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Abstract Background The objective of this paper was to estimate the impact of country-wide hospital pay-for-performance on readmissions for a set of common conditions in Lebanon. Methods This retrospective cohort study included all hospitalizations under the coverage of the Ministry of Public Health in Lebanon between 2011 and 2019. We calculated 30-day all-cause readmissions following general, pneumonia, cholecystectomy and stroke cases. We used an interrupted time series design, including the use of AutoRegressive Integrated Moving Average models. This nationwide study including 1,333,691 hospitalizations was undertaken in Lebanon, using hospitalizations at about 140 private and public hospitals contracted by the Ministry. The participants included citizens across all ages under the Ministry’s coverage (52% of citizens). The intervention was the engagement of hospital leaders by the Ministry, informing them of the addition of a readmissions component to the ongoing pay-for-performance initiative. Engagement participants included hospital directors and managers, and the leadership of the Syndicate of Private Hospitals. The main outcome measure was age-adjusted monthly all-cause readmission rates for each of general, pneumonia, cholecystectomy and stroke cases. We also assessed for change in readmissions for three conditions not included in the intervention (myocardial infarction, cataract surgery and appendectomy). Results Across 2011–2019, the overall readmission rates were 6.00% (SD 0.24%) for general readmissions, 5.06% (SD 0.22%) for pneumonia, 2.54% (SD 0.16%) for cholecystectomy, and 6.55% (SD 0.25%) for stroke. Using ARIMA models we found a relative percentage decrease in mean monthly readmissions in the post-intervention period for cholecystectomy (5.9%; CI 0.1%-11.8%) and stroke (13.6%; CI 3.1%-24.2%). There was no evidence of intervention impact on pneumonia and general readmissions, both overall and among small, medium and large hospitals. There was also no evidence of change in non-P4P readmissions of myocardial infarction, cataract surgery and appendectomy. Conclusions Including readmissions within pay-for-performance has the potential to improve hospital performance and patient outcomes, even in countries with more limited resources. Effects may vary across conditions, indicating the need for careful design and understanding of the particular context, both with respect to implementation and to evaluation of impact.

Abstract Background With the increasing number of protracted refugee crises globally, it is essential to ensure strong national health information systems (HIS) in displacement settings that include refugee-sensitive data and disaggregation by refugee status. This multi-country study aims to assess the degree of integration of refugee health data into national HIS in Jordan, Lebanon, and Uganda and identify the strengths and weaknesses of their national HIS in terms of collecting and reporting on refugee-related health indicators. Methods The study employs a comparative country analysis approach using a three-phase framework. The first phase involved reviewing 4120 indicators compiled from global health organizations, followed by a multi-stage refinement process, resulting in 45 indicators distributed across five themes. The second phase consisted of selecting relevant criteria from the literature, including data sources, annual reporting, disaggregation by refugee status, refugee population adjustments, accuracy, and consistency. The third phase involved assessing data availability and quality of the selected indicators against these criteria. Results Our analysis uncovered significant challenges in assessing the health status of refugees in Jordan, Lebanon, and Uganda, primarily stemming from limitations in the available health data and indicators. Specifically, we identified significant issues including incomplete local data collection with reliance on international data sources, fragmented data collection from various entities leading to discrepancies, and a lack of distinction between refugees and host populations in most indicators. These limitations hinder accurate comparisons and analyses. In light of these findings, a set of actionable recommendations was proposed to guide policymakers in the three countries to improve the integration of refugee health data into their national HIS ultimately enhancing refugees’ well-being and access to healthcare services. Conclusion The current status of refugee-related health data in Jordan, Lebanon, and Uganda indicates the need for improved data collection and reporting practices, disaggregation by refugee status and better integration of refugee health data into national HIS to capture the health status and needs of refugees in host countries. Key improvement strategies include establishing a centralized authority for consistent and efficient data management, fostering transparent and inclusive data governance, and strengthening workforce capacity to manage refugee health data effectively.

Introduction With shifts in international aid, international donors have increasingly regarded non-governmental organisations (NGOs) as capable of providing alternative public service arrangements. As funding flows to NGOs, particularly in contexts where both actors work towards strengthening health system resilience, NGO-donor relationships evolve. However, despite calls to investigate the contribution of relationships between actors within health systems, including NGOs and their donors, to health system resilience, empirical research is limited. Understanding these relationships is crucial for comprehending their role in fostering resilient health systems. This research fills this gap, by examining how NGO-donor coordination contributes to health system resilience in Lebanon.Methods This research focuses on Lebanon’s primary health system, primarily managed by NGOs through contracts and heavily funded by donors. It examines NGOs operating under the national primary healthcare network (PHCN). The participants, including staff from these NGOs and donor agencies funding them, were purposively selected. 31 semi-structured interviews were conducted. The analysis framework relied on a thematic analysis.Results The findings revealed that the flexibility in NGO-donor coordination in Lebanon depends on donors’ trust, regular coordination and donors’ willingness to listen to NGOs’ needs. In this light, they uncovered that flexible NGO-donor coordination enhances NGOs’ resilience capacities in shocks, allowing them to operate flexibly. By strengthening NGOs’ resilience, which contributes to the resilience of the broader health system, this relationship contributes to health system resilience.Conclusion The findings contradict the mainstream development literature on NGO-donor relationships. The latter focuses on donor funding requirements that often result in rigid NGO-donor coordination, making it difficult for NGOs to be resilient. Rather, they emphasise the donors’ role in implementing flexible development approaches, through flexible NGO-donor coordination, strengthening health system resilience. Overall, this paper contributes to the health system resilience literature by exploring how specific configurations of NGO-donor coordination strengthen health system resilience.

Abstract Background Health policy and systems research (HPSR) can strengthen health systems and improve population health outcomes. In the Eastern Mediterranean Region (EMR), there is limited recognition of the importance of HPSR and funding remains the main challenge. This study seeks to: (1) assess the reporting of funding in HPSR papers published between 2010 and 2022 in the EMR, (2) examine the source of funding in the published HPSR papers in the EMR and (3) explore variables influencing funding sources, including any difference in funding sources for coronavirus disease 2019 (COVID-19)-related articles. Methods We conducted a rapid scoping review of HPSR papers published between 2010 and 2022 (inclusively) in the EMR, addressing the following areas: reporting of funding in HPSR papers, source of funding in the published HPSR papers, authors’ affiliations and country of focus. We followed the Joanna Briggs Institute (JBI) guidelines for conducting scoping reviews. We also conducted univariate and bivariate analyses for all variables at 0.05 significance level. Results Of 10,797 articles screened, 3408 were included (of which 9.3% were COVID-19-related). More than half of the included articles originated from three EMR countries: Iran (n = 1018, 29.9%), the Kingdom of Saudi Arabia (n = 595, 17.5%) and Pakistan (n = 360, 10.6%). Approximately 30% of the included articles did not report any details on study funding. Among articles that reported funding (n = 1346, 39.5%), analysis of funding sources across all country income groups revealed that the most prominent source was national (55.4%), followed by international (41.7%) and lastly regional sources (3%). Among the national funding sources, universities accounted for 76.8%, while governments accounted for 14.9%. Further analysis of funding sources by country income group showed that, in low-income and lower-middle-income countries, all or the majority of funding came from international sources, while in high-income and upper-middle-income countries, national funding sources, mainly universities, were the primary sources of funding. The majority of funded articles’ first authors were affiliated with academia/university, while a minority were affiliated with government, healthcare organizations or intergovernmental organizations. We identified the following characteristics to be significantly associated with the funding source: country income level, the focus of HPSR articles (within the EMR only, or extending beyond the EMR as part of international research consortia), and the first author’s affiliation. Similar funding patterns were observed for COVID-19-related HPSR articles, with national funding sources (78.95%), mainly universities, comprising the main source of funding. In contrast, international funding sources decreased to 15.8%. Conclusion This is the first study to address the reporting of funding and funding sources in published HPSR articles in the EMR. Approximately 30% of HPSR articles did not report on the funding source. Study findings revealed heavy reliance on universities and international funding sources with minimal role of national governments and regional entities in funding HPSR articles in the EMR. We provide implications for policy and practice to enhance the profile of HPSR in the region.

Abstract Introduction The Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic. Methods This paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators. Results Although the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees’ access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities’ access to medications due to shortages and dramatic price increases. Conclusion Integrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

Introduction Vaccines are essential to prevent infection and reduce the morbidity of infectious diseases. Previous evidence has shown that migrants and refugees are particularly vulnerable to exclusion and discrimination, and low COVID-19 vaccine intention and uptake were observed among refugees globally. This study aimed to develop and internally validate prediction models of COVID-19 vaccine uptake by nationality.Methods This is a nested prognostic population-based cross-sectional analysis. Data were collected between June and October 2022 in Sin-El-Fil, a district of Beirut, Lebanon. The study population included a random sample of Lebanese adults and all Syrian adults residing in areas of low socioeconomic status. Data were collected through a telephone survey. The main outcome was the uptake of at least one dose of the COVID-19 vaccine. Predictors of COVID-19 vaccine uptake were assessed using the Least Absolute Shrinkage and Selection Operator regression for Lebanese and Syrian nationalities in separate models.Results Of 2028 participants, 79% were Lebanese, 18% Syrians and 3% of other nationalities. COVID-19 vaccination uptake was higher among Lebanese (85% (95% CI 82% to 86%) compared to Syrians (47% (95% CI 43% to 51%)) (p

Abstract Background Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. Methods Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. Results Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p

Abstract Background Lebanon ratified the International Health Regulations (IHR) (2005) in 2007, and since then, it has been facing complex political deadlocks, financial deterioration, and infectious disease emergencies. We aimed to understand the IHR capacities’ scores of Lebanon in comparison to other countries, the IHR milestones and activities in Lebanon, the challenges of maintaining the IHR capacities, the refugee crisis's impact on the development of these capacities; and the possible recommendations to support the IHR performance in Lebanon. Methods We used a mixed-method design. The study combined the use of secondary data analysis of the 2020 State Party Self-Assessment Annual Report (SPAR) submissions and qualitative design using semi-structured interviews with key informants. Semi-structured interviews were conducted with nine key informants. The analysis of the data generated was based on inductive thematic analysis. Results According to SPAR, Lebanon had levels of 4 out of 5 (≤ 80%) in 2020 in the prevention, detection, response, enabling functions, and operational readiness capacities, pertaining that the country was functionally capable of dealing with various events at the national and subnational levels. Lebanon scored more than its neighboring countries, Syria, and Jordan, which have similar contexts of economic crises, emergencies, and refugee waves. Despite this high level of commitment to meeting IHR capacities, the qualitative findings demonstrated several gaps in IHR performance as resource shortage, governance, and political challenges. The study also showed contradictory results regarding the impact of refugees on IHR capacities. Some key informants agreed that the Syrian crisis had a positive impact, while others suggested the opposite. Whether refugees interfere with IHR development is still an area that needs further investigation. Conclusion The study shows that urgent interventions are needed to strengthen the implementation of the IHR capacities in Lebanon. The study recommends 1) reconsidering the weight given to IHR capacities; 2) promoting governance to strengthen IHR compliance; 3) strengthening the multisectoral coordination mechanisms; 4) reinforcing risk communication strategies constantly; 5) mobilizing and advancing human resources at the central and sub-national levels; 6) ensuring sustainable financing; 7) integrating refugees and displaced persons in IHR framework and its assessment tools; 8) acknowledging risk mapping as a pre-requisite to a successful response; and 9) strengthening research on IHR capacities in Lebanon.

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has emphasized the importance of multi-sectoral collaboration to respond effectively to public health emergencies. This study aims to generate evidence on the extent to which multi-sectoral collaborations have been employed in the macro-level responses to the COVID-19 pandemic in nine selected countries of the Eastern Mediterranean region (EMR). Methods The study employed in-depth analytical research design and was conducted in two phases. In the first phase, data were collected using a comprehensive documentation review. In the second phase, key informant interviews were conducted to validate findings from the first phase and gain additional insights into key barriers and facilitators. We analysed the macro-level pandemic responses across the following seven components of the analytical framework for multi-sectoral collaborations: (1) context and trigger; (2) leadership, institutional mechanisms and processes; (3) actors; (4) administration, funding and evaluation; (5) degree of multi-sectoral engagement; (6) impact; and (7) enabling factors. Results Governments in the EMR have responded differently to the pandemic, with variations in reaction speed and strictness of implementation. While inter-ministerial committees were identified as the primary mechanism through which multi-sectoral action was established and implemented in the selected countries, there was a lack of clarity on how they functioned, particularly regarding the closeness of the cooperation and the working methods. Coordination structures lacked a clear mandate, joint costed action plan, sufficient resources and regular reporting on commitments. Furthermore, there was no evidence of robust communication planning both internally, focused on promoting internal consensual decision-making and managing power dynamics, and externally, concerning communication with the public. Across the selected countries, there was strong representation of different ministries in the pandemic response. Conversely, the contribution of non-state actors, including non-governmental organizations, civil society organizations, the private sector, the media and citizens, was relatively modest. Their involvement was more ad hoc, fragmented and largely self-initiated, particularly within the selected middle- and low income- countries of the EMR. Moreover, none of the countries incorporated explicit accountability framework or included anti-corruption and counter-fraud measures as integral components of their multi-sectoral plans and coordination mechanisms. Key enablers for the adoption of multi-sectoral collaborations have been identified, paving the way for more efficient responses in the future. Discussion Mirroring global efforts, this study demonstrates that the selected countries in the EMR are making efforts to integrate multi-sectoral action into their pandemic responses. Nevertheless, persistent challenges and gaps remain, presenting untapped opportunities that governments can leverage to enhance the efficiency of future public health emergency responses.

Abstract Background Knowledge management (KM) emerged as a strategy to promote evidence-informed decision-making. This scoping review aims to map existing KM tools and mechanisms used to promote evidence-informed health decision-making in the WHO European Region and identify knowledge gaps. Methods Following the Joanna Briggs Institute (JBI) guidance for conducting scoping reviews, we searched Medline, PubMed, EMBASE, the Cochrane library, and Open Grey. We conducted a descriptive analysis of the general characteristics of the included papers and conducted narrative analysis of the included studies and categorized studies according to KM type and phase. Results Out of 9541 citations identified, we included 141 studies. The KM tools mostly assessed are evidence networks, surveillance tools, observatories, data platforms and registries, with most examining KM tools in high-income countries of the WHO European region. Findings suggest that KM tools can identify health problems, inform health planning and resource allocation, increase the use of evidence by policymakers and stimulate policy discussion. Conclusion Policymakers and funding agencies are called to support capacity-building activities, and future studies to strengthen KM in the WHO European region particularly in Eastern Europe and Central Asia. An updated over-arching strategy to coordinate KM activities in the WHO European region will be useful in these efforts.

Abstract Background Despite the importance of evidence syntheses in informing policymaking, their production and use remain limited in the Eastern Mediterranean region (EMR). There is a lack of empirical research on approaches to promote and use policy-relevant evidence syntheses to inform policymaking processes in the EMR. Objective This study sought to describe the development of an impact-oriented approach to link evidence synthesis to policy, and its implementation through selected case studies in Lebanon, a middle-income country in the EMR. Methods This study followed a multifaceted and iterative process that included (i) a review of the literature, (ii) input from international experts in evidence synthesis and evidence-informed health policymaking, and (iii) application in a real-world setting (implementation). We describe four selected case studies of implementation. Surveys were used to assess policy briefs, deliberative dialogues, and post-dialogue activities. Additionally, Kingdon’s stream theory was adopted to further explain how and why the selected policy issues rose to the decision agenda. Results The approach incorporates three interrelated phases: (1) priority setting, (2) evidence synthesis, and (3) uptake. Policy-relevant priorities are generated through formal priority setting exercises, direct requests by policymakers and stakeholders, or a focusing event. Identified priorities are translated into focused questions that can be addressed via evidence synthesis (phase 1). Next, a scoping of the literature is conducted to identify existing evidence syntheses addressing the question of interest. Unless the team identifies relevant, up-to-date and high-quality evidence syntheses, it proceeds to conducting SRs addressing the priority questions of interest (phase 2). Next, the team prepares knowledge translation products (e.g., policy briefs) for undertaking knowledge uptake activities, followed by monitoring and evaluation (phase 3). There are two prerequisites to the application of the approach: enhancing contextual awareness and capacity strengthening. The four case studies illustrate how evidence produced from the suites of activities was used to inform health policies and practices. Conclusions To our knowledge, this is the first study to describe both the development and implementation of an approach to link evidence synthesis to policy in the EMR. We believe the approach will be useful for researchers, knowledge translation platforms, governments, and funders seeking to promote evidence-informed policymaking and practice.

Abstract Background Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings. Methods The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor’s framework for implementation outcomes. Discussion The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality. Trial registration ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Abstract Background Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges. Findings GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges. Conclusions Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN–GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South–South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

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

Abstract Background Evidence briefs for policy (EBP) draw on best-available data and research evidence (e.g., systematic reviews) to help clarify policy problems, frame options for addressing them, and identify implementation considerations for policymakers in a given context. An increasing number of governments, non-governmental organizations and research groups have been developing EBP on a wide variety of topics. However, the reporting characteristics of EBP vary across organizations due to a lack of internationally accepted standard reporting guidelines. This project aims to develop a STandard reporting guideline of Evidence briefs for Policy (STEP), which will encompass a reporting checklist and a STEP statement and a user manual. Methods We will refer to and adapt the methods recommended by the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network. The key actions include: (1) developing a protocol; (2) establishing an international multidisciplinary STEP working group (consisting of a Coordination Team and a Delphi Panel); (3) generating an initial draft of the potential items for the STEP reporting checklist through a comprehensive review of EBP-related literature and documents; (4) conducting a modified Delphi process to select and refine the reporting checklist; (5) using the STEP to evaluate published policy briefs in different countries; (6) finalizing the checklist; (7) developing the STEP statement and the user manual (8) translating the STEP into different languages; and (9) testing the reliability through real world use. Discussion Our protocol describes the development process for STEP. It will directly address what and how information should be reported in EBP and contribute to improving their quality. The decision-makers, researchers, journal editors, evaluators, and other stakeholders who support evidence-informed policymaking through the use of mechanisms like EBP will benefit from the STEP. Registration We registered the protocol on the EQUATOR network. ( https://www.equator-network.org/library/reporting-guidelines-under-development/#84 )

BackgroundIn response to worldwide calls for the need to support evidence-informed policy-making (EIPM), more countries are increasingly interested in enhancing their efforts to use research to inform policy-making. In order to inform the efforts of those asked to lead the support of EIPM, our aim is to develop a conceptual framework to guide the process of establishing a policy support organization (PSO). MethodsWe conducted a critical interpretive synthesis (CIS). We conducted a two steps literature review. In the second step, we systematically searched OVID EMBASE, PsychInfo, HealthStar, CINAHL, Web of Science, Social Science Abstract, Health Systems Evidence, and ProQuest Dissertations and Theses Global databases for documents reporting the establishment of PSOs and the contextual factors influencing the process of establishing these organizations. We assessed the eligibility of the retrieved articles and synthesized the findings iteratively. ResultsWe included 52 documents in the synthesis. Our findings suggest that a PSO establishment process has four interconnected stages: awareness, development, assessment, and maturation. The process of establishing a PSO is iterative and influenced by political, research and health systems contextual factors, which determine the availability of the resources and the trust between researchers and policy-makers. The contextual factors have an impact on each other, and the challenges that arise from one factor can be mitigated by other factors. ConclusionFor those interested in establishing a PSO, our framework provides a road map for identifying the most appropriate starting point and the factors that might influence the establishment process. Leaders of such PSOs can use our findings to expand or refine their scope of work. Given that this framework focuses only on PSOs in the health sector, an important next step for research would be to include other sectors from social systems and identify any additional insight that can enhance our framework.

Abstract Background While calls for institutionalization of evidence-informed policy-making (EIP) have become stronger in recent years, there is a paucity of methods that governments and organizational knowledge brokers can use to sustain and integrate EIP as part of mainstream health policy-making. The objective of this paper was to conduct a knowledge synthesis of the published and grey literatures to develop a theoretical framework with the key features of EIP institutionalization. Methods We applied a critical interpretive synthesis (CIS) that allowed for a systematic, yet iterative and dynamic analysis of heterogeneous bodies of literature to develop an explanatory framework for EIP institutionalization. We used a “compass” question to create a detailed search strategy and conducted electronic searches to identify papers based on their potential relevance to EIP institutionalization. Papers were screened and extracted independently and in duplicate. A constant comparative method was applied to develop a framework on EIP institutionalization. The CIS was triangulated with the findings of stakeholder dialogues that involved civil servants, policy-makers and researchers. Results We identified 3001 references, of which 88 papers met our eligibility criteria. This CIS resulted in a definition of EIP institutionalization as the “process and outcome of (re-)creating, maintaining and reinforcing norms, regulations, and standard practices that, based on collective meaning and values, actions as well as endowment of resources, allow evidence to become—over time—a legitimate and taken-for-granted part of health policy-making”. The resulting theoretical framework comprised six key domains of EIP institutionalization that capture both structure and agency: (1) governance; (2) standards and routinized processes; (3) partnership, collective action and support; (4) leadership and commitment; (5) resources; and (6) culture. Furthermore, EIP institutionalization is being achieved through five overlapping stages: (i) precipitating events; (ii) de-institutionalization; (iii) semi-institutionalization (comprising theorization and diffusion); (iv) (re)-institutionalization; and (v) renewed de-institutionalization processes. Conclusions This CIS advances the theoretical and conceptual discussions on EIP institutionalization, and provides new insights into an evidence-informed framework for initiating, strengthening and/or assessing efforts to institutionalize EIP.

IntroductionConflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region.MethodWe conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention.ResultsOut of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns.ConclusionThis review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

BackgroundPatient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems.MethodsWe conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.ResultsFive overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor.ConclusionsPatient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Introduction Governments in low-income and middle-income countries (LMICs) and official development assistance agencies use a variety of performance measurement and management approaches to improve the performance of healthcare systems. The effectiveness of such approaches is contingent on the extent to which managers and care providers use performance information. To date, major knowledge gaps exist about the contextual factors that contribute, or not, to performance information use by primary healthcare (PHC) decision-makers in LMICs. This study will address three research questions: (1) How do decision-makers use performance information, and for what purposes? (2) What are the contextual factors that influence the use or non-use of performance information? and (3) What are the proximal outcomes reported by PHC decision-makers from performance information use?Methods and analysis We present the protocol of a theory-driven, qualitative study with a multiple case study design to be conducted in El Salvador, Lebanon and Malawi.Data sources include semi structured in-depth interviews and document review. Interviews will be conducted with approximately 60 respondents including PHC system decision-makers and providers. We follow an interdisciplinary theoretical framework that draws on health policy and systems research, public administration, organisational science and health service research. Data will be analysed using thematic analysis to explore how respondents use performance information or not, and for what purposes as well as barriers and facilitators of use.Ethics and dissemination The ethical boards of the participating universities approved the protocol presented here. Study results will be disseminated through peer-reviewed journals and global health conferences.

Abstract Introduction Armed conflict may influence the size and scope of research in Arab countries. We aimed to assess the impact of the 2011 Syrian conflict on health articles about Syria published in indexed journals. Methods We conducted a scoping review on Syrian health-related articles using seven electronic databases. We included clinical, biomedical, public health, or health system topics published between 1991 and 2017. We excluded animal studies and studies conducted on Syrian refugees. We used descriptive and social network analyses to assess the differences in rates, types, topics of articles, and authorship before and after 2011, the start of the Syrian conflict. Results Of 1138 articles, 826 (72.6%) were published after 2011. Articles published after 2011 were less likely to be primary research; had a greater proportion reporting on mental health (4.6% vs. 10.0%), accidents and injuries (2.3% vs. 18.8%), and conflict and health (1.7% vs. 7.8%) (all p

Abstract Background Knowledge translation (KT) platforms are organisations, initiatives and networks that focus on supporting evidence-informed policy-making at least in part about the health-system arrangements that determine whether the right programmes, services and products get to those who need them. Many descriptions and evaluations of KT platforms in low- and middle-income countries have been produced but, to date, they have not been systematically reviewed. Methods We identified potentially relevant studies through a search of five electronic databases and a variety of approaches to identify grey literature. We used four criteria to select eligible empirical studies. We extracted data about seven characteristics of included studies and about key findings. We used explicit criteria to assess study quality. In synthesising the findings, we gave greater attention to themes that emerged from multiple studies, higher-quality studies and different contexts. Results Country was the most common jurisdictional focus of KT platforms, EVIPNet the most common name and high turnover among staff a common infrastructural feature. Evidence briefs and deliberative dialogues were the activities/outputs that were the most extensively studied and viewed as helpful, while rapid evidence services were the next most studied but only in a single jurisdiction. None of the summative evaluations used a pre–post design or a control group and, with the exception of the evaluations of the influence of briefs and dialogues on intentions to act, none of the evaluations achieved a high quality score. Conclusions A large and growing volume of research evidence suggests that KT platforms offer promise in supporting evidence-informed policy-making in low- and middle-income countries. KT platforms should consider as next steps expanding their current, relatively limited portfolio of activities and outputs, building bridges to complementary groups, and planning for evaluations that examine ‘what works’ for ‘what types of issues’ in ‘what types of contexts’.

Abstract Background The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks. Methods A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements). Results A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented. Conclusions Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Abstract The COVID-19 pandemic presents the worst public health crisis in recent history. The response to the COVID-19 pandemic has been challenged by many factors, including scientific uncertainties, scarcity of relevant research, proliferation of misinformation and fake news, poor access to actionable evidence, time constraints, and weak collaborations among relevant stakeholders. Knowledge translation (KT) platforms, composed of organisations, initiatives and networks supporting evidence-informed policy-making, can play an important role in providing relevant and timely evidence to inform pandemic responses and bridge the gap between science, policy, practice and politics. In this Commentary, we highlight the emerging roles of KT platforms in light of the COVID-19 pandemic. We also reflect on the lessons learned from the efforts of a KT platform in a middle-income country to inform decision-making and practice during the COVID-19 pandemic. The lessons learned can be integrated into strengthening the role, structures and mandates of KT platforms as hubs for trustworthy evidence that can inform policies and practice during public health crises and in promoting their integration and institutionalisation within the policy-making processes.

Abstract Background Decision-makers in crisis zones are faced with the challenge of having to make health-related decisions under limited time and resource constraints and in light of the many factors that can influence their decisions, of which research evidence is just one. To address a key gap in the research literature about how best to support the use of research evidence in such situations, we conducted a critical interpretive synthesis approach to develop a conceptual framework that outlines the strategies that leverage the facilitators and address the barriers to evidence use in crisis zones. Methods We systematically reviewed both empirical and non-empirical literature and used an interpretive analytic approach to synthesise the results and develop the conceptual framework. We used a ‘compass’ question to create a detailed search strategy and conducted electronic searches in CINAHL, EMBASE, MEDLINE, SSCI and Web of Science. A second reviewer was assigned to a representative sample of articles. We purposively sampled additional papers to fill in conceptual gaps. Results We identified 21 eligible papers to be analysed and purposively sampled an additional 6 to fill conceptual gaps. The synthesis resulted in a conceptual framework that focuses on evidence use in crisis zones examined through the lens of four systems – political, health, international humanitarian aid and health research. Within each of the four systems, the framework identifies the most actionable strategies that leverage the facilitators and address the barriers to evidence use. Conclusions This study presents a new conceptual framework that outlines strategies that leverage the facilitators and address the barriers to evidence use in crisis zones within different systems. This study expands on the literature pertaining to evidence-informed decision-making.

Objectives: To provide an overview of the current state of funding for health policy and systems research (HPSR) on a national level across the Eastern Mediterranean region (EMR), and to examine the key factors influencing funding for HPSR in the region. Methods: A multistep approach was employed, involving a documentation review, secondary data analysis and key informant interviews with 30 stakeholders from five countries in the EMR. Findings are presented narratively (and where applicable as percentages). Results: National funding for research and development (R&D) in general, and for health research in particular, has been low in comparative terms and lagging behind at the global scale, while funding for HPSR has been lacking on a national level. None of the 22 EMR countries studied had explicit national funding or a budget line for HPSR. Analysis of funding sources of 1821 published HPSR articles in the EMR (2010–2019) showed that the most notable source was external/international grants (45.6%), followed by university/academia (35.1%), and government (9.5%). Although HPSR publications have been increasing over time, this still falls short of the scale needed for strengthening health systems and informing current transformations in the region. Findings from the interviews identified several factors influencing investment in or funding for HPSR in the EMR. Conclusions: Many of the EMR’s policy priorities are related to health systems, however our research finds that overall investment in health research and HPSR is still low, with limited recognition of the importance of HPSR in the EMR.

Abstract The global health crisis created by COVID-19 is providing valuable insights into the strengths of our health research system and, perhaps even more clearly, displaying its weaknesses. Much of what is being shown so plainly in the current context is not truly new. We are being reminded that health research systems are slow and noisy as well as that there is a desire for research to inform decision-making, that researchers are great collaborators, and that the walls we are so quick to erect between health research and health practice are unhelpful facades. It is our hope that the clarity with which these issues are being demonstrated by COVID-19 might provide the impetus to address these challenges and seize these opportunities to improve our health research system, for the benefit for communities facing COVID-19 now, and for the benefit of us all in facing the further health challenges that are sure to come.

Abstract Background Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals. Objectives To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals. Methods We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30–36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings. Results Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures. Conclusions To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

Abstract Background Humanitarian action in crisis zones is fraught with many challenges, including lack of timely and accessible research evidence to inform decision-making about humanitarian interventions. Evidence websites have the potential to address this challenge. Evidence Aid is the only evidence website designed for crisis zones that focuses on providing research evidence in the form of systematic reviews. The objective of this study is to explore stakeholders’ views of Evidence Aid, contributing further to our understanding of the use of research evidence in decision-making in crisis zones. Methods We designed a qualitative user-testing study to collect interview data from stakeholders about their impressions of Evidence Aid. Eligible stakeholders included those with and without previous experience of Evidence Aid. All participants were either currently working or have worked within the last year in a crisis zone. Participants were asked to perform the same user experience-related tasks and answer questions about this experience and their knowledge needs. Data were analysed using a deductive framework analysis approach drawing on Morville’s seven facets of the user experience — findability, usability, usefulness, desirability, accessibility, credibility and value. Results A total of 31 interviews were completed with senior decision-makers (n = 8), advisors (n = 7), field managers (n = 7), analysts/researchers (n = 5) and healthcare providers (n = 4). Participant self-reported knowledge needs varied depending on their role. Overall, participants did not identify any ‘major’ problems (highest order) and identified only two ‘big’ problems (second highest order) with using the Evidence Aid website, namely the lack of a search engine on the home page and that some full-text articles linked to/from the site require a payment. Participants identified seven specific suggestions about how to improve Evidence Aid, many of which can also be applied to other evidence websites. Conclusions Stakeholders in crisis zones found Evidence Aid to be useful, accessible and credible. However, they experienced some problems with the lack of a search engine on the home page and the requirement for payment for some full-text articles linked to/from the site.

Abstract Background The unprecedented amount of resources dedicated to humanitarian aid has led many stakeholders to demand the use of reliable evidence in humanitarian aid decisions to ensure that desired impacts are achieved at acceptable costs. However, little is known about the factors that influence the use of research evidence in the policy development in humanitarian crises. We examined how research evidence was used to inform two humanitarian policies made in response to the Syrian refugee crisis. Methods We identified two policies as rich potential case studies to examine the use of evidence in humanitarian aid policy decision-making: Lebanon’s 2016 Health Response Strategy and Ontario’s 2016 Phase 2: Health System Action Plan, Syrian Refugees. To study each, we used an embedded qualitative case study methodology and recruited senior decision-makers, policy advisors, and healthcare providers who were involved with the development of each policy. We reviewed publicly available documents and media articles that spoke to the factors that influence the process. We used the analytic technique of explanation building to understand the factors that influence the use of research evidence in the policy-development process in crisis zones. Results We interviewed eight informants working in government and six in international agencies in Lebanon, and two informants working in healthcare provider organizations and two in non-governmental organizations in Ontario, for a total of 18 key informants. Based on our interviews and documentary analysis, we identified that there was limited use of research evidence and that four broad categories of factors helped to explain the policy-development process for Syrian refugees – development of health policies without significant chance for derailment from other government bodies (Lebanon) or opposition parties (Ontario) (i.e., facing no veto points), government’s engagement with key societal actors to inform the policy-development process, the values underpinning the process, and external factors significantly influencing the policy-development process. Conclusions This study suggests that use of research evidence in the policy-development process for Syrian refugees was subordinate to key political factors, resulting in limited influence of research evidence in the development of both the Lebanese and Ontarian policy.

Abstract Background There is increased interest in using narratives or storytelling to influence health policies. We aimed to systematically review the evidence on the use of narratives to impact the health policy-making process. Methods Eligible study designs included randomised studies, non-randomised studies, process evaluation studies, economic studies, qualitative studies, stakeholder analyses, policy analyses, and case studies. The MEDLINE, PsycINFO, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), WHO Global Health Library, Communication and Mass Media Complete, and Google Scholar databases were searched. We followed standard systematic review methodology for study selection, data abstraction and risk of bias assessment. We synthesised the findings narratively and presented the results stratified according to the following stages of the policy cycle: (1) agenda-setting, (2) policy formulation, (3) policy adoption, (4) policy implementation and (5) policy evaluation. Additionally, we presented the knowledge gaps relevant to using narrative to impact health policy-making. Results Eighteen studies met the eligibility criteria, and included case studies (n = 15), participatory action research (n = 1), documentary analysis (n = 1) and biographical method (n = 1). The majority were of very low methodological quality. In addition, none of the studies formally evaluated the effectiveness of the narrative-based interventions. Findings suggest that narratives may have a positive influence when used as inspiration and empowerment tools to stimulate policy inquiries, as educational and awareness tools to initiate policy discussions and gain public support, and as advocacy and lobbying tools to formulate, adopt or implement policy. There is also evidence of undesirable effects of using narratives. In one case study, narrative use led to widespread insurance reimbursement of a therapy for breast cancer that was later proven to be ineffective. Another case study described how the use of narrative inappropriately exaggerated the perceived risk of a procedure, which led to limiting its use and preventing a large number of patients from its benefits. A third case study described how optimistic ‘cure’ or ‘hope’ stories of children with cancer were selectively used to raise money for cancer research that ignored the negative realities. The majority of included studies did not provide information on the definition or content of narratives, the theoretical framework underlying the narrative intervention or the possible predictors of the success of narrative interventions. Conclusion The existing evidence base precludes any robust inferences about the impact of narrative interventions on health policy-making. We discuss the implications of the findings for research and policy. Trial registration The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42018085011).

Objectives This study examines how the results of the Hospital Survey on Patient Safety Culture changed between 2012 and 2019 and identifies organisational factors affecting these changes.Design The study combined the use of quantitative surveys of staff and qualitative interviews with hospital leadership. Secondary data analysis was performed for previous surveys.Setting This study was conducted in a tertiary care teaching multisite hospital in Riyadh, Saudi Arabia.Participants One thousand hospital staff participated in the survey. Thirty-one executive board members and directors and four focus groups of frontliners were qualitatively interviewed.Primary and secondary outcome measures Twelve safety culture dimensions were assessed to study the patient safety culture as perceived by the healthcare professionals. An additional semi-structured interview was conducted to identify organisational factors, changes, and barriers affecting the patient safety culture. Furthermore, suggestions to improve patient safety were proposed.Results Comparing the results revealed a general positive trend in scores from 2012 to 2019. The areas of strength included teamwork within and across units, organisational learning, managerial support, overall perception of safety and feedback and communication about error. Non-punitive response to error, staffing and communication and openness consistently remain the lowest-scoring composites. Interview results revealed that organisational changes may have influenced the answers of the participants on some survey composites.Conclusions Patient safety is a moving target with areas for improvement that are continuously identified. Effective quality improvement initiatives can lead to visible changes in the patient safety culture in a hospital, and consistent leadership commitment and support can maintain these improvements.

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Objectives The objective of this study was to assess the frequency and types of conflict of interest (COI) disclosed by authors of primary studies of health policy and systems research (HPSR).Design We conducted a cross-sectional survey using standard systematic review methodology for study selection and data extraction. We conducted descriptive analyses.Setting We collected data from papers published in 2016 in ‘health policy and service journals’ category in Web of Science database.Participants We included primary studies (eg, randomised controlled trials, cohort studies, qualitative studies) of HPSR published in English in 2016 peer-reviewed health policy and services journals.Outcome measures Reported COI disclosures including whether authors reported COI or not, form in which COI disclosures were provided, number of authors per paper who report any type of COI, number of authors per paper who report specific types and subtypes of COI.Results We included 200 eligible primary studies of which 132 (66%) included COI disclosure statements of authors. Of the 132 studies, 19 (14%) had at least one author reporting at least one type of COI and the most frequently reported type was individual financial COI (n=15, 11%). None of the authors reported individual intellectual COIs or personal COIs. Financial and individual COIs were reported more frequently compared with non-financial and institutional COIs.Conclusion A low percentage of HPSR primary studies included authors reporting COI. Non-financial or institutional COIs were the least reported types of COI.

Background Systematic reviews are increasingly used to inform health policy-making. The conflicts of interest (COI) of the authors of systematic reviews may bias their results and influence their conclusions. This may in turn lead to misguided public policies and systems level decisions. In order to mitigate the adverse impact of COI, scientific journals require authors to disclose their COIs. The objective of this study was to assess the frequency and different types of COI that authors of systematic reviews on health policy and systems research (HSPR) report. Methods We conducted a cross sectional survey. We searched the Health Systems Evidence (HSE) database of McMaster Health Forum for systematic reviews published in 2015. We extracted information regarding the characteristics of the systematic reviews and the associated COI disclosures. We conducted descriptive analyses. Results Eighty percent of systematic reviews included authors’ COI disclosures. Of the 160 systematic reviews that included COI disclosures, 15% had at least one author reporting at least one type of COI. The two most frequently reported types of COI were individual financial COI and individual scholarly COI (11% and 4% respectively). Institutional COIs were less commonly reported than individual COIs (3% and 15% respectively) and non-financial COIs were less commonly reported than financial COIs (6% and 14% respectively). Only one systematic review reported the COI disclosure by editors, and none reported disclosure by peer reviewers. All COI disclosures were in the form of a narrative statement in the main document and none in an online document. Conclusion A fifth of systematic reviews in HPSR do not include a COI disclosure statement, highlighting the need for journals to strengthen and/or better implement their COI disclosure policies. While only 15% of identified disclosure statements report any COI, it is not clear whether this indicates a low frequency of COI versus an underreporting of COI, or both.

Abstract Background Major research-reporting statements, such as PRISMA and CONSORT, require authors to provide information about funding. The objectives of this study were (1) to assess the reporting of funding in health policy and systems research (HPSR) papers and (2) to assess the funding reporting policies of journals publishing on HPSR. Methods We conducted two cross-sectional surveys for papers published in 2016 addressing HPSR (both primary studies and systematic reviews) and for journals publishing on HPSR (both journals under the ‘Health Policy and Services’ (HPS) category in the Web of Science, and non-HPS journals that published on HPSR). Teams of two reviewers selected studies and abstracted data in duplicate and independently. We conducted descriptive analyses and a regression analysis to investigate the association between reporting of funding by papers and the journal’s characteristics. Results We included 400 studies (200 systematic reviews and 200 primary studies) that were published in 198 journals. Approximately one-third (31%) of HPSR papers did not report on funding. Of those that did, only 11% reported on the role of funders (15% of systematic reviews and 7% of primary studies). Of the 198 journals publishing on HPSR, 89% required reporting of the source of funding. Of those that did, about one-third (34%) required reporting of the role of funders. Journals classified under the HPS category (n = 72) were less likely than non-HPS journals that published HPSR studies (n = 142) to require information on the role of funders (15% vs. 32%). We did not find any of the journals’ characteristics to be associated with the reporting of funding by papers. Conclusions Despite the majority of journals publishing on HPSR requiring the reporting of funding, approximately one-third of HPSR papers did not report on the funding source. Moreover, few journals publishing on HPSR required the reporting of the role of funders, and few HPSR papers reported on that role.

Abstract The 2030 Agenda for Sustainable Development covers a wide range of interrelated goals, including poverty eradication and economic growth, social inclusion, environmental sustainability and peace for all people by 2030. Policy decisions to meet the Sustainable Development Goals (SDGs) need to be informed by policy-relevant evidence co-designed and co-produced with the pertinent stakeholders, taking into consideration local and political contexts. Universities are uniquely placed to lead the cross-sectoral implementation of the SDGs and advance the 2030 agenda. This commentary provides the case for building, strengthening and institutionalising university partnerships with governments and communities to achieve the SDGs. The authors call for a change in mindsets and culture in both academia and government, and invite both parties to start the dialogue if we are to rise up to the global challenge.

Abstract Background Conducting patient safety culture assessments can provide hospitals with information on how structures and processes within their system can impact patient outcomes. This study used the Hospital Survey on Patient Safety Culture (HSOPSC) to conduct an assessment of patient safety culture in public hospitals in Kuwait and benchmark against regional and international studies that utilized the same tool. This objective of this study is to examine the association between the predictors and outcomes of patient safety culture. Methods This cross sectional study adopted a customized version of HSOPSC developed by the Agency for Healthcare Research and Quality. The survey targeted selected public hospital staff with at least one year of experience. Data was analyzed using SPSS 24 at a significance level of 0.05. Univariate analysis was utilized to obtain an overview of respondent demographics. The association between patient safety grade and the number of events reported and the remaining patient safety culture composites was analyzed using ANOVA f-test. Four regression models were constructed, two adopted Generalized Estimating Equations and the others were linear models. Results were benchmarked against similar initiatives in Lebanon, Saudi Arabia and USA. Results A total of 12,092 employees from 16 public hospitals in Kuwait completed the survey. The overall response rate was 60.5% (20,003 distributed surveys). Areas of strength were Teamwork within Units, Organizational Learning—Continuous Improvement, Management Support for Patient Safety, Supervisor/Manager Expectations & Actions Promoting Patient Safety, and Feedback and Communication about Error. Regression findings highlighted significant association between patient safety outcomes and composites. Benchmarking analysis revealed that Kuwaiti hospitals are performing at or better than benchmark on several composites compared to regional and international findings. Conclusion This is the first major study addressing patient safety culture in public hospitals in Kuwait. Despite having some areas for improvement, public hospitals in Kuwait were found to have multiple areas of strength. Improving patient safety culture is critical if hospitals want to improve quality and safety of medical services. Study findings can guide and inform country level strategies to further improve the systems governing patient safety practices.

Abstract Background Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. Methods We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. Results Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. Conclusion There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. Trial registration The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812).

Abstract Background Groups or institutions funding or conducting systematic reviews in health policy and systems research (HPSR) should prioritise topics according to the needs of policymakers and stakeholders. The aim of this study was to develop and validate a tool to prioritise questions for systematic reviews in HPSR. Methods We developed the tool following a four-step approach consisting of (1) the definition of the purpose and scope of tool, (2) item generation and reduction, (3) testing for content and face validity, (4) and pilot testing of the tool. The research team involved international experts in HPSR, systematic review methodology and tool development, led by the Center for Systematic Reviews on Health Policy and Systems Research (SPARK). We followed an inclusive approach in determining the final selection of items to allow customisation to the user’s needs. Results The purpose of the SPARK tool was to prioritise questions in HPSR in order to address them in systematic reviews. In the item generation and reduction phase, an extensive literature search yielded 40 relevant articles, which were reviewed by the research team to create a preliminary list of 19 candidate items for inclusion in the tool. As part of testing for content and face validity, input from international experts led to the refining, changing, merging and addition of new items, and to organisation of the tool into two modules. Following pilot testing, we finalised the tool, with 22 items organised in two modules – the first module including 13 items to be rated by policymakers and stakeholders, and the second including 9 items to be rated by systematic review teams. Users can customise the tool to their needs, by omitting items that may not be applicable to their settings. We also developed a user manual that provides guidance on how to use the SPARK tool, along with signaling questions. Conclusion We have developed and conducted initial validation of the SPARK tool to prioritise questions for systematic reviews in HPSR, along with a user manual. By aligning systematic review production to policy priorities, the tool will help support evidence-informed policymaking and reduce research waste. We invite others to contribute with additional real-life implementation of the tool.

Abstract Background The requirements of the health policy and services journals for authors to report their financial and non-financial conflicts of interest (COI) are unclear. The present article aims to assess the requirements of health policy and services journals for authors to disclose their financial and non-financial COIs. Methods This is a cross-sectional study of journals listed by the Web of Science under the category of ‘Health Policy and Services’. We reviewed the ‘Instructions for Authors’ on the journals’ websites and then simulated the submission of a manuscript to obtain any additional relevant information made available during that step. We abstracted data in duplicate and independently using a standardised form. Results Out of 72 eligible journals, 67 (93%) had a COI policy. A minority of policies described how the disclosed COIs of authors would impact the editorial process (34%). None of the policies had clear-cut criteria for rejection based on the content of the disclosure. Approximately a fifth of policies (21%) explicitly stated that inaccurate or incomplete disclosures might lead to manuscript rejection or retraction. No policy described whether the journal would verify the accuracy or completeness of authors’ disclosed COIs. Most journals’ policies (93%) required the disclosure of at least one form of financial COI. While the majority asked for specification of source of payment (71%), a minority asked for the amount (18%). Overall, 81% of policies explicitly required disclosure of non-financial COIs. Conclusion A majority of health policy and services journal policies required the disclosure of authors’ financial and non-financial COIs, but few required details on disclosed COIs. Health policy journals should provide specific definitions and instructions for disclosing non-financial COIs. A framework providing clear typology and operational definitions of the different types of COIs will facilitate both their disclosure by authors and reviewers and their assessment and management by the editorial team and the readers.

Abstract Background Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported. Methods We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA. Results Areas of strength in 2015 included Teamwork within units, and Organizational Learning—Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or better than benchmark on several composites. Conclusion The Medical City has made significant progress on several of the patient safety culture composites despite still having areas requiring additional improvement. Patient safety culture outcomes are evidently linked to better performance on specific composites. While results are comparable with regional and international benchmarks, findings confirm that regular assessment can allow hospitals to better understand and visualize changes in their performance and identify additional areas for improvement.

Abstract Background Improving quality of care and patient safety practices can strengthen health care delivery systems, improve health sector performance, and accelerate attainment of health-related Sustainability Development Goals. Although quality improvement is now prominent on the health policy agendas of governments in low- and middle-income countries (LMICs), including countries of the Eastern Mediterranean Region (EMR), progress to date has not been optimal. The objective of this study is to comprehensively review existing quality improvement and patient safety policies and strategies in two selected countries of the EMR (Lebanon and Jordan) to determine the extent to which these have been institutionalized within existing health systems. Methods We used a mixed methods approach that combined documentation review, stakeholder surveys and key informant interviews. Existing quality improvement and patient safety initiatives were assessed across five components of an analytical framework for assessing health care quality and patient safety: health systems context; national policies and legislation; organizations and institutions; methods, techniques and tools; and health care infrastructure and resources. Results Both Lebanon and Jordan have made important progress in terms of increased attention to quality and accreditation in national health plans and strategies, licensing requirements for health care professionals and organizations (albeit to varying extents), and investments in health information systems. A key deficiency in both countries is the absence of an explicit national policy for quality improvement and patient safety across the health system. Instead, there is a spread of several (disjointed) pieces of legal measures and national plans leading to fragmentation and lack of clear articulation of responsibilities across the entire continuum of care. Moreover, both countries lack national sets of standardized and applicable quality indicators for performance measurement and benchmarking. Importantly, incentive systems that link contractual agreement, regulations, accreditation, and performance indicators are underutilized in Lebanon and absent in Jordan. At the healthcare organizational level, there is a need to instill a culture of continuous quality improvement and promote professional training in quality improvement and patient safety. Conclusion Study findings highlight the importance of aligning policies, organizations, methods, capacities and resources in order to institutionalize quality improvement and patient safety practices in health systems. Gaps and dysfunctions identified can help inform national deliberations and dialogues among key stakeholders in each study country. Findings can also inform future quality improvement efforts in the EMR and beyond, with a particular emphasis on LMICs.

Abstract Background Since July 2015, Lebanon has been experiencing a waste management crisis. Dumpsites in inhabited areas and waste burning have emerged due to the waste accumulation, further adding to the gravity of the situation. However, the association between the crisis and health of the population has not been scientifically reported. Methods A comparative cross-sectional study was conducted to assess whether exposure to open dumpsites and waste burning is associated with acute health symptoms. The study sample included 221 male workers between the ages of 18–60 years selected from two areas chosen based on their proximity to a garbage dumpsite and waste burning. 110 workers were exposed to a garbage dumpsite and waste burning, and 111 workers were not. Data were collected via a face-to-face interview using a newly developed validated structured questionnaire. Chi-square tests were used to check for statistically significant differences between exposure and covariates. Multivariable analyses using multiple logistic regression were used to compare health symptoms between exposed and unexposed workers adjusting for potential confounders. Results The prevalence of acute health symptoms was greater among the exposed workers than the non-exposed workers, including gastrointestinal, respiratory, dermatological and constitutional symptoms. Controlling for confounding variables, such as age, insurance, family support, residence near dumpsite, work site, and smoking, a minimum odds ratio (OR) of 4.30 was obtained when comparing the exposed population to those non-exposed. Conclusion The strong association between improper waste management and physical health calls for immediate attention by the government, stakeholders and community members to find optimal solutions for this waste management crisis and set immediate priority interventions such as regular waste collection, volume reduction and recycling performance improvement. However, the long recall period may have underestimated our results.

Abstract Introduction Media interventions can potentially play a major role in influencing health policies. This integrative systematic review aimed to assess the effects of planned media interventions—including social media—on the health policy-making process. Methods Eligible study designs included randomized and non-randomized designs, economic studies, process evaluation studies, stakeholder analyses, qualitative methods, and case studies. We electronically searched Medline, EMBASE, Communication and Mass Media Complete, Cochrane Central Register of Controlled Trials, and the WHO Global Health Library. We followed standard systematic review methodology for study selection, data abstraction, and risk of bias assessment. Results Twenty-one studies met our eligibility criteria: 10 evaluation studies using either quantitative (n = 7) or qualitative (n = 3) designs and 11 case studies. None of the evaluation studies were on social media. The findings of the evaluation studies suggest that media interventions may have a positive impact when used as accountability tools leading to prioritizing and initiating policy discussions, as tools to increase policymakers’ awareness, as tools to influence policy formulation, as awareness tools leading to policy adoption, and as awareness tools to improve compliance with laws and regulations. In one study, media-generated attention had a negative effect on policy advocacy as it mobilized opponents who defeated the passage of the bills that the media intervention advocated for. We judged the confidence in the available evidence as limited due to the risk of bias in the included studies and the indirectness of the evidence. Conclusion There is currently a lack of reliable evidence to guide decisions on the use of media interventions to influence health policy-making. Additional and better-designed, conducted, and reported primary research is needed to better understand the effects of media interventions, particularly social media, on health policy-making processes, and the circumstances under which media interventions are successful. Trial registration PROSPERO 2015: CRD42015020243