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Background: Specialized drug shops (SDSs) are popular in Sub-Saharan Africa because they provide convenient access to medicines. There is increasing interest in how policymakers can work with them, but little knowledge on how their operation relates to regulatory frameworks. This study sought to describe characteristics and predictors of regulatory practices among SDSs in Kenya., Methods: The regulatory framework governing the Kenya pharmaceutical sector was mapped, and a list of regulations selected for inclusion in a survey questionnaire. An SDS census was conducted, and survey data collected from 213 SDSs from two districts in Western Kenya., Results: The majority of SDSs did not comply with regulations, with only 12% having a refrigerator and 22% having a separate dispensing area for instance. Additionally, less than half had at least one staff with pharmacy qualification (46%), with less than a third of all interviewed operators knowing the name of the law governing pharmacy.Regulatory infringement was more common among SDSs in rural locations; those that did not have staff with pharmacy qualifications; and those whose operator did not know the name of the pharmacy law. Compliance was not significantly associated with the frequency of inspections, with over 80% of both rural and urban SDSs reporting an inspection in the past year., Conclusion: While compliance was low overall, it was particularly poor among SDSs operating in rural locations, and those that did not have staff with pharmacy qualification. This suggested the need for policy to introduce levels of practice in recognition of the variations in resource availability. Under such a system, rural SDSs operating in low-resource setting, and selling a limited range of medicines, may be exempted from certain regulatory requirements, as long as their scope of practice is limited to certain essential services only. Future research should also explore why regulatory compliance is poor despite regular inspections.

Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between.Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively.Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse. [ABSTRACT FROM AUTHOR]

Purpose: Several studies have been carried out on defensive medicine, but research from the managerial viewpoint is still scarce. Therefore, the aim of the present study is to conduct a literature review to better understand defensive medicine from a managerial perspective. Design/methodology/approach: A literature review was conducted of studies focusing on the organisational (meso) level of healthcare providers and managerial practices. A final sample of 28 studies was processed. Findings: Defensive medicine has mainly been studied in the USA, and scholars have principally used quantitative surveys. High-risk specialities have been a critical field of investigation, and a large portion of the papers are published in journals that cover medicine, health policy, education and law fields. The analysis showed that operations and the organisation of staffing were the most discussed managerial practices. No study considered planning and budgeting aspects. Originality/value: The review confirmed that the managerial aspect of defensive medicine has not been fully addressed. Stimulated by this gap, this study analyses the managerial background of the defensive medicine phenomenon and shows which managerial practices have been most analysed. This paper also contributes to developing the literature on defensive medicine from the managerial side. Areas for future research include qualitative studies to investigate the behaviour of managers of healthcare companies to give a different perspective on defensive medicine and organisations' decision-making. Research limitations/implications: Some important publications might have been missed in this work because of the choice of only two databases. A further limit could be imposed by the use of the English language as an inclusion criterion. [ABSTRACT FROM AUTHOR]

Background: Decision models are increasingly used to inform policy-making processes, and there is a need to improve their credibility. The estimation of health and economic outcomes generated from decision models is influenced by the development process itself. This paper aims to present the conceptual model development process of cardiometabolic disease (CMD) policy models in the UK setting., Methods: This conceptual model followed the International Society of Pharmacoeconomics and Outcomes Research-Society of Medical Decision Making (ISPOR-SMDM) Modelling Good Research Practices Task Force-2., Results: First, for the conceptualisation of the problem, the CMD disease staging, progression and current clinical guidelines were summarised, followed by a systematic review of published policy models. We critically appraised policy models such as cardiovascular disease and type 2 diabetes. Key messages from the review emphasised the importance of understanding various determinants influencing model development, including risk factors, model structure, models' parameters, data utilisation, economic perspective, equality/equity consideration, transparency and validation process. Second, as a sequential process, is model conceptualisation, to determine which modelling types and their attributes best represent the defined problem. Expert opinions, including a clinician and experienced modellers, provided input on the state transition model to ensure the structure is clinically relevant. From this stage, the consideration and agreement to establish a disease state in a state transition model was discussed., Conclusion: This conceptual model serves as a basis for representing the systematic process for structuring a CMD policy model to enhance its transparency and credibility., (© 2024. The Author(s).)

Background: Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings., Methods: We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis., Results: The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy., Conclusion: This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes., (© 2024. The Author(s).)

Background: This study aims to identify policy content challenges related to high-risk sexual behaviors, stimulant drugs, and alcohol consumption in Iranian adolescents., Methods: This qualitative study analyzed high-level and national documents pertaining to adolescent health, high-risk sexual behaviors, stimulant, and alcohol consumption in adolescents. The documents, which were published by public organizations between January 1979 and February 2023 and publicly available, were complemented by interviews with policymakers and executives. The study involved reviewing 51 papers and conducting interviews with 49 policymakers and executives at the national, provincial, and local levels who were involved in addressing adolescent behaviors related to high-risk sexual behaviors, stimulant, and alcohol consumption. The data collected was analyzed using conventional content analysis., Results: The study's results involved examining policy content and identifying challenges related to policy content. The analysis revealed that from the beginning of the Iranian revolution in 1979 until the late 1990s, the dominant approach in Iran was to deny the existence of high-risk behaviors among adolescents. However, in the early 2000s, the country began to adopt a new approach that acknowledged the social harms and ineffectiveness of previous strategies. As a result, a new policy framework was introduced to address high-risk behaviors among adolescents. The study's interviews with policymakers and executives identified 12 challenges related to policy content, including parallel programs, lack of institutional mapping, lack of evidence-based policymaking, lack of integrated approach regarding training, late parent training, lack of consideration of all occurrence reasons in adolescents' high-risk behaviors policymaking, and the existence of many abstinence policies regarding high-risk behaviors., Conclusions: The study's findings suggest that high-risk behaviors among adolescents in Iran are primarily a health issue, rather than a social or ideological one. Unfortunately, ideological approaches, stigma, and policymaking based on anecdotes rather than evidence have had a significant impact on this area. To improve policymaking in this domain, it is crucial to address these challenges by tackling stigma, adopting an integrated and holistic approach, and implementing evidence-based policies that consider all relevant aspects, including adolescents' subcultures and policy audiences. Such an approach can also be useful for other countries facing similar conditions., (© 2024. The Author(s).)

Background: This paper describes a study protocol for co-producing and co-assessing a new sustainable and scalable service solution that enhances health and social integration by involving providers and volunteers delivering services for elderly people in the province of Cremona (Italy), where the elderly population will reach 27% in 2023. Methods: This upcoming study involves mixed-method participatory research and is structured in three study phases and related objectives. First, it will co-produce a new, accessible and sustainable service solution using an iterative design and management method, Plan-Do-Check-Act by involving professionals and volunteers of a heterogeneous group of health, social and third sector organizations located in the city of Cremona (Italy). Second, the study protocol will co-assess the outcomes of the new service solution using a mixed-method approach for measuring the outcomes on: professionals and volunteers (micro level) and their health, social and third sector organizations (meso level). Third, this study will co-investigate the scalability of the new solution promoting health and social integration in other similar urban areas of the Province of Cremona via the Intervention Scalability Assessment Tool (macro level). The data will be collected through the analysis of official documents, websites, policies and participatory workshops. Discussion: This protocol proposes an innovative intervention, a novel participatory approach, and an unexplored scalability assessment tool in the context of health and social care integration. This study aims to support professionals from health and social care service providers and volunteers from third-sector organizations to collaborate and integrate each other's resources. In doing so, the participatory approach will facilitate the co-creation of an effective response to the need of health and social integration, and the development of trustful relationships between health and social care service providers. Moreover, the adoption of Plan-Do-Check-Act and Intervention Scalability Assessment Tool will ensure the quality, scalability and sustainability of the new service solution in other settings. [ABSTRACT FROM AUTHOR]

Background: Physiotherapy is a growing profession in Nepal. Despite efforts to promote strengthening and development, there are still challenges in providing equitable access and availability to services, particularly in underserved areas. Updated information is needed to address challenges to provide proper planning for resource allocation. Objective: To assess implementation of physiotherapy services and to explore plans, policies and the general status of physiotherapy in Nepal. Method: Implementation was assessed with a cross-sectional survey conducted in Province III containing closed-ended questions addressing physiotherapy services, human resources, charging and record-keeping systems, and accessibility. Stratified purposive sampling was used to select eligible facilities from the list of Department of Health Services. Official records were explored through visits to governing institutions and by reviews of registers and reports to obtain data and information on status, plans and policy. Results: The survey included 25 urban and 4 rural facilities, covering hospitals and rehabilitation centres; both public (37.9%) and non-public (62.1%). Most facilities (79.3%) employed physiotherapists with bachelor’s degrees. Average number of visits were 29.55 physiotherapy outpatients and 14.17 inpatients per day. Patient records were mainly paper based. Most (69%) used the hospital main card, while others (31%) had their own physiotherapy assessment card. Most referrals came from doctors. The most offered services were musculoskeletal, neurological, and paediatric physiotherapy. Daily basis charging was common. A single visit averaged 311 Nepalese rupees ≈ 2.33 US$. Convenience for persons with disabilities was reported as partial by 79% of outpatient departments. Official register data showed 313 master’s and 2003 bachelor’s graduates. Six colleges offered physiotherapy bachelor’s degree, whereof one also offered a master’s program. Government records revealed significant progress in physiotherapy in Nepal. Conclusion: The study highlights variations in physiotherapy services within a province owing to type, size and location, but also unwarranted variations. Despite the progress, implementation of physiotherapy services in the perspective of official records imply a need of systems for proper planning and monitoring. Physiotherapy provision in underserved areas warrants further attention. [ABSTRACT FROM AUTHOR]

Background: The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame.Methods: Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases.Results: Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector.Conclusions: This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions. [ABSTRACT FROM AUTHOR]

Background: Due to an increasingly elderly population, a higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while maintaining quality. The importance of promoting systems of co-produced health between stakeholders has gained considerable traction both in the literature and in public sector policy debates. This study provides a comprehensive map of the extant literature and identifies the main themes and future research needs.Methods: A quantitative bibliometric analysis was carried out consisting of a performance analysis, science mapping, and a scientific collaboration analysis. Web of Science (WoS) was chosen to extract the dataset; the search was refined by language, i.e. English, and type of publication, i.e. journal academic articles and reviews. No time limitation was selected.Results: The dataset is made up of 295 papers ranging from 1994 to May 2019. The analysis highlighted an annual percentage growth rate in the topic of co-production of about 25%. The articles retrieved are split between 1225 authors and 148 sources. This fragmentation was confirmed by the collaboration analysis, which revealed very few long-lasting collaborations. The scientific production is geographically polarised within the EU and Anglo-Saxon countries, with the United Kingdom playing a central role. The intellectual structure consists of three main areas: public administration and management, service management and knowledge translation literature. The co-word analysis confirms the relatively low scientific maturity of co-production applied to health services. It shows few well-developed and central terms, which refer to traditional areas of co-production (e.g. public health, social care), and some emerging themes related to social and health phenomena (e.g. the elderly and chronic diseases), the use of technologies, and the recent patient-centred approach to care (patient involvement/engagement).Conclusions: The field is still far from being mature. Empirical practices, especially regarding co-delivery and co-management as well as the evaluation of their real impacts on providers and on patients are lacking and should be more widely investigated. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) is the first cause of death globally, with huge costs worldwide. Most cases of CVD could be prevented by addressing behavioural risk factors. Among these factors, there is physical and amateur sports activity (PASA), which has a linear negative correlation with the risk of CVD. Nevertheless, attempts to encourage PASA, as exercise prescription programmes, achieved little impact at the community-wide level. A new frontier to promote PASA is represented by mobile health tools, such as exergaming, mobile device apps, health wearables, GPS/GIS and virtual reality. Nevertheless, there has not yet been any evident turnabout in patient active involvement towards CVD prevention, and inactivity rates are even increasing. This study aims at framing the state of the art of the literature about the use of m-health in supporting PASA, as a user-centric innovation strategy, to promote co-production health policies aiming at CVD prevention.Methods: A mixed-method systematic literature review was conducted in the fields of health and healthcare management to highlight the intersections between PASA promotion and m-health tools in fostering co-produced services focused on CVD prevention. The literature has been extracted by the PRISMA logic application. The resulting sample has been first statistically described by a bibliometric approach and then further investigated with a conceptual analysis of the most relevant contributions, which have been qualitatively analysed.Results: We identified 2,295 studies, on which we ran the bibliometric analysis. After narrowing the research around the co-production field, we found 10 papers relevant for the concept analysis of contents. The interest about the theme has increased in the last two decades, with a high prevalence of contributions from higher income countries and those with higher CVD incidence. The field of research is highly multi-disciplinary; most of documents belong to the medical field, with only a few interconnections with the technology and health policy spheres. Although the involvement of patients is recognized as fundamental for CVD prevention through PASA, co-design schemes are still lacking at the public management level.Conclusions: While the link between the subjects of motor activity, medicine and technology is clear, the involvement of citizens in the service delivery process is still underinvestigated, especially the issue concerning how "value co-creation" could effectively be applied by public agencies. In synthesis, the analysis of the role of co-production as a system coordination method, which is so important in designing and implementing preventive care, is still lacking. [ABSTRACT FROM AUTHOR]

Background: Client-centred care serves as the foundation for healthcare policy. Indeed, various instruments for assessing clients' experiences of care and support are increasingly used to provide insights into the quality, and client-centred nature, of the care and support provided, which, in turn, aids the development of subsequent improvements. The unique characteristics of care and support for people with intellectual disabilities (ID), such as the need for both lifelong and life-wide care and support across all aspects of clients' lives, led to an initiative within Dutch ID care to jointly develop a range of instruments to assess the experiences of clients receiving ID care and support. Individual clients' experiences and suggestions for improvement, which are embedded in clients' care plan cycles, constitute the foundation of this Range of Instruments. This paper provides a unique, bottom-up, exhaustive account of the process of developing the Range of instruments used to assess the experiences of clients in the field of Dutch ID care.Methods: Relevant documents at three levels (i.e. 1) national documents, such as policy papers and governmental reports, 2) documents and reports from the Dutch Association of Healthcare Providers for People with Disabilities (VGN) along with minutes from the meetings of the expert Committee who assessed the instruments, and 3) correspondence between the Committee and developers as well as the forms used in the assessment process for each instrument) were qualitatively analysed by two researchers who had no affiliation with the development of the Range of instruments used to assess clients' experiences in ID care and support. All of the documents were inductively coded using a thematic analytical approach. Informants who were either currently or previously involved in the development of these instruments were asked to provide clarification over the documents themselves and to explain the context in which they were produced.Results: The development of the range of instruments can be classified into four phases, namely: 1) supporting the bottom-up development of initiatives to assess clients' experiences, 2) focusing on learning and further development, 3) stimulating exchange between the developers and users of the instruments and the Committee responsible for assessing them, and 4) further development in response to the changing times and new landscape.Conclusions: The range of instruments were found to be appropriate for a variety of clients in ID care and support, specifically in terms of assessing their individual experiences and gaining insight into their suggestions for improvement, and effective in terms of collaboratively improving the quality of ID care and support. In so doing, these instruments potentially provide an avenue through which clients' experiences can be embedded in the process of ID care and support. Other specific features in the development of these instruments, namely their incremental adoption, ongoing evaluation and strong practice orientation, were also found to be suitable for other care contexts' attempts to respond to the top-down policy objectives of client-centeredness and translating outcomes into direct care practice. [ABSTRACT FROM AUTHOR]

Background: Organizational reforms of hospitals in Iran are mainly aimed at improving efficiency, reducing government spending on health care, and improving the quality of services. These reforms began with hospital autonomization and have continued with other initiatives such as formation of board of trustees, independent and corporatized hospitals.Objective: The purpose of this scoping review was to summarize and compare the results of studies conducted on organizational reform of hospitals in Iran to paint a more clear picture of the status quo by identifying knowledge gaps, inform policymakers, and guide future studies and policies.Method: This review's methodology was inspired by Arksey and O'Malley's methodological framework to examine the extent, range, and nature of research activity about organizational hospital reforms in Iran. A literature search was performed using PubMed, Scopus, Web of Science, and Google Scholar for English papers as well as SID, IranDoc, Magiran, and the Social Security Research Institute Database for Persian papers from 1991 to April 2020.Results: Twenty studies were included in the review. Studies were grouped by the types of organizational reform, study's objective, setting, methodology, data collection and analysis techniques, and key findings. Thematic construction was used based on the types of organizational reform to present a narrative account of existing literature.Conclusions: The autonomy granted to the hospitals was unbalanced and paradoxical in terms of key effective dimensions. Poor governance and regulatory arrangements, low commitment to corporate governance, Inappropriate board composition, weak internal controls, unsustainable financing and inefficient payment mechanisms, poor interaction with stakeholders and ignoring contextual factors have been cited as the main reasons for the failure of organizational reforms in Iran. The limited use of evidence and research was obvious at different stages of policymaking, especially in the policy formulation phase and evaluation of its results. [ABSTRACT FROM AUTHOR]

Background: The aim of this paper is to share the results of a scoping review that examined the relationship between health care disparities and the multiplicity of vulnerability factors that are often clustered together. Methods: The conceptual framework used was an innovative dynamic model that we developed to analyze the co-existence of multiple vulnerability factors (multi-vulnerability) related to the phenomenon of the 'Inverse Care Law'. A total of 759 candidate references were identified through a literature search, of which 23 publications were deemed relevant to our scoping review. Results: The review confirmed our hypothesis of a direct correlation between co-existing vulnerability factors and health care disparities. Several gaps in the literature were identified, such as a lack of research on vulnerable populations' perception of their own vulnerability and on multimorbidity and immigrant status as aspects of vulnerability. Conclusions: Future research addressing the revealed gaps would help foster primary care interventions that are responsive to the needs of vulnerable people and, eventually, contribute to the reduction of health care disparities in society. [ABSTRACT FROM AUTHOR]

Background: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context.Main Text: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes.Conclusions: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures. [ABSTRACT FROM AUTHOR]

Background: The involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs).Methods: This systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review.Results: Twenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas.Conclusions: Further research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review. [ABSTRACT FROM AUTHOR]

Background: Since the 1980s, markets have turned increasingly to intangible goods - healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research.Main Text: This paper meta-analyses the authors' research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients' timely access to quality care and physicians' working conditions. Based on these findings, they explored the political economic of healthcare. In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa. The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards. While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues. In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. They demonstrated that commoditising healthcare increases mortality and suffering amenable to care considerably and carries professional, cultural, and ethical risks for doctors and health professionals. Pro-market policies systems cause health systems inefficiency, inequity in access to care and strain professionals' ethics.Conclusion: Policy research methodologies benefit from being inductive, as health services and systems evaluations, and population health studies are prerequisites to challenge official discourse and to explore the historical, economic, sociocultural, and political determinants of public policies. [ABSTRACT FROM AUTHOR]

Background: In the organization of health care and health care systems, there is an increasing trend towards integrated care. Policy-makers from different countries are creating policies intended to promote cooperation and collaboration between health care providers, while facilitating the integration of different health care services. Hopes are high, as such collaboration and integration of care are believed to save resources and improve quality. However, policy-makers are likely to encounter various challenges and limitations when attempting to turn these great ideas into effective policies. In this paper, we look into these challenges.Main Body: We argue that the organization of health care and integrated care is of public concern, and should thus be of crucial interest to policy-makers. We highlight three challenges or limitations likely to be encountered by policy-makers in integrated care. These are: (1) conceptual challenges; (2) empirical/methodological challenges; and (3) resource challenges. We will argue that it is still unclear what integrated care means and how we should measure it. 'Integrated care' is a single label that can refer to a great number of different processes. It can describe the integration of care for individual patients, the integration of services aimed at particular patient groups or particular conditions, or it can refer to institution-wide collaborations between different health care providers. We subsequently argue that health reform inevitably possesses a political context that should be taken into account. We also show how evidence supporting integrated care may not guarantee success in every context. Finally, we will discuss how promoting collaboration and integration might actually demand more resources. In the final section, we look at three different paradigmatic examples of integrated care policy: Norway, the UK's NHS, and Belgium.Conclusions: There seems widespread agreement that collaboration and integration are the way forward for health care and health care systems. Nevertheless, we argue that policy-makers should remain careful; they should carefully consider what they hope to achieve, the amount of resources they are willing to invest, and how they will evaluate the success of their policy. [ABSTRACT FROM AUTHOR]

Background: Efforts have been made by health research granting agencies to bring research closer to patients' concerns. In Canada, such efforts were formalized in 2011 with the funding of the Strategy for Patient-Oriented Research (SPOR)'s research networks to address research priorities identified by patients and accelerate the translation of research findings into patient care and health care policy. Among these networks, SPOR Diabetes Action Canada (DAC) has created patient-partner circles to facilitate their integration within the network. The nature of the relationships within this atypical patient-oriented research network is systematically explored in this paper.Methods: A cross-sectional social network study was conducted among the SPOR DAC's network members to examine inter-individual interactions, and the topics discussed the most between members. Descriptive data analyses were conducted to explore which discussion topics were discussed most among members whose primary roles were research, administration, governance, and patient representation.Results: The response rate was 51.9%, providing data on 76.5% of the maximum number of connections in the network. The survey captured 2763 inter-individual relationships. Responses to a sub-question inserted in the survey show that 482 of these relationships (17,4%) existed before joining the network in collaboration on a research project. Most ties captured in the survey were yearly or quarterly, while few relationships were monthly, weekly, or daily. In measured relationships, members discussed several topics, the most frequent being scientific research, patient engagement, network coordination and governance, and operations and management. The topics associated with the most significant proportion of relationships captured in the survey were scientific research (45.4%) and patient engagement (40.7%). Management & operations and governance & coordination follow, corresponding to 24.3 and 23.9% of the captured relationships. All discussion topic subnetworks were either somewhat or highly centralized, meaning that relationships were not equally distributed among members involved in these discussions. Of the 1256 relationships involving exchanges about scientific research, 647 (51.5%) involved a researcher, 419 (33.3%) an administrator, 182 (14.5%) a patient partner, and 82 (6.5%) a member whose primary role is network governance.Conclusions: Scientific research and patient engagement were the most common topics discussed, consistent with the patient-centered research at the heart of the SPOR Diabetes Action Canada network. The study identified several relationships where a patient partner has discussed scientific research with a researcher. However, relationships involving research discussions were three times more common between a researcher and an administrator than between a researcher and a patient partner, although twice as many patient partners as administrators participated in the survey. The institutionalization of patient-partner involvement in large research networks is an evolving practice for which optimal engagement methods are still being explored. [ABSTRACT FROM AUTHOR]

Background: Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.Methods: A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.Results: Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.Conclusions: Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established. [ABSTRACT FROM AUTHOR]

Background: The zero-markup drug policy (also known as the universal zero-markup drug policy (UZMDP)) was implemented in stages beginning with primary healthcare facilities in 2009 and eventually encompassing city public hospitals in 2016. This policy has been a central pillar of Chinese health reforms. While the literature has examined the impacts of this policy on healthcare utilization and expenditures, a more comprehensive and detailed assessment is warranted. The purpose of this paper is to explore the impacts of the UZMDP on inpatient and outpatient visits as well as on both aggregate healthcare expenditures and its various components (including drug, diagnosis, laboratory, and medical consumables expenditures).Methods: A pre-post design was applied to a dataset extracted from the Changde Municipal Human Resource and Social Security Bureau comprising discharge data on 27,246 inpatients and encounter data on 48,282 outpatients in Changde city, Hunan province, China. The pre-UZMDP period for the city public hospitals was defined as the period from October 2015 to September 2016, while the post-UZMDP period was defined as the period from October 2016 to September 2017. Difference-in-Difference negative binomial and Tobit regression models were employed to evaluate the impacts of the UZMDP on healthcare utilization and expenditures, respectively.Results: Four key findings flow from our assessment of the impacts of the UZMDP: first, outpatient and inpatient visits increased by 8.89 % and 9.39 %, respectively; second, average annual inpatient and outpatient drug expenditures fell by 4,349.00 CNY and 1,262.00 CNY, respectively; third, average annual expenditures on other categories of healthcare expenditures increased by 2,500.83 CNY, 417.10 CNY, 122.98 CNY, and 143.50 CNY for aggregate inpatient, inpatient diagnosis, inpatient laboratory, and outpatient medical consumables expenditures, respectively; and fourth, men and older individuals tended to have more inpatient and outpatient visits than their counterparts.Conclusions: Although the UZMDP was effective in reducing both inpatient and outpatient drug expenditures, it led to a sharp rise in other expenditure categories. Policy decision makers are advised to undertake efforts to contain the growth in total healthcare expenditures, in general, as well as to evaluate the offsetting effects of the policy on non-drug components of care. [ABSTRACT FROM AUTHOR]

Background: European societies are ageing rapidly and thus health promotion for older people (HP4OP) is becoming an increasingly relevant issue. Crucial here is not only the clinical aspect of health promotion but also its organisational and institutional dimension. The latter has been relatively neglected in research on HP4OP. This issue is addressed in this study, constituting a part of the EU project ProHealth65+, engaging ten member countries. This paper is based on two intertwining research goals: (1) exploring which institutions/organisations are performing HP4OP activities in selected European countries (including sectors involved, performed roles of these institutions, organisation of those activities); (2) developing an institutional approach to HP4OP. Thus, the paper provides a description of the analytical tools for further research in this area.Methods: The mentioned aims were addressed through the mutual use of two complementary methods: (a) a literature review of scientific and grey literature; and (b) questionnaire survey with selected expert respondents from 10 European countries. The expert respondents, selected by the project's collaborating partners, were asked to fill in a custom designed questionnaire concerning HP4OP institutional aspects.Results: The literature review provided an overview of the organisational arrangements in different HP4OP initiatives. It also enabled the development of functional institutional definitions of health promotion, health promotion activities and interventions, as well as an institutional definition adequate to the health promotion context. The distinctions between sectors were also clarified. The elaborated questionnaires provided in-depth information on countries specifically indicating the key sectors involved in HP4OP in those selected countries. These are: health care, regional/local authorities, NGO's/voluntary institutions. The questionnaire and literature review both resulted in the indication of a significant level of cross-sectorial cooperation in HP4OP.Conclusions: The inclusion of the institutional analysis within the study of HP4OP provides a valuable opportunity to analyse, in a systematic way, good practices in this respect, also in terms of institutional arrangements. A failure to address this aspect in policymaking might potentially cause organisational failure even in evidence-based programmes. This paper frames the perception of this problem. [ABSTRACT FROM AUTHOR]

Background: Accounting-that is, standardized measurement, public reporting, performance evaluation and managerial control-is commonly seen to provide the core infrastructure for quality improvement in healthcare. Yet, accounting successfully for quality has been a problematic endeavor, often producing dysfunctional effects. This has raised questions about the appropriate role for accounting in achieving quality improvement. This paper contributes to this debate by contrasting the specific way in which accounting is understood and operationalized for quality improvement in the UK National Health Service (NHS) with findings from the broadly defined 'social studies of accounting' literature and illustrative examples. Discussion: This paper highlights three significant differences between the way that accounting is understood to operate in the dominant health policy discourse and recent healthcare reforms, and in the social studies of accounting literature. It shows that accounting does not just find things out, but makes them up. It shows that accounting is not simply a matter of substance, but of style. And it shows that accounting does not just facilitate, but displaces, control. Summary: The illumination of these differences in the way that accounting is conceptualized helps to diagnose why accounting interventions often fail to produce the quality improvements that were envisioned. This paper concludes that accounting is not necessarily incompatible with the ambition of quality improvement, but that it would need to be understood and operationalized in new ways in order to contribute to this end. Proposals for this new way of advancing accounting are discussed. They include the cultivation of overlapping and even conflicting measures of quality, the evaluation of accounting regimes in terms of what they do to practice, and the development of distinctively skeptical calculative cultures. [ABSTRACT FROM AUTHOR]

Background Cost effectiveness analysis (CEA) is a useful tool for allocation of constrained resources, yet CEA methodologies are rarely taught or implemented in developing nations. We aimed to assess exposure to, and interest in CEA, and identify barriers to implementation in Uganda. Methods A cross-sectional survey was carried out in Uganda using a newly developed self-administered questionnaire (via online and paper based approaches), targeting the main health care actors as identified by a previous study. Results Overall, there was a 68% response rate, with a 92% (69/75) response rate among the paper-based respondents compared to a 40% (26/65) rate with the online respondents. Seventy eight percent (74/95) of the respondents had no exposure to CEA. None of those with a master of medicine degree had any CEA exposure, and 80% of technical officers, who are directly involved in policy formulation, had no CEA exposure. Barriers to CEA identified by more than 50% of the participants were: lack of information technology (IT) infrastructure (hardware and software); lack of local experts in the field of CEA; lack of or limited local data; limited CEA training in schools; equity or ethical issues; and lack of training grants incorporating CEA. 93% reported a lot of interest in learning to conduct CEA, and over 95% felt CEA was important for clinical decision making and policy formulation. Conclusions Among health care actors in Uganda, there is very limited exposure to, but substantial interest in conducting CEA and including it in clinical decision making and health care policy formation. Capacity to undertake CEA needs to be built through incorporation into medical training and use of regional approaches. [ABSTRACT FROM AUTHOR]

Background: There are many challenges in delivering and evaluating knowledge for healthcare, but the lack of clear routes from knowledge to practice is a root cause of failures in safety within healthcare. Various types and sources of knowledge are relevant at different levels within the healthcare system. These need to be delivered in a timely way that is useful and actionable for those providing services or developing policies. How knowledge is taken up and used through networks and relationships, and the difficulties in attributing change to knowledge-based interventions, present challenges to understanding how knowledge into action (K2A) work influences healthcare outcomes. This makes it difficult to demonstrate the importance of K2A work, and harness support for its development and resourcing. This paper presents the results from a project commissioned by NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) to create an evaluation framework to help understand the NHS Scotland Knowledge into Action model.Methods: The team took a developmental approach to creating an evaluation framework that would be useful and practical. This included a literature review to ensure the evaluation was evidence-based; adaptation of contribution analysis for K2A project; action research with K2A project leads to refine the work and develop suitable measures.Results: Principles for evaluation and an evaluation framework based on contribution analysis were developed and implemented on a trial project. An outcomes chain was developed for the K2A programme and specific projects. This was used to design, collect and collate evidence of the K2A intervention. Data collected routinely by the intervention was supplemented with specific feedback measures from K2A project users.Conclusions: The evaluation approach allowed for scrutiny of both processes and outcomes and was adaptable to projects on different scales. This framework has proved useful as a planning, reflecting and evaluation tool for K2A, and could be more widely used to evidence the ways in which knowledge to action work helps improve healthcare outcomes. [ABSTRACT FROM AUTHOR]

Background: Price regulation is a common constraint in Chinese hospitals. Based on a policy experiment conducted in China on the price deregulation of private nonprofit hospitals, this study empirically examines the impact of medical service price regulation on the pricing of medical services by hospitals.Methods: Using the claim data of insured inpatients residing in a major Chinese city for the period 2010-2015, this study constructs a DID (difference-in-differences) model to compare the impact of price deregulation on medical expenditure and expenditure structure between public and private nonprofit hospitals.Results: The empirical results based on micro data reveal that, price deregulated significantly increased the total expenditure per inpatient visit by 10.5%. In the itemized expenditure, the diagnostic test and drug expenditure per inpatient visit of private nonprofit hospitals decreased significantly, whereas the physician service expenditure per inpatient visit increased significantly. For expenditure structure, the proportions of drug expenditure and diagnostic test expenditure per inpatient visit significantly decreased by 5.7 and 3.1%, respectively. Furthermore, this paper also found that hospitals had larger price changes for dominant diseases than for non-dominant diseases.Conclusions: Under price regulation, medical service prices generally become lower than their costs. Therefore, after price deregulation, private nonprofit hospitals increase medical service prices above their cost and achieve the service premium increasing physician medical services. Further, although price deregulation causes patient expenditure to increase to a certain level, it optimizes the expenditure structure, as well. [ABSTRACT FROM AUTHOR]

Background: Ethical medical practice requires managing health services to promote professionalism and secure accessibility to care. Commercially financed and industrially managed services strain the physicians' clinical autonomy and ethics because the industry's profitability depends on commercial, clinical standardisation. Private insurance companies also reduce access to care whilst fragmenting and segmenting health systems. Against this background, given the powerful, symbolic significance of their common voice, physicians' and patients' organisations could effectively leverage together political parties and employers' organisations to promote policies favouring access to professional care.Main Text: To provide a foundation for negotiations between physicians' and patients' organisations, we propose policy principles derived from an analysis of rights-holders and duty-bearers' stakes, i.e., patients, physicians and health professionals, and taxpayers. Their concerns are scrutinised from the standpoints of public health and right to health. Illustrated with post-WWII European policies, these principles are formulated as inputs for tentative action-research. The paper also identifies potential stumbling blocks for collective doctor/patient negotiations based on the authors' personal experience. The patients' concerns are care accessibility, quality, and price. Those of physicians and other professionals are problem-solving capacity, autonomy, intellectual progress, ethics, work environment, and revenue. The majority of taxpayers have an interest in taxes being progressive and public spending on health regressive. Mutual aid associations tend to under-estimate the physician's role in delivering care. Physicians' organisations often disregard the mission of financing care and its impact on healthcare quality.Conclusion: The proposed physicians-patients' alliance could promote policies in tune with professional ethics, prevent European policies' putting industrial concerns above suffering and death, bar care financing from the ambit of international trade treaties, and foster international cooperation policies consistent with the principles that inspire the design of healthcare policies at home and so reduce international migration. To be credible partners in this alliance, physicians' associations should promote a public health culture amongst their members and a team culture in healthcare services. To promote a universal health system, patients' organisations should strive to represent universal health interests rather than those of patients with specific diseases, ethnic groups, or social classes. [ABSTRACT FROM AUTHOR]

Background: Revisiting professionalism, both as a medical ideal and educational topic, this paper asks whether, in the rise of artificial intelligence, healthcare commoditisation and environmental challenges, a rationale exists for merging clinical and public health practices. To optimize doctors' impact on community health, clinicians should introduce public health thinking and action into clinical practice, above and beyond controlling nosocomial infections and iatrogenesis. However, in the interest of effectiveness they should do everything possible to personalise care delivery. To solve this paradox, we explore why it is necessary for the boundaries between medicine and public health to be blurred.Main Body: Proceeding sequentially, we derive standards for medical professionalism from care quality criteria, neo-Hippocratic ethics, public health concepts, and policy outcomes. Thereby, we formulate benchmarks for health care management and apply them to policy evaluation. During this process we justify the social, professional - and by implication, non-commercial, non-industrial - mission of healthcare financing and policies. The complexity of ethical, person-centred, biopsychosocial practice requires a human interface between suffering, health risks and their therapeutic solution - and thus legitimises the medical profession's existence. Consequently, the universal human right to healthcare is a right to access professionally delivered care. Its enforcement requires significant updating of the existing medical culture, and not just in respect of the man/machine interface. This will allow physicians to focus on what artificial intelligence cannot do, or not do well. These duties should become the touchstone of their practice, knowledge and ethics. Artificial intelligence must support medical professionalism, not determine it. Because physicians need sufficient autonomy to exercise professional judgement, medical ethics will conflict with attempts to introduce clinical standardisation as a managerial paradigm, which is what happens when industrial-style management is applied to healthcare.Conclusion: Public healthcare financing and policy ought to support medical professionalism, alongside integrated clinical and public health practice, and its management. Publicly-financed health management should actively promote ethics in publicly- oriented services. Commercialised healthcare is antithetical to ethical medical, and to clinical / public health practice integration. To lobby governments effectively, physicians need to appreciate the political economy of care. [ABSTRACT FROM AUTHOR]

Background: Strong relations between medicine and public health have long been advocated. Today, professional medical practice assumes joint clinical/public health objectives: GPs are expected to practice community medicine; Hospital specialists can be involved in disease control and health service organisation; Doctors can teach, coach, evaluate, and coordinate care; Clinicians should interpret protocols with reference to clinical epidemiology. Public health physicians should tailor preventive medicine to individual health risks. This paper is targeted at those practitioners and academics responsible for their teams' professionalism and the accessibility of care, where the authors argue in favour of the epistemological integration of clinical medicine and public health.Main Text: Based on empirical evidence the authors revisit the epistemological border of clinical and public health knowledge to support joint practice. From action-research and cognitive psychology, we derive clinical/public health knowledge categories that require different transmission and discovery techniques. The knowledge needed to support the universal human right to access professional care bridges both clinical and public health concepts, and summons professional ethics to validate medical decisions. To provide a rational framework for teaching and research, we propose the following categories: 'Know-how/practice techniques', corresponding a.o. to behavioural, communication, and manual skills; 'Procedural knowledge' to choose and apply procedures that meet explicit quality criteria; 'Practical knowledge' to design new procedures and inform the design of established procedures in new contexts; and Theoretical knowledge teaches the reasoning and theory of knowledge and the laws of existence and functioning of reality to validate clinical and public health procedures. Even though medical interventions benefit from science, they are, in essence, professional: science cannot standardise eco-biopsychosocial decisions; doctor-patient negotiations; emotional intelligence; manual and behavioural skills; and resolution of ethical conflicts.Conclusion: Because the quality of care utilises the professionals' skill-base but is also affected by their intangible motivations, health systems should individually tailor continuing medical education and treat collective knowledge management as a priority. Teamwork and coaching by those with more experience provide such opportunities. In the future, physicians and health professionals could jointly develop clinical/public health integrated knowledge. To this end, governments should make provision to finance non-clinical activities. [ABSTRACT FROM AUTHOR]

Background: Pharmaceutical companies in Africa need to invest in both facilities and quality management systems to achieve good manufacturing practice (GMP) compliance. Compliance to international GMP standards is important to the attainment of World Health Organization (WHO) prequalification. However, most of the local pharmaceutical manufacturing companies may be deterred from investing in quality because of many reasons, ranging from financial constraints to technical capacity. This paper primarily evaluates benefits against the cost of investing in GMP, using a Nigerian pharmaceutical company, Chi Pharmaceuticals Limited, as a case study. This paper also discusses how to drive more local manufacturers to invest in quality to attain GMP compliance; and proffers practical recommendations for local manufacturers who would want to invest in quality to meet ethical and regulatory obligations.Method: The cost benefit of improving the quality of Chi Pharmaceuticals Limited's facilities and system to attain WHO GMP certification for the production of zinc sulfate 20-mg dispersible tablets was calculated by dividing the annual benefits derived from quality improvement interventions by the annual costs of implementing quality improvement interventions, referred to as a benefit-cost ratio (BCR).Result: Cost benefit of obtaining WHO GMP certification for the production of zinc sulfate 20-mg dispersible tablets was 5.3 (95% confidence interval of 5.0-5.5).Conclusion: Investment in quality improvement intervention is cost-beneficial for local manufacturing companies. Governments and regulators in African countries should support pharmaceutical companies striving to invest in quality. Collaboration of local manufacturing companies with global companies will further improve quality. Local pharmaceutical companies should be encouraged to key into development opportunities available for pharmaceutical companies in Africa. [ABSTRACT FROM AUTHOR]

Background: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care., Methods: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis., Results: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional., Conclusion: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Background: There is an increasing recognition that modelling and simulation can assist in the process of designing health care policies, strategies and operations. However, the current use is limited and answers to questions such as what methods to use and when remain somewhat underdeveloped. Aim: The aim of this study is to provide a mechanism for decision makers in health services planning and management to compare a broad range of modelling and simulation methods so that they can better select and use them or better commission relevant modelling and simulation work. Methods: This paper proposes a modelling and simulation method comparison and selection tool developed from a comprehensive literature review, the research team's extensive expertise and inputs from potential users. Twenty-eight different methods were identified, characterised by their relevance to different application areas, project life cycle stages, types of output and levels of insight, and four input resources required (time, money, knowledge and data). Results: The characterisation is presented in matrix forms to allow quick comparison and selection. This paper also highlights significant knowledge gaps in the existing literature when assessing the applicability of particular approaches to health services management, where modelling and simulation skills are scarce let alone money and time. Conclusions: A modelling and simulation method comparison and selection tool is developed to assist with the selection of methods appropriate to supporting specific decision making processes. In particular it addresses the issue of which method is most appropriate to which specific health services management problem, what the user might expect to be obtained from the method, and what is required to use the method. In summary, we believe the tool adds value to the scarce existing literature on methods comparison and selection. [ABSTRACT FROM AUTHOR]

Background: There is significant global policy interest related to enabling a data-driven approach for evidence-based primary care system development. This paper describes the development and initial testing of a prototype tool (the Problem-Oriented Primary Care System Development Record, or PCSDR) that enables a data-driven and contextualized approach to primary care system development.Methods: The PCSDR is an electronic record that enables the systematic input, classification, structuring, storage, processing and analysis of different types of data related to the structure, function and performance of primary care systems over time. Data inputted into the PCSDR was coded using the WHO's PHC-IMPACT framework and classification system. The PCSDR's functionalities were tested by using a case study of primary care system development in Tajikistan.Results: Tajikistan's case study demonstrated that the PCSDR is a potentially effective and conceptually-sound tool for the input, classification, structuring and storage of different data types from myriad sources. The PCSDR is therefore a basic data entry and data management system that enables query and analytics functions for health services research and evidence-based primary care system development functions.Conclusions: The PCSDR is a data system that enables a contextualized approach to evidence-based primary care system development. It represents a coherent and effective synthesis of the fields of primary care system development and performance assessment. The PCSDR enables analysts to leverage primary care performance assessment frameworks for a broad range of functions related to health systems analysis, improvement and the development of learning health systems. [ABSTRACT FROM AUTHOR]

Background: The consequences of annual influenza outbreaks are often underestimated by the general public. Influenza poses a serious public health threat around the world, particularly for the most vulnerable populations. Fortunately, vaccination can mitigate the negative effects of this common infectious disease. Although inoculating frontline health care workers (HCWs) helps minimize disease transmission, some HCWs continue to resist participating in voluntary immunization programs. A potential solution to this problem is government-mandated vaccination for HCWs; however, in practice, there are substantial barriers to the adoption of such policies. The purpose of this paper is to identify the likelihood of adopting a policy for mandatory immunization of HCWs in Ontario based on a historical review of barriers to the agenda setting process. Methods: Documents from secondary data sources were analysed using Kingdon's agenda setting framework of three converging streams leading to windows of opportunity for possible policy adoption. Results: The problems, politics, and policies streams of Kingdon's framework have converged and diverged repeatedly over an extended period (policy windows have opened and closed several times). In each instance, a technically feasible solution was available. However, despite the evidence supporting the value of HCW immunization, alignment of the three agenda setting streams occurred for very short periods of time, during which, opposition lobby groups reacted, making the proposed solution less politically acceptable. Conclusions: Prior to the adoption of any new policies, issues must reach a government's decision agenda. Based on Kingdon's agenda setting framework, this only occurs when there is alignment of the problems, politics, and policies streams. Understanding this process makes it easier to predict the likelihood of a policy being adopted, and ultimately implemented. Such learning may be applied to policy issues in other jurisdictions. In the case of mandatory influenza vaccinations for HCWs in Ontario, it seems highly unlikely that a new policy will be adopted until perception of the problem's importance is sufficient to overcome the political opposition to implementing a solution and thus, create a window of opportunity that is open long enough to support change. [ABSTRACT FROM AUTHOR]

Background: In Japan, local governments have rural clinics designated for areas without physicians (RCDA) to secure physicians for rural medical care. Moreover, a medical policy of dispatching physicians between the RCDA and core hospitals for rural areas (CHRA) exists. This study aimed to assess the actual situation of physician migration from RCDAs and those who migrated, and examine the factors associated with their migration. Methods: This retrospective cohort study used biennial national physicians' survey data from 2012 to 2018. It targeted physicians who worked at RCDAs in 2012 and participated in all four surveys (n = 510). The physicians were divided into two groups. One group consisted of physicians who worked continuously at the RCDA over the four study periods (retained physicians, n = 278), and the other included physicians who migrated to other institutions midway through the study period (migrated physicians, n = 232). We tracked the types of facilities where RCDA physicians worked from 2012 to 2018, also examined the factors associated with their migration. Results: Among physicians from RCDAs who migrated to other institutions (n = 151) between 2012 and 2014, many migrated to hospitals (n = 87/151, 57.6%), and some migrated to CHRA (n = 35/87, 40.2%). Physicians in their 40s (Hazard ratio 0.32 [95% CI 0.19–0.55]), 50s (0.20 [0.11–0.35]), and over 60 years (0.33 [0.20–0.56]) were more likely to remain at RCDAs. Changes in their area of practice (1.82 [1.34–2.45]) and an increase in the number of board certifications held by physicians between 2012 and 2018 (1.50 [1.09–2.06]) were associated with migration. Conclusions: Many migrating physicians choose to work at hospitals after migrating from RCDAs. It was seemed that the physician dispatch system between RCDA and CHRA has been a measure to secure physicians in rural areas. Young age, obtaining board certification, and changes in areas of practice were associated with physician migration from RCDAs. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic wreaked havoc on long-term care facilities (LTCFs). Some LTCFs performed better than others at slowing COVID-19 transmission. Emerging literature has mostly described infection prevention and control strategies implemented by LTCFs during the pandemic. However, there is a need for a comprehensive review of factors that influenced the performance of LTCFs in containing COVID-19 spread to inform public health policy. Objective: To build on the existing literature, we conducted a scoping review of factors that influenced LTCF performance during the COVID-19 pandemic using a multidimensional conceptual framework of performance. Methods: We followed the Joanna Briggs Institute's methodology for scoping reviews. We queried CINAHL, MEDLINE (Ovid), CAIRN, Science Direct, Scopus, and Web of Science for peer-reviewed literature in English or French published between January 1st, 2020 and December 31st, 2021. Retrieved records were screened for context (COVID-19 pandemic), population (LTCFs), interest (internal and external factors that influenced LTCF performance), and outcomes (dimensions of performance: equity, accessibility, reactivity, safety, continuity, efficacy, viability, efficiency). Descriptive characteristics of included articles were summarized. Dimensions of performance as well as internal (e.g., facility characteristics) and external (e.g., visitors) factors identified to have influenced LTCF performance were presented. Results: We retained 140 articles of which 68% were classified as research articles, 47% originated in North America, and most covered a period between March and July 2020. The most frequent dimensions of performance were "efficacy" (75.7%) and "safety" (75.7%). The most common internal factors were "organizational context" (72.9%) and "human resources" (62.1%), and the most common external factors were "visitors" (27.1%) and "public health guidelines" (25.7%). Conclusions: Our review contributes to a global interest in understanding the impact of the COVID-19 pandemic on vulnerable populations residing and working in LTCFs. Though a myriad of factors were reported, a lack of randomized controlled trials makes it impossible to establish causality between the identified factors and LTCF performance. The use of a multidimensional framework can be recommended to evaluate healthcare system performance not merely in terms of efficacy and safety, but alongside other critical dimensions such as efficiency and equity. Trial registration: Research Registry ID: researchregistry7026 [ABSTRACT FROM AUTHOR]

Background: Non-government, not-for-profit community health centres (CHCs) play a crucial role within healthcare systems in fostering equity, acting both as direct providers of services and as sentinels of health and social inequity. In a study of an intervention to promote equity-oriented health care, we enlisted four diverse primary healthcare clinics with mandates to serve highly marginalized populations. All of these CHCs operate as not-for-profit, non-government organizations (NGOs), and have a marginal relationship financially and socially to other parts of the system. The purpose of this paper is to provide an analysis of the factors that shape how CHCs are able to carry out an equity mandate and, from this, to identify what is required at the level of policy to enhance capacity to provide equity-oriented health care., Methods: We systematically examined the clinics' policy and funding contexts, and identified influences on the clinics' capacities to promote equity-oriented health care., Results: We identified three key mechanisms of influence, each playing out against the backdrop of a contested and marginal position of CHCs within the health care system: a) accountability and performance frameworks; b) patterns of funding and allocation of resources, and c) pathways for emergent priorities. We examine these mechanisms, considering how each influenced the pursuit of equity, and propose policy directions to optimize the primary health care sectors' capacity to support equity-oriented health care., Conclusions: Although this analysis is based on a study within a high-income country, we argue that because the dynamics between community health centres and broader healthcare systems are similar across national boundaries, the implications have applicability to low and middle-income countries.

Background: In Kenya, cardiovascular diseases (CVDs) accounted for more than 10% of total deaths and 4% of total Disability-Adjusted Life Years (DALYs) in 2015 with a steady increase over the past decade. The main objective of this paper was to review the existing policies and their content in relation to prevention, control and management of CVDs at primary health care (PHC) level in Kenya., Methods: A targeted document search in Google engine using keywords "Kenya national policy on cardiovascular diseases" and "Kenya national policy on non-communicable diseases (NCDs)" was conducted in addition to key informant interviews with Kenyan policy makers. Relevant regional and international policy documents were also included. The contents of documents identified were reviewed to assess how well they aligned with global health policies on CVD prevention, control and management. Thematic content analysis of the key informant interviews was also conducted to supplement the document reviews., Results: A total of 17 documents were reviewed and three key informants interviewed. Besides the Tobacco Control Act (2007), all policy documents for CVD prevention, control and management were developed after 2013. The national policies were preceded by global initiatives and guidelines and were similar in content with the global policies. The Kenya health policy (2014-2030), The Kenya Health Sector Strategic and Investment Plan (2014-2018) and the Kenya National Strategy for the Prevention and Control of Non-communicable diseases (2015-2020) had strategies on NCDs including CVDs. Other policy documents for behavioral risk factors (The Tobacco Control Act 2007, Alcoholic Drinks Control (Licensing) Regulations (2010)) were available. The National Nutrition Action Plan (2012-2017) was available as a draft. Although Kenya has a tiered health care system comprising primary healthcare, integration of CVD prevention and control at PHC level was not explicitly mentioned in the policy documents., Conclusion: This review revealed important gaps in the policy environment for prevention, control and management of CVDs in PHC settings in Kenya. There is need to continuously engage the ministry of health and other sectors to prioritize inclusion of CVD services in PHC.

Background: For more than 30 years policy action across sectors has been celebrated as a necessary and viable way to affect the social factors impacting on health. In particular intersectoral action on the social determinants of health is considered necessary to address social inequalities in health. However, despite growing support for intersectoral policymaking, implementation remains a challenge. Critics argue that public health has remained naïve about the policy process and a better understanding is needed. Based on ethnographic data, this paper conducts an in-depth analysis of a local process of intersectoral policymaking in order to gain a better understanding of the challenges posed by implementation. To help conceptualize the process, we apply the theoretical perspective of organizational neo-institutionalism, in particular the concepts of rationalized myth and decoupling., Methods: On the basis of an explorative study among ten Danish municipalities, we conducted an ethnographic study of the development of a municipal-wide implementation strategy for the intersectoral health policy of a medium-sized municipality. The main data sources consist of ethnographic field notes from participant observation and interview transcripts., Results: By providing detailed contextual description, we show how an apparent failure to move from policy to action is played out by the ongoing production of abstract rhetoric and vague plans. We find that idealization of universal intersectoralism, inconsistent demands, and doubts about economic outcomes challenge the notion of implementation as moving from rhetoric to action., Conclusion: We argue that the 'myth' of intersectoralism may be instrumental in avoiding the specification of action to implement the policy, and that the policy instead serves as a way to display and support good intentions and hereby continue the process. On this basis we expand the discussion on implementation challenges regarding intersectoral policymaking for health.

Background: The quality of nursing homes (NHs) has attracted a lot of interest in recent years and is one of the most challenging issues for policy-makers. Nutritional care should be considered an important variable to be measured from the perspective of quality management. The aim of this systematic review is to describe the use of structural, process, and outcome indicators of nutritional care in NHs and the relationship among them., Methods: The literature search was carried out in Pubmed, Embase, Scopus, and Web of Science. A temporal filter was applied in order to select papers published in the last 10 years. All types of studies were included, with the exception of reviews, conference proceedings, editorials, and letters to the editor. Papers published in languages other than English, Italian, and Spanish were excluded., Results: From the database search, 1063 potentially relevant studies were obtained. Of these, 19 full-text articles were considered eligible for the final synthesis. Most of the studies adopted an observational cross-sectional design. They generally assessed the quality of nutritional care using several indicators, usually including a mixture of many different structural, process, and outcome indicators. Only one of the 19 studies described the quality of care by comparing the results with the threshold values. Nine papers assessed the relationship between indicators and six of them described some significant associations-in the NHs that have a policy related to nutritional risk assessment or a suitable scale to weigh the residents, the prevalence or risk of malnutrition is lower. Finally, only four papers of these nine included risk adjustment. This could limit the comparability of the results., Conclusion: Our findings show that a consensus must be reached for defining a set of indicators and standards to improve quality in NHs. Establishing the relationship between structural, process, and outcome indicators is a challenge. There are grounds for investigating this theme by means of prospective longitudinal studies that take the risk adjustment into account.

Background: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.Methods: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.Results: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.Conclusion: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences. [ABSTRACT FROM AUTHOR]

Background: Internationally there has been a growth in the use of publicly funded service markets as a mechanism to deliver health and social services. This has accompanied the emergence of 'self-directed care' in a number of different policy areas including disability and aged care - often referred to as 'personalisation' (Giaimo and Manow, Comp. Pol Stud 32:967-1000, 1999; Needham, Public Money Manage 30:136-8, 2010; [Hood], [The Idea of Joined-up Government: A Historical Perspective], [2005]; Klijn and Koppenjan, Public Manage 2:437-54, 2000, Greener, Policy Polit 36:93-108, 2008). These reforms are underpinned by an idea that individuals should be placed in control of their own service needs, given funding directly by government and encouraged to exercise choice and control through purchasing their own services. A major challenge for governments in charge of these reforms is determining the best way to structure and govern emerging service markets markets. Given the growing international embrace of market-based reform mechanisms to provide essential services to citizens, finding ways to ensure they promote, and not diminish, people's health and wellbeing is vital., Methods: The Australian National Disability Insurance Scheme (NDIS) is Australia's first national approach to the use of personalised budgets. The program of research outlined in this paper brings together streams from a range of different studies in order to investigate the implementation of the NDIS longitudinally across different administrative levels of government, service providers and scheme participants., Conclusion: This programme of research will make a contribution to our understanding of the Australian scheme and how individualised funding operates within this context, but will also generate much needed evidence that will have relevance to other jurisdictions and help fill a gap in the evidence base.

Background: While there have been efforts to develop frameworks to guide healthcare priority setting; there has been limited focus on evaluation frameworks. Moreover, while the few frameworks identify quality indicators for successful priority setting, they do not provide the users with strategies to verify these indicators. Kapiriri and Martin (Health Care Anal 18:129-147, 2010) developed a framework for evaluating priority setting in low and middle income countries. This framework provides BOTH parameters for successful priority setting and proposes means of their verification. Before its use in real life contexts, this paper presents results from a validation process of the framework., Methods: The framework validation involved 53 policy makers and priority setting researchers at the global, national and sub-national levels (in Uganda). They were requested to indicate the relative importance of the proposed parameters as well as the feasibility of obtaining the related information. We also pilot tested the proposed means of verification., Results: Almost all the respondents evaluated all the parameters, including the contextual factors, as 'very important'. However, some respondents at the global level thought 'presence of incentives to comply', 'reduced disagreements', 'increased public understanding,' 'improved institutional accountability' and 'meeting the ministry of health objectives', which could be a reflection of their levels of decision making. All the proposed means of verification were assessed as feasible with the exception of meeting observations which would require an insider. These findings results were consistent with those obtained from the pilot testing., Conclusions: These findings are relevant to policy makers and researchers involved in priority setting in low and middle income countries. To the best of our knowledge, this is one of the few initiatives that has involved potential users of a framework (at the global and in a Low Income Country) in its validation. The favorable validation of all the parameters at the national and sub-national levels implies that the framework has potential usefulness at those levels, as is. The parameters that were disputed at the global level necessitate further discussion when using the framework at that level. The next step is to use the validated framework in evaluating actual priority setting at the different levels.

Background: Rapidly evolving socioeconomic and technological trends make it challenging to improve access, effectiveness and efficiency in the use of pharmaceuticals. This paper identifies and systematically classifies the prevailing pharmaceutical policies worldwide in relation to a country's income status., Methods: A literature search was undertaken to identify and taxonomize prevailing policies worldwide. Countries that apply those policies and those that do not were then grouped by income status., Results: Pharmaceutical policies are linked to a country's socioeconomics. Developed countries have universal coverage and control pharmaceuticals with external and internal price referencing systems, and indirect price-cost controls; they carry out health technology assessments and demand utilization controls. Price-volume and risk-sharing agreements are also evolving. Developing countries are underperforming in terms of coverage and they rely mostly on restrictive state controls to regulate prices and expenditure., Conclusions: There are significant disparities worldwide in the access to pharmaceuticals, their use, and the reimbursement of costs. The challenge in high-income countries is to maintain access to care whilst dealing with trends in technology and aging. Essential drugs should be available to all; however, many low- and middle-income countries still provide most of their population with only poor access to medicines. As economies grow, there should be greater investment in pharmaceutical care, looking to the policies of high-income countries to increase efficiency. Pharmaceutical companies could also develop special access schemes with low prices to facilitate coverage in low-income countries.

Background: Rehabilitation medicine plays an integral part in attainment of optimal functioning after injury or disease. The National Rehabilitation Policy of South Africa (NRP) (2000) highlights the need for access to professional health care services, redistribution and optimal utilisation of resources and research in the field of disability and rehabilitation. The government further ratified the Convention on the Rights of Persons with Disabilities (CRPD) (2007), which validate the urgency in advancing the agenda of persons with disabilities. This paper outlines the methodological plan for evaluating rehabilitation services in the Western Cape, South Africa against the aims and objectives of the NRP as well as its principles and concepts. The evaluation process further focused on specific articles in the CRPD that were aligned with disability, health and rehabilitation., Methods/design: A mixed-method design was used to evaluate the alignment of rehabilitation services with the NRP in the Western Cape. Four rehabilitation study settings were selected to ensure that both inpatient and outpatient rehabilitation levels of care were covered at different contexts (rural and peri-urban). The sites were checked for the most prevalent rehabilitation-related conditions to ensure the identification of suitable instruments for measuring rehabilitation outcomes. Each study setting was linked to two researchers with one exploring the rehabilitation organizational structure of the sites and the other exploring the client outcomes after receiving rehabilitation services. Patients were evaluated at baseline and discharge, within seven days after admission and seven days prior to discharge. The evaluation was based on the rehabilitation organizational capacity to provide patient-oriented rehabilitation and the measurement of rehabilitation outcomes. Kaplan's framework of organisational capacity was used in the context of each study setting. For the measurement of service users' outcomes, the International Classification of Functioning, Disability and Health was used (ICF). Standardised outcome measures were adopted for the domains of impairment, activity and participation. The World Health Organisation Community-Based Rehabilitation guidelines were used as guiding principles and concepts as suggested in the NRP., Discussion: This is a groundbreaking methodological exploration that offers both study methods and instruments to measure rehabilitation services at both in-patient and out-patient rehabilitation services.

Background: In the last decade, the health status of Afghans has improved drastically. However, the health financing system in Afghanistan remains fragile due to high out-of-pocket spending and reliance on donor funding. To address the country's health financing challenges, the Ministry of Public Health investigated health insurance as a mechanism to mobilize resources for health. This paper presents stakeholders' opinions on seven preconditions of implementing this approach, as their understanding and buy-in to such an approach will determine its success., Methods: Key informant interviews and focus group discussions were conducted with stakeholders. The interviews focused on perceptions of the seven preconditions of introducing health insurance, and adapting a framework developed by the International Labor Organization. Content analysis was conducted after interviews and discussions were transcribed and coded., Results: Almost all of the stakeholders from government agencies, the private sector, and development partners are interested in introducing health insurance in Afghanistan, and they were aware of the challenges of the country's health financing system. Stakeholders acknowledged that health insurance could be an instrument to address these challenges. However, stakeholders differed in their beliefs about how and when to initiate a health insurance scheme. In addition to increasing insecurity in the country, they saw a lack of clear legal guidance, low quality of healthcare services, poor awareness among the population, limited technical capacity, and challenges to willingness to pay as the major barriers to establishing a successful nationwide health insurance scheme., Conclusions: The identified barriers prevent Afghanistan from establishing health insurance in the short term. Afghanistan must progressively address these major impediments in order to build a health insurance system.