Health Bureaucracy Research Articles

From political priority to service delivery: complexities to real-life priority of abortion services in Ethiopia.

Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data were collected from February to April 2022. Health bureaucrats from 9 of the 12 regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programmes and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.

Paradigm Conflict: Village Health Volunteers and Public Health in Thailand

Reformist doctors in Thailand have combined to create a primary health care system in rural areas in which village health volunteers play a major role. Consistent with the WHO whole-of-society approach, these doctors have envisaged a decentralised system that emphasises volunteers as community oriented, self-reliant agents of change. Our ethnographic research in Chiang Mai, Thailand, reveals that these ideals of village health volunteer empowerment have not been realised. Rather, village health volunteers have become entrapped in a hierarchical, top-down health bureaucracy that affords them limited deliberative agency. We argue that this predicament reveals a conflict of paradigms between, on the one hand, an idealised holistic, spiritual dimension of health with village health volunteers as dedicated, self-sacrificing agents of local communities and, on the other hand, the imperatives of state authoritarian interventions in the avian influenza and COVID-19 pandemics, including rigorous public health protocols and epidemiological methods.

Healthcare for sex workers—access, barriers, and needs

BackgroundStigma has a significant impact on the health of different societal groups and contributes to inequalities in healthcare. Sex work is associated with significant social stigma, which has detrimental effects on sex workers’ access to healthcare. This exploratory study gives first insights into the perspectives of sex workers and counselors in Germany on sex workers’ access, needs, and barriers with respect to healthcare. We focused on an established network of services for sex workers in Bochum.MethodsWe conducted in-depth guideline-based interviews with four counselors at centers that provide social and medical support for sex workers and three sex workers who use these services. Interviews were analyzed using qualitative content analysis.ResultsThe main barriers reported with respect to sex workers’ access to healthcare were health insurance, language barriers, bureaucracy, mobility, and discrimination. Sex work stigma within healthcare was reported to intersect with other forms of discrimination, such as racism. Specific needs and barriers were reported regarding mental health, which emerged as an important topic for sex workers. Free and anonymous healthcare offers were evaluated positively. Interviewees noted a lack of services that address the needs of sex workers beyond sexually transmitted infections, such as mental healthcare.ConclusionSeveral barriers to accessing healthcare remain for sex workers, many of which are particularly relevant for migrant sex workers from Eastern European countries. The development of additional antidiscriminatory healthcare services is necessary and should give priority to sex workers’ perspectives.

Expert perspectives on the changing dynamics of policy advisory systems: the COVID-19 crisis and policy learning in Belgium and Australia

Expert advice played a pivotal role in shaping the COVID-19 policy responses of different countries. Such measures had wide ranging impacts beyond health, including education, economy, law, and other societal aspects. Thus, analysis of how expertise was utilised and adjusted to adapt to changes during the crisis can draw valuable insights into how to better prepare policy advisory systems to respond to future crises. Here we examine the dynamics of COVID-19 policy advisory systems in Belgium and Australia through interviews with 34 experts directly involved during the first two years of the crisis. We examine the temporal changes in how expert advice was sought, provided, and utilised for crisis decision-making, and the various expert groupings and their relationships over time. In both countries, there was policy learning and adjustment, signalled primarily by an expansion in the breadth of perceived relevant expertise as the scope was re-framed from a ‘health’ crisis to an all-encompassing socio-economic crisis. In Australia, policy responses were shaped by a relatively cohesive inter-governmental group of senior health bureaucrats who became gatekeepers of the evidence presented to state and federal government leaders in the National Cabinet. In Belgium, the more fragmented and changing array of advisory groups reflected tensions within crisis management arrangements, resulting in divergent expert opinions both within the formal advisory groups and in the public realm throughout the crisis. Our findings build on the policy advisory systems and policy learning literature and suggest that more adaptive frameworks and principles be developed for specific contexts.

The golden rule for prioritisation of treatment for substance use and mental health care – a qualitative study

For many years there has been broad political agreement on prioritising substance use treatment and mental health care in the specialist health service. Between 2014 and 2021, the 'golden rule' applied, meaning that there should be higher relative growth in mental health care and interdisciplinary specialised substance use treatment compared to somatic healthcare services. This study aimed to investigate the understanding among Norwegian health leaders and bureaucrats of the golden rule's role in the prioritisation of resources to the field of substance use and psychiatry in the specialist health service. The study is based on a one-year ethnographic study of priority-setting in Norwegian health trusts and bureaucracy. Documents, observations of meetings and twelve qualitative in-depth interviews were analysed using a qualitative discourse method. The golden rule contributed to an increased investment in substance use treatment and mental health care in the health trusts, according to health leaders. However, the golden rule was only one of many competing and at times conflicting guidelines they had to take into account. Many factors impeded higher growth in substance use treatment and mental health care compared to somatic health care. Several participants argued that it was impossible to follow the golden rule. The inability to achieve the goal was explained by demographic trends, funding arrangements and lack of follow-up of the rule. Healthcare priorities are set in institutions that have to consider numerous political interests and social mandates. The study's findings illustrate the complexity of practical implementation of political priorities.

Exploring recent patterns of migration of doctors to the United Kingdom: a mixed-methods study

IntroductionA shortage of doctors is currently one of the biggest challenges faced by the healthcare workforce in the United Kingdom (UK). While plans are in place to increase the number of medical school places, in the short-term this gap will need to continue to be filled by the international recruitment of doctors. The aim of this study is to identify key factors that explain the patterns of migration of doctors to the UK, in order to aid the development of policies to recruit and retain a sustainable workforce.MethodsWe analysed General Medical Council (GMC) secondary data on the patterns of migration of internationally trained doctors (2009–2019). Qualitative interviews were conducted with 17 stakeholders by videoconferencing which were audio-recorded, transcribed and thematically analysed using NVivo.ResultsIn 2019, 34.5% of UK doctors were trained internationally mainly in India, Pakistan, Italy, Nigeria, Greece, Romania and Egypt. Most new registrations by internationally trained doctors from 2009–2019 did not have a specialty at the time of initial registration (96.2% in 2019). Only a relatively small number of these doctors go on to gain specialist or GP registration (11.6% within 5 years and 27.2% within 10 years of registration). The stakeholder interviews highlighted training opportunities and career progression as the main drivers of migration. The barriers internationally trained doctors face regarding specialty training included differences between UK and destination health systems, systematic bias, bureaucracy and selection processes not being accessible.ConclusionThis study makes a contribution to the literature by identifying recent patterns in the migration of doctors to the UK. The UK’s dependence on internationally trained doctors has important global implications as source countries are losing skilled health workers which is undermining their health systems. In keeping with the WHO Global Code on the International Recruitment of Healthcare Personnel, policymakers need to consider how to reduce the UK’s reliance on internationally trained doctors, particularly from countries on the safeguard list whilst continuing the drive to increase medical school places. Additional support is required for internationally trained doctors, to ensure that they get on the training programmes they seek, enabling their career progression.

Taking the developmental state seriously: Why South Korea outperformed neoliberal regulatory states in rapid coronavirus disease 2019 vaccinations and saving lives

Coronavirus disease 2019 claimed more than three million lives worldwide in 2020, giving national governments the most urgent task for 2021 to achieve high vaccination rates to save lives. The World Health Organization declared that “vaccines are the most critical tool to end the pandemic and save lives.” In this context, South Korea (hereafter, Korea) achieved a remarkable milestone by outperforming the United Kingdom and the United States in vaccinations rate, where the world's earliest vaccination programs started. Thanks to its high vaccination rate, Korea recorded less than 100 deaths per million populations in 2021 compared to more than 1000 in the United Kingdom and the United States. Why Korea leaped ahead of the United Kingdom and the United States in rapid vaccinations that saved many lives? To answer this question, I first conceptualize contemporary Korea as a developmental state which retained its institutional capacity despite its transition from authoritarianism to liberal democracy, distinguishing it from the UK and the US's neoliberal regulatory states, where reforms hallowed out state capacity. I then advance two core claims. First, Korea surpassed the United Kingdom and the United States in vaccine rollout because of its developmental state-type goal-oriented autonomous policymaking and strong institutional capacity, manifested as Korea's central agency deployed a command and control vaccination program led by a coherent health bureaucracy. Second, the Korean state's strategic intervention in the market and its capacity to foster public–private partnerships to realize national goals boosted its vaccinations. Finally, the paper suggests how neoliberal regulatory states in the global north can learn lessons from the Korean experience in rebuilding state capacity to deal with the future global pandemic.

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

The Central Role of Relevant Health Information for Promoting Cancer Prevention and Control

Despite major scientific gains in important new knowledge about risks, biological processes, prevention practices, and advanced treatments for many forms of cancer, epidemiological evidence shows that cancer continues to evolve as an increasingly dangerous health issue responsible for unacceptably high levels of death and disability world-wide. Sadly, many major advances in cancer knowledge have not been adequately translated into needed personal and institutional actions that could significantly reduce cancer morbidity and mortality. Disseminating relevant and actionable cancer-related health information to those who are confronting cancer is essential for promoting needed cancer prevention and control. Cancer information dissemination efforts should clearly and persuasively communicate complex cancer information to diverse and often vulnerable audiences who desperately need relevant information about key cancer issues, including cancer prevention, early detection, informed diagnosis, cancer treatment, and successful cancer survivorship. Strategic health communication can build needed awareness about cancer risks and responses, promote trust, cooperation, and personal engagement, as well as support informed cancer decision-making. Communicating meaningfully with those who are at greatest risk from cancer, such as members of the most vulnerable segments of society who suffer from high levels of cancer morbidity and mortality, is especially important for promoting cancer prevention and control. However, effective communication with members of these high-risk populations is often fraught with communication barriers. Since many members of at-risk groups are among the poorest, lowest educated, and most disenfranchised members of society, they may encounter serious challenges to accessing and making sense of relevant health information. They often experience health literacy deficits that make it difficult for them to understand complex cancer information. Their cultural backgrounds may not support their following recommended cancer prevention and control health and life-style practices. They may experience economic limitations that make it difficult to access needed care, as well as to navigate complicated and bureaucratic health care systems. This review and policy article examines these serious challenges to effectively communicating relevant health information to vulnerable populations and suggests strategies for enhancing strategic use of communication messages and media to promote cancer prevention and control.

Public Health and the Politics of Knowledge: The Role of Traditional Medicine in the Management of COVID-19 in Two South Indian States

Public health discourse about COVID-19 pandemic has mostly been framed around biomedical interventions, although there is evidence of the effective use of traditional medicine (TM) to manage the pandemic by some Asian countries such as China, Thailand, Vietnam and India. This article aims to place on record the policy of medical pluralism in the two South Indian states of Tamil Nadu and Kerala in their respective deployment of Siddha and Ayurveda in the management of COVID-19. Based on interviews with physicians of TM and health administrators, press reports, social media posts and published research, this article reconstructs the crucial yet undocumented process of incorporating TM in the biomedicine-based health bureaucracy in Tamil Nadu and Kerala to deal with infectious fevers such as dengue and chikungunya in the past and COVID-19 in the present. It is our argument that those methods of TM which are safe and in long recent use could provide low-cost and accessible means of prevention and early treatment of infectious fevers. They have to be identified and subjected to further investigation as innovations in social medicine brought forth by the state and its officials and are different from the highly expensive projects of the corporate pharmaceutical sector.

Prevalence, features and workplace factors associated with burnout among intensivists in Australia and New Zealand

Objectives: To investigate the prevalence and features of self-reported burnout among intensivists working in Australia and New Zealand, and evaluate potentially modifiable workplace stressors associated with increased risk of self-reported burnout. Methods: We performed an electronic survey among registered intensivists in Australia and New Zealand. Burnout and professional quality of life were measured using the Professional Quality of Life Scale version 5 (ProQOL-5). Socio-organisational factors were defined a priori and assessed using a five-point Likert scale. Thematic analysis was conducted on an open-ended question on workplace stressors. Results: 261 of 921 estimated intensivists responded (response rate, 28.3%). Overall, few participants (0.8%) demonstrated high scores (> 75th centile) for burnout, and 70.9% of participants scored in the average range for burnout. Of note, 98.1% of participants scored in the average to high range for compassion satisfaction. No association was found between sex, age, or years of practice with the level of burnout or compassion satisfaction. Seven themes emerged regarding intensivists' most stressful aspects of work: interpersonal interactions and workplace relationships (25.5%), workload and its impact (24.9%), resources and capacity (22.6%), health systems leadership and bureaucracy (16.1%), end-of-life issues and moral distress (8.4%), clinical management (4.9%), and job security and future uncertainty (1.3%). Conclusion: Fewer Australian and New Zealand intensivists experienced burnout than previously reported. Many self-reported work stressors do not relate to clinical work and are due to interpersonal interactions with other colleges and hospital administrators. Such factors are potentially modifiable and could be the focus of future interventions.

Emergence and Development of Health Risk Communication Networks Among Street-Level Health Bureaucrats During the COVID-19 Pandemic Crisis in Myanmar

Street-level health bureaucrats have actively contributed to implementing the COVID-19 prevention, control, and treatment policies of the Myanmar government. However, the need for bureaucrats on the frontlines of policy implementation to maintain a safe distance from others to prevent the spread of COVID-19 has posed challenges for the sharing and exchange of information related to health risks. In this context, this study examined what health risk communication patterns have emerged and developed among street-level health bureaucrats during the COVID-19 pandemic, and how this risk communication has been affected by street-level health bureaucrats’ perceptions of client meaningfulness and willingness to implement COVID-19 policies. The results reveal that street-level health bureaucrats in the health risk communication network are embedded in reciprocally or transitively connected discussion relationships that sustain their health risk communication over time. Moreover, when specific healthcare staff members perceive more benefits of COVID-19 policies for their patients and are more willing to care for patients, other healthcare staff avoid them to protect themselves from COVID-19 infection. Due to their higher level of understanding of the adopted measures, healthcare staff members who are highly willing to implement COVID-19 policies are frequently approached by other staff members to communicate about COVID-19 issues. This study empirically contributes to the literature on street-level bureaucrats in times of pandemic crisis by examining the formation of health risk communications in the context of street-level health bureaucrats’ responses to and participation in public healthcare policy implementation processes.

Key Challenges to Optimal Therapeutic Coverage and Maternal Utilization of CMAM Program in Rural Southern Pakistan: A Qualitative Exploratory Study.

Severe Acute Malnutrition (SAM) is a serious public health problem in many low- and middle-income countries (LMICs). Therapeutic programs are often considered the most effective solution to this problem. However, multiple social and structural factors challenge the social inclusion, sustainability, and effectiveness of such programs. In this article, we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutrition-specific programs in Pakistan. The study specifically highlights significant reasons for the low coverage of the Community Management of Acute Malnutrition (CMAM) program in one of the most marginalized districts of south Punjab. Qualitative data are collected using in-depth interviews and FGDs with mothers and health and nutrition officials. The study reveals that mothers’ access to the program is restricted by multiple structural, logistical, social, and behavioral causes. At the district level, certain populations are served, while illiterate, and poor mothers with lower cultural capital from rural and remote areas are neglected. The lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy. The subsequent work burden on Lady Health Workers (LHWs) and the lack of proper training of field staff impact the screening of SAM cases. Moreover, medical corruption in the distribution of therapeutic food, long distances, traveling or staying difficulties, the lack of social capital, and the stigmatization of mothers are other prominent difficulties. The study concludes that nutrition governance in Pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved.

The 'Sic Vos non Vobis' of Interventional Radiology - Rebranding and modernising the Interventional Specialities of Radiology in Australia and New Zealand.

The 'Sic Vos non Vobis' of Interventional Radiology - Rebranding and modernising the Interventional Specialities of Radiology in Australia and New Zealand.

Deinstitutionalisation and mental health activism in Australia: emerging voices of individuals with lived experience of severe mental distress, 1975–1985

Starting in the 1960s, large numbers of patients in Australia’s mental hospitals were released even though hardly any support services were available in the community. By the 1970s, a small number of psychiatrists, psychologists, social workers, volunteers, and consumer advocates were building alliances and coalitions with each other and with politicians and health bureaucrats to realise change. Using archival records and interviews as sources, we analyse how, in the early 1980s, Simon Champ, Meg Smith, and Janet Meagher, three pioneering Australian consumer advocates, started to speak out and influence discussions about mental health policy. They were also invited to join boards of non-government organisations in mental health care, foreshadowing later developments. Today, the participation of consumers of mental health care in mental health services is taken for granted and mandated, and most services have consumer advisory groups.

Healthcare - Where to from here?

In writing an editorial it is difficult to ignore the impact and ramifications of addressing the Covid Pandemic. In Australia, there is emerging political and media signals that are saying we must start to move on and get people back to work and living normally. At the same time our health bureaucracies are pointing to higher vaccination rates, new variants, the need for ‘booster shots’ and continued reticence in some about opening state and national borders....

Jobs for Sale: Corruption and Misallocation in Hiring

Corrupt government hiring is common in developing countries. This paper uses original data to document the operation and consequences of corrupt hiring in a health bureaucracy. Hires pay bribes averaging 17 months of salary, but contrary to conventional wisdom, their observable quality is comparable to counterfactual merit-based hires. Exploiting variation across jobs, I show that the consequences of corrupt allocations depend on the correlation between wealth and quality among applicants: service delivery outcomes are good for jobs where this was positive and poor when negative. In this setting, the correlation was typically positive, leading to relatively good performance of hires. (JEL D73, I11, J16, J24, J45, M51, O17)

Development of integrated model of communication for implementing media strategy to prevent hypertension in a northern state of India.

Media plays a major role in inculcating positive changes or averting negative changes in health-related behaviors across populations. Although various mass media interventions have proven their effectiveness in changing individuals' behavior for various diseases and risk factors, current literature is limited regarding a conceptual framework/model for the prevention of hypertension and cardiovascular diseases. The present study describes the process of development and implementation of a comprehensive and need-based media strategy with an aim to generate politico-administrative support for strengthening hypertension services in the state of Punjab, India. The preparation of theoretical framework underwent two stages, that is, item generation and item reduction. The item generation involved extensive literature search, development of consensus among experts using Delphi technique and its validation. The item reduction involved the selection of models among existing communication and health promotion models, placement of items in the selected models and development of final conceptual framework model. Based upon the review and expert's consensus, we zeroed in on three models of communication - communication campaign model, paid earned social owned model, and staircase model - in order to come up with the framework requisite for a systematic media strategy. The model focused upon context-specific messages involving both traditional and modern means and tools of communication. This model (conceptual framework) was the product of intense literature review followed by opinion of the experts from various disciplines such as medical professionals, public health specialists, communication experts, social scientists, politicians, bureaucrats, state-level representatives, media journalists and hypertensive patients. The present model can effectively be used by the program implementers, educators and policy makers in similar settings.

FlorentBédécarrats, IsabelleGuérin, FrançoisRoubaud (Eds.) Randomized Control Trials in the Field of Development: A Critical PerspectiveOxford University Press, 2020, 448 p., $100.00

FlorentBédécarrats, IsabelleGuérin, FrançoisRoubaud (Eds.) Randomized Control Trials in the Field of Development: A Critical PerspectiveOxford University Press, 2020, 448 p., $100.00

Introduction to "Subnational COVID-19 Politics and Policy".

Introduction to "Subnational COVID-19 Politics and Policy".