Policy Dialogue Research Articles

Approaches, enablers and barriers to govern the private sector in health in low- and middle-income countries: a scoping review

IntroductionThe private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes...

Development of a regionally consistent and fully probabilistic earthquake risk model for Central Asia

Abstract. A fully probabilistic earthquake risk model was developed for five countries in Central Asia, providing updated earthquake loss estimates with a higher level of detail on all components with respect to previous studies in the region. Additionally, a regionally consistent approach that, on the one hand, allows for direct comparisons at different disaggregation levels (e.g., country and oblast) was used. On the other hand, this updated earthquake risk assessment aims to facilitate initiating a policy dialogue regarding national and regional disaster risk financing and insurance applications. This earthquake risk model made use of a regional probabilistic seismic hazard analysis and a comprehensive exposure database on which different types of assets and sectors were included and for which two scenarios (the years 2020 and 2080) were modeled. For each type of asset, a unique vulnerability function was derived and later used for convolution with the hazard data, which allowed for the estimation of the loss exceedance curve, at different disaggregation levels, from where other risk metrics such as the average annual loss (AAL) and specific return period losses were obtained. The regional earthquake AAL for the five countries and for the 2020 exposure scenario has been estimated to be around USD 2 billion, with the Kyrgyz Republic and Tajikistan being the countries with the highest earthquake risk levels in the region. Besides the probabilistic earthquake risk results, as-if scenarios were modeled using a pseudo-deterministic approach to assess the human and economic losses for realistic and representative earthquakes for the main cities within earthquake-prone regions in the five countries of the study area.

Targeting COVID-19 and Human Resources for Health News Information Extraction: Algorithm Development and Validation.

Global pandemics like COVID-19 put a high amount of strain on health care systems and health workers worldwide. These crises generate a vast amount of news information published online across the globe. This extensive corpus of articles has the potential to provide valuable insights into the nature of ongoing events and guide interventions and policies. However, the sheer volume of information is beyond the capacity of human experts to process and analyze effectively. The aim of this study was to explore how natural language processing (NLP) can be leveraged to build a system that allows for quick analysis of a high volume of news articles. Along with this, the objective was to create a workflow comprising human-computer symbiosis to derive valuable insights to support health workforce strategic policy dialogue, advocacy, and decision-making. We conducted a review of open-source news coverage from January 2020 to June 2022 on COVID-19 and its impacts on the health workforce from the World Health Organization (WHO) Epidemic Intelligence from Open Sources (EIOS) by synergizing NLP models, including classification and extractive summarization, and human-generated analyses. Our DeepCovid system was trained on 2.8 million news articles in English from more than 3000 internet sources across hundreds of jurisdictions. Rules-based classification with hand-designed rules narrowed the data set to 8508 articles with high relevancy confirmed in the human-led evaluation. DeepCovid's automated information targeting component reached a very strong binary classification performance of 98.98 for the area under the receiver operating characteristic curve (ROC-AUC) and 47.21 for the area under the precision recall curve (PR-AUC). Its information extraction component attained good performance in automatic extractive summarization with a mean Recall-Oriented Understudy for Gisting Evaluation (ROUGE) score of 47.76. DeepCovid's final summaries were used by human experts to write reports on the COVID-19 pandemic. It is feasible to synergize high-performing NLP models and human-generated analyses to benefit open-source health workforce intelligence. The DeepCovid approach can contribute to an agile and timely global view, providing complementary information to scientific literature.

A Comparative Analysis of Butter, Ghee, and Margarine and Its Implications for Healthier Fat and Oil Group Choices: SWOT Analysis

ABSTRACTThis study aims to comparatively analyze butter, ghee, and margarine fatty acid profiles and their implications for healthier fat and oil group choices. In this cross‐sectional study, 60 samples from best‐selling brands of butter, ghee, and margarine were randomly selected from five food chain stores in Tehran, Iran. Then, all the samples were coded, packed in cool conditions, and sent to the laboratory to determine the fatty acid profiles by using gas chromatography (GC). Based on the authors' experiences and the available literature, a policy dialogue session was held with stakeholders about oil and fat challenges, followed by a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. The mean ± SE of total fatty acids in butter, ghee, and margarine was 94.07 ± 0.17, 94.49 ± 0.61, and 99.00 ± 0.18; total saturated fatty acid (TSFA) 66.69 ± 0.39, 64.26 ± 0.63, and 40.36 ± 0.87; trans fatty acid (TFA) 2.43 ± 0.09, 3.60 ± 0.29, and 0.83 ± 0.15 g/100 gfat, respectively. The predominant TFAs in butter and ghee were vaccenic acid (animal source) (2.06 ± 0.07 and 2.41 ± 0.17), while in margarine, it was elaidic acid (plant‐based source) (0.32 ± 0.12 g/100 gfat), respectively. Also, the SWOT findings showed being TFAs in the acceptable range (as the main strength), mismanagement (Weakness), reducing taxes based on lower TFA content (Opportunity), and sanctions (as the main Threat) were the most important criteria affecting fat choices in the Iranian food basket. The results of the study found that butter, ghee, and margarine contain relatively low levels of TFAs; however, butter and ghee were rich in beneficial fatty acids, which have been shown to have health‐protective properties. Policymakers can implicate the proposed strategies and opportunities from the SWOT analysis for healthier fat and oil choices to promote public health.

Quitting with pride: Differences in smoking behaviour across sexual identity groups in Ireland

Abstract Background As smoking prevalence reduces, smoking inequalities across population groups is emerging as a key challenge. Despite recognition of specific needs among members of the Lesbian, Gay, Bisexual, Transexual Plus (LGBT+) community, differences in smoking across sexual identity groups is uncharted in Ireland and the community is not represented in tobacco policy agenda setting. This study aimed to measure and compare the prevalence of smoking, quitting intention and quitting behaviour across sexual identify groups in Ireland. Methods Secondary analysis of the 2023 “Healthy Ireland” cross sectional survey of health status was conducted (n = 7,411). For the first time, this survey included a question on self-reported sexual identify, along with standard questions on smoking prevalence, quitting intention and quitting behaviour. Prevalence of smoking, quitting intention and quitting behaviour were calculated with 95% Confidence Intervals (CI) and compared across groups with Chi Square tests. Results In total, 2.3% (95% CI 2.0-2.7%) of respondents reported an LGB+ identity. Compared to those reporting straight identity, LGB+ respondents reported higher smoking prevalence (17.6% versus 21.4% respectively); intention to quit was similar across groups, however, LBG+ respondents also reported a higher prevalence of making at least one quit attempt in the previous 12 months (51.3% versus 78.0% respectively, p < 0.0001). Conclusions While this study highlighted tobacco-use as a health challenge for the LGB+ community in Ireland, it also identified an opportunity for tailored stop smoking approaches to support quit success. As a consequence, an innovative Fulbright-sponsored policy dialogue was convened between leaders in tobacco control, LGBT+ community leaders, health services and academia across Ireland and the USA to explore solutions, underlining the important role equity stratifiers and population surveillance play in agenda setting for public health. Key messages • Including sexual identity in the national population health survey enabled tobacco-use needs across sexual identity groups in Ireland delineated for the first time. • Equity-stratified population health surveillance informed a policy dialogue to better represent needs of LGBT+ community in public health agenda setting.

10.X.2. Strengthening primary health care through best practice transfer: the CIRCE-JA approach

Abstract Primary health care (PHC) is a fundamental component of resilient, strong, and sustainable health systems. The main aim of PHC is to address people’s health in a high-quality comprehensive system approach, ensuring person-centred and integrated care across their lifespan, which includes their physical, mental and social well-being. Following the COVID-19 pandemic, health systems’ strengthening has become a global public health and European public health priority, and an overarching objective of the EU4Health programme. In Feb 2023, the three-year Joint Action on the transfer of best praCtices In pRimary CarE (CIRCE-JA) was launched. Its overall objective is to effectively transfer and implement six identified PHC best practices (BPs) across EU Member States (MS), with scientifically robust evidence-based approach, to ensure sound transferability methodology. Critically, it aims to increase MS capacity to deploy innovative care models in PHC and to effectively support health system transformation at this level of care. CIRCE-JA is a collaborative effort with 14 MS participating, bringing together 48 entities, to initially transfer the identified BPs into 42 new implementation sites, whilst at the same time generate all the necessary tools to facilitate uptake and evidence-informed decision-making across all MS. This implementation is based on the alignment of key BP characteristics to meet the local healthcare needs and priorities and match them with national and regional policies. It aims to facilitate integration of public health priorities to PHC practice, and to support the reorganization of services, for strong health promotion focus, synergies with community care, and better coordination of care. During this session key aspects will be discussed using the Pecha Kucha style, to inform the audience about current progress and CIRCE-JA using short stories, also on EU policies and priorities, and the EU4Health support for PHC and public health integration. What is urgently needed at EU-level when it comes to health systems’ strengthening in the post-COVID-19 period and why is PHC critical in this respect? How can the CIRCE-JA developments inform the ongoing transfer and future efforts for the selected BPs in terms of a robust scientifically evidence-based approach? How does the policy dialogue CIRCE-JA is establishing locally, nationally, regionally, supports not only the JA’s sustainability, but all future implementation efforts for PHC? Finally, a brief interaction with the audience will take a place to allow attendees to discuss on key priorities and challenges in their own settings and practice, including the barriers and difficulties that they have initially identifies in the implementation efforts. The output of this interaction will also inform the initial steps towards the establishment of the final deliverable of CIRCE-JA, i.e., the European Primary Healthcare Observatory, to sit on the European Commission’s Health Policy Platform. Key messages • Health systems’ strengthening necessitates strong PHC. CIRCE-JA delivers state-of-the-art tools and brokers policy dialogue to achieve it across Europe. • Several barriers and issues that facilitate the transferring process have been identified in the first implementation of this European initiative. Speakers/Panelists Christos Lionis CSFM & HSR-PH Lab, Faculty of Medicine, University of Crete, Heraklion, Greece Ana M Carriazo Regional Ministry of Health and Families of Andalusia, Seville, Spain Alice Borghini National Agency for Regional Health Services AGENAS, Rome, Italy Radivoje Pribakovic NIJZ, Ljubljana, Slovenia

A pathway design framework for national freight transport decarbonization strategies

ABSTRACT National and international freight transport emissions represent about 40% of global transport emissions, with demand expected to triple by 2050, which will increase emissions further. However, to meet the 1.5°C climate goal, a rapid decrease in transport emissions is required, along with the achievement of zero emissions as soon as possible around mid-century. Given this context, long-term low-emission national development pathways provide a strategic instrument to align short-term action with long-term objectives and to reduce national freight transport emissions. However, current transport-energy modelling studies often exclude the structural and systemic mitigation options that influence the industrial production and supply chain structure, as well as modal and logistics choices, and instead focus mainly on the technological options related to road freight vehicles and fuels. In addition, such studies lack relevant policy and stakeholder-oriented explanations of the barriers and enablers associated with these options. In this paper, we introduce a new framework to design and compare long-term national and sectoral decarbonization pathways for freight transportation, facilitating the consideration of all decarbonization options and the organization of stakeholder-oriented policy dialogues. The development of this sectoral framework builds on the general Deep Decarbonization Pathways (DDP) framework and a first implementation in France. It is then applied and tested in three emerging countries: Brazil, India and South Africa and the results show that the linking of systemic and technological changes could reduce emissions per tonne-km by at least 60%, and up to 100% by 2050, while also reducing energy consumption and supporting national development.

The political economy of national health insurance schemes: evidence from Zambia.

Governments in low and middle-income countries (LMICs) are increasingly considering the introduction of national health insurance scheme (NHIS) as a strategy to achieve universal health coverage (UHC) targets. The literature has widely documented the technical challenges associated with implementing UHC policies in LMICs but much less is known about the political process necessary to pass UHC legislation. In this article, we document the political economy issues surrounding the establishment of the Zambia NHIS in 2018. We adapted a political economy framework incorporating, semi-structured interviews with diverse stakeholders and document analysis of policies, operational reports, and legislatures from 1991 and 2018. Our findings show the 26-year journey towards the establishment of the NHIS in Zambia involved a long sequence of policy dialogue, technical review and stakeholder engagement. Our interviews with key stakeholders suggest that the act was eventually passed due to strong political will and dominant leadership of the Ministry of Health. Passing the law required trade-offs between choices influenced by stakeholder pressures and recommendations from research and actuarial studies. Another equally critical factor was the high public support and legacies of past policies, such as the removal of user fees that had created quality gaps and inequities in the health system. Furthermore, global ideas about UHC and initiatives implemented by other countries also generated support for Zambia's NHIS. Overall, this study highlights the complex set of political economy factors that need to align in order for governments to be able to adopt health insurance in low-income settings. We show that political leadership and commitment to getting reforms passed is crucial. We also highlight how certain narratives about countries in the global health sphere can shape policies in other countries.

Russian-speaking (but not Russian) mothers in Finland: positioning ethnolinguistic identities in family language policy talk

ABSTRACT Anti-Russian sentiment or ‘Russophobia’ has been on the rise around the world since the 2022 invasion of Ukraine (Washington Post, 2022). Negative attitudes towards Russians and the Russian language can potentially influence the desires and practices of Russian-speaking parents in using the language with their children in contexts outside of Russia. This article examines the language ideologies and family language policies of a diverse group of Russian-s peaking mothers in Finland before the Ukraine war. Most of the mothers noted in interviews that some form of Russophobia (e.g. perceived negative attitudes, cutting off funding for Russian programmes, and/or their own stereotypes about Russians) influenced their own use of Russian in certain contexts, their perceptions of their Russian-speaking children, and/or their language education decisions. This article explores an understudied area of family language policy, that is how xenophobia and/or racism in the context of conflict (in this case after the annexation of Crimea in 2014) influence a minority migrant group's use of their home language abroad. By situating mothers’ family language planning and ideologies in the larger sociohistorical context, this paper contributes to an expanded view of family external or non-linguistic factors in family language policy.

Tropical forest cover, oil palm plantations, and precipitation drive flooding events in Aceh, Indonesia, and hit the poorest people hardest.

Tropical forest loss and degradation in watersheds disrupt essential ecosystem services that regulate water flow, often causing devastating floods that impact agricultural productivity and impoverish downstream communities. Despite its importance, evaluations of the interconnectedness between the depletion of hydrological services and flooding lack an evidence-base in the Global South and, therefore, have little influence on policy dialogue. In this study, we focus on the forest-rich province of Aceh, Indonesia, using local and national newspaper articles to compile information on flood events between 2011 and 2018. We explored spatio-temporal flood patterns with a combination of climatic, topographic, and environmental factors. We compiled 2,029 reported flood events in mainland Aceh located in 20 of the 21 districts/cities, with a disproportionately high occurrence (71%) in four districts. The trend of flood events exhibited an increasing pattern between 2011 and 2018. Over this period, floods displaced ~158,000 people and damaged ~24,500 houses and ~11,500 ha of agricultural land. Our generalized linear mixed-effect model found that reported flood events were more likely to occur in areas with lower tree cover, more oil palm plantations, and higher precipitation. Areas with a lower human population density and higher poverty rates were found to be most susceptible to flooding events. Our findings highlight the critical link between forest preservation and flood prevention, and the irreplaceable role that forests play in ensuring the well-being of local communities, especially those affected by poverty. Our study underscores the importance of considering these interconnected factors in future land use and economic development plans and policies.

Competition policy and agent discretion: transatlantic regulatory cooperation in the digital economy

ABSTRACT Despite a framework of bilateral agreements governing cooperation in competition policy since 1991, the European Union (EU) and United States of America (US) established a new Joint Technology Competition Policy Dialogue in 2021, which was different from previous cooperation and separate from the transatlantic Trade and Technology Council. Drawing from the principal-agent literature, this article argues that the choice to establish the new Joint Dialogue can be understood as an exercise of discretionary authority by agents in different jurisdictions with similar preferences who responded similarly to the common external factor of digitalisation. Facing new and shared challenges arising from the digital economy, the EU and US competition authorities undertook a new effort at cooperation – the Joint Dialogue – through which regulatory agents at various levels can interact, exchange information and improve enforcement in a rapidly changing business environment.

Who Cares? Women entrepreneurs and the transition to the Canada-wide Early Learning and Child Care Agreement in Nova Scotia

The Canada-wide Early Learning and Child Care Agreements signed in 2021/2022 represent an unprecedented investment into child care across Canada, supporting the expansion of care spaces, reductions in parent fees, and increased wages for care workers. In the province of Nova Scotia, however, the new funding model faced considerable pushback from women entrepreneurs in the care field, who felt overlooked and bullied by the provincial government amidst the policy rollout. This paper evaluates the experiences of child care owners in Nova Scotia during the transition to the new funding agreement through a series of interviews with entrepreneurs. The paper posits that the consultation and communications between the province and care owners reified gendered power relations, particularly through the devaluation and exploitation of women's care work. Interviewees report feeling treated as “glorified babysitters” and experiencing significant mental health strains as a result of the policy negotiation with the province.

Christian perspectives on the regulation of posthumous medical data donation (PMDD): An empirical study

This article sets out the results of an empirical study exploring the intersection of religious views and perspectives and the regulation of post-mortem data donation (PMDD), particularly focusing on issues of consent and individual control. Through semi-structured interviews with practicing members of the Christian clergy of the United Kingdom, the study investigated the ethical and practical implications of integrating religious viewpoints into secular debates on data protection and privacy, using PMDD as a use case. The findings revealed a consensus among participants that religious perspectives, including Christian perspectives, can enhance the ethical robustness of PMDD regulatory frameworks by promoting values such as dignity, autonomy, and respect for individual preferences. However, the study also identified a possible gap in the systematic consideration of these views within existing regulatory practices pertaining to data protection and privacy. Pursuant to these findings, the article argues for the adoption of an "opt-out" consent mechanism, which balances public health benefits with individual rights, as a pragmatic approach to PMDD regulation. Additionally, the article highlights the potential for religious insights to enrich policy dialogues, ensuring that legal rules relating to data protection and information governance resonate with a broader array of societal values.

Populists in the Shadow of Unanimity: Contestation of EU Foreign and Security Policy

The arrival of populist political parties to power in several member states and the increasing politicisation of EU foreign policy has made intra-European consensus more difficult to reach in the past decade. This article examines the impact of populist contestation on EU foreign policy negotiations in the Council, a policy area governed by unanimity. This decision-making mode makes the policy especially vulnerable to the impact of contestation and, at the same time, gives power to those willing to use their veto. Drawing on the idea of unpopulist politics, this study shows how Hungary and, to a lesser degree, Poland have contested the established formal and informal norms (such as consensus-building or reflex coordination) through discursive and behavioural non-compliance. The “domestication” of EU foreign policy has meant that, in general, populists show less willingness to compromise and resort to non-decisions to demonstrate the EU’s weakness. However, there are exceptions, and it is possible to see variations in populist strategies when faced with similar challenges, as exemplified by the EU’s response to Russia’s war in Ukraine. By testing the scope conditions under which unpolitics might be activated, we show that the same crisis situation did not lead to a uniform response amongst populist governments. This is because both the nature of the crisis and perceptions of risk/gain were understood differently (and actively constructed as such) by populists in power. This finding emphasises the social, relational, and multi-level nature of unpolitics as a phenomenon.

New Evidence of the Impact of the National Drug Price Negotiation Policy on the Availability, Utilization, and Cost of Anticancer Medicines in China: An Interrupted Time Series Study.

The increasing global burden of cancer has become a significant challenge for public health. The Chinese government introduced the National Drug Price Negotiation (NDPN) policy with the goal of lowering the prices of innovative drugs and enhancing their accessibility. This study aims to evaluate the impact of the 2021 NDPN policy on the availability, utilization, and cost of anticancer medicines in China. Data was gathered from 1519hospitals between April 2021 and December 2022, with a focus on eight anticancer drugs affected by the 2021 NDPN policy. The availability, Defined Daily Doses (DDDs), and cost per Defined Daily Dose (DDDc) before and after the intervention were evaluated through interrupted time series analysis. The NDPN policy resulted in a substantial 5.10% increase in the availability of anticancer drugs (p < 0.001). Utilization also experienced a significant surge, with an immediate increase of 11,254.36 DDDs (p < 0.001) and a monthly increase of 1208.28 DDDs (p < 0.001) following policy implementation. The DDDc decreased by US$ 111.00 (p < 0.001) immediately after the policy. Disparities in regional drug utilization were evident, with higher usage in the eastern region. The 2021 NDPN policy has notably enhanced the availability and utilization of anticancer medications in China while reducing their cost, in line with the policy's objectives. However, continuous monitoring is essential to ensure sustained access and to tackle regional disparities in drug utilization.

Drafting a Cybersecurity Standard for Outer Space Missions: On Critical Infrastructure, China, and the Indispensability of a Global Inclusive Approach

Despite limited progress within international institutions, the need for articulating a regulatory framework for cyber operations in outer space is becoming a pressing concern. One precondition for regulation is to share cybersecurity and outer-space common terminology that can inform the negotiation of standards, policies and laws. While the UN Institute for Disarmament Research has recently issued a baseline policy glossary, binding technical definitions are missing, and the lack of a binding international cybersecurity regime adds to the obsolescence of a binding outer-space regime tracing back to half a century ago. As the IEEE SA embarks on the drafting of the first-ever technical standard for cybersecure-by- design outer-space missions, scoping and conceptual challenges abound. Technical standards are US-centred, non-binding, engineering-intensive exercises, where lawyers and Asian jurisdictions are only marginally involved; nevertheless, as China’s framework for cybersecurity is refined and its involvement in outer-space policing deepens, its disengagement from Western-driven standard-setting bodies appears unsustainable. Drawing on the specific challenge of defining what makes a cyber system ‘mission-critical’, I expose the necessity to examine how domestic cybersecurity laws from a diverse range of States identify ‘critical’ information infrastructure. Generalising therefrom, I advocate a jurisdictionally inclusive process that combines American supremacy in technical standard-setting for outer-space missions with Chinese normative contributions to cybersecurity regulation, including on data localisation and mandatory multilevel cyber-hygiene requirements. I further argue that involving legal experts from a diverse range of jurisdictions and sociolegal cultures may enhance the global reception of standardisation outputs, thus securing higher degrees of voluntary compliance therewith. This could foster cooperation and promote regional and global satellite cybersecurity.

Governance by Gaslight: The Reproductive Politics of the Two-Child Limit

Abstract In 2017, the UK government limited the number of children for a whom a low-income family could claim a means tested benefit (the “child element” of “Universal Credit”) to two. Since then, over 400,000 families—including 1.5 million children—have been affected by the “two-child limit.” Emerging research indicates that the limit has done little to influence fertility rates, nothing to influence workforce participation, and a great deal to increase financial hardship and poverty. Via a synthesis of existing research, and a critical analysis of formal policy dialogue, I explore the specifically reproductive politics of the two-child limit. I cast the limit as “successful” reproductive governance, a “technology of discipline” with complementary effects and rationales, which works by further marginalizing intersectionally marginalized women. In concluding, I argue that the state justifies this abject outcome via what has been termed “cultural gaslighting.”

How informality keeps multilateralism going: the role of informal groupings in EU foreign policy negotiations

How informality keeps multilateralism going: the role of informal groupings in EU foreign policy negotiations

Counting women? Gendered sustainability and inclusivity for an ocean accounting framework

ABSTRACT The oceans are increasingly pivotal in scholarly and policy dialogues focused on achieving inclusive economic and social prosperity. The Ocean Account Global Framework (2020) underscores oceans' role as essential for social and economic development, crucially contributing to human well-being and gender equality. With oceans holding significant economic potential, governments face mounting pressure to systematically account for ocean resources and their utilisation (Ocean Account Global Framework, 2020). This need is particularly acute given the evolving relationships between economic prosperity, inclusive development, social well-being, and oceans. However, a knowledge gap persists, impairing governments' ability to make informed and gender inclusive decisions about oceans and undermining long-term commitments outlined in the 2030 Agenda for Sustainable Development (Ocean Global Account Framework, 2020). This article examines ocean governance, focusing on gender-related aspects and integrating gender perspectives into the ocean accounting framework using a political economy lens, supported by environmental and gender political economy analyses.

Power Relations in Optimisation of Therapies and Equity in Access to Antibiotics (PROTEA) Study: investigating the intersection of socio-economic and cultural drivers on antimicrobial resistance (AMR) and its influence on healthcare access and health-providing behaviours in India and South Africa.

Across social structures within society, including healthcare, power relations manifest according to gender, socioeconomic status, race, ethnicity, and class influencing infection related healthcare access and health providing-behaviours. Therefore, accounting for sociocultural drivers, including gender, race, and class, and their influence on economic status can improve healthcare access and health-providing behaviours in infection prevention and control (IPC) as well as antibiotic use, which in turn helps mitigate the spread of antimicrobial resistance (AMR). This Wellcome funded research will investigate how and why the social determinants of health and economic status influence how people seek, experience, and provide healthcare for suspected or proven (bacterial) infections and how these factors influence antibiotic prescribing and use in South Africa (upper middle-income country) and India (lower middle-income country). The aim of this body of work is to, (1) define and estimate the sociocultural and economic drivers for AMR in different resource settings, (2) design, implement and evaluate context-sensitive IPC and antimicrobial stewardship (AMS) interventions, and (3) inform policy and strategy for AMR mitigation. The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related healthcare access and health-providing behaviours will be studied. Qualitative methods will include ethnographic research, semi-structured in-depth interviews, and focus groups with healthcare providers, patients and carers. Quantitative analysis of bedside observational data from hospitals and population level data on antibiotic use will study the various predictors of AMR using bivariable and multivariable regression analyses. The research will provide high-quality evidence on how social determinants intersect with health, social well-being, and vulnerability in IPC practices and antibiotic use. Using this knowledge we will: 1) design, implement, and measure effects of interventions accounting for these factors; 2) provide a toolkit for advocacy for actors in AMR, and healthcare to assist them to promote dialogue, including policy dialogue on this issue. This work directly benefits the target population and informs healthcare services and practice across the participating countries with potential for wider translation. The setting will be hospitals in South Africa (middle-income country) and India (lower middle-income country). The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related health-seeking and health-providing behaviours will be studied. These populations represent communities most affected by infections and AMR because existing interventions do not address a) differences in how surgical versus medical teams manage infections; b) the role of the wider social network of individuals on their decision-making, c) intersection of the social determinants of health including race, gender, socioeconomic deprivation with AMR.