefit increased with increasing screening intensity and declined after 90%, with the highest value of US$ 40693. All new infections and 52.5% mortality could be avoided from 2020 to 2049 if all patients were properly treated and all susceptible individuals were immunized. The results were stable within a wide range of parameters. Conclusions  It was cost-effective to implement the mass hepatitis B screening, treatment, and immunization strategy in areas of rural China with high prevalence, and the strategy gained the most net monetary benefit at a screening intensity of 90%. Although it was impractical to fulfill 100% coverage, efforts should be made to obtain more people screened.
       
  • Designed to Fail' Revisiting Uganda’s Maternal Health Policies to
           Understand Policy Design Issues Underpinning missed Targets for Reduction
           of Maternal Mortality Ratio (MMR): 2000-2015

    • Abstract: Background  Despite Uganda and other Sub-Saharan African countries missing their Maternal Mortality Ratio (MMR) targets for Millenium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to ‘3Cs’ (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. Methods  We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and twenty-one national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the ‘three delay model’ combined with a broader literature on ‘policy mixing’. Results  Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality. By the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues. ConclusionThe piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the ‘three delays’ but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.
       
  • Knowledge Mobilization and Academic Health Science Centres in Australia;
           Comment on “Academic Health Science Centres as Vehicles for Knowledge
           Mobilisation in Australia' A Qualitative Study”

    • Abstract: Extant research on knowledge mobilization points to barriers and opportunities for innovation. Edelman et al paper “Academic Health Science Centres as Vehicles for Knowledge Mobilisation in Australia' A Qualitative Study” builds nicely on the existing knowledge base by evaluating the early stages of organisational development of Academic Health Science Centers in Australia. This commentary discusses their research findings by drawing on relevant themes including knowledge mobilization initiatives that have been developed globally to bridge the research-practice gap and knowledge brokering roles for service improvement. Following which, the commentary draws on organizational capabilities literature for knowledge brokering to happen, the latter including the need for measuring implementation fidelity amongst other capabilities. Finally, building on Edelman et al call for more attention to actionoriented roles and knowledge mobilization processes to deliver strategic goals the commentary concludes with a note for collective leadership as an enabler of knowledge mobilization with impact and at scale.
       
  • Consucrats and Pathocrats: The Prequel, Quel, and Sequel; A Response to
           the Recent Commentaries

    •  
  • Local Dynamics of Collaboration for Maternal, Newborn and Child Health: A
           Social Network Analysis of Healthcare Providers and Their Managers in Gert
           Sibande District, South Africa

    • Abstract: Background  Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.   Methods  Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams).   Results  The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning.   Conclusion  SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.
       
  • The Role of Intersectoral Action in Response to COVID-19: A Qualitative
           Study of the Roles of Academia and the Private Sector in Colombia

    • Abstract: Background  The integration of health services with other sectors is hypothesised to support adaptation of health systems in response to coronavirus disease 2019 (COVID-19). This study identified barriers and enablers associated with intersectoral coordination at an early stage of the pandemic. The study focused on the roles played by the academic and private sector in different areas of public health planning and delivery concerning COVID-19 in Colombia. Methods  A qualitative approach was used to understand stakeholders’ experiences and perceptions of intersectoral working in response to COVID-19 in three Colombian cities (Bogotá, Cali and Cartagena). Between March and November 2020, data was collected via semi-structured interviews conducted online with 42 key actors, including representatives of governmental bodies, universities, and professional associations. The dataset was analysed thematically using a combination of inductive and deductive methods. Results  Organizations adjacent to the health system, including universities and the private sector, supported responses to COVID-19 by providing evidence to inform decision-making, additional service capacity, and supporting coordination (eg, convening intersectoral “roundtables”). The academic and private sector involvement in intersectoral coordination was stimulated by solidarity (being the “right thing to do”) and motivation for supporting local companies (reopening the economy). Intersectoral working was influenced by pre-existing (substantive) and emerging (situational) enablers and barriers. Conclusion  This study showed that intersectoral coordination has played an important role in responding to COVID-19 in Colombia. Coordination was influenced by substantive and situational enablers and barriers. Based on our findings, policy-makers should focus on addressing substantive barriers to coordination, including the pre-existing tensions and mistrust among national and local healthcare actors, strict regulations and limited financial and human resources, while providing support for situational enablers, including alignment of public and private actors’ interests, intersectoral government support and establishing frequent communication channels and formal spaces of interaction among sector, in processes of decision-making.
       
  • Impact of the COVID-19 Pandemic on Outpatient Service in Primary Health
           Care Institutions: An Inspiration from Yinchuan of China

    • Abstract: Background  The coronavirus disease 2019 (COVID-19) pandemic has posed a great challenge to the health care system. This study evaluated the impact of the pandemic on the utilization of primary health care (PHC). Methods  The outpatient data from 158 PHC institutions in Yinchuan from May 1, 2017 to April 30, 2020 were used. The difference in difference (DID) model was used to analyze the difference in the number of outpatient visits per day, total outpatient expenditure per day, and outpatient expenditure per visit between December 2019 and February 2020 compared with the same periods in two previous years. The autoregressive integrated moving average modelling was used to investigate the association between the outpatient volume and the number of the last week's new COVID-19 cases in Yinchuan, Ningxia, and China. Results  From December 2019 to February 2020, the decline in the number of outpatient visits per day (DID: -367.21 times, P=0.004) was larger than that in two previous years, and a similar trend can be seen in the outpatient expenditure per day. However, the rise in the outpatient expenditure per visit (DID: 19.06 thousand yuan, P=0.003) was larger than that in two previous years. In 2020, the outpatient visits for most types of diseases decreased from week 3 and rebounded after week 5. The decline and rebound of outpatient visits in the population aged 45 years and older were steeper than in those younger. The outpatient volume was negatively associated with the number of the last week's new COVID-19 cases. Conclusion  This study indicated a significant impact of the pandemic on PHC service utilization. Since PHC service is the foundation of the health care system in most developing countries, measures should be taken to make PHC help cope with the crisis and relieve the burden of hospital care.
       
  • Research in Hard-to-Reach Populations: Challenges and Strategies for
           Conducting Sexual Violence Studies in Applicants for International
           Protection beyond the European General Data Protection Regulation

    • Abstract: BackgroundConducting research in hard-to-reach populations such as applicants for international protection (AIPs) brings along a number of research challenges. This is especially true for sexual violence (SV) research. MethodsWe developed a study design with the intent to reach AIPs in a randomized and anonymous manner including potential illiterate respondents as well, while avoiding as much bias as possible. However, this method was developed just before the entry into force of the new European General Data Protection Regulation (GDPR), upon which important new research challenges emerged. ResultsThis paper describes the original study design developed to estimate SV prevalence in AIPs in Belgium. We discuss the impact of the GDPR on the recruitment strategy applied to conduct a survey on SV in a randomly selected sample of AIPs, the adapted approach to conduct the study beyond GDPR and lessons learned for future research on sensitive topics in hard-to-reach populations such as AIPs. ConclusionsTo achieve reliable prevalence numbers and provide high-quality data on SV in AIPs while respecting the GDPR regulations, studies will require an approach that has become significantly more time consuming and resource-intensive to implement.
       
  • Financial Assistance for Health Security: Effects of International
           Financial Assistance on Capacities for Preventing, Detecting, and
           Responding to Public Health Emergencies

    • Abstract: Background  Health security funding is intended to improve capacities for preventing, detecting, and responding to public health emergencies. Recent years have witnessed substantial increases in the amounts of donor financial assistance to health security from countries, philanthropies, and other development partners. To date, no work has examined the effects of assistance on health security capacity development over time. This paper presents an analysis of the time-lagged effects of assistance for health security on levels of capacity. Methods  We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial assistance for health security. Using validated methods, we rescaled assessment scores on analogous scales to enable comparison and binned them in quartiles. We then used a distributed lag model in a Bayesian ordinal regression framework to assess the effects of assistance for health security on capacity development over time. Results  Strong evidence exists for associations between financial assistance and select capacities on a variety of lagged time intervals. Financial assistance had positive effects on zoonotic disease capacities in the year it was disbursed, and positive effects on legislation, laboratory, workforce, and risk communication capacities one year after disbursal. Financial assistance had negative effects on laboratory and emergency response capacities two years after it was disbursed. Financial assistance did not have measurable effects on coordination, antimicrobial resistance, food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered. Conclusions  Financial assistance for health security is associated with positive effects for several core health security capacities. However, for the majority of capacities, levels of funding were not significantly associated with capacity level, though we cannot fully exclude endogeneity. Future work should continue to investigate these relationships in different contexts and examine other factors that may contribute to capacity development.
       
  • Individual and Contextual Factors Associated With Maternal and Child
           Health Essential Health Services Indicators: A Multilevel Analysis of
           Universal Health Coverage in 58 Low & Middle-Income Countries

    • Abstract: Background  Universal health coverage (UHC) is part of the global health agenda to tackle the lack of access to essential health services (EHS). This study developed and tested models to examine the individual, neighbourhood and country-level determinants associated with access to coverage of EHS under the UHC agenda in low- and middle-income countries (LMICs). Methods  We used datasets from the Demographic and Health Surveys of 58 LMICs. Suboptimal and optimal access to EHS were computed using nine indicators. Descriptive and multilevel multinomial regression analyses were performed using R & STATA. Result  The prevalence of suboptimal and optimal access to EHS varies across the countries, the former ranging from 5.55% to 100%, and the latter ranging from 0% to 90.36% both in Honduras and Colombia, respectively. In the fully adjusted model, children of mothers with lower educational attainment (RRR 2.11, 95% credible interval [CrI] 1.92 to 2.32) and those from poor households (RRR 1.79, 95%CrI 1.61 to 2.00) were more likely to have suboptimal access to EHS. Also, those with health insurance (RRR 0.72, 95% CrI 0.59 to 0.85) and access to media (RRR 0.59, 95% CrI 0.51 to 0.67) were at lesser risk of having suboptimal EHS. Similar trends, although in the opposite direction, were observed in the analysis involving optimal access. The intra-neighbourhood and intra-country correlation coefficients were estimated using the intercept component variance; 57.50%% and 27.70% of variances in suboptimal access to EHS are attributable to the neighbourhood and country-level factors.  Conclusion  Neighbourhood-level poverty, illiteracy, and rurality modify access to EHS coverage in LMICs. Interventions aimed at achieving the 2030 UHC goals should consider integrating socioeconomic and living conditions of people.
       
  • UK Healthcare Workers’ Experiences of Major System Change in Elective
           Surgery During the COVID-19 Pandemic: Reflections on Rapid Service
           Adaptation

    • Abstract: Background  The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).Methods   Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings. Results  Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started. Conclusion  Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decisionmaking and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.
       
  • Impact of COVID-19 on Timing of Hip-Fracture Surgeries: An Interrupted
           Time-Series Analysis of the Pre/Post-Quarantine Period in Northern Italy

    • Abstract: Background  To assess whether the imposition of the coronavirus disease 2019 (COVID-19) national quarantine (March 10, 2020) resulted in a shift in the proportion of patients operated for hip fracture on the day of admission, the following day and two days after admission in the region of Piedmont, northern Italy. Methods  Interrupted time-series analysis (ITSA) comparing hospitalization rate and timing of hip-fracture surgeries between pre- and post-quarantine period. The same data observed in Piedmont the year before were included as a control time series with no “intervention” (quarantine) in the middle of the observation period. Results  We found that 70.3% and 69.4% of hip-fracture patients received surgery within 2 days of hospital admission in the 16 weeks before and after the national quarantine, respectively. One-day surgery went from 46.0% to 46.5%, and same- day surgery from 13.3% to 12.4%. Unchanged trends were confirmed by ITSA after controlling for the 32-week time- series observed the year before. In the second week of March 2020, there was a borderline significant decrease in weekly hospital admissions for hip fractures as compared with that of the same week of March 2019 (–1.95 per 100 000, 95% CI = –4.10 to 0.21, P value = .075), followed by a weekly significant increase in the hospitalization rate (+0.14 per 100 000, 95% CI = 0.01 to 0.27, P value = .039), although the difference-in-differences of slopes failed to achieve statistical significance (0.19 per 100 000, 95% CI = –0.03 to 0.41, P value = .090). Conclusion  Our study shows that the timing of hip-fracture surgery was unchanged during the lockdown period. This suggests that  the healthcare systems can be resilient and able to guarantee a high-quality and safe healthcare to hipfracture patients, even in the most challenging working conditions.
       
  • Public-Private Partnerships With Unhealthy Commodity Industries: Are They
           Undermining Real Progress in Non-Communicable Disease Prevention'
           Competing Frames in Global Health Governance: An Analysis of Stakeholder
           Influence on the Political Declaration on Non-communicable Diseases

    • Abstract: Public-private partnerships (PPPs) and whole-of-society approaches are increasingly common in public health promotion and non-communicable disease prevention, despite a lack of evidence in favour of their effectiveness in improving health outcomes. While PPPs may have advantages, they also give industry actors more influence over the design and implementation of public health strategies and interventions. Partnering with unhealthy commodity industries in particular – including the alcohol and ultra-processed food and beverages industries – can pose significant risks to public health due to these industries’ deep-rooted conflicts of interest. In this commentary, I reiterate Suzuki et al.’s message about the importance of assessing and managing conflicts of interest before engaging with non-state actors through PPPs or other forms of engagement.
       
  • Lacking Clarity or Strategic Ambiguity'; Comment on “Competing
           Frames in Global Health Governance: An Analysis of Stakeholder Influence
           on the Political Declaration on Non-Communicable Diseases”

    • Abstract: This commentary engages with Suzuki and colleagues’ analysis about the ambiguity of multi-stakeholder discourses in the United Nations (UN) Political Declaration of the 3rd High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (HLM-NCDs), suggesting that blurring between public and private sector in this declaration reflects broader debates about multi-stakeholder partnerships (MSPs) and publicprivate partnerships (PPPs) in health governance. We argue that the ambiguity between the roles and responsibilities of public and private actors involved may downplay the role (and regulation) of conflicts of interest (COI) between unhealthy commodity industries and public health. We argue that this ambiguity is not simply an artefact of the Political Declaration process, but a feature of multi-stakeholderism, which assumes that commercial actors´ interests can be aligned with the public interest. To safeguard global health governance, we recommend further empirical and conceptual research on COI and how it can be managed.
       
  • Factors Influencing Procurement of Digital Health Care: A Case Study in
           Dutch District Nursing

    • Abstract: Background  Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing. Methods  A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports. Results  Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side. Conclusions  This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.
       
  • Health Coverage and Financial Protection in Uganda: A Political Economy
           Perspective

    • Abstract:  Background  As countries health financing policies supporting progress towards Universal Health Coverage (UHC), an analysis of these policies is particularly relevant in Low and Middle-Income Countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. Objective  This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition.    Methods  The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 Key Informant Interviews in the health sector. Results  We find that the current political situation is not yet conducive for implementing a universal health coverage system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. Conclusion: By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.
       
  • Brazilian Survey on Preventive Actions for the Population With Access to
           Primary Healthcare: Inefficient Spending in a Country in Economic Crisis

    • Abstract:  Background  Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government.   Methods  We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter.   Results  The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment.   Conclusion  These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.
       
  • What Lies Behind Successful Regulation' A Qualitative Evaluation of
           Pilot Implementation of Kenya’s Health Facility Inspection Reforms

    • Abstract: Background  Health facility regulation in low- and middle-income countries (LMICs) is generally weak, with potentially serious consequences for safety and quality. Innovative regulatory reforms were piloted in three Kenyan counties including: a Joint Health Inspection Checklist (JHIC) synthesizing requirements across multiple regulatory agencies; increased inspection frequency; allocating facilities to compliance categories which determined warnings, sanctions and/or time to re-inspection; and public display of regulatory results. The reforms substantially increased inspection scores compared with control facilities. We developed lessons for future regulatory policy from this pilot by identifying key factors that facilitated or hindered its implementation.   Methods  We conducted a qualitative study to understand views and experiences of actors involved in the one-year pilot. We interviewed 77 purposively selected staff from the national, county and facility levels. Data were analyzed using the framework approach, identifying facilitating/hindering factors at the facility, inspection system, and health system levels.   Results  The joint health inspections (JHIs) were generally viewed as fair, objective and transparent, which enhanced their perceived legitimacy. Interactions with inspectors were described as friendly and supportive, in contrast to the punitive culture of previous inspections when bribery had been common. Inspector training and use of an electronic checklist were strongly praised. However, practical challenges with transport, route planning and budgets highlighted the critical nature of strong logistical management. The effectiveness of inspection in improving compliance was hampered by limitations in related systems, particularly facility licensing, enforcement of closures and, in the public sector, control of funds. However, an inclusive reform development process had led to high buy-in across regulatory agencies which was key to the system’s success.   Conclusion  Effective facility inspection involves more than “hardware” such as checklists, protocols and training. Cultural, relational and institutional “software” are also crucial for legitimacy, feasibility of implementation and enforceability, and should be carefully integrated into regulatory reforms.
       
  • Policy Instruments for Health Promotion: A Comparison of WHO Policy
           Guidance for Tobacco, Alcohol, Nutrition and Physical Activity

    • Abstract: Background  Policy is an important element of influencing individual health-related behaviours associated to major risk factors for non-communicable diseases (NCDs) such as smoking, alcohol consumption, unhealthy eating and physical inactivity. However, our understanding of the specific measures recommended in NCD prevention policy-making remains limited. This study analysed recent World Health Organization (WHO) documents to identify common policy instruments suggested for national NCD prevention policy and to assess similarities and differences between policies targeting different health-related behaviours.   Methods  Evert Vedung’s typology of policy instruments, which differentiates between regulatory, economic/fiscal and soft instruments, served as a basis for this analysis. A systematic search on WHO websites was conducted to identify documents relating to tobacco, alcohol, nutrition and physical activity. The staff of the respective units at the WHO Regional Office for Europe conducted an expert validation of these documents. The resulting documents were systematically searched for policy instruments. A word frequency analysis was conducted to estimate the use of individual instruments in the different policy fields, followed by an additional in-depth coding and content analysis by two independent reviewers.   Results  Across all health-related behaviours, the following policy instruments were suggested most frequently in WHO guidance documents: laws, regulations, standards, taxes, prices, campaigns, recommendations, partnerships and coordination. The analysis showed that regulatory and economic/fiscal policy instruments are mainly applied in tobacco and alcohol policy, while soft instruments dominate in the fields of nutrition and especially physical activity.   Conclusion  The study confirms perceived differences regarding recommended policy instruments in the different policy fields and supports arguments that “harder” instruments still appear to be underutilized in nutrition and physical activity. However, more comprehensive research is needed, especially with respect to actual instrument use and effectiveness in national- level NCD prevention policy.
       
  • Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption
           Among Households in Mongolia

    • Abstract: Background  High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs.   Methods  This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP.   Results  The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD] = 259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI = -8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI = 737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI = 66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI = -445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI.   Conclusion  Our findings suggest that Mongolia’s OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest- income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.
       
  • When Health Systems Consider Research to Be Beyond the Scope of Healthcare
           Delivery, Research Translation Is Crippled; Comment on “Academic Health
           Science Centres as Vehicles for Knowledge Mobilisation in Australia' A
           Qualitative Study”

    • Abstract: Edelman and colleagues’ analysis of the views of Board members of Australian Research Translation Centres (RTCs) is well timed. There has been little study of Australian RTCs to date. We focus on their recommendations regarding knowledge mobilisation (KM) to open broader debate on the wisdom of regarding UK practices as a blueprint. We go further and ask whether successful RTCs might, as a result of responding to local context, create idiosyncratic structures and solutions, making generalisable learning less likely' There has been much invested in Australian RTCs and implications of government’s formative evaluation of their work is discussed. Five recommendations are made that could help RTCs: allowing system end-users a greater say in funding decisions, taking a broader, more democratic approach to kinds of knowledge that are valued; investing in methodologies derived from the innovation space; and, a creative attention to governance to support these ideas.
       
  • Effects of Vertical Integration Reform on Primary Healthcare Institutions
           in China: Evidence From a Longitudinal Study

    • Abstract: Background  Integrated care is a global trend in international healthcare reform, particularly for piloting vertical integration involving hospitals and primary healthcare institutions (PHIs). However, evidence regarding the impact of vertical integration on primary healthcare has been mixed and limited. Our study aims to evaluate the empirical effects of vertical integration reform on PHIs in China, and examines variations across integration intensity (tight integration vs. loose collaboration).   Methods  This study used a longitudinal design. The time-varying difference-in-difference (DID) method with a fixedeffect model for panel data was adopted. A total of 370 PHIs in the eastern, central, and western areas of China from 2009 to 2018 were covered. Outcome measures included the indicators at three dimensions regarding inpatient and outpatient service volume, patient flow between PHIs and hospitals and quality of chronic disease care (hypertension and diabetes).   Results  Significant increases in absolute (the number) and relative (the ratio between PHIs and hospitals) volume of inpatient admissions have been found after reform under tight integration, peaking at 183% and 15.0% respectively, in the third reform year. The quality of hypertension and diabetes care (by indicators of control rate of blood pressure and blood glucose) showed significant improvements under both types of vertical integration after reform. It was much more distinct for the PHIs under tight integration, which had the most significant increase of 34.0% and 22.8% under tight integration for the control rate of hypertension and diabetes compared to the peak of 21.2% and 22.1% respectively under loose collaboration.   Conclusion  Our findings suggest that vertical integration (especially tight integration) in China significantly contributed to strengthening primary healthcare in terms of inpatient services and quality of hypertension and diabetes care, providing empirical evidence to other countries on integrating primary healthcare-based health systems.
       
  • Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a
           Crowded Emergency Department in Taiwan

    • Abstract: Background  Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed- to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes.   Methods  A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching.   Results  Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P = .245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P = .344).   Conclusion  Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.
       
  • “My Cancer Is Worth Only Fifteen Weeks'” A Critical Analysis of
           the Lived Experiences of Financial Toxicity and Cancer in Canada

    • Abstract: Background  Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients.   Methods  We conducted a theory-informed thematic analysis of data collected from twenty semi- structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues’ intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens.   Results  Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed.   Conclusion  Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.
       
  • Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply
           to Reconcile Dilemmas Between Clinical and Economic Considerations'

    • Abstract: Background  Hospital professionals are “dual agents” who may face dilemmas between their commitment to patients’ clinical needs and hospitals’ financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems.   Methods  We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning.   Results  Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include ‘reshaping management,’ such as better planning of the entire course of treatment and improvement of the coding; and ‘reframing decision- making,’ which involves working with averages and developing tool-kits for decision- making.   Conclusion  Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision- making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
       
  • A Critical Analysis of Representations of Inequalities in Childhood
           Obesity in Australian Health Policy Documents

    • Abstract: Background  In Australia, childhood obesity follows a socioeconomic gradient whereby children with lower socioeconomic position are disproportionately burdened. To reduce these inequalities in childhood obesity requires a multi-component policy-driven response. Action to address health issues is underpinned by the ways in which they are represented as ‘problems’ in public policy. This study critically examines representations of inequalities in childhood obesity within Australian health policy documents published between 2000-2019.   Methods  Australia’s federal, state and territory government health department websites were searched for health policy documents including healthy weight, obesity, healthy eating, food and nutrition strategies; child and youth health strategies; and broader health and wellbeing, prevention and health promotion policies that proposed objectives or strategies for childhood obesity prevention. Thematic analysis of eligible documents was guided by a theoretical framework informed by problematization theory, ecological systems theory, and theoretical principles for equity in health policy.   Results  Eighteen policy documents were eligible for inclusion. The dominant representation of inequalities in childhood obesity was one of individual responsibility. The social determinants of inequalities in childhood obesity were acknowledged, yet policy actions predominantly focused on individual determinants. Equity was positioned as a principle of policy documents but was seldom mentioned in policy actions.   Conclusion  Current representations of inequalities in childhood obesity in Australian health policy documents do not adequately address the underlying causes of health inequities. In order to reduce inequalities in childhood obesity future policies will need greater focus on health equity and the social determinants of health (SDoH).
       
  • Length of Stay, Hospital Costs and Mortality Associated With Comorbidity
           According to the Charlson Comorbidity Index in Immobile Patients After
           Ischemic Stroke in China: A National Study

    • Abstract: Background  In this study, we examined the length of stay (LoS)-predictive comorbidities, hospital costs-predictive comorbidities, and mortality‐predictive comorbidities in immobile ischemic stroke (IS) patients; second, we used the Charlson Comorbidity Index (CCI) to assess the association between comorbidity and the LoS and hospitalization costs of stroke; third, we assessed the magnitude of excess IS mortality related to comorbidities.   Methods  Between November 2015 and July 2017, 5114 patients hospitalized for IS in 25 general hospitals from six provinces in eastern, western, and central China were evaluated. LoS was the period from the date of admission to the date of discharge or date of death. Costs were collected from the hospital information system (HIS) after the enrolled patients were discharged or died in hospital. The HIS belongs to the hospital’s financial system, which records all the expenses of the patient during the hospital stay. Cause of death was recorded in the HIS for 90 days after admission regardless of whether death occurred before or after discharge. Using the CCI, a comorbidity index was categorized as zero, one, two, and three or more CCI diseases. A generalized linear model with a gamma distribution and a log link was used to assess the association of LoS and hospital costs with the comorbidity index. Kaplan–Meier survival curves was used to examine overall survival rates.   Results  We found that 55.2% of IS patients had a comorbidity. Prevalence of peripheral vascular disease (21.7%) and diabetes without end-organ damage (18.8%) were the major comorbidities. A high CCI=3+ score was an effective predictor of a high risk of longer LoS and death compared with a low CCI score; and CCI=2 score and CCI=3+ score were efficient predictors of a high risk of elevated hospital costs. Specifically, the most notable LoS-specific comorbidities, and cost-specific comorbidities was dementia, while the most notable mortality-specific comorbidities was moderate or severe renal disease.   Conclusion  CCI has significant predictive value for clinical outcomes in IS. Due to population aging, the CCI should be used to identify, monitor and manage chronic comorbidities among immobile IS populations.
       
  • Examining and Contextualizing Approaches to Establish Policy Support
           Organizations – A Mixed Method Study

    • Abstract: Background  There has been an increase in the number of policy support organizations (PSOs) that have been created to foster the systematic use of evidence in health system policymaking. Our aim was to identify approaches for establishing a PSO or similar entities by soliciting insights from those with practical experience with developing and operationalizing PSOs in real-world contexts.   Methods  We used a sequential mixed method approached. We first conducted a survey to identify the views and experiences of those who were directly involved in the establishment of PSOs that have been developed and implemented across a variety of political-, health- and research-system contexts. The survey findings were then used to develop a purposive sample of PSO leaders and refine an interview guide for interviews with them.   Results  We received 19 completed surveys from leaders of PSOs in countries across the WHO regions and that operate in different settings (eg, as independent organization or within a university or government department) and conducted interviews with 15 senior managers from nine PSOs. Our findings provide in-depth insights about approaches and strategies across four stages for establishing a PSO, which include: (i) building awareness for the PSO; (ii) developing the PSO; (iii) assessing the PSO to identify potential areas for enhancement; and (iv) supporting maturation to build sustainability in the long-term. Our findings provide rich insights about the process of establishing a PSO from leaders who have undertaken the process.   Conclusion  While all PSOs share the same objective in supporting evidence-informed policy-making (EIPM), there is no single approach that can be considered to be the most successful in establishing a PSO, and each country should identify the approach based on its context.
       
  • Recovered but Constrained: Narratives of Ghanaian COVID-19 Survivors
           Experiences and Coping Pathways of Stigma, Discrimination, Social
           Exclusion and Their Sequels

    • Abstract: Background  Research about the coronavirus disease 2019 (COVID-19), its epidemiology and socio- economic impact on populations worldwide has gained attention. However, there is dearth of empirical knowledge in low- and middleincome settings about the pandemic’s impact on survivors, particularly the tension of their everyday life arising from the experiences and consequences of stigma, discrimination and social exclusion, and how they cope with these behavioral adversities.   Methods  Realist qualitative approach drawing data from people clinically diagnosed positive of COVID-19, admitted into therapy in a designated treatment facility, and subsequently recovered and discharged for or without follow-up domiciliary care. In-depth interviews were conducted by maintaining a code book for identifying and documenting thematic categories in a progression leading to thematic saturation with 45 participants. Data were transcribed and coded deductively for broad themes at the start before systematically nesting emerging themes into the broad ones with the aid of NVivo 12 software.   Results  Everyday lived experiences of the participants were disrupted with acts of indirect stigmatization (against relatives and family members), direct stigmatization (labeling, prejudices and stereotyping), barriers to realizing full social life and discriminatory behaviors across socio-ecological structures (workplace, community, family, and social institutions). These behavioral adversities were associated with self-reported poor health, anxiety and psychological disorders, and frustrations among others. Consequently, supplicatory prayers, societal and organizational withdrawal, aggressive behaviors, supportive counseling, and self-assertive behaviors were adopted to cope and modify the adverse behaviors driven by misinformation and fearful perceptions of the COVID-19 and its contagious proportions.   Conclusion  In the face of the analysis, social campaigns and dissemination of toolkits that can trigger behavior change and responsible behaviors toward COVID-19 survivors are proposed to be implemented by health stakeholders, policy and decision makers in partnership with social influencers, the media, and telecoms.
       
  • Thinking Politically About UN Political Declarations: A Recipe for
           Healthier Commitments—Free of Commercial Interests; Comment on
           “Competing Frames in Global Health Governance: An Analysis of
           Stakeholder Influence on the Political Declaration on Non-communicable
           Diseases”

    • Abstract: As evidence mounts that corporate actor engagement in United Nations (UN) policy- making processes leads to weaker and shallower public health commitments, greater attention is being paid to how to minimise undue interference and manage conflicts of interest (CoI). While we welcome efforts to develop normative guidance on managing such conflicts, we argue that there is the need to go further. In particular, we propose that an index be developed that would assess the health impacts of individual corporate actors, and those actors who fail to achieve a set benchmark would not have engagement privileges. We further propose the establishment of an independent panel of experts to advise on corporate actor engagement as well as on ambiguous and potentially health- harming commitments in text under negotiation in the UN. Recognising that the implementation of such measures will be contested, we recommend a number of practical steps to make their implementation more politically palatable.
       
  • Improving Access to Surgery Through Surgical Team Mentoring – Policy
           Lessons From Group Model Building With Local Stakeholders in Malawi

    • Abstract: Background  There is much scope to empower district hospital (DH) surgical teams in low- and middle- income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals.   Methods  A mixed methods approach was used which combined stakeholder input – obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff – and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed.   Results  Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved – notably DHs, CHs and the party that would finance the required mentoring trips – along with the potential for scaling up surgery at DHs under severe financial constraints.   Conclusion  To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery.
       
  • Exploring the Role of Leadership in Facilitating Change to Improve Cancer
           Survival: An Analysis of Experiences in Seven High Income Countries in the
           International Cancer Benchmarking Partnership (ICBP)

    • Abstract: Background  The differences in cancer survival across countries and over time are well recognised, with progress varying even among high-income countries with comparable health systems. Previous research has examined several possible explanations, but the role of leadership in systems providing cancer care has attracted little attention. As part of the International Cancer Benchmarking Partnership (ICBP), this study looked at diverse aspects of leadership to identify drivers of change and opportunities for improvement across seven high-income countries.   Methods  Key informants in 13 jurisdictions were interviewed: Australia (2 states), Canada (3 provinces), Denmark, Ireland, New Zealand, Norway and United Kingdom (4 countries). Participants represented a range of stakeholders at different tiers of the system. They were recruited through a combination of purposive and ‘snowball’ strategies and participated in semi-structured telephone interviews. Interview transcripts were analysed thematically drawing on the World Health Organization (WHO) health systems framework and previous work analysing national cancer control programmes (NCCPs).   Results  Several facets of leadership were perceived as important for improving outcomes. These included political leadership to initiate and maintain progress, intellectual leadership to support those engaged in local implementation of national policies and drive change, and a coherent vision from leaders at different levels of the system. Clinical leadership was also viewed as vital for translating policy into action.   Conclusion  Certain aspects of cancer care leadership emerged as underpinning and sustaining improvements, such as appointing a central agency, involving clinicians at every stage, ensuring strong leadership of cancer care with a consistent political mandate. Improving cancer outcomes is challenging and complex, but it is unlikely to be achieved without effective leadership, both political and clinical.
       
  • Unbalanced Treatment Costs of Breast Cancer in China: Implications From
           the Direct Costs of Inpatient and Outpatient Care in Liaoning Province

    • Abstract: Background  The increasing incidence of breast cancer and its financial burden highlights the need for controlling treatment costs. This study aimed to assess the direct costs of inpatient and outpatient care for breast cancer patients in Liaoning Province to provide a policy reference for cost containment.   Methods  Based on the System of Health Accounts 2011 (SHA 2011), systematic data collection was conducted via multistage stratified cluster random sampling. A total of 1160 health institutions, including 83 hospitals, 16 public health institutions, 120 primary health institutions, and 941 outpatient institutions were enrolled in 2017. A database was established containing 20 035 patient-level medical records from the information system of these institutions. Curative care expenditure (CCE)was calculated, and generalized linear modeling was performed to determine cost-related factors.   Results  In 2017, the CCE for breast cancer was approximately CNY 830.19 million (US$122.96 million) in Liaoning province (0.7% of the total health expenditure and 9.9% of cancer- related healthcare costs). Inpatient care costs were estimated to be CNY 617.27 million (US$91.42 million), accounting for 74.4% of the CCE for breast cancer, almost three times as large as outpatient costs (25.6%). The average inpatient and outpatient costs for breast cancer were estimated to be CNY 12 108 (US$1793) and CNY 829 (US$123) per visit. Medication cost was the main cost driver, which comprised 84.0% of the average outpatient cost and 37.2% of the mean inpatient cost.   Conclusion  Breast cancer imposes a large economic burden on patients and the social health insurance system. Results show an irrational cost pattern of inpatient and outpatient services, with patients relying excessively on inpatient services for treatment. Promoting outpatient care whenever relevant is conducive to cost containment and rational utilization of resources.
       
  • Portuguese Primary Healthcare and Prevention Quality Indicators for
           Diabetes Mellitus – A Data Envelopment Analysis

    • Abstract: Background  Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings).   Methods  We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care.   Results  A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation.   Conclusion  Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.
       
  • Smoke-Free Policies and 30-Day Mortality Rates for Chronic Obstructive
           Pulmonary Disease

    • Abstract: Background  Smoke-free policies have been shown to impact 30-day readmission rates due to chronic obstructive pulmonary disease (COPD) among adults aged ≥65 years. However, little is known about the association between smokefree policies and 30-day mortality rates for COPD. Therefore, we investigated the association between comprehensive smoke-free policies and 30-day mortality rates for COPD.   Methods  We used a cross-sectional study design and retrospectively examined risk-adjusted 30- day mortality rates for COPD across US hospitals in 1171 counties. Data were sourced from Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) Program, American Hospital Association (AHA) Annual Surveys, US Census Bureau Current Population Survey, and US Tobacco Control Laws Database from the American Nonsmokers’ Rights Foundation (ANRF). Data were averaged at the county level for years 2015-2018. Hierarchical Poisson models adjusted for differences in hospital characteristics and accounted for the clustering of hospitals within a county were used.   Results  Our findings show a consistent association between stronger smoke-free policies and a reduction in COPD mortality. When evaluating smoke-free policy, county characteristics, and hospital characteristics individually, we found that counties with full coverage or partial coverage had a reduced incidence rate of COPD mortality compared to no coverage counties. After adjusting for the county and hospital characteristics, counties with full coverage of smoke-free policies had a reduced rate of 30-day COPD mortality (adjusted incidence rate ratio [IRR]: 0.87, 95% CI: 0.79, 0.96) compared to counties with no policy coverage.   Conclusion  Comprehensive smoke-free policies are associated with a reduction in 30-day mortality following hospital admission for COPD. Partial smoke-free legislation is an insufficient preventative measure. These findings have strong implications for hospital policy- makers, suggesting that policy interventions to reduce COPD-related 30-day mortality should include implementing smoke-free policies and public health policy-makers to incentivize comprehensive smokefree policies.
       
  • Policy Processes in Multisectoral Tobacco Control in India: The Role of
           Institutional Architecture, Political Engagement and Legal Interventions

    • Abstract: Background  The development and implementation of health policy have become more overt in the era of Sustainable Development Goals, with expectations for greater inclusivity and comprehensiveness in addressing health holistically. Such challenges are more marked in low- and middle-income countries (LMICs), where policy contexts, actor interests and participation mechanisms are not always well-researched. In this analysis of a multisectoral policy, the Tobacco Control Program in India, our objective was to understand the processes involved in policy formulation and adoption, describing context, enablers, and key drivers, as well as highlight the challenges of policy.   Methods  We used a qualitative case study methodology, drawing on the health policy triangle, and a deliberative policy analysis approach. We conducted document review and in-depth interviews with diverse stakeholders (n = 17) and anlayzed the data thematically.   Results  The policy context was framed by national law in India, the signing of a global treaty, and the adoption of a dedicated national program. Key actors included the national Ministry of Health and Family Welfare (MoHFW), State Health Departments, technical support organizations, research organizations, non-governmental bodies, citizenry and media, engaged in collaborative and, at times, overlapping roles. Lobbying groups, in particular the tobacco industry, were strong opponents with negative implications for policy adoption. The state-level implementation relied on creating an enabling politico-administrative framework and providing institutional structure and resources to take concrete action.   Conclusion  Key drivers in this collaborative governance process were institutional mechanisms for collaboration, multi-level and effective cross-sectoral leadership, as well as political prioritization and social mobilization. A stronger legal framework, continued engagement, and action to address policy incoherence issues can lead to better uptake of multisectoral policies. As the impetus for multisectoral policy grows, research needs to map, understand stakeholders’ incentives and interests to engage with policy, and inform systems design for joint action.
       
  • Financial Risk Protection and Unmet Healthcare Need in Russia

    • Abstract: Background Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system’s financial risk protection by focusing on CHE, OOP and unmet healthcare need.   Methods  The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators – CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need –were used.   Results  We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014–2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis.   Conclusion  As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.
       
  • Transparency in Healthcare Reporting: The Case of External Contractors and
           Consultants in New Zealand’s Healthcare System

    • Abstract: This study investigates the quality of reporting around the spending related to the use of external consultant and contractors in New Zealand’s 20 District Health Boards (DHBs). We make use of the publicly available annual reviews conducted by the New Zealand Parliament Health Select Committee (HSC) as well as DHB data which were retrieved using Official Information Act (OIA) requests. The quality of reporting was judged on the differences and discrepancies observed in the HSC reports each year as well as the DHB internal data. Perhaps, unsurprisingly, total spending on external consultants and contractors has been increasing over the years while the quality of reporting has been decreasing. Our analysis highlighted a number of quality issues—mistakes, discrepancies and an overall lack of standardised reporting in almost all of the DHBs. Some of these discrepancies included failure to provide information required by the HSC, differences in yearly total amounts in consecutive reports and differences between information provided to the HSC and to the authors of this article. It is hoped that this research and the prospective areas for improvement highlighted here are used as a guide to improve the quality of healthcare financial reporting.
       
  • Integration or Fragmentation of Health Care' Examining Policies and
           Politics in a Belgian Case Study

    • Abstract: Background  Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi- stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies.   Methods  We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders’ power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals’ associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007–2020) through literature review was used to frame the interviews by means of a chronic care policy timeline.   Results  In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform.   Conclusion  The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.
       
  • Government Actions and Their Relation to Resilience in Healthcare During
           the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada

    • Abstract: Background  Resilience, a system’s ability to maintain a desired level of performance when circumstances disturb its functioning, is an increasingly important concept in healthcare. However, empirical investigations of resilience in healthcare (RiH) remain uncommon, particularly those that examine how government actions contribute to the capacity for resilient performance in the healthcare setting. We sought to investigate how governmental actions during the coronavirus disease 2019 (COVID-19) pandemic related to the concept of resilience, how these actions contributed to the potential for resilient performance in healthcare, and what opportunities exist for governments to foster resilience within healthcare systems.   Methods  We conducted case studies of government actions pertaining to the COVID-19 pandemic in New South Wales, Australia and Ontario, Canada. Using media releases issued by each government between December 2019 and August 2020, we performed qualitative content analysis to identify themes relevant to the resilience potentials (anticipate, monitor, respond, learn) and RiH.   Results  Direct references to the term ‘resilience’ appeared in the media releases of both governments. However, these references focused on the reactive aspects of resilience. While actions that constitute the resilience potentials were evident, the media releases also revealed opportunities to enhance learning (eg, a need to capitalize on opportunities for double-loop learning and identify strategies appropriate for complex systems) and anticipating (eg, incorporating the concept of hedging into frameworks of RiH).   Conclusion  Though fostering RiH through government action remains a challenge, this study suggests opportunities to realize this goal. Articulating a proactive vision of resilience and recognizing the complex nature of current systems could enhance governments’ ability to coordinate resilient performance in healthcare. Reflection on how anticipation relates to resilience appears necessary at both the practical and conceptual levels to further develop the capacity for RiH.
       
  • Assessment of the Benefits and Cost-Effectiveness of Population-Based
           Breast Cancer Screening in Urban China: A Model-Based Analysis

    • Abstract: Background  To decrease the burden of breast cancer (BC), the Chinese government recently introduced biennial mammography screening for women aged 45-70 years. In this study, we assess the effectiveness and cost-effectiveness of implementing this programme in urban China using a micro-simulation model.   Methods  The ‘Simulation Model on radiation Risk and breast cancer Screening’ (SiMRiSc) was applied, with parameters updated based on available data for the Chinese population. The base scenario was biennial mammography screening for women aged 45-70 years, and this was compared to a reference population with no screening. Seven alternative scenarios were then simulated by varying the screening intervals and participant ages. This analysis was conducted from a societal perspective. The discounted incremental cost- effectiveness ratio (ICER) was compared to a threshold of triple the gross domestic product (GDP) per life years gained (LYG), which was 30 785 USD/LYG. Univariate sensitivity analyses were conducted to evaluate model robustness. In addition, a budget impact analysis was performed by comparing biennial screening with no screening at a time horizon of 10 years.   Results  Compared with no screening, the base scenario was cost-effective in urban China, giving a discounted average cost-effectiveness ratio (ACER) of 17 309 USD/LYG. The model was most sensitive to the cost of mammography per screen, followed by mean size of self- detected tumours, mammographic breast density and the cumulative lifetime risk of BC. The efficient frontier showed that at a threshold of 30 785 USD/LYG, the base scenario was the optimal scenario with a discounted ICER of 25 261 USD/LYG. Over 10 years, screening would incur a net cost of almost 38.1 million USD for a city with 1 million citizens.   Conclusion  Compared to no screening, biennial mammography screening for women aged from 45-70 is cost-effective in urban China.
       
  • A Framing Analysis of Consultation Submissions on the WHO Global Strategy
           to Reduce the Harmful Use of Alcohol: Values and Interests

    • Abstract: Background  In response to the magnitude of harms caused by alcohol, the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol (GAS) was endorsed in 2010. We analysed submissions to the 2019 WHO consultation on the implementation of the GAS to identify how different stakeholders frame alcohol use and control; and to assess how stakeholders engage with the consultation process, with possibly harmful consequences for public health policy.   Methods  All submissions from WHO Member States, international organisations, non-governmental organisations (NGOs), academic institutions and private sector entities were identified and used as data for an inductive framing analysis. This involved close reading and data familiarisation, thematic coding and identifying emergent framings. Through the analysis of texts, framing analysis can give insights into the values and interests of stakeholders. Because framing influences how issues are conceptualised and addressed, framing analysis is a useful tool to study policy-making processes.   Results  We identified 161 unique submissions and seven attachments. Emerging frames were grouped according to their function: defining the problem, assigning causation, proposing solutions, or justifying and persuading. Submissions varied in terms of the framing they deployed and how this was presented, eg, how the problem was defined. Proposed policy solutions also varied. Targeted solutions emphasising individual responsibility tended to be supported by industry and some Member States. Calls for universal regulation and global mobilisation often came from NGOs and academia. Stakeholders drew on evidence and specific value systems to support the adoption of certain problem and solution ideas and to oppose competing framing.   Conclusion  Alcohol control is a contested policy field in which different stakeholders use framing to set the agenda and influence what policy solutions are considered legitimate. WHO should consider which interests are served by these different framings and how to weigh different stakeholders in the consultation process.
       
  • Prosociality and Social Responsibility Were Associated With Intention of
           COVID-19 Vaccination Among University Students in China

    • Abstract: Background  Coronavirus disease 2019 (COVID-19) vaccination is expected to end the pandemic; a high coverage rate is required to meet this end. This study aimed to investigate the prevalence of behavioral intention of free/self-paid COVID-19 vaccination and its associations with prosociality and social responsibility among university students in China.   Methods  An anonymous online cross-sectional survey was conducted among 6922 university students in five provinces in China during November 1-28, 2020. With informed consent, participants filled out an online survey link distributed to them via WeChat study groups. The response rate was 72.3%.   Results  The prevalence of behavioral intentions of free COVID-19 vaccination was 78.1%, but it dropped to 57.7% if the COVID-19 vaccination involved self-payment (400 RMB; around 42 USD). After adjusting for background factors, prosociality (free vaccination: adjusted odds ratio [ORa] = 1.10, 95% CI: 1.09-1.12; self-paid vaccination: ORa = 1.08, 95% CI: 1.07-1.09) and social responsibility (free vaccination: ORa = 1.17, 95% CI: 1.14-1.19; self-paid vaccination: ORa = 1.13, 95% CI: 1.11-1.14) were positively associated with the two variables of COVID-19 vaccination intention.   Conclusion  The present study demonstrated the positive effects of prosociality and social responsibility on the intention of COVID-19 vaccination. Accordingly, modification of prosociality and social responsibility can potentially improve COVID-19 vaccination. Future longitudinal and intervention studies are warranted to confirm such associations across populations and countries.
       
  • Bridging the Gap Between Public Health and Political Science to Study the
           Populist Radical Right in its Multiple Manifestations: A Response to
           Recent Commentaries

    •  
  • Developing a National Set of Health Equity Indicators Using a Consensus
           Building Process

    • Abstract: Background  Considerable health inequities documented in Israel between communities, populations and regions, undermine the rights of all citizens to optimal health. The first step towards health equity is agreement on a set of national indicators, reflecting equity in healthcare provision and health outcomes, and allowing monitoring of the impact of interventions on the reduction of disparities. We describe the process of reaching a consensus on a defined set of national equity indicators.   Methods  The study was conducted between January 2019 and June 2020, in a multistage design: (A) Identifying appropriate and available inequity measures via interviews with stakeholders. (B) Agreement on the screening criteria (public health importance; gap characteristics; potential for change; public interest) and relative weighting. (C) Constructing the consultation framework as an online, 3-round Delphi technique, with a range of experts recruited from the health, welfare and education sectors.   Results  Participants were of diverse age, gender, geographic location, religion and ethnicity, and came from academia, healthcare provision, government ministries and patient representative groups. Thirty measures of inequity, presented to participants, represented the following domains: Health promotion (11 indicators), acute and chronic morbidity (11), life expectancy and mortality (2), health infrastructures and affordability of care (4), education and employment (2). Of the 77 individuals contacted, 75 (97%) expressed willingness to participate, and 55 (73%) completed all three scoring rounds. The leading ten indicators were: Diabetes care, childhood obesity, adult obesity, distribution of healthcare personnel, fatal childhood injuries, cigarette smoking, infant mortality, ability to afford care, access to psychotherapy and distribution of hospital beds. Agreement among raters, measured as intra-class correlation coefficient (ICC), was 0.75.   Conclusion  A diverse range of consultants reached a consensus on the most important national equity indicators, including both clinical and system indicators. Results should be used to guide governmental decision-making and inter-sectoral strategies, furthering the pursuit of a more equitable healthcare system.
       
  • Forecasting Future Demand of Nursing Staff for the Oldest-Old in China by
           2025 Based on Markov Model

    • Abstract: Background  An aging population and an increase in the proportion of disabled elderly have brought an unprecedented global challenge, especially in China. Aside lack of professional long- term care facilities, the shortage of human resource for old-age care is also a major threat. Therefore, this study tries to forecast the demand scale of nursing staff for the oldest-old in 2025 in China servicing as a reference for the development plan of human resource for elderly nursing.   Methods  Based on CLHLS (Chinese Longitudinal Healthy Longevity Survey) 2011 and 2014, Logit model was used to construct the transition probability matrix of the elderly’s health status (health/mild/moderate/severe disability and death). By using the data of the elderly population aged 65 or over in the 2010 national population census, we projected the number of Chinese oldest-old population in different health status by 2025 through Markov model and projected the scale of the demand of nursing staff combined with the human population ratio method.   Results  The forecast shows that the Chinese oldest-old population is about 52.6 million, among which 46.9 million are healthy, 3.7 million are mild, 0.8 million are moderate, and 1.2 million are severely disabled in 2025. Concurrently, the demand scale of nursing staff will be 5.6 million according to the low standard and 11.5 million according to the high standard. Thus, human resource supply of long-term care is worrying.   Conclusion  In 2025, the population size of the Chinese oldest-old will be further expanded, and the demand of care will increase accordingly, leading to a vast gap in the nursing staff. Therefore, it is urgent to build a professional nursing staff with excellent comprehensive quality and reasonable quantity, to ensure the sustainable development of China’s elderly care service industry.
       
  • Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users
           and Non-users in Rural Zambia

    • Abstract: Background  Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed deliveryrelated expenditure for women who used MWHs and those who did not who delivered at a rural health facility.   Methods  During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD).   Results  After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P = .06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery.   Conclusion  Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.
       
  • Doctor Retention in a COVID-World: An Opportunity to Reconfigure the
           Health Workforce, or “Plus ça change plus c’est la meme chose”'
           A Response to the Recent Commentaries

    •  
  • Local Government Stakeholder Perceptions of Legitimacy and Conflict of
           Interest: The Alcohol Industry and the “Drink Free Days” Campaign in
           England

    • Abstract: Background  Industry involvement in alcohol policy is highly contentious. The Drink Free Days (DFD) campaign (2018-2019) run by Public Health England (PHE), an executive agency of government, and Drinkaware, an industry-funded ‘alcohol education charity’ to encourage middle-aged drinkers to abstain from drinking on some days was criticised for perceived industry involvement. We examine the extent to which the DFD campaign was supported by local-authority Directors of Public Health (DPHs) in England – which have a statutory remit for promoting population health within their locality – and their reasons for this.   Methods  Our mixed-methods approach included a stakeholder mapping, online survey, and semi- structured interviews. The stakeholder mapping provided the basis for sampling survey and interview respondents. In total, 25 respondents completed the survey, and we conducted 21 interviews with DPHs and their local authority (LA) representatives. We examined survey responses, and coded free-text survey and interview responses to identify key themes.   Results  While some respondents supported the DFD campaign, others did not promote it, or actively opposed it, due mainly to concerns about conflicts of interest and the legitimacy of industry involvement in the campaign. These were considered to undermine PHE’s independence and deflect attention from more important, evidence-based policy interventions such as alcohol pricing while conferring vicarious credibility on Drinkaware. We also found low levels of knowledge about alcohol-related harm, the effectiveness of different policies to address these and the policy-influencing strategies used by the alcohol industry.   Conclusion  The findings highlight the dangers of industry partnership and potential conflicts of interest for government agencies and the ineffectiveness of the campaigns they run at local and national levels. They demonstrate the need for caution in engaging with industry-associated bodies at all levels of government and are thus of potential relevance to studies of other health-harming industries and policy contexts.
       
  • Key Factors that Promote Low-Value Care: Views of Experts From the United
           States, Canada, and the Netherlands

    • Abstract: Background  Around the world, policies and interventions are used to encourage clinicians to reduce low- value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.   Methods  We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.   Results  The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a ‘more is better’ culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.   Conclusions  Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.
       
  • The Regulation of the Complementary Health Sector: General Public’s
           Knowledge of Complementary MedicineRelated Quality Assurance and Consumer
           Protection

    • Abstract: Background  Complementary medicine (CM) use is a ubiquitous aspect of an increasingly consumer- driven model of healthcare delivery and plays an increasingly prominent role in the Australian health sector. Yet there is limited empirical research investigating the quality and integrity of protections for consumers in Australia. The aim of this study is to help address this gap in knowledge by exploring how members of the public engage with protection mechanisms related to CM use.   Methods  This study utilised a cross-sectional online survey to recruit a sample of 1132 Australian adults aged 18 and over. Purposive convenience sampling was used to recruit participants from an existing database of Australian adults who had expressed interest in participating in research.   Results  The majority of the participants (64.0%) had visited a CM practitioner in their lifetime. However, a minority of participants (36.9%) indicated they would feel confident in knowing where to complain if something went wrong with the treatment they received from a CM practitioner. Most participants (74.7%) had used a CM product in their lifetime. Specifically, 32.3% had ‘ever’ used an herbal product and 69.9% had ‘ever’ used a nutritional supplement. However, a minority of participants (32.7%) indicated they would feel confident knowing where to complain if something went wrong with a herbal or nutritional supplement they used. Most participants indicated a lack of knowledge about how CM practitioners and CM products are regulated in Australia.   Conclusion  The findings of this study clearly highlight a concerning lack of knowledge by CM patients and consumers regarding the regulation of CM in Australia. From a policy perspective, it is necessary to seek proactive approaches that target complaint-related knowledge of the CM patients and consumers through education and advocacy efforts.
       
  • Trends of Negotiated Targeted Anticancer Medicines Use in China: An
           Interrupted Time Series Analysis

    • Abstract: Background  In order to relieve the financial burden of the patients in China, the Ministry of Health (MoH) conducted the first national price negotiation and successfully negotiated three expensive medicines including 2 targeted anticancer medicines (TAMs), icotinib and gefitinib. However, little evidence was available to demonstrate the impact of the national negotiation on TAMs use. The purpose of the study is to evaluate the implementation of the national price negotiation policy in China on TAMs use.   Methods  We used interrupted time series (ITS) design to examine the changes in the daily cost, the monthly hospital purchasing volume and spending of icotinib and gefitinib with pharmaceutical procurement data from 594 tertiary hospitals in 29 provinces of mainland China between January 2015 and July 2017. The period between May and July 2016 was applied to assess the impact of policy.   Results  The daily cost of icotinib and gefitinib decreased by 50.08% (P < .001) and 53.89% (P < .001) 12 months after the national negotiation, respectively. In terms of volume, the negotiation was associated with increases in the trend of the monthly hospital purchasing volume of icotinib and gefitinib by 4.87 thousand defined daily doses (DDDs) (P < .001) and 6.89 thousand DDDs (P < .001). However, the monthly hospital purchasing spending of icotinib and gefitinib decreased rapidly by US$0.51 million (P < .010) and US$0.82 million (P < .050) following policy implementation, respectively.   Conclusion  The first national negotiation had successfully cut off the price of two negotiated TAMs and promoted TAMs use in China. In the future, government should conduct further price negotiations and include more medicines with clinical benefits into reimbursement schemes to alleviate patients’ financial burden and promote their access to essential treatment.
       
  • Traditional and Complementary Medicine in Tanzania: Regulation Awareness,
           Adherence and Challenges

    • Abstract: Background  The demand for and use of Traditional and Complementary Medicine (T&CM) has recently increased worldwide drawing a public health attention including malpractice, which puts the health of its clients at risk. Despite efforts made by Tanzania to integrate T&CM in the health system to protect the clients, regulating the subsector has remained a challenge due to lack of information and operational factors facing the regulatory frameworks in Tanzania. The aim of this study was to determine the extent of imperfect information, regulation adherence and challenges among T&CM practitioners and regulators in Tanzania.   Methods  In-depth interviews were carried out with T&CM practitioners in Dar es Salaam Region in Tanzania, and officials from the Ministry of Health and the study municipals. Purposive and snowballing approaches were used to select study participants. Thematic data analysis was done with the help of NVIVO.   Results  Awareness of regulations and tools used for regulating the T&CM operations among practitioners was generally very low. There was fragmentation of knowledge on what they were practicing as well as on awareness of the regulations, and what is regulated. Practitioners argued that they cannot be controlled by conventional medical trained personnel. Regulators at municipal level reported to have had no knowledge, interest, and time to work on T&CM. Lack of adequately trained and qualified manpower, lack of financial resources, poor transport and other infrastructure at the municipal regulatory units aggravated non-adherence to regulations, and therefore rendered ineffectiveness to the regulatory framework.   Conclusion  Existence of imperfect information on T&CM among regulators and practitioners affect effectiveness of T&CM regulatory process. Awareness of regulations among practitioners, presence of knowledgeable regulators, as well as capacity would facilitate adherence to regulations.
       
  • Challenges in Implementing Community-Based Healthcare Teams in a
           

    • Abstract: Background  Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia’s family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities.   Methods  Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and systemlevel factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains.   Results  Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally- driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators.   Conclusion  Lessons from Ethiopia’s challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.
       
  • Impact of Non-pharmaceutical Interventions on the Control of COVID-19 in
           Iran: A Mathematical Modeling Study

    • Abstract: Background  During the first months of the coronavirus disease 2019 (COVID-19) pandemic, Iran reported high numbers of infections and deaths. In the following months, the burden of this infection decreased significantly, possibly due to the impact of a package of interventions. We modeled the dynamics of COVID-19 infection in Iran to quantify the impacts of these interventions.   Methods  We used a modified susceptible–exposed–infected–recovered (SEIR) model to model the COVID-19 epidemic in Iran, from 21 January to 21 September 2020. We estimated the 95% uncertainty intervals (UIs) using Markov chain Monte Carlo simulation. Under different scenarios, we assessed the effectiveness of non-pharmaceutical interventions (NPIs) including physical distancing measures and self-isolation. We also estimated the time-varying reproduction number (Rt), using our mathematical model and epidemiologic data.   Results  If no NPIs were applied, there could have been a cumulative number of 51 800 000 (95% UI: 1 910 000–77 600 000) COVID-19 infections and 266 000 (95% UI: 119 000–476 000) deaths by September 21, 2020. If physical distancing interventions, such as school/border closures and self-isolation interventions had been introduced a week earlier than they were actually launched, 30.8% and 35.2% reduction in the number of deaths and infections respectively could have been achieved by September 21, 2020. The observed daily number of deaths showed that the Rt was one or more than one almost every day during the analysis period.   Conclusion  Our models suggest that the NPIs implemented in Iran between January 21, 2020 and September 21, 2020 had significant effects on the spread of the COVID-19 epidemic. Our study also showed that the timely implementation of NPIs showed a profound effect on further reductions in the numbers of infections and deaths. This highlights the importance of forecasting and early detection of future waves of infection and of the need for effective preparedness and response capabilities.
       
  • Socio-Demographic Predictors of Willingness to Pay for Premium of National
           Health Insurance: A Cross-sectional Survey of Six Districts in Sierra
           Leone

    • Abstract: Background  The government of Sierra Leone introduced Social Health Insurance Scheme as a measure to remove financial barriers that beset the people in accessing health to ensure universal coverage. Under this policy, the citizens were encouraged to subscribe to the scheme to avoid out of pocket payment for healthcare at the point of use. This study was conducted to find out the predictors of willingness among the people to pay for health insurance premium.    Methods  A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data was collected for this study through the use of semi-structured questionnaire with a sample size of 1185 respondents. Data was analysed into descriptive and inferential statistics using the contingent valuation model. Statistical analysis was run at 5% significant level using Stata version 14.0 software.    Results  The results showed that majority of the respondent are willing to join and pay a monthly premium of Le 10 000 (US$1.03) with an estimated mean contribution of about Le 14 089 (US$1.44) and the top five predictors of willingness to pay (WTP) were household monthly income, age, district of resident, gender, and educational qualification.    Conclusion  The findings on predictors of WTP premium of Sierra Leone National Social Health Insurance (SLeNSHI), suggests that the socio-demographic characteristics of the population are important in premium design and payment. Efforts at improving the socio- economic statuses of the population could be helpful in premium design and payment.
       
  • A Complexity Lens on the COVID-19 Pandemic

    •  
  • Vaccine Inequities, Intellectual Property Rights and Pathologies of Power
           in the Global Response to COVID-19

    •  
  • Policy Challenges Facing the Scale Up of Integrated Community Case
           Management (iCCM) in Uganda

    • Abstract: Background  Integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is an equity focused strategy, to increase access to care for febrile illness in children under-5 years of age, in rural communities. Lay community members are trained to diagnose and treat malaria, pneumonia and diarrhoea in children, and to identify and refer very ill children. Today, many low-income countries including Uganda, have a policy for iCCM which is being rolled out through public sector community health workers (CHWs). Ten years after the introduction of the iCCM strategy in Uganda, it is important to take stock and understand the barriers and facilitators affecting implementation of the iCCM policy.   Methods  We conducted an iCCM policy analysis in order to identify the challenges, enablers and priorities for scale-up of the iCCM strategy in Uganda. This was a qualitative case study research which included a document review (n = 52) and key informant interviews (n = 15) with Ugandan stakeholders. Interviews were conducted in 2017 and the desk review included literature up to 2019.   Results  This paper highlights the iCCM policy trajectory since 2010 in Uganda and includes a policy timeline. The iCCM policy process was mainly led by international agencies from inception, with little ownership of the government. Many implementation challenges including low government funding, weak coordination and contradicting policies were identified, which could contribute to the slow scale up of the iCCM program. Despite the challenges, many enablers and opportunities also exist within the health system, which should be further harnessed to scale up iCCM in Uganda. These enabling factors include strong community commitment, existing policy instruments and the potential of utilizing also the private sector for iCCM implementation.   Conclusion  The iCCM program in Uganda needs to be strengthen through increased domestic funding, strong coordination and a focus on monitoring, evaluation and operational research.
       
  • Access to Care for Mental Health Problems in Afghanistan: A National
           Challenge

    • Abstract: Background  This paper describes the access to care for mental health problems in Afghanistan, according to the nature of the mental health problems and the service provider. Following the Andersen model, it evaluates the respective roles in access to care of “predisposing,” “needs,” “enabling” factors, and other “environmental” factors such as exposure to traumatic events and level of danger of the place of residence.    Methods  Trans-sectional probability survey in general population by multistage sampling in 16 provinces, nationally representative: N = 4445 (15 years or older), participation rate of 81%. Face to face interviews using standardized measures of mental health (CIDI, Composite International Diagnostic Interview). Different logistic regression models are presented.    Results  The 12-month rate of mental health help-seeking was 6.56% with substantial regional variation (2.35% to 12.65%). Providers were mainly from the health sector; the non- health sector (religious and healers) was also prevalent. Most consultations were held in private clinics (non-governmental organisation, NGO). The severity of mental health disorders as well as the perceived impairment due to mental health were independently very important: odds ratio (OR) = 6.04 for severe disorder, OR = 3.79 for perceived impairment. Living in a dangerous area decreased access to care: for high level of danger and for very high level: OR = 0.22. Gender, education and ethnicity were not associated with mental health help-seeking after controlling for exposure to trauma.    Conclusion  Access to care for mental health problems depended mainly on the needs as defined as disorder severity level and impairment, and on environmental factors such as exposure to traumatic events. The system seems equitable; however, this is counterbalanced by a very challenging environment. This survey is a testimony to the hardship experienced by the Afghan population and by health professionals, and to the efforts to deliver organized mental healthcare in a challenging situation. This research may inform and support policy-makers and NGOs in other countries undergoing similar challenges.
       
  • Regional Differences in Admission Rates of Emergency Patients Who Visited
           a Private General Hospital in the Capital City of Cambodia: A Three-Year
           Observational Study

    • Abstract: Background  Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban–rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline.   Methods  To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients’ addresses were classified into 4 areas based on distance from the capital.   Results  A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P < .01: Chi- square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season.   Conclusion  The admission rate of emergency patients who visited a private general hospital in Cambodia’s capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.
       
  • Researchers’ and Research Users’ Experiences With and Reasons for
           Working Together in Spinal Cord Injury Research Partnerships: A
           Qualitative Study

    • Abstract: Background  Research partnership approaches are becoming popular within spinal cord injury (SCI) health research system, providing opportunities to explore experiences of and learn from SCI research partnership champions. This study aimed to explore and describe SCI researchers’ and research users’ (RU’) experiences with and reasons for conducting and/or disseminating (health) research in partnership in order to gain more insight into potentially ways to build capacity for and foster change to support research partnerships within a health research system.   Methods  Underpinned by a pragmatic perspective, ten semi-structured timeline interviews were conducted with researchers and RU who have experiences with SCI research partnerships. Interviews focused on experiences in participants’ lives that have led them to become a person who conducts and/or disseminates research in partnership. Data were analysed using narrative thematic analysis.   Results  We identified three threads from participants’ stories: (1) seeing and valuing different perspectives, (2) inspirational role models, and (3) relational and personal aspect of research partnerships. We identified sub-threads related to experiences that participants draw on how they came to be a person who engage in (health) research partnerships, and sub-threads related to participants’ reasons for engaging in research partnerships. While most subthreads were identified from both researchers’ and RU’ perspectives (eg, partnership successes and failures), some were unique for researchers (morally the right thing to do) or RU (advocating).   Conclusion  Using a narrative and pragmatic approach, this study provided a new understanding of SCI researchers’ and RU’ partnership experiences over time. We found that participants’ research partnership experiences and motivations align with components of leadership theories. The findings from this study may be used to inform strategies and policy programs to build capacity for conducting and disseminating (health) research in partnership, within and beyond SCI research.
       
  • Health Inequalities of STEMI Care Before Implementation of a New Regional
           Network: A Prefecture-Level Analysis of Social Determinants of Healthcare
           in Yunnan, China

    • Abstract: Background  As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.   Methods  Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.   Results  A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR] = 0.47, 95% CI: 0.28-0.80, P = .004) and timely reperfusion therapy (OR = 0.32, 95% CI: 0.14-0.70, P = .005). Rural residents were less likely to present to hospital promptly than urban residents (HR = 0.65, 95% CI = 0.52-0.82, P < .001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR] = 0.40, 95% CI: 0.29-0.54, P < .001) and reperfusion therapy (HR = 0.37, 95% CI: 0.25-0.56, P < .001) compared to urban patients.   Conclusion  Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.
       
  • Performance of Stepwise Screening Methods in Identifying Individuals at
           High Risk of Type 2 Diabetes in an Iranian Population

    • Abstract: Background Recent evidence recommended stepwise screening methods for identifying individuals at high risk of type 2 diabetes to be recruited in the lifestyle intervention programs for the prevention of the disease. This study aims to assess the performance of different stepwise screening methods that combine non-invasive measurements with lab-based measurements for identifying those with 5-years incident type 2 diabetes.   Methods  3037 participants aged ≥30 years without diabetes at baseline in the Tehran Lipid and Glucose Study (TLGS) were followed. Thirty-two stepwise screening methods were developed by combining a non-invasive measurement (an anthropometric measurement (waist-to-height ratio, WtHR) or a score based on a non-invasive risk score [Australian Type 2 Diabetes Risk Assessment Tool, AUSDRISK]) with a lab-based measurement (different cut-offs of fasting plasma glucose [FPG] or predicted risk based on three lab-based prediction models [Saint Antonio, SA; Framingham Offspring Study, FOS; and the Atherosclerosis Risk in Communities, ARIC]). The validation, calibration, and usefulness of lab-based prediction models were assessed before developing the stepwise screening methods. Cut-offs were derived either based on previous studies or decision-curve analyses.   Results  203 participants developed diabetes in 5 years. Lab-based risk prediction models had good discrimination power (area under the curves [AUCs]: 0.80-0.83), achieved acceptable calibration and net benefits after recalibration for population’s characteristics and were useful in a wide range of risk thresholds (5%-21%). Different stepwise methods had sensitivity ranged 20%-68%, specificity 70%-98%, and positive predictive value (PPV) 14%-46%; they identified 3%-33% of the screened population eligible for preventive interventions.   Conclusion  Stepwise methods have acceptable performance in identifying those at high risk of incident type 2 diabetes.
       
  • The Responsibility-Sharing of Nation-States and the ACT-Accelerator

    •  
  • E-Cigarette Markets and Policy Responses in Southeast Asia: A Scoping
           Review

    • Abstract: Background The global e-cigarette market has proliferated and is increasingly dominated by transnational tobacco companies. While Southeast Asian countries have received relatively little attention in e-cigarette research, the region represents an area of potentially untapped growth for the industry. We review the e-cigarette situation in Southeast Asia in terms of the e-cigarette markets, advertising and promotion of e-cigarettes, reported health impacts of e-cigarette use, and policy responses in the region.   Methods  We examined e-cigarette market data from the Euromonitor Global Market Information Database (GMID) Passport database, searched in the academic literature, grey literature and news archives for any reports or studies of e-cigarette related diseases or injuries, e-cigarette marketing, and e-cigarette policy responses in Southeast Asian countries, and browsed the websites of online e-cigarette retailers catering to the region’s active e-cigarette markets.   Results In 2019, e-cigarettes were sold in six Southeast Asian markets with a total market value of $595 million, projected to grow to $766 million by 2023. E-commerce is a significant and growing sales channel in the region, with most of the popular or featured brands in online shops originating from China. Southeast Asian youth are targeted with a wide variety of flavours, trendy designs and point of sale promotions, and several e-cigarette related injuries and diseases have been reported in the region. Policy responses vary considerably between countries, ranging from strict bans to no or partial regulations.   Conclusion Although Southeast Asia’s e-cigarette market is relatively nascent, this is likely to change if transnationals invest more heavily in the region. Populous countries with weak e-cigarette regulations, notably Indonesia, Malaysia, Vietnam and the Philippines, are desirable targets for the transnationals. Regulatory action is needed to prevent e-cigarette use from becoming entrenched into these societies, especially among young people.
       
  • COVID-19 Lockdown and Social Capital Changes Among Youths in China

    • Abstract: Social capital refers to the effective functioning of social groups through networks of relationships. The lockdown measures due to coronavirus disease 2019 (COVID-19) may change the social capital among youths. This study aimed to evaluate changes in social capital before and during COVID-19 lockdown among Chinese youths. It was based on the online COVID-19 Impact on Lifestyle Change Survey (COINLICS) conducted among 10 540 youths at three educational levels, including high/vocational school, undergraduate, and graduate, before and during COVID-19 lockdown. Measures of perceptions of social capital were adapted from a validated Chinese version of Health-related Social Capital Measurement based on youths’ characteristics of living and studying environment. Social capital was measured at four dimensions, including individual social capital (ISC), family social capital (FSC), community social capital (CSC), and society social capital (SSC). Overall, compared to before lockdown, ISC and CSC scores decreased, while FSC and SSC scores increased during lockdown. When stratified by educational levels, the trends for each dimension of social capital were consistent with the overall population. There were 43.9%, 5.7%, 32.1%, and 3.7% of the participants showing decreased scores during lockdown for ISC, FSC, CSC, and SSC, respectively, while 7.2%, 24.0%, 15.3%, and 10.7% of participants showed increased scores for ISC, FSC, CSC, and SSC, respectively. Our timely, largescale study showed decreased social capital in individual and community dimensions and increased social capital in family and society dimensions during lockdown.
       
  • Implications of COVID-19: The Effect of Working From Home on Financial and
           Mental Well-Being in the UK

    • Abstract: In response to the threat posed by coronavirus disease 2019 (COVID-19), the UK prime minister announced on the 23rd of March strict lockdowns and introduced a new way of living and working, at least temporarily. This included working from home (WHF) wherever possible. Many experts from the IT industry were long arguing about the potential for WFH, which suddenly now became indisputable. The objective of this study is to evaluate the impact of WFH on the individuals’ perception about their future financial situation and their mental well-being. We apply a differencein-differences (DiD) framework using data from the UK Household Longitudinal Study (UKHLS) combined with the UKHLS COVID-19 survey conducted in April 2020. Our findings suggest that those who have not experienced a shift from working at the employer’s premises to WFH became more concerned about their future financial situation. However, we find that WFH has a negative impact on mental well-being. On the other hand, we find no difference in the mental well- being when we consider those who work from home on occasion. The findings of this study have policy implications for government, firms and health practitioners. In particular, a balance between WFH and at the employer’s premises may provide both financial security and maintain the mental and psychological well-being at satisfying levels.
       
  • Clinical Priority Setting and Decision-Making in Sweden: A Cross-sectional
           Survey Among Physicians

    • Abstract: Background  Priority setting in healthcare that aims to achieve a fair and efficient allocation of limited resources is a worldwide challenge. Sweden has developed a sophisticated approach. Still, there is a need for a more detailed insight on how measures permeate clinical life. This study aimed to assess physicians’ views regarding (1) impact of scarce resources on patient care, (2) clinical decision-making, and (3) the ethical platform and national guidelines for healthcare by the National Board of Health and Welfare (NBHW).   Methods  An online cross-sectional questionnaire was sent to two groups in Sweden, 2016 and 2017. Group 1 represented 331 physicians from different departments at one University hospital and group 2 consisted of 923 members of the Society of Cardiology.   Results  Overall, a 26% (328/1254) response rate was achieved, 49% in group 1 (162/331), 18% in group 2 (166/923). Scarcity of resources was perceived by 59% more often than ‘at least once per month,’ whilst 60% felt less than ‘wellprepared’ to address this issue. Guidelines in general had a lot of influence and 19% perceived them as limiting decisionmaking. 86% professed to be mostly independent in decision-making. 36% knew the ethical platform ‘well’ and ‘very well’ and 64% NBHW’s national guidelines. 57% expressed a wish for further knowledge and training regarding the ethical platform and 51% for support in applying NBHW’s national guidelines.   Conclusion  There was a need for more support to deal with scarcity of resources and for increased knowledge about the ethical platform and NBHW’s national guidelines. Independence in clinical decision-making was perceived as high and guidelines in general as important. Priority setting as one potential pathway to fair and transparent decision-making should be highlighted more in Swedish clinical settings, with special emphasis on the ethical platform.
       
  • Health in Food Systems Policies in India: A Document Review

    • Abstract: Background  Food systems affect nutritional and other health outcomes. Recent literature from India has described policy aspects addressing nutritional implications of specific foods (eg, fruits, vegetables, and trans-fats), and identified opportunities to tackle the double burden of malnutrition. This paper attempts to deepen the understanding on how health concerns and the role of the health sector are addressed across food systems policies in India.   Methods  This qualitative study used two approaches; namely (i) the framework method and (ii) manifest content analysis, to investigate national-level policy documents from relevant sectors (ie, food security, agriculture, biodiversity, food processing, trade, and waste management, besides health and nutrition). The documents were selected purposively. The textual data were coded and compared, from which themes were identified, described, and interpreted. Additionally, mentions of various health concerns and of the health ministry in the included documents were recorded and collated.   Results  A total of 35 policy documents were included in the analysis. A variety of health concerns spanning nutritional, communicable and non-communicable diseases (NCDs) were mentioned. Undernutrition received specific attention even beyond nutrition policies. Only few policies mentioned NCDs, infectious diseases, and injuries. Governing and advisory bodies were instituted by 17 of the analysed policies (eg, food safety, agriculture, and food processing), and often included representation from the health ministry (9 of the 17 identified inter-ministerial bodies).   Conclusion  We found some evidence of concern for health, and inclusion of health ministry in food policy documents in India. The ongoing and planned intersectoral coordination to tackle undernutrition could inform actions to address other relevant but currently underappreciated concerns such as NCDs. Our study demonstrated a method for analysis of health consideration and intersectoral coordination in food policy documents, which could be applied to studies in other settings and policy domains.
       
  • “Apples and Oranges:” Examining Different Social Groups’ Compliance
           With Government Health Instructions During the COVID-19 Pandemic

    • Abstract: Background  The coronavirus outbreak has demonstrated the crucial effect of the public’s compliance with the government’s health instructions on the population’s health. However, evidence shows that some communities are less likely to comply with such instructions than others. This study highlights the factors related to intentions to comply with newly issued health directives during an ongoing extreme crisis, such as the current pandemic. In addition, it compares the impact of these factors on different minority groups and the general population in Israel.   Methods  Using an online survey (N = 1005), we examined the impact of compliance-related factors on compliance intentions with newly issued health directives in two minority groups in Israel: the ultra-Orthodox Jewish community (N = 323) and the Arab community (N = 361), as well as in the general population (N = 321), during the first outbreak of coronavirus disease 2019 (COVID-19). Participants were presented with a new made-up COVID-19-related instruction simulated to be issued by the Israeli Ministry of Health. Compliance intentions and compliance-related factors were measured.   Results  The Arab minority expressed greater intentions of complying with the instructions than the other groups. Perceptions on risk and the effectiveness of the instruction were the only two significantly associated factors with compliance intentions in all of the social groups. Additional factors affected different groups to different extents. Trust in government was related to compliance intentions only in the Arab minority.   Conclusion  Intentions to comply with health instructions during a crisis differ in various minority groups and in comparison to the general population, both in their levels and in the factors related to them. Policy-makers and health authorities should consider providing information about the risks and negative outcomes of the crisis as well as the expected effectiveness of the recommended behaviors. Future research should examine other minority groups and other types of instructions in different stages of a crisis.
       
  • Policy Implementation Challenges and Barriers to Access Sexual and
           Reproductive Health Services Faced By People With Disabilities: An
           Intersectional Analysis of Policy Actors’ Perspectives in Post-Conflict
           Northern Uganda

    • Abstract: Background Emerging from a 20-year armed conflict, Uganda adopted several laws and policies to protect the rights of people with disabilities, including their sexual and reproductive health (SRH) rights. However, the SRH rights of people with disabilities continue to be infringed in Uganda. We explored policy actors’ perceptions of existing prodisability legislation and policy implementation, their perceptions of potential barriers experienced by people with disabilities in accessing and using SRH services in post-conflict Northern Uganda, and their recommendations on how to redress these inequities.   Methods  Through an intersectionality-informed approach, we conducted and thematically analysed 13 in-depth semi-structured interviews with macro level policy actors (national policy-makers and international and national organisations); seven focus groups (FGs) at meso level with 68 health service providers and representatives of disabled people’s organisations (DPOs); and a two-day participatory workshop on disability-sensitive health service provision for 34 healthcare providers.   Results We identified four main themes: (1) legislation and policy implementation was fraught with numerous technical and financial challenges, coupled with lack of prioritisation of disability issues; (2) people with disabilities experienced multiple physical, attitudinal, communication, and structural barriers to access and use SRH services; (3) the conflict was perceived to have persisting impacts on the access to services; and (4) policy actors recommended concrete solutions to reduce health inequities faced by people with disabilities.   Conclusion  This study provides substantial evidence of the multilayered disadvantages people with disabilities face when using SRH services and the difficulty of implementing disability-focused policy in Uganda. Informed by an intersectionality approach, policy actors were able to identify concrete solutions and recommendations beyond the identification of problems. These recommendations can be acted upon in a practical road map to remove different types of barriers in the access to SRH services by people with disabilities, irrespective of their geographic location in Uganda.
       
  • Community Health Center Efficiency. The Impact of Organization Design and
           Local Context: The Case of Indonesia

    • Abstract: Background  The decentralization of the Indonesian healthcare system, launched in the year 2000, allowed the authorities of local community health centers (CHCs) to tailor their services to the needs of their clients. Many observers see this as an opportunity to increase CHC efficiency. Building on the Context Design Performance Framework, this paper assesses the extent to which efficiency variations between CHCs can be explained by the degree of fit between their organizational design characteristics and aspects of the communities in which they are embedded.    Methods  Data envelopment analysis (DEA) was applied to construct a measure of CHC efficiency for a sample of 598 CHCs in 2011, drawn from a publicly available Ministry of Health (MoH) dataset. Tobit regression analysis was applied to assess the impact of organization design and community characteristics and their interplay on efficiency.   Results Large variations in CHC efficiency were discovered, suggesting that not all CHCs are equally capable of finding the optimal design to operate most efficiently. A significant inverted U-shape relationship was found for the organization design-efficiency link: efficiency is highest for CHCs with 1-2 horizontal units and decreases for CHCs exceeding or not reaching this number. No significant association was found between community characteristics (proportion of poor people, remote location of CHC) and CHC efficiency.   Conclusion  Organizational design matters for CHC efficiency, but no evidence was found for the hypothesis that a better fit between community characteristics and CHC design increases efficiency. A potential reason for this might be that CHC management’s main design challenge is how to cope with the scarce availability of well-trained health personnel.
       
  • Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients
           With Early-Stage Chronic Kidney Disease in Taiwan

    • Abstract: Background With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.   Methods  We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) 2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray’s test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.   Results  The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P < .0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58–0.64, P < .0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54–0.67, P < .0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.   Conclusion  The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.
       
  • Seeking Healthcare During Lockdown: Challenges, Opportunities and Lessons
           for the Future

    • Abstract: Background  In Aotearoa/New Zealand, the first nation-wide coronavirus disease 2019 (COVID-19) lockdown occurred from March 23, 2020 to May 13, 2020, requiring most people to stay at home. Health services had to suddenly change how they delivered healthcare and some services were limited or postponed. This study investigated access to healthcare during this lockdown period, whether patients delayed seeking healthcare and reasons for these delays, focusing on the accessibility of primary care services.   Methods  Adults (aged 18 years or older) who had contact with primary care services were invited through social media and email lists to participate in an online survey (n = 1010) and 38 people were recruited for in-depth interviews. We thematically analysed qualitative data from the survey and interviews, reported alongside relevant descriptive survey results.   Results  More than half (55%) of survey respondents delayed seeking healthcare during lockdown. Factors at a national or health system-level that could influence delay were changing public service messages, an excessive focus on COVID-19 and urgent issues, and poor service integration. Influential factors at a primary care-level were communication and outreach, use of technology, gatekeeping, staff manner and the safety of the clinical practice environment. Factors that influenced patients’ individual decisions to seek healthcare were the ability to self-manage and self-triage, consciousness of perceived pressure on health services and fear of infection.   Conclusion In future pandemic lockdowns or crises, appropriate access to primary care services can be improved by unambiguous national messages and better integration of services. Primary care practices should adopt rapid proactive outreach to patients, fostering a calm but safe clinical practice environment. More support for patients to self-manage and self-triage appropriately could benefit over-burdened health systems during lockdowns and as part of business as usual in less extraordinary times.
       
  • The Electronic Health Insurance Card for Asylum-Seekers in Berlin: Effects
           on the Local Health System

    • Abstract: Background  In debates on asylum-seekers’ access to healthcare it is frequently claimed that restrictions are necessary to prevent unduly high health service utilization and costs. Within Germany, healthcare provision for asylum-seekers varies across the different states. Berlin’s authorities removed some barriers to healthcare for asylum-seekers by introducing an electronic health insurance card (HIC) in 2016. We used the HIC introduction in Berlin as an opportunity to investigate the effects of improved healthcare access for asylum-seekers on the local health system.   Methods  The study applied a mixed-methods design. A cost analysis compared expenses for outpatient and inpatient health services for asylum-seekers before and after the HIC introduction, based on aggregate claims data and information on expenses for humanitarian healthcare provision that were retrieved from the Berlin authorities. Semi- structured interviews with 12 key informants explored organizational effects like administrative workloads and ethical dilemmas for staff. We performed a content analysis and used respondent validation to enhance the accuracy and trustworthiness of our results.   Results  The HIC has reduced bureaucratic complexity and administrative workloads; it has enabled unprecedented financial transparency and control; and it has mitigated ethical tensions. All the while, average per person expenses for outpatient health services have declined since the HIC introduction. However, our cost analysis also indicates a rise in the utilization and costs of inpatient care.   Conclusion  The HIC introduction in Berlin suggests that the removal of barriers to healthcare for asylum-seekers can create win-win-situations by reducing administrative workloads, advancing financial transparency, and mitigating ethical tensions, whilst cutting the costs of outpatient healthcare provision. Removing barriers to healthcare thus appears to be a more prudent policy choice than maintaining mechanisms of restriction and control. However, high inpatient care utilization and costs warrant further research.
       
  • Factors Associated With Missed Nursing Care in Nursing Homes: A
           Multicentre Cross-sectional Study

    • Abstract: Background  Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care.   Methods  In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs’ judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner.   Results  Younger RNs (P = .026), freelance RNs (P = .046), RNs with a permanent contract (P = .035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P < .012). Public ownership (odds ratio [OR] = 9.88; 95% CI 2.22–44.03; P = .003), a higher proportion of residents with severe clinical conditions (OR = 2.45; 95% CI 1.12–5.37; P = .025), a lower proportion of RNs (OR = 2.24; 95% CI 1.10–4.54; P = .026), and perceived lack of time to care for residents (OR = 2.33; 95% CI 1.04–5.26; P = .041) were statistically significantly associated with missed nursing care.   Conclusion  Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.
       
  • Motivations and Limits for COVID-19 Policy Compliance in Germany and
           Switzerland

    • Abstract: Background  In contrast to neighboring countries, German and Swiss authorities refrained from general curfews during the first pandemic wave in spring 2020, calling for solidarity and personal responsibility instead. Using a qualitative methodology, this study aims to explore why people in Germany and Switzerland were motivated to comply with policy measures during the first wave of the coronavirus disease 2019 (COVID-19) pandemic, and what factors hindered or limited their motivation. While quantitative surveys can measure the level of compliance, or broadly ask what motives people had for compliance, we here strive to explain why and how these motives lead to compliance.   Methods  This publication has been made possible by the joint work of the members of the “Solidarity in times of pandemics” (SolPan) research commons. Seventy-seven semi- structured qualitative interviews were conducted with members of the general public in Germany (n = 46) and the German-speaking part of Switzerland (n = 31) in April 2020. Interviews were transcribed and analyzed following a grounded theory approach.   Results  Three themes were identified that summarize factors contributing to compliant or noncompliant behavior. (1) Social cohesion was, on the one hand, an important motivator for compliance, but at the same time related to conflicting needs, illustrating the limits of compliance. (2) Consequences were considered on both the individual level (eg, consequences of individual infection) and societal level (eg, the societal and economic consequences of restrictions). (3) While for some participants following the rules was perceived as a matter of principle, others stressed the importance of making their own risk assessment, which was often associated with with a need for evidence on the effectiveness and reasons behind measures.   Conclusion  A variety of motives contribute to COVID-19 related compliance. Authorities should seek to address these multi-faceted aspects to support motivation for compliance in a large proportion of the population.
       
  • Inpatient Care Costs of COVID-19 in South Africa’s Public Healthcare
           System

    • Abstract: Background  Coronavirus disease 2019 (COVID-19) has had a devastating impact globally, with severe health and economic consequences. To prepare health systems to deal with the pandemic, epidemiological and cost projection models are required to inform budgets and efficient allocation of resources. This study estimates daily inpatient care costs of COVID-19 in South Africa, an important input into cost projection and economic evaluation models.   Methods  We adopted a micro-costing approach, which involved the identification, measurement and valuation of resources used in the clinical management of COVID-19. We considered only direct medical costs for an episode of hospitalisation from the South African public health system perspective. Resource quantities and unit costs were obtained from various sources. Inpatient costs per patient day was estimated for consumables, capital equipment and human resources for three levels of inpatient care – general wards, high care wards and intensive care units (ICUs).   Results  Average daily costs per patient increased with the level of care. The highest average daily cost was estimated for ICU admissions – 271 USD to 306 USD (financial costs) and ~800 USD to 830 USD (economic costs, excluding facility fee) depending on the need for invasive vs. non-invasive ventilation (NIV). Conversely, the lowest cost was estimated for general ward-based care – 62 USD to 79 USD (financial costs) and 119 USD to 278 USD (economic costs, excluding facility fees) depending on the need for supplemental oxygen. In high care wards, total cost was estimated at 156 USD, financial costs and 277 USD, economic costs (excluding facility fees). Probabilistic sensitivity analyses suggest our costs estimates are robust to uncertainty in cost inputs.   Conclusion  Our estimates of inpatient costs are useful for informing budgeting and planning processes and costeffectiveness analysis in the South African context. However, these estimates can be adapted to inform policy decisions in other context.
       
  • How Do Health Systems Address Patient Flow When Services Are Misaligned
           With Population Needs' A Qualitative Study

    • Abstract: Background  Patient flow through health services is increasingly recognized as a system issue, yet the flow literature has focused overwhelmingly on localized interventions, with limited examination of system-level causes or remedies. Research suggests that intractable flow problems may reflect a basic misalignment between service offerings and population needs, requiring fundamental system redesign. However, little is known about health systems’ approaches to population–capacity misalignment, and guidance for system redesign remains underdeveloped.   Methods  This qualitative study, part of a broader investigation of patient flow in urban Western Canada, explored health-system strategies to address or prevent population–capacity misalignment. We conducted in-depth interviews with a purposive sample of managers in 10 jurisdictions across 4 provinces (N = 300), spanning all healthcare sectors and levels of management. We used the constant comparative method to develop an understanding of relevant strategies and derive principles for system design.   Results  All regions showed evidence of pervasive population–capacity misalignment. The most superficial level of response – mutual accommodation (case-by-case problem solving) – was most prevalent; capacity (re)allocation occurred less frequently; population redefinition most rarely. Participants’ insights yielded a general principle: Define populations on the basis of clusters of co-occurring need. However, defining such clusters demands a difficult balance between narrowness/rigidity and breadth/flexibility. Deeper analysis suggested a further principle: Populations that can be divided into homogeneous subgroups experiencing similar needs (eg, surgical patients) are best served by narrow/ rigid models; heterogeneous populations featuring diverse constellations of need (eg, frail older adults) require broad/ flexible models.   Conclusion  To remedy population–capacity misalignment, health system planners should determine whether clusters of population need are separable vs. fused, select an appropriate service model for each population, allocate sufficient capacity, and only then promote mutual accommodation to address exceptions. Overreliance on case-by-case solutions to systemic problems ensures the persistence of population–capacity misalignment.
       
  • Stakeholder Perspectives of Attributes and Features of Context Relevant to
           Knowledge Translation in Health Settings: A Multi-Country Analysis

    • Abstract: Background  Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare.   Methods  A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role.   Results  A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes).   Conclusion  The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.
       
  • Telehealth, COVID-19 and Refugees and Migrants in Australia: Policy and
           Related Barriers and Opportunities for More Inclusive Health and
           Technology Systems

    •  
  • Emerging and Re-emerging Infectious Diseases in the WHO Eastern
           Mediterranean Region, 2001-2018

    • Abstract: Background  Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018.   Methods  To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect.   Results  Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia.   Conclusion  EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.
       
  • The Evolution of Trust Within a Global Health Partnership With the Private
           Sector: An Inductive Framework

    • Abstract: Background  Public-private partnerships (PPPs) in global health are increasingly common to support sustainable development and strengthen health systems in low- and middle-income countries. Since the release of the Sustainable Development Goals (SDGs) in 2015 culminating in a discrete goal “to revitalize the global partnership for sustainable development,” public health scholars have sought to understand what makes PPPs successful in different contexts. While trust has long been identified as a key component of successful strategic alliances in the private sector, less is known about how trust emerges between public- and private- sector partners, particularly in global health. Therefore, we investigated how trust between partners evolved in the context of Project Last Mile (PLM), a global health partnership that translates the business acumen of The Coca-Cola Company to strengthen public health systems across Africa.   Methods  This study draws upon secondary analysis of qualitative data generated as part of the longitudinal, mixedmethods evaluation of PLM across country settings. Seventy-seven interviews with a purposeful sample of key stakeholders were conducted in Mozambique, South Africa and eSwatini between August 2016 and July 2018. Trained qualitative interviewers followed a standard discussion guide, and audio-recorded interviews with participants’ consent. In this secondary analysis, we analyzed qualitative data to understand how trust between partners was cultivated across settings.   Results  We drew upon stakeholder experiences to inform an inductive framework for how trust develops over time. Our analysis revealed five domains that were foundational to building trust: (1) reputational context, (2) team composition, (3) tangible outputs, (4) shared values, and (5) effective communication. Conclusion: The framework may be useful for private and public sector entities seeking to establish and sustain trust within their global health partnerships.
       
  • Conflict of Interest Policies at Medical Schools and Teaching Hospitals: A
           Systematic Review of Cross-sectional Studies

    • Abstract: Background  This systematic review aims to estimate the proportion of medical schools and teaching hospitals with conflicts of interest (COI) policies for health research and education, to describe the provisions included in the policies and their impact on research outputs and educational quality or content.   Methods  Experimental and observational studies reporting at least one of the above mentioned aims were included irrespective of language, publication type or geographical setting. MEDLINE, Scopus, Embase and the Cochrane Methodology Register were searched from inception to March 2020. Methodological study quality was assessed using an amended version of the Joanna Briggs Institute’s checklist for prevalence studies.   Results  Twenty-two cross-sectional studies were included; all were conducted in high-income countries. Of these, 20 studies estimated the prevalence of COI policies, which ranged from 5% to 100% (median: 85%). Twenty studies assessed the provisions included in COI policies with different assessment methods. Of these, nine analysed the strength of the content of medical schools’ COI policies using various assessment tools that looked at a range of policy domains. The mean standardised summary score of policy strength ranged from 2% to 73% (median: 30%), with a low score indicating a weak policy. North American institutions more frequently had COI policies and their content was rated as stronger than policies from European institutions. None of the included studies assessed the impact of COI policies on research outputs or educational quality or content.   Conclusion  Prevalence of COI policies at medical schools and teaching hospitals varied greatly in high-income countries. No studies estimated the prevalence of policies in low to middle-income countries. The content of COI policies varied widely and while most European institutions ranked poorly, in North America more medical schools had strong policies. No studies were identified on impact of COI policies on research outputs and educational quality or content.
       
  • Density of Patient-Sharing Networks: Impact on the Value of Parkinson Care

    • Abstract: Background  Optimal care for Parkinson’s disease (PD) requires coordination and collaboration between providers within a complex care network. Individual patients have personalised networks of their own providers, creating a unique informal network of providers who treat (‘share’) the same patient. These ‘patient-sharing networks’ differ in density, ie, the number of identical patients they share. Denser patient-sharing networks might reflect better care provision, since providers who share many patients might have made efforts to improve their mutual care delivery. We evaluated whether the density of these patient-sharing networks affects patient outcomes and costs.   Methods  We analysed medical claims data from all PD patients in the Netherlands between 2012 and 2016. We focused on seven professional disciplines that are commonly involved in Parkinson care. We calculated for each patient the density score: the average number of patients that each patient’s providers shared. Density scores could range from 1.00 (which might reflect poor collaboration) to 83.00 (which might reflect better collaboration). This score was also calculated at the hospital level by averaging the scores for all patients belonging to a specific hospital. Using logistic and linear regression analyses we estimated the relationship between density scores and health outcomes, healthcare utilization, and healthcare costs.   Results  The average density score varied considerably (average 6.7, SD 8.2). Adjusted for confounders, higher density scores were associated with a lower risk of PD-related complications (odds ratio [OR]: 0.901; P < .001) and with lower healthcare costs (coefficients: -0.018, P = .005). Higher density scores were associated with more frequent involvement of neurologists (coefficient 0.068), physiotherapists (coefficient 0.052) and occupational therapists (coefficient 0.048) (P values all <.001).   Conclusion  Patient sharing networks showed large variations in density, which appears unwanted as denser networks are associated with better outcomes and lower costs.
       
  • Economic Costs of Providing District- and Regional-Level Surgeries in
           Tanzania

    • Abstract: Background Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.   Methods Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.   Results The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.   Conclusion Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.
       
  • The Use of Intersectional Analysis in Assessing Women’s Leadership
           Progress in the Health Workforce in LMICs: A Review

    • Abstract: Background Human resources are at the heart of health systems, playing a central role in their functionality globally. It is estimated that up to 70% of the health workforce are women, however, this pattern is not reflected in the leadership of health systems where women are under-represented.   Methods This systematized review explored the existing literature around women’s progress towards leadership in the health sector in low- and middle-income countries (LMICs) which has used intersectional analysis.   Results While there are studies that have looked at the inequities and barriers women face in progressing towards leadership positions in health systems within LMICs, none explicitly used an intersectionality framework in their approach. These studies did nevertheless show recurring barriers to health systems leadership created at the intersection of gender and social identities such as professional cadre, race/ethnicity, financial status, and culture. These barriers limit women’s access to resources that improve career development, including mentorship and sponsorship opportunities, reduce value, recognition and respect at work for women, and increase the likelihood of women to take on dual burdens of professional work and childcare and domestic work, and, create biased views about effectiveness of men and women’s leadership styles. An intersectional lens helps to better understand how gender intersects with other social identities which results in upholding these persisting barriers to career progression and leadership.   Conclusion As efforts to reduce gender inequity in health systems are gaining momentum, it is important to look beyond gender and take into account other intersecting social identities that create unique positionalities of privilege and/or disadvantage. This approach should be adopted across a diverse range of health systems programs and policies in an effort to strengthen gender equity in health and specifically human resources for health (HRH), and improve health system governance, functioning and outcomes.
       
  • Major Thalassemia, Screening or Treatment: An Economic Evaluation Study in
           Iran

    • Abstract: Background Beta-thalassemia minor and thalassemia major are an autosomal recessive disease with hypochromic, microcytic anemia, and morbidities, Today, therapeutic advances have significantly improved the life expectancy of thalassemia major patients, but at the cost of financial toxicity. The present study aimed to investigate the possibility of increasing the funding for thalassemia screening programs and comparing the cost-effectiveness of screening for thalassemia in the treatment of the patients.   Methods In this study, screening for thalassemia minor was compared with the treatment of thalassemia major patients. A decision tree model was used for analysis. A hospital database, supplemented with a review of published literature, was used to derive input parameters for the model. A lifetime study horizon was used and future costs and consequences were discounted at 3%. The approach of purchases of services was used to evaluate the screening test costs for patients with thalassemia major. Also, a bottom-up method was applied to estimate other screening and treatment costs. All the costs were calculated over one year. The number of gained quality-adjusted life years (QALYs) was calculated using the EQ-5D questionnaire in the evaluated patients.   Results In this study, 26.97 births of patients with thalassemia major were prevented by screening techniques. On the other hand, total screening costs for patients with thalassemia major were estimated equal to US$ 879 879, while the costs of preventing the birth of each thalassaemia major patient was US$ 32 624 by screening techniques. In comparison, the cost of managing a patient with thalassemia major is about US$ 136 532 per year. The life time QALYs for this is 11.8 QALYs. Results are presented using a societal perspective. Incremental cost per QALY gained with screening as compared with managing thalassaemia major was US$ 11 571.   Conclusion Screening is a long-term value for money intervention that is highly cost effective and its long-term clinical and economic benefits outweigh those of managing thalassaemia major patients.
       
  • Conceptualising the Commercial Determinants of Health Using a Power Lens:
           A Review and Synthesis of Existing Frameworks

    • Abstract: Background There is increasing recognition that power imbalances that favour corporations, especially those active in unhealthy commodity industries, over other actors are central to the ways in which corporations influence population health. However, existing frameworks for analysing corporate strategies and practices that impact on health do not incorporate concepts of power in consistent ways. This paper aimed to review the ways in which corporate power has been incorporated into such frameworks, and to propose a revised framing of the commercial determinants of health(CDoH) that makes concepts of power explicit.   Methods We conducted a narrative review of frameworks that identify corporate strategies and practices and explain how these influence population health. Content analysis was conducted to identify explicit references to different qualities of power – its origins, nature, and manifestations.   Results Twenty-two frameworks were identified, five of which used theories of power. A wide range of contexts that shape, and are shaped by corporate power were discussed, as were a diversity of corporate, social and ecological outcomes. A variety of material and ideational sources of power was also covered. We proposed an integrated ‘Corporate Power and Health’ framework to inform analysis of the CDoH, organised around key questions on power set out by Foucault. The proposed framework draws from a number of well-established corporate power theories and synthesises key features of existing CDoH frameworks.   Conclusion Public health advocates, researchers and policy-makers would likely be better placed to understand and address the CDoH by engaging with theories of power to a greater extent, and by explicitly incorporating concepts of corporate power in analyses of how the deployment of corporate strategies and practices influence population health.
       
  • Feasibility of Good Governance at Health Facilities: A Proposed Framework
           and its Application Using Empirical Insights From Kenya

    • Abstract: Background Governance is a social phenomenon which permeates throughout systemic, organisational and individual levels. Studies of health systems governance traditionally assessed performance of systems or organisations against principles of good governance. However, understanding key pre-conditions to embed good governance required for healthcare organisations is limited. We explore the feasibility of embedding good governance at healthcare facilities in Kenya.   Methods Our conceptualisation of organisational readiness for embedding good governance stems from a theory of institutional analysis and frameworks for understanding organisational readiness for change. Four inter-related constructs underpin to embed good governance: (i) individual motivations, determined by (ii) mechanisms for encouraging adherence to good governance through (iii) organisation’s institutional arrangements, all within (iv) a wider context. We propose a framework, validated through qualitative methods and collected through 39 semi-structured interviews with healthcare providers, county and national-level policy-makers in Kenya. Data was analysed using framework approach, guided by the four constructs of the theoretical framework. We explored each construct in relation to three key principles of good governance: accountability, participation and transparency of information.   Results Embedding good governance in healthcare organisations in Kenya is influenced by political and socio-cultural contexts. Individual motivations were a critical element of self-enforcement to embed principles of good governance by healthcare providers within their facilities. Healthcare providers possess strong moral incentives to self-enforce accountability to local populations, but their participation in decision-making was limited. Health facilities lacked effective mechanisms for enforcing good governance such as combating corruption, which led to a proliferation of informal institutional arrangements.   Conclusion Organisational readiness for good governance is context-specific so future work should recognise different interpretations of acceptable degrees of transparency, accountability and participation. While good governance involves collective social action, organisational readiness relies on individual choices and decisions within the context of organisational rules and cultural and historical environments.
       
  • A Report on Statistics of an Online Self-screening Platform for COVID-19
           and Its Effectiveness in Iran

    • Abstract: Background The most recent emerging infectious disease, coronavirus disease 2019 (COVID-19), is pandemic now. Iran is a country with community transmission of the disease. Telehealth tools have been proved to be useful in controlling public health disasters. We developed an online self-screening platform to offer a population-wide strategy to control the massive influx to medical centers.   Methods We developed a platform operating based on given history by participants, including sex, age, weight, height, location, primary symptoms and signs, and high risk past medical histories. Based on a decision-making algorithm, participants were categorized into four levels of suspected cases, requiring diagnostic tests, supportive care, not suspected cases. We made comparisons with Iran STEPs (STEPwise approach to Surveillance) 2016 study and data from the Statistical Centre of Iran to assess population representativeness of data. Also, we made a comparison with officially confirmed cases to investigate the effectiveness of the platform. A multilevel mixed-effects Poisson regression was used to check the association of visiting platform and deaths caused by COVID-19.   Results About 310 000 individuals participated in the online self-screening platform in 33 days. The majority of participants were in younger age groups, and males involved more. A significant number of participants were screened not to be suspected or needing supportive care, and only 10.4% of males and 12.0% of females had suspected results of COVID-19. The penetration of the platform was assessed to be acceptable. A correlation coefficient of 0.51 was calculated between suspected results and confirmed cases of the disease, expressing the platform’s effectiveness.   Conclusion Implementation of a proper online self-screening tool can mitigate population panic during wide-spread epidemics and relieve massive influx to medical centers. Also, an evidence-based education platform can help fighting infodemic. Noticeable utilization and verified effectiveness of such platform validate the potency of telehealth tools in controlling epidemics and pandemics.
       
  • Competing Frames in Global Health Governance: An Analysis of Stakeholder
           Influence on the Political Declaration on Non-communicable Diseases

    • Abstract: Background Non-communicable diseases (NCDs) are increasingly recognized as a significant threat to health and development globally, and United Nations (UN) Member States adopted the Political Declaration of the Third High-level Meeting (HLM) on the prevention and control of NCDs in 2018. The negotiation process for the Declaration included consultations with Member States, intergovernmental organizations (IGOs), and non-state actors such as non-governmental organizations (NGOs) and the private sector. With NCD responses facing charges of inadequacy, it is important to scrutinize the governance process behind relevant high-level global decisions and commitments.   Methods Through a review of 159 documents submitted by stakeholders during the negotiation process, we outline a typology of policy positions advocated by various stakeholders in the development of the Declaration. We document changes in text from the draft to the final version of the Declaration to analyse the extent to which various positions and their proponents were influential.   Results NGOs and low- and middle-income countries (LMICs) generally pursued ‘stricter’ governance of NCD risk factors including stronger regulation of unhealthy products and improved management of conflicts of interest that arise when health-harming industries are involved in health policy-making. The private sector and high-income countries generally opposed greater restrictions on commercial factors. The pattern of changes between the draft and final Declaration indicate that advocated positions tended to be included in the Declaration if there was no clear opponent, whereas opposed positions were either not included or included with ambiguous language.   Conclusion Many cost-effective policy options to address NCDs, such as taxation of health-harming products, were opposed by high-income countries and the private sector and not well-represented in the Declaration. To ensure robust political commitments and action on NCDs, multi-stakeholder governance for NCDs must consider imbalances in power and influence amongst constituents as well as biases and conflicts in positioning.
       
  • Understanding the Prevalence and Associated Factors of Behavioral
           Intention of COVID-19 Vaccination Under Specific Scenarios Combining
           Effectiveness, Safety, and Cost in the Hong Kong Chinese General
           Population

    • Abstract: Background The prevalence of coronavirus disease 2019 (COVID-19) vaccination is very critical in controlling COVID-19. This study mainly aimed to (1) investigate behavioral intentions of COVID-19 vaccination under various specific scenarios, and (2) associated factors of the afore-mentioned vaccination intentions.   Methods A random anonymous telephone survey interviewed 450 Chinese adults from September 16-30, 2020 in Hong Kong, China. Nine scenarios of behavioral intentions of COVID-19 vaccinations were measured combining effectiveness (80% versus 50%), safety (rare versus common mild side effect), and cost (free versus HK$ 500).   Results The prevalence of behavioral intentions of COVID-19 vaccination under the 9 specific scenarios was very low and varied greatly (4.2% to 38.0%). The prospective countries of manufacture also influenced vaccination intention (eg, Japan: 55.8% vs China: 31.1%). Only 13.1% intended to take up COVID-19 vaccination at the soonest upon its availability. The attributes of effectiveness and side effect influenced vaccination intention most. Positively associated factors of behavioral intentions of COVID-19 vaccination included trust/satisfaction toward the government, exposure to positive social media information about COVID-19 vaccines, descriptive norms, perceived impact on the pandemic, perceived duration of protectiveness, and life satisfaction.   Conclusion Intention of COVID-19 vaccination was low in the Hong Kong general population, especially among younger people, females, and single people. Health promotion is warranted to enhance the intention. The significant factors identified in this study may be considered when designing such health promotion. Future research is required to confirm the findings in other countries. Such studies should pay attention to the specific context of cost, safety, and effectiveness, which would lead to different responses in the level of behavioral intention of COVID-19 vaccination (BICV).
       
  • Enhancing the Understanding of Resilience in Health Systems of Low- and
           Middle-income Countries: A Qualitative Evidence Synthesis

    • Abstract: Background A country’s health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications.   Methods The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study.   Results Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms.   Conclusion The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.
       
  • How Can Reasoned Transparency Enhance Co-Creation in Health Care and
           Remedy the Pitfalls of Digitization in Doctor-Patient Relationships'

    • Abstract: This article addresses transparency in the current era of digital co-creation between healthcare professionals and patients. The concept of reasoned transparency is presented as a potential tool to guide the development of digital co-creation that is rapidly growing. The aim was to reflect on how doctors can apply transparency in their daily practice, following the shift from paternalistic to more collaborative relationships. On the one hand, our contribution indicates ways to take advantage of the existing digital tools to improve efficiency and increase patient trust, including the latest trend of artificial intelligence. On the other hand, this article identifies pitfalls of digitization and proposes reasoned transparency as remedy for the challenges rose by artificial intelligence. As a result, this perspective article tackles the issue of maintaining trustful and high-quality relationships between doctors and patients, increasingly challenged by the dissemination of online information and the pressures on healthcare professionals’ accountability towards patients and the general public.
       
  • The Viability of Online Pharmacies in COVID-19 Era in Korea

    •  
  • Towards Core Competencies for Health Policy and Systems Research (HPSR)
           Training: Results From a Global Mapping and Consensus-Building Process

    • Abstract: Background As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning.   Methods Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework.   Results Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions.   Conclusion The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, ad evaluate their use in different settings.
       
  • “There’s Not Enough Bodies to Do the Demand:” An Exploration of Key
           Stakeholder Views on the Role of Health Service Capacity in Shaping Cancer
           Outcomes in 7 International Cancer Benchmarking Partnership Countries

    • Abstract: Background Differences in cancer survival are shaped by differences in health system capacity in workforce and infrastructure. Part of the International Cancer Benchmarking Partnership (ICBP), this study explored stakeholders’ perceptions of the role of health system capacity necessary for cancer care in influencing cancer survival in 7 high-income countries.   Methods We conducted semi-structured interviews with 79 key informants from national, regional, and local tiers of health systems, professional bodies, patient associations, and academic experts in Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the United Kingdom. Data collection was guided by a conceptual model linking characteristics of health systems and cancer survival along the cancer patient journey, from recognition of symptoms at pre-diagnostic stages through to survivorship or death. Data were analysed using a thematic approach.   Results We identified 3 themes as important in shaping cancer outcomes: primary care and access to diagnostic evaluation, specialist care and access to treatment, and workforce pertaining to diagnostic and treatment phases. Improved infrastructure for diagnosis and treatment had improved cancer outcomes in all jurisdictions. However, this was seen as insufficient if staffing was inadequate. Consolidation of services and greater surgical specialisation was important in some jurisdictions if accompanied by a reconfiguration of services, in particular the creation of specialist multidisciplinary teams, along with supporting capacity in the wider health system. Staff shortages were commonly cited as reasons why some jurisdictions lagged behind others.   Conclusion Continued improvement in cancer outcomes will require sustained investment in plans to deliver and maintain the workforce engaged in cancer care and in the infrastructure on which they depend. However, strategic plans must recognise that systems for cancer care do not work in isolation from the rest of the health system and a whole systems approach is essential if we are to improve outcomes for an ageing, increasingly multimorbid population.
       
  • Measuring the Overall Burden of Early Childhood Malnutrition in Ghana: A
           Comparison of Estimates from Multiple Data Sources

    • Abstract: Background Childhood malnutrition contributes to nearly half (45%) of all deaths among children under 5 globally. The United Nations’ Sustainable Development Goals (SDGs) aims to end all forms of malnutrition by 2030; however, measuring progress towards these goals is challenging, particularly in countries with emerging economies where nationally-representative data are limited. The primary objective of this study was to estimate the overall burden of childhood malnutrition in Ghana at national and regional levels using 3 data sources.   Methods Using data from the long-standing Ghana Demographic and Health Surveys (GDHS), Ghana Multiple Indicator Cluster Survey (GMICS), and the emerging Ghana Socioeconomic Panel Survey (GSPS), we compared the prevalence of malnutrition using the extended composite index of anthropometric failure (eCIAF) for the period 2008-2011. This study included data for children aged 6-59 months and calculated all anthropometric z-scores based on the World Health Organization (WHO) Growth Standards. We tested for differences in malnutrition subtypes using two-group configural frequency analysis (CFA).   Results Of the 10 281 children (6532 from GMICS, 2141 from GDHS and 1608 from GSPS) included in the study, the only demographic difference observed was the children included in the GSPS were slightly older than those included in the GDHS and GMICS (median age of 36 vs 30 vs 33 months, P < .001). Based on the eCIAF, the overall prevalence of malnutrition at the national level was higher among children in the GSPS (57.3%, 95% CI: 53.9%–60.6%), followed by the GDHS (39.7%, 95% CI: 37.0%–42.5%), and then those in the GMICS (31.2%, 95% CI: 29.3%–33.1%). The two-group CFA showed that the 3 data sources also estimated different prevalence rates for most of the malnutrition subtypes included in the eCIAF.   Conclusion Depending on the data source adopted, our estimates of eCIAF showed that between one-third and half of all Ghanaian children aged 6-59 months had at least one form of malnutrition over the period 2008-2011. These eCIAF estimates should complement the commonly reported measures such as stunting and wasting when interpreting the severity of malnutrition in the country to inform policy decisions.
       
  • Barriers to Equitable Public Participation in Health-System Priority
           Setting Within the Context of Decentralization: The Case of Vulnerable
           Women in a Ugandan District

    • Abstract: Background Decentralization of healthcare decision-making in Uganda led to the promotion of public participation. To facilitate this, participatory structures have been developed at sub-national levels. However, the degree to which the participation structures have contributed to improving the participation of vulnerable populations, specifically vulnerable women, remains unclear. We aim to understand whether and how vulnerable women participate in health-system priority setting; identify any barriers to vulnerable women’s participation; and to establish how the barriers to vulnerable women’s participation can be addressed.   Methods We used a qualitative description study design involving interviews with district decision-makers (n = 12), subcounty leaders (n = 10), and vulnerable women (n = 35) living in Tororo District, Uganda. Data was collected between May and June 2017. The analysis was conducting using an editing analysis style.   Results The vulnerable women expressed interest in participating in priority setting, believing they would make valuable contributions. However, both decision-makers and vulnerable women reported that vulnerable women did not consistently participate in decision-making, despite participatory structures that were instituted through decentralization. There are financial (transportation and lack of incentives), biomedical (illness/disability and menstruation), knowledge-based (lack of knowledge and/or information about participation), motivational (perceived disinterest, lack of feedback, and competing needs), socio-cultural (lack of decision-making power), and structural (hunger and poverty) barriers which hamper vulnerable women’s participation.   Conclusion The identified barriers hinder vulnerable women’s participation in health- system priority setting. Some of the barriers could be addressed through the existing decentralization participatory structures. Respondents made both short-term, feasible recommendations and more systemic, ideational recommendations to improve vulnerable women’s participation. Integrating the vulnerable women’s creative and feasible ideas to enhance their participation in health-system decision-making should be prioritized.
       
  • Can the Use of Health Insurance Claim Data Benefit the Risk-Based
           Supervision of General Practitioner Practices' An Exploratory Study in
           the Netherlands

    • Abstract: Background The Dutch Health and Youth Care Inspectorate has organized a study investigating whether there are benefits to using claim data in the risk-based supervision of general practitioner (GP) practices.   Methods We identified and selected signals of risks based on interviews with experts. Next, we selected 3 indicators that could be measured in the claim database. These were: the expected and actual costs of the GP practice; the percentage of reserve antibiotics prescribed; and the percentage of patients undergoing an emergency admission during the weekend. We corrected the scores of the GP practices based on their casemix and identified practices with the most unfavorable scores, ‘red flags,’ in 2015, or the trend between 2013-2015. Finally, we analysed the data of GP practices already identified as delivering substandard care by the Health and Youth Care Inspectorate and calculated the sensitivity and specificity of using the indicators to identify poor performing GP practices.   Results By combining the 3 indicators, we identified 1 GP practice with 3 red flags and 24 GP practices with 2 red flags. The a priori chance of identifying a GP practice that shows substandard care is 0.3%. Using the indicators, this improved to 1.0%. The sensitivity was 26.7%, the specificity was 92.8%.   Conclusion The Dutch Health and Youth Care Inspectorate might use claim data to calculate indicators on costs, the prescribing of reserve antibiotics and emergency admissions during the weekend, when setting priorities for its visits to GP practices. Visiting more GP practices by the Health and Youth Care Inspectorate, and identifying substandard care, is necessary to validate the use of these indicators.
       
  • Functional Dependency in Mexico: Measurement Issues and Policy Challenges

    • Abstract: Background Different definitions have been used to measure functional dependency (FD) in Mexico. This study aims to explore if different definitions of FD lead to low consistency between the estimations of its prevalence. Accurate estimations of FD are useful to estimate the potential demand for long-term care (LTC) services in the country.   Methods A literature review including documents with estimations on the number or prevalence of dependents in Mexico with national representativeness between 2000 and 2019 was performed as well as estimations of different definitions of FD, using the National Study on Health and Aging in Mexico (ENASEM).   Results There is a lack of consensus on the definition of FD. Among the most frequently used terms to define FD are “disability” and “dependency.” The heterogeneity of definitions results in a wide range of estimations of the demand for LTC. Methodological choices can lead to important differences in FD prevalence estimations. Results from ENASEM 2001 show that FD prevalence could range from 13% to 35% in people 60+; sex prevalences also vary when using different ways to measure FD.   Conclusion Besides the highlighted issues in calculating FD in the population, Mexico should consider broadening the assessment of FD, including people with dementia and younger populations. Although the literature search is not systematic, it helps exemplifying the current issues when measuring FD in Mexico. A consensual definition of dependency is required to have a more accurate estimated demand for LTC. Having good data sources is not enough when dissimilar estimations of an indicator like dependency result from the same study. Wide heterogeneity in estimations of dependency could be an obstacle to inform public policies during the construction of a care system in Mexico.
       
  • Occupational Therapists, Physiotherapists and Orthopaedic Surgeons Agree
           on the Decision for Carpal Tunnel Surgery

    • Abstract: Background Therapist-led pathways have been proposed as waitlist management strategies prior to surgery for conditions such as carpal tunnel syndrome (CTS) in public hospitals. These models of care typically shift the initial care of patients and decision-making from surgeons to therapists and, have been shown to reduce the number of patients requiring surgery and improve wait-times. This occurs despite limited evidence of surgeon-therapist agreement on key decisions, such as the need for surgery. The purpose of this was study was to assess the agreement between therapists and orthopaedic surgeons regarding the need for surgery for patients who have CTS.   Methods This blinded inter-rated agreement study was embedded in a multicentre randomised parallel groups trial of 105 patients with CTS referred to four orthopaedic departments and waitlisted for an appointment. The trial evaluated the effect of a therapist-led care pathway on the need for surgery and outcomes related to symptoms and function. Patients were randomised to either remain on the orthopaedic waitlist or receive group education, a splint and home exercises. The decision on the need for surgery at 6 months was made by a member of the orthopaedic consultant team or by one of the 14 participating therapists. The therapists and surgeons were blinded to each other’s decision. Agreement was determined using percentage agreement, kappa coefficients (k), prevalence-adjusted and bias-adjusted kappa (PABAK), and Gwet’s first-order agreement coefficient (AC1).   Results Substantial agreement was seen between therapists and surgeons regarding the need for surgery (PABAK = 0.74 (0.60-0.88)). Agreement was significantly associated with experience (P = .02). Therapists with advanced experience and scope of practice demonstrated perfect agreement with surgeons (PABAK = 1.00 (95% CI: 1.00-1.00)). Mid-career therapists demonstrated substantial agreement (PABAK = 0.67 (95% CI: 0.42-0.91)) and early-career therapists demonstrated fair agreement (PABAK = 0.43 (95% CI: -0.04-0.90)).   Conclusion Therapists with advanced scope of practice make decisions that are consistent with orthopaedic surgeons.
       
  • Hollow Threats: Transnational Food and Beverage Companies’ Use of
           International Agreements to Fight Front-of-Pack Nutrition Labeling in
           Mexico and Beyond

    • Abstract: In October 2019, the Mexican government reformed its General Health Law thus establishing the warning approach to front-of-pack nutrition labeling (FOPNL), and in March 2020, modified its national standard, revamping its ineffective FOPNL, one preemptively developed by industry actors. Implementation is scheduled for later in 2020. However, the new regulation faces fierce opposition from transnational food and beverage companies (TFBCs), including Nestlé, Kellogg, Grupo Bimbo, Coca-Cola, PepsiCo through their trade associations, the National Manufacturers, American Bakers Associations, the Confederation of Industrial Chambers of Mexico and ConMéxico. Mexico, as a regional leader, could tip momentum in favor of FOPNL diffusion across Latin America. But the fate of the Mexican FOPNL and the region currently lies in this government’s response to three threats of legal challenges by TFBCs, citing international laws and guidelines including the World Trade Organization (WTO), Codex Alimentarius, and the North American Free Trade Agreement (NAFTA)/US-Mexico-Canada Agreement (USMCA). In this perspective, we argue that these threats should not prevent Mexico or other countries from implementing evidence-informed policies, such as FOPNLs, that pursue legitimate public health objectives.
       
  • Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and
           Goals for the Next Decade

    • Abstract: While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society’s role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.
       
  • Prevention of Adolescent Pregnancy in Anglophone Sub-Saharan Africa: A
           Scoping Review of National Policies

    • Abstract: Background Despite the existence of preventive policies across sub-Saharan Africa, countries within the sub-region lead global rankings for rates of adolescent pregnancy. The aim of this scoping review was to identify and review national policies on the prevention of adolescent pregnancy in Anglophone sub-Saharan Africa.   Methods Relevant policies were identified from searches of national government websites and the search engine Google. Recognised screening and data extraction processes were used; data were subjected to content analysis using a published Framework for Evaluating Program and Policy Design on Adolescent Reproductive Health. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews guidelines was used in reporting the review.   Results In line with the inclusion criteria that guided the selection of relevant policies in this study, 17 of 75 national policies were suitable for the analysis. All were backed by political recognition, were government and public initiatives, acknowledged a range of determinants of adolescent pregnancy and allocated human resources to policy activities. Few specified financial resourcing. Most policies acknowledged the importance of coordination and collaboration among public and private actors. All policies had objectives that addressed adolescent pregnancy but none were measurable or included timeframes. Provision of comprehensive sexuality education and adolescent reproductive health services were the most common recommendations. Monitoring and evaluation plans were present in all the policies. However, youth involvement in policy formulation, and plans for implementation, monitoring and evaluation was scarce.   Conclusion Overall, national policy strengths were seen in relation to their political recognition, and all aspects of policy formulation. Policy implementation strengths and weaknesses were identified, the latter in relation to clear descriptions of financial resources. Importantly, the absence of measurable and time-bound objectives or formal evaluation of policy effectiveness confounds demonstration of what has been delivered and achieved. Youth involvement was notably absent in many policies. For future policy-setting, governments and policy-makers should make efforts to engage young people in policy development and to be transparent, realistic and address the necessary financial resourcing. They should set quantifiable policy objectives that provide a basis for assessing the adoption, uptake and effectiveness of policies in relation to measurable objectives.
       
  • The Implementation of Improvement Interventions for “Low Performing”
           and “High Performing” Organisations in Health, Education and Local
           Government: A Phased Literature Review

    • Abstract: Background There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government.   Methods We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024).   Results Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs.   Conclusion Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.
       
  • Mapping the Qualitative Evidence Base on the Use of Research Evidence in
           Health Policy-Making: A Systematic Review

    • Abstract: Background The use of research evidence in health policy-making is a popular line of inquiry for scholars of public health and policy studies, with qualitative methods constituting the dominant strategy in this area. Research on this subject has been criticized for, among other things, disproportionately focusing on high-income countries; overemphasizing ‘barriers and facilitators’ related to evidence use to the neglect of other, less descriptive concerns; relying on descriptive, rather than in-depth explanatory designs; and failing to draw on insights from political/policy studies theories and concepts. We aimed to comprehensively map the global, peer-reviewed qualitative literature on the use of research evidence in health policy-making and to provide a descriptive overview of the geographic, temporal, methodological, and theoretical characteristics of this body of literature.   Methods We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched nine electronic databases, hand-searched 11 health- and policy-related journals, and systematically scanned the reference lists of included sudies and previous reviews. No language, date or geographic limitations were imposed.   Results The review identified 319 qualitative studies on a diverse array of topics related to the use of evidence in health policy-making, spanning 72 countries and published over a nearly 40 year period. A majority of these studies were conducted in high-income countries, but a growing proportion of the research output in this area is now coming from low- and middle-income countries, especially from sub-Saharan Africa. While over half of all studies did not use an identifiable theory or framework, and only one fifth of studies used a theory or conceptual framework drawn from policy studies or political science, we found some evidence that theory-driven and explanatory (eg, comparative case study) designs are becoming more common in this literature. Investigations of the barriers and facilitators related to evidence use constitute a large proportion but by no means a majority of the work in this area.   Conclusion This review provides a bird’s eye mapping of the peer reviewed qualitative research on evidence-to-policy processes, and has identified key features of – and gaps within – this body of literature that will hopefully inform, and improve, research in this area moving forward.
       
  • Gender Equality and the Global Gender Gap in Life Expectancy: An
           Exploratory Analysis of 152 Countries

    • Abstract: When looking at life expectancy (LE) by sex, women live longer than men in all countries. Biological factors alone do not explain gender differences in LE, and examining structural differences may help illuminate other explanatory factors. The aim of this research is to analyse the influence of gender inequality on the gender gap in LE globally. We have carried out a regression analysis between the gender gap in relativised LE and the UN Gender Inequality Index (GII), with a sensitivity analysis conducted for its three dimensions, stratified by the six World Health Organization (WHO) regions. We adjusted the model by taking into consideration gross national income (GNI), democratic status and rural population. The results indicated a positive association for the European region (ß=0.184) and the Americas (ß=0.136) in our adjusted model. Conversely, for the African region, the relations between gender equality and the LE gender gap were found to be negative (ß=-0.125). The findings suggest that in the WHO European region and the Americas, greater gender equality leads to a narrowing of the gender LE gap, while it has a contrary relationship in Africa. We suggest that this could be because only higher scores in the GII between men and women show health benefits.
       
  • Measuring Organizational Readiness for Implementing Change in Primary Care
           Facilities in Rural Bushbuckridge, South Africa

    • Abstract: Meaningful gains in health outcomes require successful implementation of evidence-based interventions. Organizations such as health facilities must be ready to implement efficacious interventions, but tools to measure organizational readiness have rarely been validated outside of high-income settings. We conducted a pilot study of the organizational readiness to implement change (ORIC) measure in public primary care facilities serving Bushbuckridge Municipality in South Africa in early 2019. We administered the 10-item ORIC to 54 nurses and lay counsellors in 9 facilities to gauge readiness to implement the national Central Chronic Medicine Dispensing and Distribution (CCMDD) programme intended to declutter busy health facilities. We used exploratory factor analysis (EFA) to identify factor structure. We used Cronbach alpha and intraclass correlation (ICC) to assess reliability at the individual and facility levels. To assess validity, we drew on existing data from routine clinic monitoring and a 2018 quality assessment to test the correlation of ORIC with facility resources, value of CCMDD programme, and better programme uptake and service quality. Six items from the ORIC loaded onto a single factor with Cronbach’s alpha of 0.82 and ICC of 0.23. While facility ORIC score was not correlated with implementation of CCMDD, higher scores were correlated with facility resources, perceived value of the CCMDD program, patient satisfaction with wait time, and greater linkage to care following positive HIV testing. The study is limited by measuring ORIC after programme implementation. The findings support the relevance of ORIC, but identify a need for greater adaptation and validation of the measure.
       
  • Partnering to Build Human Resources for Health Capacity in Africa: A
           Descriptive Review of the Global Health Service Partnership’s Innovative
           Model for Health Professional Education and Training From 2013-2018

    • Abstract: Several Sustainable Development Goals (SDGs) (3, 16, 17) point to the need to systematically address massive shortages of human resources for health (HRH), build capacity and leverage partnerships to reduce the burden of global illness. Addressing these complex needs remain challenging, as simple increases in absolute numbers of healthcare providers trained is insufficient; substantial investment into long-term high-quality training programs is needed, as are incentives to retain qualified professionals within local systems of care delivery. We describe a novel HRH initiative, the Global Health Service Partnership (GHSP), involving collaboration between the US government (President’s Emergency Plan for AIDS Relief [PEPFAR], Peace Corps), 5 African countries, and a US-based non-profit, Seed Global Health. GHSP was formed to enlist US health professionals to assist in strengthening teaching and training capacity and focused on pre-and in-service medical and nursing education in Malawi, Tanzania, Uganda, Eswatini and Liberia. From 2013-2018, GHSP sent 186 US health professionals to 27 institutions in 5 countries, helping to train 16 280 unique trainees of all levels. Qualitative impacts included cultivating a supportive classroom learning environment, providing a pedagogical bridge to clinical service, and fostering a supportive clinical learning and practice environment through role modeling, mentorship and personalized learning at the bedside. GHSP represented a novel, multilateral, public-private collaboration to help address HRH needs in Africa. It offers a plausible, structured template for engagement and partnership in the field.
       
  • Assistive Technology Use and Provision During COVID-19: Results From a
           Rapid Global Survey

    • Abstract: Background The coronavirus disease 2019 (COVID-19) pandemic has impacted all segments of society, but it has posed particular challenges for the inclusion of persons with disabilities, those with chronic illness and older people regarding their participation in daily life. These groups often benefit from assistive technology (AT) and so it is important to understand how use of AT may be affected by or may help to mitigate the impacts of COVID-19.   Objective The objectives of this study were to explore the how AT use and provision have been affected during the initial stages of the COVID-19 pandemic, and how AT policies and systems may be made more resilient based on lessons learned during this global crisis.   Methods This study was a rapid, international online qualitative survey in the 6 United Nations (UN) languages (English, French, Spanish, Russian, Arabic, Mandarin Chinese) facilitated by extant World Health Organization (WHO) and International Disability Alliance networks. Themes and subthems of the qualitative responses were identified using Braun and Clarke’s 6-phase analysis.   Results Four primary themes were identified in in the data: Disruption of Services, Insufficient Emergency Preparedness, Limitations in Existing Technology, and Inadequate Policies and Systems. Subthemes were identified within each theme, including subthemes related to developing resilience in AT systems, based on learning from the pandemic.   Conclusion COVID-19 has disrupted the delivery of AT services, primarily due to infection control measures resulting in lack of provider availability and diminished one-to-one services. This study identified a need for stronger user-centred development of funding policies and infrastructures that are more sustainable and resilient, best practices for remote service delivery, robust and accessible tools and systems, and increased capacity of clients, caregivers, and clinicians to respond to pandemic and other crisis situations.
       
  • Addressing Policy Coherence Between Health in All Policies Approach and
           the Sustainable Development Goals Implementation: Insights From Kenya

    • Abstract: Background Addressing health in the Sustainable Development Goals (SDGs) calls for intersectoral strategies that mutually enhance both health promotion and sustainable development. Health in All Policies (HiAP) approach aims to address this as well as promote ownership among key stakeholders. Kenya was at the forefront of adopting the SDGs and has committed to the HiAP approach in its Health Policy document for the period 2014-2030. This study aims to assess how the adoption of the HiAP approach can leverage on SDGs implementation in Kenya.   Methods This is an exploratory case study using qualitative data and some descriptive quantitative data. The Organisation for Economic Co-operation and Development’s (OECD’s) eight building blocks for policy coherence on sustainable development was our guiding framework. Qualitative data was derived from a review of relevant peer-reviewed and grey literature, as well as 40 key informant interviews and analyzed in NVIVO. Quantitative data was accessed from the United Nations SDG indicator database and exported to Excel.   Results Kenya has expressed a strong political commitment to achieving the SDGs and has now adopted HiAP. The study showed that Kenya can leverage on local level implementation and long-term planning horizons that it currently has in place to address the SDGs as it rolls out the HiAP approach. The SDGs could be mapped out against the sectors outlined in the Adelaide statement on HiAP. It is also possible to map out how various ministries could coordinate to effectively address HiAP and SDGs concurrently. Funding for HiAP was not addressed in the OECD framework.   Conclusion Kenya can advance a HiAP approach by leveraging the ongoing SDGs implementation. This will be made possible by facilitating coordinated intersectoral action both at national and local level. Funding for HiAP is crucial for its propagation, especially in low- and middle-income countries (LMICs) and can be considered in the budgetary allocations for SDGs.
       
  • The Impact of Tiered-Pricing Framework on Generic Entry in Canada

    • Abstract: Background Generic drug prices have been capped at specified percentages of the interchangeable branded drug’s price by the Canadian provincial public drug plans since 1993. The Pan-Canadian Pharmaceutical Alliance, formed as a coalition by the provinces/territories in Canada, implemented an alternative approach, a tiered-pricing framework (TPF) for new generic drugs on April 1, 2014, under which the percentage varies with the number of generic firms in each market. We evaluate the impact of the TPF on generic entry, ie, listing in public drug plans in Canada.   Methods Our study compared the pre-TPF period (01/01/2012-03/31/2014) with the TPF period (04/01/2014-06/30/2016). Prescription drugs from nine provincial public drug plans were grouped into a “market” if they had the same active ingredient and strength, route of administration, and dosage form. Each “market” was contestable by generics and met the eligibility criteria for TPF. At the “market” level, Cox proportional-hazards models with time-varying covariates were used to measure the impact of the TPF on the first generic listing in any provincial public drug plan in Canada relative to the first launch date worldwide.   Results A total of 189 markets in Canada were selected for the analyses. Generic drugs in small markets were more likely to be listed in Canada during the TPF period compared to the pre-TPF period (hazard ratio [HR], 95% CI: 3.81, 1.51-9.62). There was no significant difference in generic drug listings in large markets between the two policy periods.   Conclusion TPF speeds up generic entry in small markets and generates the benefits of generic competition while avoiding the pitfalls of the previously employed price-cap regulations.
       
  • Introducing voluntary assisted dying: Staff perspectives in an acute
           hospital

    • Abstract: Background Voluntary assisted dying (VAD) was legalised in Victoria, Australia in June 2019. Physicians can now assist patients to end their lives by providing drugs for self-administration at their voluntary and competent request (or for physician administration in limited circumstances). This study investigates the opinions of clinicians on the implementation of the legislation in one Victorian hospital.   Methods This exploratory survey study was conducted at a 600-bed acute hospital in Melbourne, Australia in Jan 2019. 382 clinicians completed one or more qualitative questions. Participants commented on VAD, potential workplace challenges and staff support required. Free-text responses were analysed using inductive content analysis.   Results Six themes: (1) Polarised views; (2) Fear of conflict; (3) Emotional burden; (4) Vulnerable patients; (5) Organisational challenges; (6) Decision-making. There were diverse views including objections to VAD for religious or ethical reasons, and whole-hearted support based on a compassionate response to suffering and the right of patients to self-determination. Participants feared conflict between colleagues, families and patients, and aggression towards staff. Clinicians called for educational and psychological support. There was concern that vulnerable patients may be coerced to opt for VAD to lessen the burden on families or the health system. Clinicians feared workloads would increase with the introduction of VAD. Patient decision-making capacity in this context must be firmly established before proceeding, and thorough assessments for depression, and optimal symptom management must be implemented before VAD is approved. A dedicated VAD team was suggested to support staff and manage VAD patients.   Conclusion Participants expressed polarised opinions about VAD and showed considerable anxiety about its introduction. Additional education and support are required to ensure that clinicians understand details of the legislation and their professional and personal options. Tolerance and respect for alternative viewpoints must be advocated within the organisation and more broadly.
       
  • Integrating Palliative Care by Virtue of Diplomacy; A Cross-sectional
           Group Interview Study of the Roles and Attitudes of Palliative Care
           Professionals to Further Integrate Palliative Care in Europe

    • Abstract: Background Palliative care involves the care for patients with severe and advanced diseases with a focus on quality of life and symptom management. Integration of palliative care with curative and/or chronic care is expected to lead to better results in terms of quality of life and reduced costs. Although initiatives in different countries in Europe choose different structures to integrate care, they face similar challenges when it comes to creating trust and aligning visions, cultures and professional values. This paper sets out to answer the following research question: what roles and attitudes do palliative care professionals need to adopt to further integrate palliative care in Europe'   Methods As part of the European Union (EU)-funded research project InSup-C (Integrated Supportive and Palliative Care). (2012-2016), 19 semi-structured group interviews with 136 (palliative) care professionals in 5 European countries (Germany, the United Kingdom, Belgium, the Netherlands, Hungary) were conducted. A thematic analysis was conducted.   Results Integration of palliative care calls for diplomatic professionals that can bring a cultural shift: to get palliative care, with its particular focus on the four dimensions (physical, psychological, social, spiritual), integrated into historically established medical procedures and guidelines. This requires (a) to find an entrance (for telling a normative story), and (b) to maintain and deepen relationships (in order to build trust). It means using the appropriate words and sending a univocal team message to patients and being grateful, modest, and aiming for a quiet revolution with curation oriented healthcare professionals.   Conclusion Diplomacy appears to be essential to palliative care providers for realizing trust and what can be defined as normative integration between palliative and curative and/or chronic medicine. It requires a practical wisdom about the culture and goals of regular care, as well as keeping a middle road between assimilating with values in regular medicine and standing up for the basic values central to palliative care.
       
  • A Proposed Regulatory Review Model to Support the South African Health
           Products Regulatory Authority to Become a More Efficient and Effective
           Agency

    • Abstract: Background National regulatory agencies of various sizes and maturity levels, including the South African Health Products Regulatory Authority (SAHPRA), have had to revise systems and re-engineer processes in order to adapt to the new regulatory environment and increase the effectiveness of regulatory operations. This study aimed to develop a new regulatory review model for improved regulatory performance, underpinned by the parameters of the World Health Organization Global Benchmarking Tool (WHO GBT) that support strengthening of regulatory systems.   Methods A new enhanced model for regulatory review, was developed based on the key recommendations from 6 studies, previously conducted by the authors, that were identified as fundamental elements in enhancing regulatory performance. The elements selected to define the new regulatory review model were endorsed through the integration of the parameters of the WHO GBT that, when embedded within regulatory systems, support enhanced regulatory performance.   Results Opportunities for improvement in regulatory performance were identified and include quality measures; monitoring and evaluating review times; a risk-based evaluation; transparency and communication; and training and education. An improved model for the South African regulatory review and benefit-risk (BR) assessment supported by quality decision-making was proposed as well as recommendations for the application of risk-stratification strategies, strengthening of reliance networks, reinforcing good regulatory practices (GRPs) and enhancing transparency.   Conclusion If implemented the proposed improved regulatory model may pave the way towards more efficient and transparent, streamlined review processes, coupled with increased consistency, evidence-based decision-making practices, reduced timelines and improved patients’ access to new medicines in South Africa.
       
  • Implementing the UN Sustainable Development Goals: How Is Health Framed in
           the Norwegian and Swedish Voluntary National Review Reports'

    • Abstract: Background The United Nations (UN) Sustainable Development Goals (SDGs) are parts of an ambitious framework for global development, the 2030 Agenda. Voluntary national reviews (VNRs) are described as “cornerstones” in the follow-up system, which is premised on international sharing of knowledge and experience. Norway and Sweden are among the world’s most sustainable countries, aiming to be leaders in the implementation of the SDGs. The objective of this article is to investigate and compare how health is framed in the VNRs of these two high-income countries, and to discuss the implications of these framings for potential actions.   Methods Discourse analysis inspired by the concept of ‘framing,’ which refers to the discursive presentation of an issue where certain problem definitions and solutions are privileged over others. Frames are structures that organise and direct attention to particular aspects of reality, and define what is seen.   Results Our analysis demonstrates that in the Norwegian VNR (NVNR), the issue of health is simplistically framed, focusing on the favourable situation of the majority, thus providing weak grounds for transformative action. In the Swedish VNR (SVNR), health is framed to highlight health as inextricably tied to societal inequalities. This underscores the need for integrated political action and leadership to counteract structural differences with negative consequences for health.   Conclusion Analysis of the two VNRs studied found a difference in how health is framed in these documents and these frames point to differences in approach and capacity to address health inequities and realise the holistic and integrative concept of health promoted in the 2030 Agenda. To realize the Agenda’s vision of “leaving no one behind” discourses of implementation that support the Agenda’s inclusive and holistic ambition must be developed. Further development of the follow-up and review system should acknowledge and address how frames can limit or enable integrative actions and are therefore important drivers of change.
       
  • Excess Cardiovascular Mortality in Latvia: A Novel Approach Based on
           Patient-Level Data to Estimate the Separate Contributions of Primary
           Prevention, Accessibility and Quality of Hospital Care

    • Abstract: Background Because quantifying the relative contributions of prevention and medical care to the decline in cardiovascular mortality is controversial, at present mortality indicators use a fifty-fifty allocation to fraction avoidable cardiovascular deaths as being partly preventable and partly amenable. The aim of this study was to develop a dynamic approach to estimate the contributions of preventable versus amenable mortality, and to estimate the proportion of amenable mortality due to non-utilisation of care versus suboptimal quality of care.   Methods We calculated the contribution of primary prevention, healthcare utilisation and healthcare quality in Latvia by using Emilia-Romagna (ER) (Italy) as the best performer reference standard. In particular, we considered preventable mortality as the number of cardiovascular deaths that could be avoided if Latvia had the same incidence as ER, and then apportioned non-preventable mortality into the two components of non-utilisation versus suboptimal quality of hospital care based on the presence of hospital admissions in the days before death. This calculation was possible thanks to the availability of the unique patient identifier in the administrative databases of Latvia and ER.   Results 41.5 people per 100 000 population died in Latvia in 2016 from cardiovascular causes amenable to healthcare; about half of these (21.4 per 100 000) had had no contact with acute care settings, while the other half (20.1 per 100 000) had accessed the hospital but received suboptimal-quality healthcare. Another estimated 26.8 deaths per 100 000 population were due to lack of primary prevention. Deaths attributable to suboptimal quality or non-utilisation of hospital care constituted 60.7% of all avoidable cardiovascular mortality.   Conclusion If research is undertaken to understand the reasons for differences between territories and their possible relevance to lower performing countries, the dynamic assessment of country-specific contributions to avoidable mortality has considerable potential to stimulate cross-national learning and continuous improvement in population health outcomes.
       
  • Evaluation of the Participation of Community Pharmacists in Primary
           Healthcare Services in Nigeria: A Mixed-Method Survey

    • Abstract: Background Achieving universal health coverage in poorly-resourced settings like Nigeria demands optimal mobilization of all healthcare resources including community pharmacists. Such efforts are hampered by insufficient data on primary healthcare (PHC) contributions by community pharmacists. The study aimed to identify PHC services offered by community pharmacists; assess impact of technologies on PHC service quality; and evaluate factors influencing management of PHC services in Nigeria.   Methods A descriptive cross-sectional survey of 321 community pharmacies and 642 clients was undertaken between April and August, 2019. Semi-structured pre-tested questionnaires were administered on randomly-selected community pharmacists and clients. Interviews were conducted with key informants. Data were summarized using frequency and percentages while weighted averages on 5-point ordinal scales and chi-square tests were used to identify weights and associations between variables respectively at P < .050.   Results Response rates of pharmacists and clients were 74.7% (N = 321) and 100% (N = 642); while their median ages were 39.41 and 51.20 years respectively. Community pharmacists offered services in all eight domains of PHC, especially supply of medicines for treating of endemic diseases (mean weighted average [MWA] = 4.59), and disease prevention (4.54) but least of vaccine administration (2.39). Blood glucose screening devices were the most adopted technology with significant impact on service quality (χ2 6.86, P = .030). Major challenges to management of PHC services were poor awareness of pharmacists’ roles (4.31) and lack of integration with the PHC infrastructure (4.31). Capacity constraints in finances (4.11), technologies (4.09), and human resources (3.99) were significant. However, major facilitators were pharmacists’ managerial skills (4.35), and strong client relationships (4.27).   Conclusion In Nigeria, community pharmacists offered important PHC services. Deploying technologies were associated with improved service quality. If community pharmacists are integrated in the national PHC architecture and financial incentives are provided, their competences and goodwill would enhance the achievement of universal health coverage.
       
  • Examining Governing Board Functions and Health Center Performances During
           Health System Reform: A Cross-sectional Study in 4 Regional States of
           Ethiopia

    • Abstract: Background Since 1995, the Ethiopian health system has been managed through decentralizing functions, resources, and authorities to local levels. As a result, health centers are led and managed by governing boards. In addition, the national health system strives to transform the performance of health centers through the implementation of reforms. Therefore, this study aims to examine the relationship between governing board functions and health center performances within a health reform context in 4 agrarian regions of Ethiopia.   Methods A cross-sectional survey was conducted from August 28, 2018 to September 30, 2018. Primary data were collected from governing board chairpersons or their designees using interviewer-administered structured questionnaires. The performance of each health center was rated out of 100 percentage points against the Ethiopian Health Center Reform Guideline (EHCRIG) standards. Secondary data were abstracted from a routine health information database using customized tools to capture achievements on 69 EHCRIG standards and its 174 validation criteria. Since the data violate the assumptions of the parametric test, the Spearman’s rank (rho) correlation test, (a non-parametric test) was employed to see if any correlation exists among 4 parameters; namely: structure, roles and responsibilities, training and development of governing boards, and performance of health centers against EHCRIGs standards. A statistically significant relationship was claimed at P < .050.   Results All 83 health center governing boards or designees who were approached for this study, participated. The mean health center governing board function score with standard deviation was 56.0% (SD ± 14.5%). The overall performance of health centers against EHCRIGs was 70.4% (SD ± 15.0%). There was a statistically significant and strong correlation (Spearman rho correlation coefficient) between health center performance scores measured against reform standards with governing board scores of (rho = 0.866, P < .001) and overall governance scores (rho = 0.828, P < .001).   Conclusion Based on the results of this study, we can conclude that well-functioning health center governing boards can improve the performance of health centers against clinical, and management reform standards. Therefore, continuous strengthening of the capacity of governing boards, focusing on improving implementation of their roles and responsibilities, and continuing training on business management is recommended.
       
  • Did an Intervention Programme Aimed at Strengthening the Maternal and
           Child Health Services in Nigeria Improve the Completeness of Routine
           Health Data Within the Health Management Information System'

    • Abstract: Background During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS.   Methods This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods.   Results Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives.   Conclusion Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.
       
  • Creating Political Will for Action on Health Equity: Practical Lessons for
           Public Health Policy Actors

    • Abstract: Background Despite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors.   Methods Eight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis.   Results Our case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying.   Conclusion Public health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.
       
  • Are We Asking Too Much of the Health Sector' Exploring the Readiness
           of Brazilian Primary Healthcare to Respond to Domestic Violence Against
           Women

    • Abstract: Background There is growing recognition of the health sector’s potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response.   Methods We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis.   Results Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers’ time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV.   Conclusion Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.
       
  • District-Level Health Management and Health System Performance: The
           Ethiopia Primary Healthcare Transformation Initiative

    • Abstract: Background Despite a wide range of interventions to improve district health management capacity in low-income settings, evidence of the impact of these investments on system-wide management capacity and primary healthcare systems performance is limited. To address this gap, we conducted a longitudinal study of the 36 rural districts (woredas), including 229 health centers, participating in the Primary Healthcare Transformation Initiative (PTI) in Ethiopia.   Methods Between 2015 and 2017, we collected quantitative measures of management capacity at the district and health center levels and a primary healthcare key performance indicator (KPI) summary score based on antenatal care (ANC) coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We conducted repeated measures analysis of variance (ANOVA) to assess (1) changes in management capacities at the district health office level and health center level, (2) changes in health systems performance, and (3) the differential effects of more vs less intensive intervention models.   Results Adherence to management standards at both district and health center levels improved during the intervention, and the most prominent improvement was achieved during district managers’ exposure to intensive mentorship and education. We did not observe similar patterns of change in KPI summary score.   Conclusion The district health office is a valuable entry point for primary healthcare reform, and district- and facility-level management capacity can be measured and improved in a relatively short period of time. A combination of intensive mentorship and structured team-based education can serve as boh an accelerator for change and a mechanism to inform broader reform efforts.
       
  • Using Group Model Building to Capture the Complex Dynamics of Scaling Up
           District-Level Surgery in Arusha Region, Tanzania

    • Abstract: Background Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach.   Methods A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model.   Results The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or ‘resistors to change:’ recurrent costs, income lost, staff stress, and brain drain.   Conclusion This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of ‘quick fixes’ that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.
       
  • Academic Health Science Centres as Vehicles for Knowledge Mobilisation in
           Australia' A Qualitative Study

    • Abstract: Background Despite increasing investments in academic health science centres (AHSCs) in Australia and an expectation that they will serve as vehicles for knowledge translation and exchange, there is limited empirical evidence on whether and how they deliver impact. The aim of this study was to examine and compare the early development of four Australian AHSCs to explore how they are enacting their impact-focused role.   Methods A descriptive qualitative methodology was employed across four AHSCs located in diverse health system settings in urban and regional locations across Australia. Data were collected via semi-structured interviews with 15 academic, industry and executive board members of participating AHSCs. The analysis combined inductive and deductive elements, with inductive categories mapped to deductive themes corresponding to the study aims.   Results AHSCs in Australia are in an emergent state of development and are following different pathways. Whilst varied approaches to support research translation are apparent, there is a dominant focus on structure and governance, as opposed to action-oriented roles and processes to deliver strategic goals. Balancing collaboration and competition between partners presents a challenge, as does identifying appropriate ways to evaluate impact.   Conclusion The early stage of development of AHSCs in Australia presents an important opportunity for formative learning and evaluation to optimise their enactment of knowledge mobilisation processes for impact.
       
  • Evaluation of Pharmacovigilance System in Iran

    • Abstract: Background Evaluating a pharmacovigilance system helps identify its deficiencies and could facilitate measures to remedy and improve the quantity and quality of adverse drug reaction (ADR) reports and other opportunities for pharmacovigilance systems strengthening. This study aimed to evaluate the status of pharmacovigilance in Iran using the World Health Organization (WHO) pharmacovigilance indicators with the prospect of identifying the gaps and areas for improvement.   Methods This study was conducted in 2 parts. The first part included a secondary analysis of the national data obtained from the Iranian National Pharmacovigilance Center (PVC) using a structured data collection form based on WHO core pharmacovigilance indicators. In the second part, a 3-month prospective study was carried out to investigate 2 outcome indicators, ie, length of stay and costs of medicine-related hospitalization in all patients of 2 main referral hospitals in the southeast and north of Iran.   Results Iran has a PVC with national policy, trained staff, and a statutory budget. In 2017, the number of ADR reports was 15.0 per 100 000 population, and 262 signals were detected during the preceding 5 years. The average length of stay and costs of medicine-related hospitalization were 5 days and US$817.2 in Afzalipour hospital and 6.6 days and US$306.7 in Razi hospital, respectively. The status of pharmacovigilance in the Iranian public health programs (PHPs) is unknown, and most of the indicators could not be assessed.   Conclusion A robust pharmacovigilance system is a pivotal part of the overall medicines regulatory system. The Iranian pharmacovigilance system has relatively the proper structural condition. Though the underreporting of ADRs, especially medicine-related deaths, is an important issue, and some indicators’ status was unclear. The Iranian pharmacovigilance program requires a higher prioritization, particularly in the PHPs, a greater allocation of resources, and cross-sectoral cooperation to bolster and achieve the pharmacovigilance objectives.
       
  • “When My Information Changes, I Alter My Conclusions.” What Can We
           Learn From the Failures to Adaptively Respond to the SARS-CoV-2 Pandemic
           and the Under Preparedness of Health Systems to Manage COVID-19'

    •  
  • COVID-19 and a Window of Opportunity: Guiding Principles for a
           Health-Promoting Trade Agenda

    •  
  • Despite COVID-19 Member States Need to Adequately Resource WHO’s
           Work to Address Alcohol Harm

    •  
 
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School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
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