Health System Governance Research Articles

Implementing an intervention to improve leadership/management of public healthcare services in the Free State Province, South Africa: lessons learned.

Based on the World Health Organization's health systems strengthening framework, the Health Systems Governance and Accountability (HSGA) intervention to strengthen public health leadership/management, service integration and outcomes was developed in the Free State. This study describes the process to implement and measure the effects of the HSGA intervention for system-wide improvement of leadership/management under routine conditions in a resource-constrained setting. Based on normalisation process theory, participatory discussions were held with health managers, staff and local stakeholders to attain buy-in. Evaluation of the implementation process considered progress in improving leadership/management through application of the Balanced Scorecard (BSC). All provincial reporting units were assessed during 2014/15 and again during 2015/16. The mean scores on three BSC perspectives improved statistically significantly from 2014/15 to 2015/16: customer (p=0.0085), internal business processes (p=0.0008) and finance (p=0.0001). Overall leadership/management also improved significantly (p=0.0007). Improvement in leadership/management resulting from implementation of the HSGA intervention was observed during the two years under study. From this experience, successful implementation of a health systems strengthening intervention hinges on a participatory design, appropriate use of theory, as well as application of an evaluation approach to assess the success of implementation.

Pandemic preparedness and response regulations in Finland: Experiences and implications for post-COVID-19 reforms

The COVID-19 pandemic has plagued health systems in an unprecedented way and challenged the traditional ways to respond to epidemics. It has also revealed several vulnerabilities in countries’ health systems and preparedness. In this paper we take the Finnish health system as an example to analyse how pre-COVID-19 preparedness plans, regulations, and health system governance were challenged by the pandemic and what lessons can be learned for the future. Our analysis draws on policy documents, grey literature, published research, and the COVID-19 Health System Response Monitor. The analysis shows how major public health crises often reveal weaknesses in health systems, also in countries which have been ranked highly in terms of crisis preparedness. In Finland, there were apparent regulative and structural problems which challenged the health system response, but in terms of epidemic control, the results appear to be relatively good. The pandemic may have long-term effects on the health system functioning and governance. In January 2023, an extensive health and social services reform has taken place in Finland. The new health system structure needs to be adjusted to take on board the legacy of the pandemic and a new regulatory frame for health security should be considered.

Building a global community of health for all: A positive discourse analysis of COVID-19 discourse

‘A global community of health for all’ has become a dominant concept in China’s global health governance system. Although this concept has been investigated by several studies in different domains, little attention has been given to its discursive legitimation in China’s media communication from a linguistic perspective. To fill this gap, the present study employs positive discourse analysis to investigate how the aforementioned concept is legitimised via the predominant discourses associated with COVID-19 in state-run Chinese English-language newspapers. The findings show that the Chinese news media attempted to formulate the positive discourses, including cooperation as a win-win solution, people’s lives and well-being as the priority and science as the spirit, though the discourses may not resonate with some countries. The findings shed light on the use of language by the media in promoting official ideologies, projecting China’s national image and improving China’s international relations amid a global health crisis.

”Peruskehikko on olemassa, mutta sitä ei seurattu” – asiantuntijanäkemykset kansanterveysjärjestelmän toiminnasta ja ketterästä hallinnasta COVID-19-pandemiassa vuosina 2020–2021

“A basic framework for pandemic governance existed, but was not followed” – expert views of agile governance and performance of the Finnish public health system during the COVID-19 pandemic in 2020–2021 The aim is to examine how public health authorities acted, what kind of roles they adopted, and how the expected roles and actions appeared in relation to the legislative framework and national preparedness plans during the COVID-19 pandemic. The research is theoretically grounded in the concepts of agile and adaptive governance. Our empirical data consists of 53 qualitative interviews with public health actors at national, regional and local level collected from March 2021–February 2022. We analyzed interviews using directed content analysis. Major issues regarding the response of public health authorities included ambiguity, lack of knowledge in decision-making, and a mismatch between the locations of public health competence and public health authority.

Do smart cities perform better in governing the COVID-19 crisis? Empirical evidence from Indonesian cities

The COVID-19 pandemic has shocked the world due to its pronounced mortality rate, rapid worldwide spread, and profound socioeconomic effects across all societies. As the spearhead of urban policies, local governments play an important role in crisis management during the pandemic. In the context of smart cities, innovative solutions have been required, especially to improve the local government's capacity to manage health crises. This study asks whether smart cities perform better in governing the COVID-19 pandemic. This article focuses on how urban governance impacted cities’ performance in dealing with the COVID-19 pandemic. Using a city-level data set from Indonesia, we constructed a COVID-19 response performance index using principal component analysis that is used in an empirical strategy with quasi-experimental cross-sectional methods to minimize the influence of unobserved covariates and selection bias. This study concludes that smart city status does not have a statistically significant impact on the COVID-19 performance index. We offer three possible accounts based on expert insights, previous empirical studies, and digital upshots on data monitoring and reporting cases. Both theoretical and practical implications can be drawn, thus highlighting the lack of effective integration of technological dimensions into health and urban governance systems in the context of a public health crisis.

Power and politics in a pandemic: Insights from Finnish health system leaders during COVID-19

Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experience issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n = 53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems.

Health system response to COVID-19 among primary health care units in Ethiopia: A qualitative study.

There was limited data on the experiences and roles of sub-national health systems in the response against COVID-19 in Ethiopia. This study explored how sub-national primary health care units and coordinating bodies in Ethiopia responded to COVID-19 during the first 6 months of pandemic. We conducted a qualitative study with descriptive phenomenological design using 59 key informants that were purposively selected. The interviews included leaders across Ethiopia's 10 regions and 2 administrative cities. Data were collected using a semi-structured interview guide that was translated into a local language. The interviews were conducted in person or by phone. Coding and categorizing led to the development of themes and subthemes. Data were analyzed using thematic analysis. Local administrators across different levels took the lead in responding to COVID-19 by organizing multisectoral planning and monitoring committees at regional, zonal and woreda (district) levels. Health leaders reacted to the demand for an expanded workforce by reassigning health professionals to COVID-19 surveillance and case management activities, adding COVID-19-related responsibilities to their workloads, temporarily blocking leave, and hiring new staff on contractual basis. Training was prioritized for: rapid response teams, laboratory technicians, healthcare providers assigned to treatment centers where care was provided for patients with COVID-19, and health extension workers. COVID-19 supplies and equipment, particularly personal protective equipment, were difficult to obtain at the beginning of the pandemic. Health officials used a variety of means to equip and protect staff, but the quantity fell short of their needs. Local health structures used broadcast media, print materials, and house-to-house education to raise community awareness about COVID-19. Rapid response teams took the lead in case investigation, contact tracing, and sample collection. The care for mild cases was shifted to home-based isolation as the number of infections increased and space became limited. However, essential health services were neglected at the beginning of the pandemic while the intensity of local multisectoral response (sectoral engagement) declined as the pandemic progressed. Local government authorities and health systems across Ethiopia waged an early response to the pandemic, drawing on multisectoral support and directing human, material, and financial resources toward the effort. But, the intensity of the multisectoral response waned and essential services began suffering as the pandemic progressed. There is a need to learn from the pandemic and invest in the basics of the health system-health workers, supplies, equipment, and infrastructure-as well as coordination of interventions.

Health Technology Assessment in nephrology and dialysis

The nephrology and dialysis sector is characterized by a high technological content, considerable technological and digital complexity, continuous innovation within the care processes and a strong economic impact on the national and regional health system. The purpose of this article is to illustrate the application of the Health Technology Assessment (HTA) methodology in the evaluation of technological innovations in the nephrology and dialysis field. In particular, the evaluation steps of the multidimensional and multidisciplinary process applied to the nephrodialysis field will be described, specifically a device to be used in patients with chronic kidney disease, also considering important comorbidities such as cardiomyopathies and arrhythmias, which often require implantation of electronic cardiac implantable devices in renal patients. The HTA uses a rigorous scientific methodology, and today represents an essential tool for a governance of the modern health system, in which every innovative technological element that significantly modifies the organization must be evaluated. For this strategic reason, HTA becomes an important intervention for the dialysis sector, where technological innovations are a fundamental sector. For a precise understanding of the function of HTA in dialysis, a complete example of the application of HTA for the evaluation of a resorbable antibacterial device for the prevention of infections from cardiac implantable electronic devices on patients with high infectious risk has been shown, such as patients with chronic kidney disease.

Health System Governance Evaluation: A Scoping Review.

Governance is one of the critical functions of the health system. Good governance of the health system leads to better performance and outcomes. Evaluation is the first step to improving health system governance. Therefore, this research aimed to identify evaluation tools for health system governance. In the current scoping review, we searched all documents related to health system governance evaluation indexed in Medline, EMBASE, ProQuest, Scopus, Cochrane Library, Science Direct databases, and Google Scholar search engines to 2022, extracted, and assessed. Finally, documents were selected and analyzed by thematic analysis. Thirty tools were found to evaluate health system governance. Among the proposed tools, 11 specific tools have been designed just for health system governance evaluation, while others have governance as a component of health system evaluation. Health system governance's significant components are health policy-making, strategic planning, organizing, stewardship, and control. Indicators such as accountability, participation, transparency, equity, efficiency, accountability, corruption control, effectiveness, ethic, the rule of law, and sustainability could be used to evaluate the health system governance. Different tools have been used to evaluate governance worldwide, and each governance evaluation tool has different components suitable for governance evaluation. However, these tools cannot fully evaluate governance and have shortcomings. A comprehensive evaluation of governance and sharing lessons denrael will affect the health system's capacity and ability to provide quality, safe and effective health services. It will lead to the stability of the health system.

Integrating an algorithmic and health systems thinking approach to improve the uptake of government antenatal nutrition services in Vidisha, Madhya Pradesh (India), 2018 to 2021.

In 2018, the Government of Madhya Pradesh initiated the feasibility testing of integrating an algorithmic approach (assess, give, counsel, treat) to strengthen antenatal nutrition services in routine government-funded programmes coupled with a health system thinking approach to strengthen the health service delivery platform. Implementation phases included (1) an evidence review and stakeholder consultations (April 2018) and (2) a health systems strengthening preparedness phase (May-December 2018), including pilot testing in Vidisha district (January-December 2019) covering ∼54 100 pregnant women with 237 antenatal contact points through 241 government auxiliary nurse midwives/staff nurses. During 2020-21, feasibility testing was expanded to an additional 7 districts. We used programme registers of the Auxiliary Nurse Midwives Registers (2019-21) and National Family Health Survey data for 2016 and 2021 to show changes in the Vidisha district and 7 expansion districts. We compare the performance of Vidisha district with Ashok Nagar district, where no such intervention occurred. Comparing 2016 and 2021 data, the Vidisha district showed improvements in receipt of antenatal care in the first trimester (29 to 85%) and in four antenatal visits (17 to 54%). Using the difference-in-difference approach, a 42% net increase in first-trimester antenatal check-ups in Vidisha as compared to Ashok Nagar is observed. There was also an improvement in the maternal nutrition budget of the state from USD 8.5 million to USD 17.8 million during this period. The Vidisha initiative offers several lessons in time-effective workflow to deliver all constituents of nutrition services at various antenatal contact points through and via routine government health systems. Continued execution of the algorithm for screening, with longitudinal data on the management of all nutrition risks, will be critical to show its long-term impact on maternal morbidities and birth outcomes.

Multidrug-resistant tuberculosis in Moldova and the Former Yugoslav Republic of Macedonia: The importance of health system governance

Aim: Multidrug-resistant tuberculosis (MDR-TB) arises where treatment is interrupted or inadequate, when patients are treated inappropriately, or when an individual has impaired immune function, which can lead to a rapid progression from infection with an MDR-strain to disease. This study examines the role of health systems in amplifying or preventing the development of MDR-TB. Methods: We present two comparative studies, which were undertaken in The Former Yugoslav Republic of Macedonia (TFYR Macedonia) and Moldova. Results: The findings reveal several health systems-level factors that contribute to the different rates of MDR-TB observed in these two countries, including: pre-existing burden of disease; organization of the health system, with the existence of parallel systems; power dynamics among policy makers and disease programmes; and the accountability & effectiveness of programme oversight. Conclusions: The findings do not offer a universal template for health system reform but do identify specific factors that may be contributing to the epidemic and are worthy of further attention in the two countries.

The economic cost of Indigenous child health inequities in Aotearoa New Zealand-an updated analysis for 2003-2014.

This study estimates of the cost of Indigenous child health inequities in New Zealand. Standard quantitative epidemiological and cost of illness methodologies were used within a Kaupapa Māori framework. Data for 2003-2014 on children under 15 years were obtained from government datasets. Rates of potentially avoidable hospitalisations and mortality, as well as excess or under-utilisation were calculated. Publicly funded health sector costs, costs to families and costs of premature mortality were used to estimate the costs (or savings) of inequities. Māori children had lower utilisation rates than non-Māori for primary healthcare, outpatient care, medicines, laboratory investigations and care after an accident/injury. Māori children had greater rates of avoidable hospitalisation (RR=1.36, 95% CI 1.35-1.37) and death (RR 1.98, 95% CI 1.84-2.13). Inequalities between Māori and non-Māori children cost in excess of $170 million NZD each year. This includes an annual net savings for the government health sector of $4 million NZD, with an annual cost to society of around $175 million NZD. The under-serving of Māori children in the health sector saves the government health system money, yet imposes a huge cost on Māori families and society. In addition to avoiding considerable human suffering, reducing child health inequities would result in significant economic benefits.

Access to novel drugs and therapeutics for children and youth: Eliciting citizens' values to inform public funding decisions.

The unique evidentiary, economicand ethical challenges associated with health technology assessment (HTA) of precision therapies limit access to novel drugs and therapeutics for children and youth, for whom such challenges are amplified. We elicited citizens' perspectives about values-based criteria relevant to the assessment of paediatric precision therapies to inform the development of a child-tailored HTA framework. We held four citizen panels virtually in May-June 2021, informed by a plain-language citizen brief summarizing global and local evidence about the challenges, policy and programmatic optionsand implementation strategies related to enhancing access to precision therapies for Canadian children and youth. Panellists were recruited through a nationally representative database, medical/patient networksand social media. We inductively coded and thematically analysed panel transcripts to generate themes and identify priority values. The perspectives of panellists (n = 45) coalesced into four overlapping themes, with attendant subthemes, relevant to a child-tailored HTA framework: (1) Childhood Distinctions: vulnerability, 'fair innings', future potential, family impacts; (2) Voice: agency of children and youth; lived versus no lived experience; (3) One versus Many: disease severity, rarity, equity, unmet needand (4) Health System Governance: funding, implementation inequities, effectivenessand safety. Participants broadly agreed that childhood distinctions, particularly family impacts, justify child-tailored HTA. Dissent arose over whose voice should inform HTA and how such perspectives are best incorporated. Citizens can offer unique insights into criteria relevant to the development or revision of HTA frameworks to capture holistic, societally responsive dimensions of value attached to unique contexts or populations, including children. Balancing the hopes and expectations of patients and caregivers for access to expensive but potentiallife-altering therapies against the opportunity costs borne by encompassing health systems is a fundamental challenge that will require rigorous methods to elicit, weighand reconcile varied views. A patient advocate served on the steering committee of this study and co-authored this article. Key informants for the Citizen Brief included patient advocates and caregivers; a separate patient advocate reviewed the Brief before dissemination. Qualitative and quantitative data were collected from the general public and caregivers of children, with written consent.

Building an action plan to tackle palliative care inequality through multi-stakeholder platforms.

To achieve universal care and overcome existing barriers, the most effective strategy is to devise an action plan that incorporates palliative care into primary health care (PHC), as recommended by the World Health Organization's (WHO) Astana Declaration. In Colombia, a country with an upper-middle-income status, about 128,000 individuals experience severe health-related suffering (SHS) that necessitates palliative care. Although the country's healthcare system has made steady strides in the integration and development of palliative care, there is still no national plan in place for palliative care. Build up Colombia's palliative care plan through stakeholder consensus. Based on the participatory action research method and the multi-stakeholder platforms model, this study convened 142 stakeholders from different levels of the health system (patient representatives, journalists, health professionals, government entities, insurance companies, universities, and drug regulatory authorities). The national plan aims to achieve its objectives through a series of strategic actions. These include integrating and diversifying palliative care services, improving access to opioids, increasing palliative care education, promoting community-based palliative care programs, securing funding, and implementing a regulatory framework for palliative care by public policymakers. The national palliative care is an alliance that aims to reduce palliative care inequity in Colombia by 2026 by empowering stakeholders nationwide to collaborate around specific goals and objectives.

Comparison of Cancer Mortality and Incidence Between New Zealand and Australia and Reflection on Differences in Cancer Care: An Ecological Cross-Sectional Study of 2014-2018.

Despite many background similarities, New Zealand showed excess cancer deaths compared to Australia in previous studies. This study extends this comparison using the most recent data of 2014-2018. This study used publicly available cancer mortality and incidence data of New Zealand Ministry of Health and Australian Institute of Health and Welfare, and resident population data of Statistics New Zealand. Australian cancer mortality and incidence rates were applied to New Zealand population, by site of cancer, year, age and sex, to estimate the expected numbers, which were compared with the New Zealand observed numbers. For total cancers in 2014-2018, New Zealand had 780 excess deaths in women (17.1% of the annual total 4549; 95% confidence interval (CI) 15.8-18.4%), and 281 excess deaths in men (5.5% of the annual total 5105; 95% CI 4.3-6.7%) compared to Australia. The excess was contributed by many major cancers including colorectal, melanoma, and stomach cancer in both sexes; lung, uterine, and breast cancer in women, and prostate cancer in men. New Zealand's total cancer incidences were lower than those expected from Australia's in both women and men: average annual difference of 419 cases (-3.6% of the annual total 11505; 95% CI -4.5 to -2.8%), and 1485 (-11.7% of the annual total 12669; 95% CI -12.5 to -10.9%), respectively. Comparing time periods, the excesses in total cancer deaths in women were 15.1% in 2000-07, and 17.5% in 1996-1997; and in men 4.7% in 2000-2007 and 5.6% in 1996-1997. The differences by time period were non-significant. Excess mortality from all cancers combined and several common cancers in New Zealand, compared to Australia, persisted in 2014-2018, being similar to excesses in 2000-2007 and 1996-1997. It cannot be explained by differences in incidence, but may be attributable to various aspects of health systems governance and performance.

The Future Effects of COVID-19 on the Health System: Applying the Futures Wheel Method.

Background: Although the evidence emphasizes that COVID-9 incurs considerable primary effects on public economics and health, it is not so clear what the future effects of this pandemic might be. This study aims to identify the primary and future effects of COVID-19 on the health system. Methods: Futures Wheel (FW) method was used to find the primary and future effects of COVID-19 on eight important dimensions of the health system, including the six building blocks. To gather relevant information, PubMed, SCOPUS, Web of Knowledge, and other sources were searched to find potential studies reporting the potential effects of COVID-19 on the health system. Following that, an expert panel with nine participants to depict the findings was held. Results: Fifty-four studies met the inclusion criteria. The participants reached a consensus on nineteen main primary effects of COVID-19 that could impose 26 main future effects with specific risk opportunities on different dimensions of the health system. Workforce, stewardship and health policy, and infrastructure and hospital capacity dimensions were the most affected by COVID-19 in both the primary and future timeframe. Most of the signals of COVID-19-related opportunities could stem from health technologies and research systems, and service delivery dimensions. Conclusion: COVID-19 comes with considerable risks, especially for the health system governance and workforce dimensions. There are some opportunities to improve the resilience of the health system by using digital health platforms, promoting health literacy of the population, and also adopting inclusive health policy-making processes.

Health Systems of Iran and Portugal: A Comparative Study.

Background: A health system consists of people, institutions, and resources that provide health services to meet the health needs of the target population. Health systems in developed and developing countries have different characteristics from which some lessons can be learned. The aim of this study is to compare the two health systems of Portugal and Iran. Methods: The study was conducted in 2021 using a comparative study approach. The WHO's six building blocks framework was used for the comparison (i.e., governance and leadership, health financing, health workforce, health information system, medication, and service delivery). A six-step protocol was used to review the literature. International databases such as Medline / Pub Med and Scopus were searched. Policy briefs, reports, and dissertations were also reviewed. Results: In both countries, the Ministry of Health is centrally responsible for health system governance. Healthcare financing is 80% government-funded in Portugal and 55% in Iran. In both countries, Health systems are mixed (NHS, NHI, and out-of-pocket model) and the unbalanced regional distribution is a major problem for human resources. In Iran, generic drugs are used, while Portugal combines generic and branded systems. In both countries, there are some challenges in integrating health information systems for health centers and hospitals. Conclusion: In both countries, some autonomy should be delegated to the regions. In Iran, public sector investment in the health system in Iran should be increased to reduce the currently very high out-of-pocket payments in the health system. In both countries, the distribution of resources, especially human resources, should be modified by designing some incentives. Increasing the share of generic drugs in Portugal will have a positive impact on cost control in the drug sector. It seems necessary to develop programs to strengthen the health information system in both countries.

Equitable implementation of innovations to promote successful aging in place.

Equitable implementation of innovations to promote successful aging in place.

The 21st Century Cures Act and psychosocial electronic documentation in solid organ transplantation: Potential harms and practical strategies

Recent health system initiatives and government legislation have enhanced electronic health information (EHI) sharing in the healthcare technology environment. These measures are favorably viewed by most patients and clinicians. The 21st Century Cures Act, whose final rules went into effect in the United States in 2021, prohibits information blocking practices except in the case of potential harm. The definition of such harm, particularly regarding psychosocial EHI, is unclear and little guidance has been published. No articles address the matter in solid organ transplantation (SOT) despite the crucial role of psychosocial data in organ allocation. This article describes the implications of patient and family access to psychosocial EHI in SOT, discusses potential mechanisms of harm, and suggests practical communication strategies relevant to clinicians of all disciplines to promote high quality care and favorable interactions with patients and families.

Does Technical and Democratic Governance Have the Potential to Enhance Health Spending Allocations?

Abstract Nowadays, the medical systems of the EU Member States have a need for more efficient public policies and strategies to integrate the new societal challenges, the fragile economic recovery from the COVID-19 pandemic, and sustain the development of health systems. This research explores the relationship between public governance and health expenditures allocation, under the theory of welfare economics and the concern for economic development. The research approaches both qualitative and quantitative methodologies. The first refers to bibliometric analysis and review of the existing literature, followed by data mapping process to rank the EU countries based on the variables employed. The quantitative approach also includes advanced empirical analyses (principal component analysis - PCA and regression analysis) performed over the period 2007-2020. Two indices were created through PCA, technical governance and democratic governance, gathering the effects from different world governance indicators. The main results reveal that both governance indices have a direct influence on health expenditures per capita, while GDP growth, applied as a control variable, negatively influences health expenditures. Our results emphasise a need to redesign the public governance of health systems in terms of health spending allocations and increase investments in healthcare to support economic growth in the long run.