Non-health Sectors Research Articles

6.P. Scientific session: Economic evaluation of health impacts for better decision choices

Abstract The strategy of Health in All Policies (HiAP) pursues to analyse the wider determinants of health affected by the decision-making process of traditionally non-health sectors, seeking to enhance population health benefits while avoiding health inequalities. This usually involves the use of health impact assessment (HIA) or health lens analysis to any policy, program, plan or project (PPPP), preferably prior to its implementation. On the other hand, decision-makers from a wide range of public and private sectors also demand a better insight of the meaning of the health impacts quantified under HIA. Assuming the (ubiquitous) situation of limited resources and budgets, decisions need to be based on cost effectiveness criteria and, whenever possible, direct and indirect health costs should be part of the impact assessment. Economic appraisal attempts to define whether a proposal makes a net contribution to social welfare, quantifying and valuing changes to individuals’ utility from the societal perspective, taking into account the impact of health on the individual, their family, employers, healthcare providers and the state. This approach can incorporate different components of the welfare costs of illness, including direct medical and paid care expenses, indirect lost opportunity costs such as productivity and the value of informal care time, as well as a value that monetises the disutility or pain and suffering associated with disease. The range of methods and estimated benefits can make it challenging to identify a best practice approach. The present session aims to address certain methodological aspects related to the economic evaluation of health impacts, which still generate some controversy and debate, with particular emphasis on the following topics: • Approaches for synthesizing evidence on health impact pathways and economic evaluation of health impacts for a better decision choice; • Health metrics: influence on the conclusions of economic analysis within HIA; • Sources of metrics used for economic analysis; • Uncertainties inherent to economic valuation of health outcomes: how to deal with it. Key messages • The economic analysis of health impacts can help prioritizing aspects with the greatest impact on population health, facilitating a more effective use of human and economic resources. • The economic analysis within HIA can improve decision-making but requires careful consideration of health metrics, sourcing of data, and management of uncertainties.

Meeting The Needs Of Socially Vulnerable Patients: Views Of ACO Leaders On Moving From Intent To Action.

The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September-December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non-health care sectors, to help socially vulnerable patients.

A qualitative assessment of multi-sectoral action for non-communicable diseases (NCDs) in Uttar Pradesh, India

IntroductionNon-communicable diseases (NCDs) on the rise globally, especially affecting vulnerable populations in low- and middle-income countries. To tackle this, urgent and comprehensive actions are needed. The main preventable risk factors for NCDs are tobacco and alcohol use, unhealthy diet, physical inactivity, and air pollution, rooted in social determinants of health (SDOH). In India, some states are adopting a multi-sectoral approach (MSA) to manage NCDs. A qualitative assessment was conducted to evaluate MSA implementation in Uttar Pradesh, India.MethodsInductive approach i.e., grounded theory was used to understand the perceptions regarding MSA. Key-Informant Interviews (KIIs) of senior level officers from both non-health and health sectors were conducted using an interview guide. We targeted all 17 priority sectors as identified in National Multi-sectoral Action plan (NMAP) for prevention and control of NCDs in India. Data could be collected from officials of 14 sectors. Data thus collected was transcribed, translated and coded for identifying themes.ResultsThe non-health sectors expressed readiness to act but don’t have guidelines. They explained the risk factors such as behaviours; nutrition and physical inactivity associated with NCDs and also appreciated the role of MSA in prevention and control of NCD. The attitude and perception of health sector towards implementation of MSA was less promising. Their perspective was based upon the existing vertical structures, response and support they have experienced before from other sectors and from the administration. Non-health sectors uniformly emphasised that health should lead MSA as health sector has scientific knowledge and experience in operationalizing health programs.ConclusionThere is a need to have a common action platform for NCD prevention and control to bridge the gap between health and non-health sectors. A dedicated, parallel structure is essential to translate policy into practice effectively.

A qualitative study of Suaahara II influence on nutrition governance in Nepal.

Maternal and child undernutrition remain major public health problems in Nepal. Suaahara is a USAID-funded multi-sectoral nutrition programme aiming to strengthen local nutrition governance to reduce maternal and child undernutrition, among other objectives. The purpose of this study is to present findings from a recent qualitative evaluation of Suaahara II's influence on the decentralised implementation of Nepal's Multi-sectoral Nutrition Plan (MSNP) and identifying gaps and areas for improvement at the federal, provincial, and local levels to strengthen nutrition governance. This study employed multiple qualitative methods, engaging over 100 multi-sectoral nutrition stakeholders across three levels of government and eight districts. Thematic qualitative analysis was employed to identify emergent and salient themes, which were triangulated with other secondary data sources. Suaahara II had a positive influence on strengthening horizontal coordination for implementing the MSNP and effectively leveraged existing networks to strengthen implementation of nutrition-focused activities at the municipal level. Although there was an observable increased demand for nutrition budgets attributable to Suaahara II activities, sufficient allocation and utilisation, particularly in non-health sectors, did not meet these levels. Nepal's shift to federalism hindered vertical coordination of MSNP implementation. Some formal coordination mechanisms were strengthened, but variation in their effectiveness to strengthen horizontal and vertical coordination to implement MSNP activities continues. Finally, limited government ownership over nutrition activities and facilitating multi-sector coordination to implement the MSNP threatened sustainability of Suaahara II's outcomes on nutrition governance. Future programmes should continue to build on the progress made under Suaahara II, and specifically aim to address challenges in vertical coordination to strengthen nutrition governance in Nepal.

Assessment of Knowledge and Attitude of First Aid Management of Epistaxis among the General Population in Najran Region: A Cross-Sectional Study

Background: Nasal bleeding, epistaxis, is a common emergency. Few Saudi studies exist on epistaxis awareness and first aid management. We aimed to assess knowledge and attitude of adults in Najran, Saudi Arabia towards epistaxis first aid management, as well as their association with sociodemographic factors.Methods: A cross-sectional web-based survey was carried out involving general adults of Najran, Saudi Arabia, using a snowball sampling method. A pretested questionnaire was utilized for data collection. Knowledge and attitude scores were categorized as good/positive or poor/negative. Both descriptive and inferential statistics were carried out with odds ratio (OR), 95% confidence intervals (CIs), and logistic regression analysis to investigate factors associated with knowledge and attitude towards epistaxis first aid management using SPSS Software.Results: The study included 518 participants with 58.9% experienced nosebleeds. Common causes were hypertension (24.5%) and nose injuries (23.7%). Factors as nasal dryness, blood thinner use, and tumors/nasal polyps were also identified. Around 60.2% believed first aid was necessary and 59.5% had good knowledge about epistaxis first aid management. Participants with university/higher education, employed in health sector, and with previous experience with nosebleed were more knowledgeable, more likely to have positive attitudes, and showed significantly higher ORs for knowledge and attitude scores compared to others.Conclusion: The study showed fair knowledge and attitude of Najran adults towards epistaxis first aid management with sociodemographic variables showing varying associations. Educational initiatives are needed especially for those with lower education, non-health sectors, and not experienced nosebleeds, to improve public first aid knowledge and attitudes.Keywords: Epistaxis; Knowledge; Attitude; First aid management; Saudi Arabia

The Peran Intervensi Gizi Sensitif (Program Kesehatan Lingkungan, Masalah Kemiskinan dan Pemberdayaan Perempuan) dalam Perbaikan Masalah Gizi Balita Stunting di Kelurahan Landasan Ulin Utara

Stunting is defined as a state of short or very short stature caused by linear growth that fails to reach its proper genetic potential. Stunting affects brain growth and development. Stunted children also have a higher risk of suffering from chronic diseases in their adult years. Stunting reduction requires integrated interventions, including specific nutrition interventions and sensitive nutrition interventions. This study aims to identify sensitive nutritional interventions (environmental health programs, poverty issues and women's empowerment) in overcoming the nutritional problem of stunting toddlers. This type of research is qualitative which is analyzed descriptively and in-depth interviews and observations with research samples are informants from the non-health sector, namely village heads, RW heads, RT heads, PKK. The sampling technique was carried out by purposive sampling technique. This research was conducted in the Village of Landasan Ulin Utara, Banjarbaru City. The results showed sensitive nutritional interventions for environmental health (clean Saturday or Sunday program, mutual cooperation, and eco engine training), poverty issues (keluarga harapan program, provision of BST, BLT BBM, KIS, BPJS, PNPM, and business equipment assistance), and women's empowerment (DASHAT program, MSME training, seed and livestock assistance). Sensitive nutritional interventions can be carried out on an ongoing basis and combined with specific nutritional interventions in handling stunting toddler nutritional problems.

The Model of Worker’s Quality of Life During Covid-19 Pandemic: The Role of Perceived Organizational Support (POS), Digital Literacy, Covid-19-Related Workplace Policy, Quality Culture, and Safety Culture

The quality of life (QoL) of workers during the Covid-19 pandemic is an important issue that must be considered. Unfortunately, research related to the QoL of workers during the Covid-19 pandemic for the non-health sector is still very limited. Moreover, no one has comprehensively investigated QoL involving not only the perceived threat of Covid-19, Covid-19-related workplace policy, and job insecurity but also digital literacy, perceived organizational support (POS) during Covid-19, quality culture, and safety culture. Therefore, to fill the gap in the literature, this study studied QoL by involving perceived threat of Covid-19, Covid-19 related workplace policy, job insecurity, digital literacy, POS, quality culture, and safety culture. Quantitative research method was carried out in this research. Data collection was conducted through an online survey. The research respondents were 181 non-health sector workers in Indonesia. SEM-PLS was used as an analytical tool. The results showed that QoL was directly and positively affected by POS and safety culture. In addition, QoL was also indirectly affected by Covid-19-related workplace policy, quality culture and safety culture by post. However, several factors, namely the perceived threat of Covid-19, job insecurity, and digital literacy did not have a significant effect on the QoL of non-health sector workers during the Covid-19 pandemic. In addition, this research also found that quality culture did not affect Covid-19 related workplace policy and job insecurity. The perceived threat of Covid-19 was not affected by the Covid-19-related workplace policy and safety culture. Job insecurity was affected by the perceived threat of Covid-19.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences.

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

The Coproduction of Health Framework: Seeking Instructive Management Models and Theories.

At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.

Pengetahuan dan Perilaku Sehat Masyarakat D.I Yogyakarta Terhadap Covid-19 Era Pandemi dan Endemi

Background of Study: The President has declared the end of the Covid-19 pandemic status in Indonesia on June 21, 2023. This means that the Covid-19 pandemic status has ended and changed the factual status of Covid-19 to an endemic disease in Indonesia. Public attitudes have begun to not pay more attention to the pandemic and Covid-19 protocol that occurred in Indonesia. This study aims to describe knowledge and health behavior towards Covid-19 in the pandemic and endemic era. Methods: This study used an observational method with a cross sectional design. The study population was people who live in DI Province. Yogyakarta Province with purposive sampling. The research sample must meet the inclusion and exclusion criteria. Inclusion criteria in this study, namely people domiciled in Yogyakarta Province who are willing to fill out informed consent, aged 17 years and over and work in the non-health sector. Exclusion criteria in this study are people who live in DI Province. Yogyakarta Province who did not answer the questionnaire completely. Data analysis used is univariate analysis Results: The level of knowledge of the people of D. I Yogyakarta regarding Covid-19 in the pandemic and endemic era is quite good. 71.5% of respondents had a good level of knowledge about Covid-19 and experienced a decrease in healthy behavior in the endemic era compared to the pandemic period. Conclusion: The level of public knowledge related to Covid-19 in the pandemic and endemic era is quite good, but the healthy behavior of the community towards Covid-19 in the endemic era has decreased compared to during the pandemic. Keywords: Knowledge, Health Behavior, Covid-19, Pandemic, Endemic

Job Flows Into and Out of Health Care Before and After the COVID-19 Pandemic

Anecdotal evidence suggests that health care employers have faced increased difficulty recruiting and retaining staff in the wake of the COVID-19 pandemic. Empirical research is needed to understand the magnitude and persistence of these changes, and whether they have disproportionate implications for certain types of workers or regions of the country. To quantify the number of workers exiting from and entering into the health care workforce before and after the pandemic and to examine variations over time and across states and worker demographics. This cohort study used US Census Bureau state unemployment insurance data on job-to-job flows in the continental US to construct state-level quarterly exit and entry rates for the health care industry from January 2018 through December 2021 (Arkansas, Mississippi, and Tennessee were omitted due to missing data). An event study design was used to compute quarterly mean adjusted rates of job exit from and entry into the health care sector as defined by the North American Industry Classification System. Data were examined from January to June 2023. The COVID-19 pandemic. The main outcomes were the mean adjusted health care worker exit and entry rates in each quarter by state and by worker demographics (age, gender, race and ethnicity, and education level). In quarter 1 of 2020, there were approximately 18.8 million people (14.6 million females [77.6%]) working in the health care sector in our sample. The exit rate for health care workers increased at the onset of the pandemic, from a baseline quarterly mean of 5.9 percentage points in 2018 to 8.0 (95% CI, 7.7-8.3) percentage points in quarter 1 of 2020. Exit rates remained higher than baseline levels through quarter 4 of 2021, when the health care exit rate was 7.7 (95% CI, 7.4-7.9) percentage points higher than the 2018 baseline. In quarter 1 of 2020, the increase in health care worker exit rates was dominated by an increase in workers exiting to nonemployment (78% increase compared with baseline); in contrast, by quarter 4 of 2021, the exit rate was dominated by workers exiting to employment in non-health care sectors (38% increase compared with baseline). Entry rates into health care also increased in the postpandemic period, from 6.2 percentage points at baseline to 7.7 percentage points (95% CI, 7.4-7.9 percentage points) in the last quarter of 2021, suggesting increased turnover of health care staff. Compared with prepandemic job flows, the share of workers exiting health care after the pandemic who were female was disproportionately larger, and the shares of workers entering health care who were female or Black was disproportionately smaller. Results of this cohort study suggest a substantial and persistent increase in health care workforce turnover after the pandemic, which may have long-lasting implications for workers' willingness to remain in health care jobs. Policymakers and health care organizations may need to act to prevent further losses of experienced staff.

Investing in Child Health Through Alternative Payment Models: Lessons From North Carolina Integrated Care for Kids.

Pediatric value-based payment reform has been hindered by limited return on investment (ROI) for child-focused measures and the accrual of financial benefits to non-health care sectors. States participating in the federally-funded Integrated Care for Kids (InCK) models are required to design child-centered alternative payment models (APMs) for Medicaid-enrolled children. The North Carolina InCK pediatric APM launched in January 2023 and includes innovative measures focused on school readiness and social needs. We interviewed experts at NC Medicaid managed care organizations, NC Medicaid, and actuaries with pediatric value-based payment experience to assess the NC InCK APM design process and develop strategies for future child-focused value-based payment reform. Key principles emerging from conversations included: accounting for payer priorities and readiness to implement measures; impact of data uncertainty on investment in novel measures; misalignment of a short-term ROI framework with whole child health measures; and state levers like mandates and financial incentives to promote implementation.

Economic Policy Responses to Covid-19 and Expenditures on Domestic Travel: International Evidence

In response to the unprecedented circumstances resulting from the COVID-19 pandemic, various national government policies were implemented to reduce the serious economic damage caused by the pandemic and attempts to control it. These policies generally aimed to kick-start domestic-led recoveries in many sectors. This study examines how different types of fiscal measures adopted by governments in response to this pandemic are associated with the growth of expenditure on domestic travel in 2020. Utilizing data from 76 countries and applying OLS estimator and 2SLS regression (which mitigates the potential endogeneity problem), the study shows that governments’ additional spending and tax reductions (especially in non-health sectors) positively contributed to rising expenditure in domestic travel destinations. Similar results are found for countries that are very reliant on tourism. Our findings lend empirical support for Keynesian theory’s prediction concerning the effect of government spending and tax reduction on household consumption behavior in the short run, particularly during periods of economic stress and uncertainty.

Discourse Analysis Fiscal Stimulus Policy During the Covid-19 Pandemic: Comparatives Study of Indonesia and Japan

Objective: This study attempts to explain the fiscal stimulus policy of Indonesia and Japan in the economic recovery due to the COVID-19 pandemic from a neo-Marxist perspective.
 Theoretical Framework: Fiscal Stimulus Policy in the Health and Non-Health Sectors in Indonesia and Japan.
 
 Method: The research was conducted with a qualitative approach. This study used secondary data, including the literature of previous research results, state budget documents, policy documents, official circulars of relevant institutions, news media articles, public opinion polls, and reports published by the IMF, OECD, and ECDC. Researchers analyzed secondary data from the IMF and OECD because they are trusted and updated organizations related to data development.
 
 Results and Conclusion: The results showed that the proportion of fiscal stimulus policy between the two countries is different from the total economic recovery of GDP increase during 2020-2021 in Indonesia increased by 5.76% and Japan by 3.6%. Identifying the composition of fiscal stimulus policy shows that Indonesia's intervention level is categorized as Mixed towards Compulsory Instruments while Japan is at the Mixed Instruments level. The intervention level reflects the implicit Neo-Marxist perspective that tends to be higher in Indonesia's Keynesian fiscal stimulus than in Japan.
 
 Research Implications: This study provides an overview of the relationship between theory and concrete reality in depth to provide a contribution value to the development of government intervention theory related to the terminology of the degree/level of intervention in economic recovery when the country is at the site of a global crisis.
 Originality/value: The level of intervention of the Indonesian and Japanese governments reflects the explanation and answer from the Neo-Marxist perspective to the building elements of the Theory of Keynesian understanding. The answer to the description is mainly related to the aspects of the State's role, which are not clear and thorough, and the Keynesian Understanding synthesizes the Neo-Marxist Perspective.

Improving substance use disorder care: Service providers' perceptions on barriers to drug use treatment in the Western Province Sri Lanka

The increasing prevalence of drug use as well as a large number of drug users not seeking treatment is a major concern in Sri Lanka. Drug abuse treatment providers are in a unique position to identify barriers that deter drug users from accessing their services. Hence this study aimed to explore the service providers' perceptions of the barriers to drug users accessing treatment services. A qualitative study was conducted with 12 purposely selected service providers from drug treatment centres representing government, non-government, health and non-health sector institutions in the Western Province. In-depth interviews using a semi-structured questionnaire were used as the data collection method. All interviews were conducted by the Principal Investigator and were manually and digitally recorded. Interview data were transcribed and analysed using the inductive thematic analysis method. Five main themes emerged from the data. The main themes were easily identified as being drug user-related factors and service provider-related factors. Poor drug-related health literacy and negative environmental influences were drug user-related factors which service providers perceived as barriers. Service providers perceived that poor provider training, bureaucratic challenges and poor interagency cooperation are barriers within their own programmes that act as barriers for drug users when accessing treatment services. Service providers perceived that drug users who require treatment confront numerous barriers when accessing the help, they need. It is important to address these barriers in order to improve treatment services for this marginalized group.

Enhancing Health through Built Environment Improvement: A Southern Nevada Health Impact Assessment Case Study

Background: Health Impact Assessment (HIA) is a public health tool to evaluate how choices made outside the health sector can affect health. HIAs are utilized in transportation, housing, planning, and other fields. Since the built environment can impact community health outcomes, including physical activity rates, injuries, and overweight and obesity, an interdisciplinary team composed of public health, planning, transportation, and land use professionals conducted an HIA in Las Vegas, Nevada.
 Methods: The HIA consisted of (1) screening, (2) scoping, (3) assessment, (4) recommendations, (5) reporting, and (6) monitoring and evaluation. It examined proposed physical improvements to a 0.66 mile stretch of a major arterial roadway in the City of Las Vegas where nearby residents experience many health inequities. Collection and analysis of land use and survey data, analysis of secondary data, and literature reviews were completed to predict potential health effects produced by built environment changes. Stakeholder feedback informed each HIA step.
 Results: The HIA generated recommendations to improve physical activity, reduce pedestrian and bicyclist injury rates, and decrease obesity and overweight prevalence, by presenting “good,” “better,” and “best” physical infrastructure improvements. The process and resulting recommendations enhanced collaboration among health and nonhealth sectors.
 Conclusions: Data and analysis revealed that the proposed changes could improve walkability and bikeability and reduce pedestrian and bicyclist injury. By encouraging active transportation through bicycling and walking, the plan could, over time, contribute to reduced overweight and obesity. The HIA facilitated inter-sector cross collaboration and the integration of health into future decision-making.

Making multisectoral committees work: Lessons from tobacco control in two Pacific small island developing states

AbstractThe consumption of harmful commodities drives the noncommunicable disease (NCD) epidemic globally and in Pacific small island developing states. Multisectoral committees are commonly chosen avenues to facilitate policy coherence across government sectors in regulating the commercial determinants of health (CDoH), but these committees often fail to function as intended. This paper aims to explore the institutional conditions that enable or constrain multisectoral committees in facilitating policy coherence for tobacco control in Fiji and Vanuatu. An exploratory, qualitative research design was applied, incorporating a two‐case study design with within‐case analysis and cross‐case synthesis. Data collection consisted of 70 in‐depth interviews in 2018 and 2019. Data collection and analysis were informed by an analytical framework drawn from the institutional collective action framework. The results show that the current amount of authority behind the investigated multisectoral committees in Fiji and Vanuatu is inadequate to meaningfully bring stakeholders together for an issue with high complexity. Moreover, multisectoral discussions on tobacco control have a high risk to break down, as the collaboration may generate unwanted impacts to one or more actors and the net benefits are perceived to be low. The authority behind multisectoral committees might be strengthened by the chairmanship of a cross‐sectoral, high‐level government official and the allocation of more resources for managing intersectoral engagement. Divergent preferences might be brought closer together by showcasing the socioeconomic costs of NCDs and policies affecting the availability, affordability, accessibility, and desirability of tobacco and raising awareness about CDoH in nonhealth sectors.

Examining the roles of partnerships in enhancing the health systems response to COVID-19 in Nigeria

BackgroundThe COVID-19 pandemic overwhelmed the health systems and socio-economic foundations of many countries, Nigeria inclusive. The study was carried out to assess, understand, document and report the activities/measures that are considered nationally and sub-nationally significant, both in terms of COVID-19 responses and in terms of strengthening the health system for the future, in response to future threats since this will not be the last pandemic This paper examines how partnerships contributed to the health system and other sectors’ responses to COVID − 19 infection in Nigeria.MethodsThis was a qualitative study. Data was collected using a scoping literature review and key informant interviews with 36 key stakeholders in the COVID-19 response in Nigeria, in Abuja (national level) Lagos and Enugu states (sub-national level). Interviews were recorded and transcribed verbatim. The qualitative data was analysed using thematic analysis.ResultsIt was found that many partnerships were formed when responding to the COVID-19 pandemic in Nigeria. The health system leaned towards a horizontal dimension of partnership with non-health governmental sectors, non-governmental sectors, and other countries. All the components of the health system building blocks had a measure of partnership contributing to its accomplishments The partnerships came in varied forms, ranging from advocacy, funding, provision of palliatives to the citizens because of lockdowns, technical assistance, support to research, development of guidelines and health educational materials.ConclusionThe health sector’s collaboration with other sectors strengthened all the building blocks of the health system and was invaluable in enhancing the response to COVID-19, which needed a whole of government and a multi-sectoral approach. Formal frameworks for quickly initiating whole-of-government and multi-sectoral partnerships should be developed, with clear roles and responsibilities. This should be deployed for health system resilience and for response to shocks such as the COVID-19 pandemic.

Multisectoral actions in primary health care: A realist synthesis of scoping review.

Multisectoral actions (MSAs) on health are key to implementation of primary health care (PHC) and achieving the targets of the Sustainable Development Goal 3. However, there is limited understanding and interpretation of how MSAs on health articulate and mediate health outcomes. This realist review explored how MSAs influence on implementing PHC towards universal health coverage (UHC) in the context of multilevel health systems. We reviewed published evidence that reported the MSAs, PHC and UHC. The keywords used in the search strategy were built on these three key concepts. We employed Pawson and Tilley's realist review approach to synthesize data following Realist and Meta-narrative Evidence Syntheses: Evolving Standards publication standards for realist synthesis. We explained findings using a multilevel lens: MSAs at the strategic level (macro-level), coordination and partnerships at the operational level (meso-level) and MSAs employing to modify behaviours and provide services at the local level (micro-level). A total of 40 studies were included in the final review. The analysis identified six themes of MSAs contributing to the implementation of PHC towards UHC. At the macro-level, themes included influence on the policy rules and regulations for governance, and health in all policies for collaborative decision makings. The meso-level themes were spillover effects of the non-health sector, and the role of community health organizations on health. Finally, the micro-level themes were community engagement for health services/activities of health promotion and addressing individuals' social determinants of health. Multisectoral actions enable policy and actions of other sectors in health involving multiple stakeholders and processes. Multisectoral actions at the macro-level provide strategic policy directions; and operationalise non-health sector policies to mitigate their spillover effects on health at the meso-level. At micro-level, MSAs support service provision and utilisation, and lifestyle and behaviour modification of people leading to equity and universality of health outcomes. Proper functional institutional mechanisms are warranted at all levels of health systems to implement MSAs on health.

Multidomain and multilevel strategies to improve equity in maternal and newborn health services in Nepal: perspectives of health managers and policymakers

BackgroundNepal has committed to achieving universal coverage of quality maternal and newborn health (MNH) services by 2030. Achieving this, however, requires urgently addressing the widening inequity gradient in MNH care utilisation. This qualitative study examined the multidomain systemic and organisational challenges, operating in multi-level health systems, that influence equitable access to MNH services in Nepal.MethodsTwenty-eight in-depth interviews were conducted with health policymakers and program managers to understand supply-side perspectives of drivers of inequity in MNH services. Braun and Clarke’s thematic approach was employed in analysing the data. Themes were generated and explained using a multidomain (structural, intermediary, and health system) and multi-level (micro, meso and macro) analytical framework.ResultsParticipants identified underlying factors that intersect at the micro, meso and macro levels of the health system to create inequity in MNH services. Key challenges identified at the macro (federal) level included corruption and poor accountability, weak digital governance and institutionalisation of policies, politicisation of the health workforce, poor regulation of private MNH services, weak health management, and lack of integration of health in all policies. At the meso (provincial) level, identified factors included weak decentralisation, inadequate evidence-based planning, lack of contextualizing health services for the population, and non-health sector policies. Challenges at the micro (local) level were poor quality health care, inadequate empowerment in household decision making and lack of community participation. Structural drivers operated mostly at macro-level political factors; intermediary challenges were within the non-health sector but influenced supply and demand sides of health systems.ConclusionsMultidomain systemic and organisational challenges, operating in multi-level health systems, influence the provision of equitable health services in Nepal. Policy reforms and institutional arrangements that align with the country’s federalised health system are needed to narrow the gap. Such reform efforts should include policy and strategic reforms at the federal level, contextualisation of macro-policies at the provincial level, and context-specific health service delivery at the local level. Macro-level policies should be guided by political commitment and strong accountability, including a policy framework for regulating private health services. The decentralisation of power, resources, and institutions at the provincial level is essential for technical support to the local health systems. Integrating health in all policies and implementation is critical in addressing contextual social determinants of health.