Health System Governance Research Articles

The role of parliamentarians in promoting self-care interventions for sexual and reproductive health and rights: applying COVID-19 lens in the Eastern Mediterranean region

Innovative people-centered care modalities including self-care interventions offer an opportunity to ensure continuity of healthcare services during COVID-19 and in post-COVID-19, as well as contribute to the achievement of universal health coverage. Parliamentarians are uniquely positioned to promote self-care interventions for sexual and reproductive health and rights through their legislative, budget allocation, oversight, and advocacy roles. However, existing health systems governance challenges in the Eastern Mediterranean region such as weak institutions setups, fragmentation of health programs, and limitation of resources could impede parliamentarians’ progress. To address these challenges, the following recommended actions should be considered: (1) promote the adaptation of sexual and reproductive health and rights service packages at primary healthcare level to integrate self-care interventions (2) govern innovative people-centered care channels including self-care interventions; and (3) engage in a dialogue with civil society and communities to meet needs, raise public awareness and generate demand.

La gobernanza global de la salud y los límites de las redes de expertos en la respuesta al brote de la Covid-19 en México

En el presente estudio se argumenta que a partir del sistema de gobernanza global de la salud se han configurado distintas redes de expertos que sirven como mecanismos para la difusión de ideas basadas en la evidencia científica, que promueven la cooperación y la implementación de recomendaciones originadas en la Organización Mundial de la Salud (oms). Sin embargo, el brote de la Covid-19 ha visibilizado las limitaciones de estas redes. En el caso de México, se han observado dos problemas principales: primero, la existencia de expertos miembros de una red transgubernamental que toman decisiones basadas en intereses políticos, dejando de lado las recomendaciones derivadas de lo global; y segundo, una comunidad epistémica dividida, con grupos rivales, lo que perjudica la actuación de estos expertos en su labor como transmisores de ideas y difusores de conocimiento.

Diminishing Value from Multiple Serial Bone Densitometry in Women Receiving Antiresorptive Medication for Osteoporosis

The value of serial bone mineral density (BMD) monitoring while on osteoporosis therapy is controversial. We determined the percentage of women classified as suboptimal responders to therapy with antiresorptive medications according to 2 definitions of serial BMD change. This was a cohort study using administrative databases at a single-payer government health system in Manitoba, Canada. Participants were postmenopausal women aged 40 years or older receiving antiresorptive medications and having 3 sequential BMD measures. Women stopping or switching therapies were excluded. The percentage of women whose spine or hip BMD decreased significantly during the first or second interval of monitoring by BMD was determined. Suboptimal responder status was defined as BMD decrease during both monitoring intervals or BMD decreased from baseline to final BMD. There were 1369 women in the analytic cohort. Mean BMD monitoring intervals were 3.0 (0.8) and 3.2 (0.8) years. In the first interval, 3.2% and 6.5% of women had a decrease in spine or hip BMD; 8.0% and 16.9% had decreases in the second monitoring interval; but only 1.4% showed repeated losses in both intervals. Considering the entire treatment interval, only 3.2% and 7.4% showed BMD loss at spine or hip. Results may not apply to situations of poor adherence to antiresorptive medication or anabolic therapy use. Among women highly adherent to antiresorptive therapy for osteoporosis, a very small percentage sustained BMD losses on repeated measures. The value of multiple serial BMD monitoring to detect persistent suboptimal responders should be questioned.

Mapping the burden of diabetes in five small countries in Europe and setting the agenda for health policy and strategic action

BackgroundDiabetes is a global epidemic affecting every country. Small countries, however, face distinctive challenges related to their health system governance and their ability to implement effective health systems’ reforms. The aim of this research was to perform a comparative assessment of existing diabetes management practices at the population level and explore governmental-related policy for Cyprus, Iceland, Luxembourg, Malta and Montenegro. This is the first time that such an evidence-based review study has been performed in the field of diabetes. The overall purpose was to set the agenda for health policy and inform strategic actions for small countries that can benefit from dealing with the diabetes epidemic at a country level.MethodsWe collected data and synthesized the evidence on dealing with diabetes for each of the five small European countries according to the (1) epidemiology of diabetes and other related metabolic abnormalities, (2) burden of diabetes status and (3) diabetes registers and national plans. We collected data by contacting Ministry representatives and other bodies in each state, and by searching through publicly available information from the respective Ministry of Health website on strategies and policies.ResultsDiabetes rates were highest in Cyprus and Malta. National diabetes registers are present in Cyprus and Montenegro, while national diabetes plans and diabetes-specific strategies have been established in Cyprus, Malta and Montenegro. These three countries also offer a free holistic healthcare service to their diabetes population.ConclusionsMultistakeholder, national diabetes plans and public health strategies are important means to provide direction on diabetes management and health service provision at the population level. However, political support is not always present, as seen for Iceland. The absence of evidence-based strategies, lack of funding for conducting regular health examination surveys, omission of monitoring practices and capacity scarcity are among the greatest challenges faced by small countries to effectively measure health outcomes. Nevertheless, we identified means of how these can be overcome. For example, the creation of public interdisciplinary repositories enables easily accessible data that can be used for health policy and strategic planning. Health policy-makers, funders and practitioners can consider the use of regular health examination surveys and other tools to effectively manage diabetes at the population level.

Stewardship of noncommunicable diseases in Iran: a qualitative study

PurposeNoncommunicable diseases (NCDs) count for over 80% of premature death worldwide. More than 76% of the total burden of diseases in Iran is devoted to NCDs. In line with the World Health Organization action plan, Iran has developed its national action plan that led to establishment of the National Committee for Prevention and Control of NCDs (INCDC), whose aim is 30% mortality reduction attributed to NCDs by 2030. The stewardship of health system is the cornerstone of performing and sustaining meaningful actions toward prevention and control of NCDs. The literature is tiny on how to materialize the stewardship and governance of health system. The purpose of this article is to report the findings of a national study that aimed to identity functions and subfunctions of stewardship of NCDs and its related risk factors in Iran.Design/methodology/approachThis is a qualitative study. The authors conducted interviews with 18 purposefully selected interviewees until the authors reached saturation. Thematic content analysis was used for analysis and MAXQDA 10 was employed for data management. The difficulty of coordinating with interviewers and health policymakers in the field slowed the process of research progress.FindingsThe authors identified seven themes and categorized them as main functions for appropriate stewardship of NCDs in Iran, including intelligence generation; strategic framework; evidence-based policies/decisions; system design; resource allocation/development; capacity-building and enforcement/alignment; and categorized them as important.Practical implicationsThe seven themes presented as stewardship functions include concepts and practical examples of the experiences and performance of leading countries in the field of NCDs control that can help policymakers and health managers for better descion-making.Originality/valueIran adopted its national action plan in 2015 and WHO selected Iran as a fast-track country in 2017. The study confirmed that to achieve the global targets, appropriate and contextual stewardship for any specific setting is fundamental. Iran needs to improve its stewardship for prevention and control of NCDs and implement its national action plan. Therefore, the functions and policies outlined in this article for the proper performance of NCDs can improve more meaningful practices in this area in Iran and many other countries.

World Health Organization building blocks in rural community health services: An integrative review.

IntroductionDeveloping and adapting health service models to effectively meet the needs of rural and remote communities is an international priority given inequities in health outcomes compared with metropolitan counterparts. This integrative review aims to inform rural and remote health service delivery systems by drawing on the WHO Framework building blocks to identify lessons learned from the literature describing experiences of rural and remote community health service planning and implementation; and inform recommendations to strengthen often disadvantaged rural and remote health systems for policy makers, health service managers, and those implementing international healthcare initiatives within these contexts.MethodsThe integrative review examined the literature reporting rural and remote community health service delivery published from 2007 to 2017 (the decade following the release of the WHO Framework). Using an analytic frame, a structured template was developed to extract data and categorized against the WHO building blocks, followed by a synthesis of the key findings.ResultsThis integrative review identified that WHO Framework building blocks such as “Service Delivery” and “Health Workforce” are commonly reflected in rural and remote community health service delivery literature in the decade since the Framework's release. However, others such as “Sustainable Funding and Social Protection” are less commonly reported in the literature despite these elements being identified by the WHO as being integral to successful, sustainable health service delivery systems.ConclusionsWe found that collaboration across the health system governance continuum from local to policy level is an essential enabler for rural and remote health service delivery. Community‐based participatory action research provides an opportunity to learn from one another, build capacity, optimize service model suitability, and promotes cultural safety by demonstrating respect and inclusivity in decision‐making. Policy makers and funders need to acknowledge the time and resources required to build trust and community coalitions to inform effective planning and implementation.

Participation in Social Policy: Public Health in Comparative Perspective (Elements in the Politics of Development)

Participation in Social Policy: Public Health in Comparative Perspective (Elements in the Politics of Development)

Exploring collective consumer innovation in health care: Cases and formal modeling

Research on consumer innovation in health care has shown that patients are important sources of new or improved treatments, care services and diagnostic tools. This paper points to another hitherto overlooked class of consumer innovation in health care, which we call collective consumer innovation. These self-organized service innovations emerge under regulatory constraints, occur on the system level, are collaborative, and tend to cause institutional change. We use historic and contemporary cases from the field of health care in order to document the importance of collective consumer innovation and devise a model to analyze their economic role.Collective consumer innovation is more likely under stricter regulation and when the production cost disadvantage of consumers vis-à-vis the formal sector is smaller. The role of market size and the scale of technological change is more complex. If either is large, innovation will be undertaken by the formal sector, while no innovation at all takes place if either is small. The model demonstrates that consumer innovations can enhance social welfare by improving the tradeoff between safety and experimental leeway, though they under certain conditions can lower welfare. Empirically, there are numerous cases where collective consumer innovations in the form of novel health services, policies and governance systems were adapted by public or corporate health care providers.

The Use of Intersectional Analysis in Assessing Women's Leadership Progress in the Health Workforce in LMICs: A Review.

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

Life-Saving Drugs in Sudan: A Matter of Defi nitions and Concepts

Background: Drugs are one of the most crucial pillars in the provision of healthcare services and achieving Universal Health Coverage (UHC). Life-Saving Drugs (LSDs) are the drugs that save someone’s life, require immediate administration in most of the cases, as they sustain life, and prevent complications. They are top priority healthcare needs, which required to be available and aff ordable at all time in adequate quantities and low cost for the whole population and thus achieving equity. Since pharmaceutical sector in Sudan is highly fragmented, this study is conducted to determine the degree of stakeholders’ knowledge about the defi nition of LSD, whether there is a policy governing them, if they have a standard list and their availability status in Sudan. Methods: G rounded theory qualitative (exploratory) study design. The theory is grounded from the actual data after being collected and analysed. Results: Only essential medicines is the well-known term for the stakeholders -mainly at the governance level- with its policy and list. The other LSDs terminologies were found to be ambiguous, with no policies or standard lists. The status of the availability of the diff erent LSDs terminologies (as it perceived by each stakeholder) was found to be poor and there is a signifi cant shortage mainly due to the economic issues. Conclusions: Unifi cation of pharmaceutical organization in Sudan is a must and a priority issue due to its ultimate importance in the provision of healthcare services. Consensus and participation of all the relevant stakeholders in designing policies is an important input for a well-designed health system governance. Further researches in diff erent areas must be conducted, and awareness of policymakers and service providers must be raised.

The shift from inpatient care to outpatient care in Switzerland since 2017: Policy processes and the role of evidence

The shift from inpatient care to the ambulatory sector is a central aspiration of European health systems. Despite demonstrated benefits, health reforms have struggled to realize their potential. In this context, we discuss recent hospital sector reforms in Switzerland and analyze the content, process, and role of evidence in the recent introduction of policies to substitute inpatient care with ambulatory care. The prevailing payment system incentivized hospitals to provide unnecessary and costly inpatient services, but federal reform on tariff structures was deemed politically unfeasible. Instead, driven by the pressure to contain costs, cantonal and federal health authorities began to deny reimbursement for selected inpatient procedures in 2017. These regulatory measures were effective in reducing inpatient admissions and health care costs. This case study illustrates that clear, simple messages about hospital sector reform can raise awareness of the need for change. However, the evidence used in the policy process was limited and not critically reviewed. Stakeholders used long-standing international comparisons of inpatient substitution potential to legitimize policies, but not to develop them. The analysis restates the importance of inter- and intranational comparative analyses and institutions such as health observatories and suggests aligning health system governance more proactively with international developments.

Feasibility of Good Governance at Health Facilities: A Proposed Framework and its Application Using Empirical Insights From Kenya.

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

Bone densitometry categories as a salient distracting feature in the modern clinical pathways of osteoporosis care: A retrospective 20-year cohort study.

It is unknown as to what factors typically drive osteoporosis therapy decisions in real-world practice. Retrospective, 20-year cohort study within the government health system of Manitoba including all women having bone densitometry (BMD) tests between 1996 and 2017. Osteoporosis prescription data was linked to registry data on fractures, clinical risk factors and BMD tests. We defined 6 possible treatment decisions by prescription data: no treatment, starting, stopping, continuing, drug hiatus and re-starting. For each decision, we tested the association between salient patient factors (age, glucocorticoid use, recent fracture, BMD hip or spine T-score≤-2.5, FRAX major osteoporotic fracture probability ≥20%) using multivariable logistic regression. The factors were rank-ordered by decreasing Wald χ2 statistic to determine the relative importance. There were 64,181 women, 33.8% of whom started osteoporosis therapy. For patients who begin therapy after a first BMD, the rank-ordered multivariable logistic regression factor most strongly associated was the T-score≤-2.5 [OR of 7.59(95%CI 7.19-8.01, p<0.001)]. This was followed by glucocorticoid use [OR 2.89(95%CI 2.59-3.22, p<0.001)]. Increasing age and recent fracture (within 2years) were weak predictors of therapy and high FRAX score associated with reduced odds of therapy [OR 0.80 (95%CI 0.74-0.88, p<0.001)]. T-scores were the strongest factor predicting therapy stop/continuation/re-starting; age and prior fracture had weak or no associations. Despite recommendations for fracture-risk-based approach to osteoporosis therapy, BMD T-score continues to be the dominant factor in actual practice. Age, prior fracture or global fracture risk are much less associated; it is possible that BMD T-score categories are therefore acting as a clinically salient distracting factor.

A Policy Analysis Regarding Education, Career, and Governance of the Nurses in Bangladesh: A Qualitative Exploration.

Nurses, short in production and inequitable in the distribution in Bangladesh, require the government's efforts to increase enrolment in nursing education and a smooth career progression. Given the importance of an assessment of the current nursing scenario to inform the decision makers and practitioners to implement the new policies successfully, we analyzed relevant policies on education, career, and governance of nurses in Bangladesh. We used documents review and qualitative methods such as key informant interviews (n = 13) and stakeholder analysis. We found that nursing education faced several backlashes: resistance from diploma nurses while attempting to establish a graduate (bachelor) course in 1977, and the reluctance of politicians and entrepreneurs to establish nursing institutions. Many challenges with the implementation of nursing policies are attributable to social, cultural, religious, and historical factors. For example, Hindus considered touching the bodily excretions as the task of the lower castes, while Muslims considered women touching the body of the men immoral. Nurses also face governance challenges linked with their performance and reward. For example, nurses have little voice over the decisions related to their profession, and they are not allowed to perform clinical duties unsupervised. To improve the situation, the government has made new policies, including upliftment of nurses' position in public service, the creation of an independent Directorate General, and improvement of nursing education and service. New policies often come with new apprehensions. Therefore, nurses should be included in the policy processes, and their capacity should be developed in nursing leadership and health system governance.

A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study

BackgroundFollowing the World Health Organization’s (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges.MethodsA three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as “stable” on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data.DiscussionThis trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings.Trial registrationClinicalTrials.gov NCT03025165. Registered on 19 January 2017

Health System Governance: A Qualitative Study with Grounded Theory Approach in Iran

Health System Governance: A Qualitative Study with Grounded Theory Approach in Iran

A comparative study of cooperation models in city council and municipalities with the health system in Iran and selected countries.

AIM:This study aimed to identify models for the participation of the city council and municipality with the health system in selected countries.SUBJECTS AND METHODS:This is a descriptive comparative study conducted in 2020 qualitatively. The countries studied were examined in terms of the following characteristics: type of political structure, type of health system, level of cooperation between local government and health system, municipal financing, type of financial participation of local government and health system, method or institution for participation Created, level of participation, local government influence on health system decisions, advantages and disadvantages of a partnership between local government and health system. Data were collected through valid databases (PubMed, Scopus, Embase, and Google Search engine) and website of the World Health Organization, local government, and the Ministry of Health of countries concerned and analyzed in a framework of analysis.RESULTS:Countries were divided into two groups in terms of a partnership between the health system and local governments, which had a distinct partnership between the health system and local government and without their participation. Factors that contribute to the creating and strengthening of partnerships include beliefs of health authorities and local government, the need for participation, transparency in participatory programs, designing a specific mechanism for participation, local authority, and financing joint participation plans.CONCLUSION:In countries with planned participation, citizens have better access to services. Citizens' participation, as well as the private sector, is greater in health issues. In these countries, participation in health financing by the private sector and other related agencies has increased. Planning and service delivery increases according to neighborhood needs. The variety of services provided and the use of new methods of service are more, and in these countries, the focus of the Ministry of Health on the preparation of strategies and monitoring the quality of services is increasing.

Health System Governance for the Integration of Mental Health Services into Primary Health Care in the Sub-Saharan Africa and South Asia Region: A Systematic Review.

Governance has been highlighted as an important building block underpinning the process of mental health integration into primary healthcare. This qualitative systematic review aims to identify the governance issues faced by countries in the Sub-Saharan Africa and South Asia Region in the implementation of integrated primary mental healthcare. PRISMA guideline was used to conduct a systematic search of relevant studies from 4 online databases that were filtered according to inclusion and exclusion criteria. Using the Critical Appraisal Skills Program (CASP) Qualitative Checklist, a quality appraisal of the selected articles was performed. By drawing upon institutional theory, data was extracted based on a pre-constructed matrix. The CERQual approach synthesized evidence and rank confidence level as low, moderate or high for 5 key findings. From 567 references identified, a total of 8 studies were included. Respondents were policymakers or implementers involved in integrated primary mental healthcare from the national, state, and district level. Overall, the main governance issues identified were a lack of leadership and mental health prioritization; inadequate financing and human resource capacity; and negative mental health perceptions/attitudes. The implication of the findings is that such issues must be addressed for long-term health system performance. This can also improve policymaking for better integration of primary mental health services into the health systems of countries in the Sub-Saharan and South Asia region.

HCFMUSP: Resilience in Response to the COVID-19 Pandemic

ABSTRACT The teaching case describes a set of emergency actions taken by HCFMUSP to manage the needs brought by the COVID-19 pandemic in Brazil. The case objective considers the issues related to the impact of the pandemic mostly in healthcare operations, emphasizing how to: (a) adapt health system governance in response to a crisis (crisis management); (b) manage the health system capacity, which traditionally is not so resilient; (c) deal with a new disease (knowledge management). Thus, it should allow gathering elements for the management of future crises.

HCFMUSP: Resilience in Response to the COVID-19 Pandemic

ABSTRACT The teaching case describes a set of emergency actions taken by HCFMUSP to manage the needs brought by the COVID-19 pandemic in Brazil. The case objective considers the issues related to the impact of the pandemic mostly in healthcare operations, emphasizing how to: (a) adapt health system governance in response to a crisis (crisis management); (b) manage the health system capacity, which traditionally is not so resilient; (c) deal with a new disease (knowledge management). Thus, it should allow gathering elements for the management of future crises.