International Journal of Health Policy and Management
Volume:10 Issue: 6, Jun 2021

Throughout the United Kingdom, the National Health Service (NHS) struggles to meet demand and achieve performance targets. Services need to work with individuals and communities to reduce avoidable disease and dependence. All four UK nations have separately realised the need for change but 20 years’ experience suggests that vision and rhetoric are not enough. Success requires reformed systems and changed leadership behaviour to enable frontline staff to break the status quo. Top down, target driven behaviour must be replaced with a real focus on improvement, championing those who have the knowledge to deliver it.

The failure of some high-income countries to retain their medical graduates is one driver of doctor immigration from low- and middle-income countries. Ireland, which attracts many international medical graduates, implemented a doctor retention strategy from early 2015. This study measures junior doctors’ migration intentions, the reasons they leave and likelihood of them returning. The aim is to identify the characteristics and patterns of doctors who plan to emigrate to inform targeted measures to retain these doctors.

A national sample of 1148 junior hospital doctors completed an online survey in early 2018, eliciting their experiences of training and working conditions. Respondents were asked to choose between the following career options: remain in Ireland, go and return, go and stay away, or quit medicine. Bivariate analyses and a two-stage multivariable analysis were used to model the factors associated with these outcomes.

45% of respondents planned to remain in Ireland, 35% leave but return later, 17% leave and not return; and 3% to quit medicine. An intention to go abroad versus remain in Ireland was independently associated (P<.05) with the doctor being under 30 years (odds ratio [OR]=1.09 per year under 30), a non-European Union (EU) national (OR=1.54), a trainee (OR=1.50), and with hospital specialization, especially in Anesthesiology (OR=5.09). Respondents were more likely to remain if they had experienced improvements in supervision and training costs. Intention to go abroad and not return versus go and return was independently associated (P<.05) with: age over 30 years (OR=1.16 per year over 30); being a non-EU (OR=9.85) or non-Irish EU (OR=3.42) national; having trained through a graduate entry pathway (OR=2.17), specializing in Psychiatry (OR=4.76) and reporting that mentoring had become worse (OR=5.85).

Ireland’s doctor retention strategy has not addressed the root causes of poor training and working experiences in Irish hospitals. It needs a more diversified retention strategy that addresses under-staffing, facilitates circular migration by younger trainees who choose to train abroad, identifies and addresses specialty-specific factors, and builds mentoring linkages between trainees and senior specialists.ش

Transnational networks such as Communities of Practice (CoPs) are flourishing, yet their role in diffusing health systems reforms has been seldom investigated. Over the past decade, performance-based financing (PBF) has rapidly spread in Africa. This study explores how, through the PBF Community of Practice’s attributes, structure, and strategies, PBF diffusion was fostered in sub-Saharan Africa (SSA).

Informed by the diffusion entrepreneurs’ (DEs) framework dimensions, we used a mixed methods convergent design to investigate how the attributes, structure, and strategies of this community fostered the diffusion of PBF. The quantitative strand of work included firstly a semantic discourse analysis of textual data extracted from CoP’s online discussion forum (n=1346 posts). Secondly, the relational data extracted from these 1346 forum posts was examined using social network analysis (SNA). We confronted these quantitative results with a thematic analysis of qualitative interviews (n=40) and data extracted from the CoP’s key documentation (n=17).

CoP members’ attributes included: representation systems anchored in clinical and economic sciences, strong expectations that the CoP would boost professional visibility and career, and significant health systems knowledge and social resources. The CoP’s core group, dominated by high-income country (HIC) members, critically matched PBF principles to major health systems issues in Africa. The broad consensus in online PBF thematic discussions created a strong sense of community, a breeding ground for emulation among CoP members. The CoP also sought to produce and promote experiential knowledge exchanges about PBF amongst African practitioners. Findings from network analyses showed that the promoted Africa-driven community was led by HIC members, although their prominence tended to decrease with time.

This empirical research highlighted some of the constituting features, structure, and strategies of policy networks in influencing health policy diffusion. Despite good intentions to disrupt the established governance landscape, influential actors coming from HICs continued to drive the framing, and shaped health systems policy experimentation, emulation, and learning in African countries. Beyond mere knowledge exchange platforms, CoP can act as meaningful transnational policy networks pursuing the diffusion of health systems reforms, such as PBF.

Transnational tobacco companies (TTCs) have a well-established presence in Southeast Asia and are now targeting other low- and middle-income countries (LMICs), especially Africa. While the tobacco industry’s tactics in Southeast Asia are well-documented, no study has systematically reviewed these tactics to inform tobacco control policies and movements in Africa, where the tobacco epidemic is spreading.

We conducted a systematic literature review of articles that describe tobacco industry tactics in Southeast Asia, which includes Singapore, Indonesia, Malaysia, the Philippines, Myanmar, East Timor, Thailand, Cambodia, Vietnam, Laos, and Brunei. After screening 512 articles, we gathered and analysed data from 134 articles which met our final inclusion criteria.

Tobacco transnationals gained dominance in Southeast Asian markets by positioning themselves as good corporate citizens with corporate social responsibility (CSR) initiatives, promoting the industry as a pillar of, and partner for, economic growth. Tobacco transnationals also formed strategic sectoral alliances and reinforced their political ties to delay the implementation of regulations and lobby for weaker tobacco control. Where governments resisted the transnationals’ attempts to enter a market, they used litigation and deceptive tactics including smuggling to pressure governments to open markets, and tarnished the reputation of public health organizations. The tobacco industry undermined tobacco advertising, promotion and sponsorship (TAPS) regulations through a broad range of direct and indirect marketing tactics.

The experience of Southeast Asia with tobacco transnationals show that, beyond highlighting the public health benefits, underscoring the economic benefits of tobacco control might be a more compelling argument for governments in LMICs to prioritise tobacco control. Given the tobacco industry’s widespread use of litigation, LMICs need more legal support and resources to counter industry litigations. LMICs should also prioritize measures to protect health policy from the vested interests of the tobacco industry, and to close regulatory loopholes in tobacco marketing restrictions.

It is widely acknowledged that systems thinking (ST) should be implemented in the area of public health, but how this should be done is less clear. In this commentary we focus on sense-making and double-loop learning processes when using ST and soft systems methodology in research collaborations with policy-makers. In their study of policy-makers’ experiences of ST, Haynes et al emphasize the importance of knowledge processes and mutual learning between researchers and policy-makers, processes which can change how policy-makers think and thus have impact on real-world policy concerns. We provide some additional examples from Sweden on how ST has been applied to create learning and shared mental models among stakeholders and researchers in national and regional healthcare development initiatives. We conclude that investigating and describing such processes on micro-level can aid the knowledge on how to implement ST in public health.

Advocates suggest that a paradigm shift in preventive health towards systems thinking is desirable and may be underway. In a recent study of policy-makers’ opinions, Haynes and colleagues found a mixed response to an Australian initiative that sought to apply systems theories and associated methods to preventive health. Some were enthusiastic about systems, but others were concerned or unconvinced about its usefulness. This commentary responds to such concerns. We argue that a systems perspective can help provide policy-makers with timely evidence to inform decisions about intervention planning and delivery. We also suggest that research applying a systems perspective could provide policy-makers with evidence to support planning and incremental decision-making; make recommendations to support intervention adaptability; consider potential barriers due to incoherent systems, and consider the political consequences of interventions.

In this paper we argue, for an increased congruence between the conceptual frameworks and the research methodology in studies focused on the theory or practice of systems and complexity-informed thinking (SCT). In doing so, we believe we can build more complex forms of knowledge with clearer and more impactful implications for practice. There is scope for both methodological innovations and the adaptation of traditional research methods to enact properties congruent with the systemic complexity of our targeted realities. We organise our reflection around the paper of Haynes et al. We provide examples of how a research methodology more deeply embedded in systems and complexity-thinking may add depth and meaning to the research results and their interpretation. We explore the creative adaptation of the interview techniques to integrate systemic forms of questioning (eg, circular and reflexive questioning) to map the patterns of interaction contributing to the outcomes of interventions.

The published literature on the application of systems thinking to influence policies and programs has grown in recent years. The original article by Haynes et al and the subsequent commentaries have focused on the upstream connection between capacity building for systems thinking and systems informed decision-making. This commentary explores the downstream connection between systems-informed decision-making and broader impacts on the health system, the health of the population and other economic and social benefits. Storytelling, systems-based syntheses and systems intervention principles are explored as approaches to strengthen the evidence base. For systems thinking to gain broader acceptance and application to complex health-related challenges, we need more of an evidence base demonstrating impact.