International Journal of Health Policy and Management
Volume:11 Issue: 5, May 2022

The control and prevention of public health emergencies can face severe challenges, especially financial and material challenges during the coronavirus disease 2019 (COVID-19). Enabling and ensuring smooth financial and material flows across levels, within the country, and across countries are essentially important to preparedness for global health emergencies, which cannot easily be achieved without being facilitated by preferential tax policies. China’s preferential tax policy practice developed at early stages of the COVID-19 pandemic could be useful experiences which can be adapted to unique contexts of other countries, so different stakeholders including citizens could be effectively motivated and involved in the fight against the COVID-19 pandemic. However, we should see that these policies are temporary and issued as an afterthought. There is still much to learn about how epidemic responders and policy-makers can make the most of each other’s expertise to fit into the wider information architecture of epidemic response.

In response to worldwide calls for the need to support evidence-informed policy-making (EIPM), more countries are increasingly interested in enhancing their efforts to use research to inform policy-making. In order to inform the efforts of those asked to lead the support of EIPM, our aim is to develop a conceptual framework to guide the process of establishing a policy support organization (PSO).

We conducted a critical interpretive synthesis (CIS). We conducted a two steps literature review. In the second step, we systematically searched OVID EMBASE, PsychInfo, HealthStar, CINAHL, Web of Science, Social Science Abstract, Health Systems Evidence, and ProQuest Dissertations and Theses Global databases for documents reporting the establishment of PSOs and the contextual factors influencing the process of establishing these organizations. We assessed the eligibility of the retrieved articles and synthesized the findings iteratively.

We included 52 documents in the synthesis. Our findings suggest that a PSO establishment process has four interconnected stages: awareness, development, assessment, and maturation. The process of establishing a PSO is iterative and influenced by political, research and health systems contextual factors, which determine the availability of the resources and the trust between researchers and policy-makers. The contextual factors have an impact on each other, and the challenges that arise from one factor can be mitigated by other factors.

For those interested in establishing a PSO, our framework provides a road map for identifying the most appropriate starting point and the factors that might influence the establishment process. Leaders of such PSOs can use our findings to expand or refine their scope of work. Given that this framework focuses only on PSOs in the health sector, an important next step for research would be to include other sectors from social systems and identify any additional insight that can enhance our framework.

Public investment, through both research grants and university funding, plays a crucial role in the research and development (R&D) of novel health technologies, including diagnostics, therapies, and vaccines, to address the coronavirus disease 2019 (COVID-19) pandemic. Using the example of remdesivir, one of the most promising COVID-19 treatments, this paper traces back public contributions to different stages of the innovation process. Applying the Risk-Reward Nexus framework to the R&D of remdesivir, we analyse the role of the public in risk-taking and reward and address inequities in the biomedical innovation system. We discuss the collective, cumulative and uncertain characteristics of innovation, highlighting the lack of transparency in the biomedical R&D system, the need for public investment in the innovation process, and the “time-lag” between risk-taking and reward. Despite the significant public transnational contributions to the R&D of remdesivir, the rewards are extracted by few actors and the return to the public in the form of equitable access and affordable pricing is limited. Beyond the necessity to treat remdesivir as a global public good, we argue that biomedical innovation needs to be viewed in the broader concept of public value to prevent the same equity issues currently seen in the COVID-19 pandemic. This requires the state to take a market-shaping rather than market-fixing role, thereby steering innovation, ensuring that patents do not hinder global equitable access and affordable pricing and safeguarding a global medicines supply.

The unprecedented severity of coronavirus disease 2019 (COVID-19) constitutes a serious public health concern. However, adoption of COVID-19-related preventive behaviours remain relatively unknown. This study investigated predictors of preventive behaviours.

An analytical sample of 897 Singaporean adults who were quota sampled based on age, gender, and ethnicity were recruited through a web-enabled survey. Outcomes were adoption of, or increased frequency of preventive behaviours (avoiding social events; avoiding public transport; reducing time spent shopping and eating out; wearing a mask in public; avoiding hospitals/clinics; keeping children out of school, washing hands/using sanitisers; keeping surroundings clean; avoiding touching public surfaces; working from/studying at home). Public perceptions regarding COVID-19 (chances of getting COVID-19; perceived likelihood of COVID-19-related intensive care unit (ICU) admission; government trust; self-efficacy; perceived appropriateness of COVID-19 behaviours; response efficacy), anxiety, and demographic characteristics (age; ethnicity; marital status; education; chronic conditions; current living arrangements) were investigated as predictors of preventive behaviours adopted during COVID-19 in binomial and ordered logistic regressions.

Though adoption of preventive behaviours among Singaporeans varied, it was, overall, high, and consistent with government recommendations. Nearly a quarter reported moderate to severe anxiety (General Anxiety Disorder 7-item – GAD-7 scores). Respondents who perceived higher COVID-19 risks, had higher government trust, higher self-efficacy, and perceived that others acted appropriately reported increased adoption/frequency of preventive measures. The strongest indicator of behavioural change was response efficacy. Respondents who were older, highly educated, anxious and married reported higher adoption/frequency of preventive measures.

To successfully influence appropriate preventive behaviours, public health messages should highlight response efficacy, increase self-efficacy, and promote trust in governmental response. Focus should be on demographic segments with low adoptions, such as younger individuals and those with low education.

Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model.

Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060.

SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases.Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060.

Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

We evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and ‘normalisation.’

A team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors (‘dose’ and ‘reach’ of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes and semi-structured interviews for determinants of CQI implementation and ‘normalisation’ using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks.

All interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered ‘dose’ was higher than planned but ‘reach’ was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation.

While CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements.

Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making.

We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis.

Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria.

The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0.

The European Medicines Agency (EMA) aims to resolve uncertainties associated with conditionally approved drugs by imposing post-approval studies. Results from these studies may be relevant for health technology assessment (HTA) organizations. This study investigated the role of regulator-imposed post-approval studies within HTA.

For all conditionally approved drugs up to December 2018, regulator-imposed post-approval studies were identified from EMA’s public assessment reports. The availability for and inclusion of study results in relative effectiveness (re)assessments were analyzed for 4 European HTA organizations: NICE (National Institute for Health and Care Excellence, England/Wales), HAS (Haute Autorité de Santé, France), ZIN (Zorginstituut Nederland, the Netherlands) and the European Network for Health Technology Assessment (EUnetHTA, Europe). When study results became available between an HTA organization’s initial assessment and reassessment, it was evaluated whether and how they affected the assessment and its outcome.

For 36 conditionally approved drugs, 98 post-approval studies were imposed. In total, 81 initial relative effectiveness assessments (REAs) and 13 reassessments were available, with numbers of drugs (re)assessed varying greatly between jurisdictions. Study results were available for 16 initial REAs (20%) and included in 14 (88%), and available for 10 reassessments (77%) and included in all (100%). Five reassessments had an outcome different from the initial REA, with 4 (2 positive and 2 negative changes) relating directly to the new study results. Reassessments often cited the inability of post-approval studies to resolve the concerns reported in the initial REA.

Results from regulator-imposed post-approval studies for conditionally approved drugs were not often used in REAs by HTA organizations, because they were often not yet available at the time of initial assessment and because reassessments were scarce. When available, results from post-approval studies were almost always used within HTA, and they have led to changes in conclusions about drugs’ relative effectiveness. Post-approval studies can be relevant within HTA but the current lack of alignment between regulators and HTA organizations limits their potential.

Following the re-imposition of US sanctions against Iran in 2018, unprecedented inflation has occurred in Iran’s food market that will undoubtedly affect the food security of the Iranian people. The present study aims to determine the effects of the sanctions on food prices and food security of Iranian households.

Interrupted time series (ITS) analysis was applied to assess the effects of sanctions on the average retail price of food products in Iran. Household food security was estimated by calculating the share of household food expenditure. Costs of following a healthy diet based on the food pyramid were estimated.

The import dependency ratio of Iran’s food market was about 25%. After sanctions due to the limitations in international financial exchanges a significant increase in the prices of all food groups occurred in 2018, the year after the re-imposition of sanctions. The highest inflation rate was observed in vegetable, meat, and fruit groups. The percentage of urban and rural households in Iran that were prone to food insecurity increased from 8.84% and 25.17% to 11.2% and 29.2%, respectively, from 2017 to 2019. The annual average cost of a healthy diet for a sample Iranian family of 3.3, based on the current prices, is 341 866 008 IRR (US$2849) which is 3.6 times greater than the average amount Iranian families spent on food last year (94 505 000 IRR or US$788).

After the re-imposition of US sanctions against Iran, food insecurity as a result of economic vulnerability, has increased and due to the current status of food prices and incomes, following a healthy diet has become more difficult for most Iranians. This makes the Iranian population more prone to chronic diseases in the near future and if this trend persists, it places the country in danger of food crisis and political instability.

Individuals with serious mental illness face challenges in managing their health, leading to the need for integrating their needs and preferences in care decisions. One way to enhance collaboration between users and providers is to improve clinical governance; a shared responsibility between managers and providers, supported by healthcare organizations (HCOs), policies, and standards. We applied the concept of clinical governance to understand (1) how managers and providers can enhance the involvement of users in mental health, (2) the contextual and organizational factors that facilitate user involvement in care, and (3) the users’ perceptions of their involvement in care.

We conducted two, in-depth case studies from two clinical teams in Canada offering outpatient care for users with acute mental illness. A total of 25 interviews were carried out with managers, and four focus groups were held with providers. A measure of patient-reported experience was used to evaluate the users’ perceptions of their involvement in care.

The providers used two methods to involve users in the care planning process: encouraging users to identify their life goals and supporting them to define recovery-oriented objectives. To encourage the adoption of collaborative practices, the managers used various practices such as revising care protocols, strengthening providers’ knowledge of best practices and integrating peer-support workers (PSWs) in the team. Compliance with organizational and external commitments/requirements for user involvement, access to specific training and the institutionalization of a culture promoting user involvement facilitated the adoption of collaborative practices. We found that mental health teams that adopt recovery and collaborative practices with users show a high degree of user-perceived involvement in care.

This is the first study to apply the concept of clinical governance to understand how managerial and clinical practices, and other organizational and contextual factors, can enhance the involvement of mental healthcare users.

Numerous countries have undertaken performance-based financing (PBF) reforms to improve quality and quantity of healthcare services. However, only few reforms have successfully managed to achieve the different scale-up phases. In Burkina Faso, a pilot project was implemented, but was put on hold before being scaled. During the writing of this article, discussions to scale-up were still ongoing on a national strategic purchasing strategy within a government led user fee exemption policy.

This study’s objective is to identify facilitators and barriers to scaling-up for that pilot, based on the World Health Organization’s (WHO’s) theoretical framework. Interviews were conducted in three health centres and in Ouagadougou to discuss the scale-up with different actors. The software QDA Miner© was used to help in the framework analysis.

The low involvement of some key stakeholders (mainly decision-makers) and the unstable context hindered ownership of the project, thus its priority on the political agenda. PBF reform therefore lost its momentum to the benefit of a user fee exemption policy. This latter program was seen to be more beneficial since it addressed access to healthcare services, in comparison to service quality, which was the PBF’s relative advantage. A scale-up of some PBF elements (eg, strategic purchasing tools) is however still in discussion in 2019, but would be integrated within the user fee exemption program. Increased costs during the PBF’s implementation gave the impression that the project was too costly and not scalable. The involvement of an important funding agency (World Bank, WB) also fed the impression of high costs, which demotivated the actors, especially decision-makers.

Contextual factors remain central to the implementation of PBF, while their evaluation and mitigation have remained unclear. The participation of key actors in scaling-up operations and the use of social science as tools to better understand the context is therefore primordial.

The growth of chain pharmacies in India, and other low- and middle-income countries (LMICs), is challenging the status quo of pharmacy retail markets which have historically been dominated by independent pharmacies. This raises the question of whether such organisations will have a positive impact on affordability and access to medicines. 

This paper draws on a standardised patient (SP) survey to measure the prices of medicines and expenditure on consultations for two tracer conditions (suspected tuberculosis [TB] in an adult and diarrhoea in an absent child) at a random sample of 230 chain and independent pharmacies in Bengaluru. Asset data were collected from 808 exit interviews with pharmacy customers to determine socioeconomic profiles of clients. 

Chain pharmacies were found to provide lower priced medicines for patients seeking care for diarrhoea and TB, with expenditure also lower for diarrhoea patients, compared to independent pharmacies. This was seemingly driven by lower prices rather than number of medicines dispensed or prescribing habits. Despite the availability of cheaper medicines, chains served wealthier clients, compared to independent pharmacies. 

The findings indicate the potential for chains to contribute to improving medicine affordability as they expand. However, any attempt to leverage this organisational model for public health good would need to take account of the current client-mix of these pharmacies and be accompanied by appropriate regulatory constraints in order to realise the potential benefits for poorer groups.

Universal health coverage (UHC) is central to current international debate on health policy. The primary healthcare (PHC) system is crucial to achieving UHC, in order to address the rising incidence of non-communicable diseases (NCDs) more effectively and equitably. In this paper, we examine the Australian case as a mature system of UHC and identify lessons for UHC policy to support equity of access to PHC and reduce NCDs.

Our qualitative research used policy mapping and monitoring and 30 key informant interviews, and applied policy theory, to investigate the implementation of Australian PHC policy between 2008 and 2018.

Although the Australian PHC system does support equity of access to primary medical care, other ideational, actor-centred and structural features of policy detract from the capacities of the system to prevent and manage NCDs effectively, deliver equity of access according to need, and support equity in health outcomes. These features include a dominant focus on episodic primary medical care, which is a poor model of care for NCDs, and an inequitable distribution of these services. Also, a mixed system of public and private insurance coverage in PHC contributes to inequities in access and health outcomes, driving additional NCD demand into the health system.

Countries aiming to achieve UHC to support health equity and reduce NCDs can learn from strengths and weaknesses in the Australian system. We recommend a range of ideational, actor-centred and structural features of UHC systems in PHC that will support effective action on NCDs, equity of access to care according to need, and equity in health outcomes across geographically and ethnically diverse populations.

The World Health Organization (WHO) aims to facilitate the development of universal health coverage (UHC) wherever possible. One of its major concerns is the epidemic of non-communicable disease (NCD). For health systems to address this epidemic, countries need primary health care systems which are affordable, accessible, integrated and comprehensive. This commentary addresses that issue with reference to the paper by Fisher et al with respect to the structures, actors, and ideas identified in the paper. It focuses mainly on funding models to address structural issues and control actors, and on the importance of constant lobbying to address the ideas needed to achieve UHC.

Equity and universality are implicit in universal health coverage (UHC), although ambiguity has led to differing interpretations and policy emphases that limit their achievement. Diverse country experiences indicate a policy focus on differences in service availability and costs of care, and neoliberal policies that have focused UHC on segmented financing and disease- focused benefit packages, ignoring evidence on financing, service, rights-based and social features that enable equity, continuity of care and improved population health. Public policies that do not confront these neoliberal pressures limit equity-promoting features in UHC. In raising the impetus for UHC and widening public awareness of the need for public health systems, coronavirus disease 2019 (COVID-19) presents an opportunity for challenging market driven approaches to UHC, but also a need to make clear the features that are essential for ensuring equity in the progression towards universal health systems.

Health systems built on the foundation of primary healthcare (PHC) are essential to achieve universal health coverage (UHC). To adequately respond to the needs of people with non- communicable diseases (NCDs) and enable optimal management in primary care settings, changes are needed at many levels. PHC levers recommended in the UHC framework as the cornerstone of achieving Sustainable Development Goal (SDG) goals by strengthening the primary care system include strategic and operational levers. Experience from hypertension control programs across 18 countries has shown that rapid scale-up can be achieved through systematic improvement of the PHC system brought about by political commitment, financial support, and high-quality people-centred primary care. As countries are gripped with the pandemic the importance of an appropriate and resilient health system fit for the country is emerging as a priority for building preparedness. While there are general principles, each country must learn by doing and scale up models relevant to the national context.

Fisher et al have published a thought-provoking article exploring the complex relationship between universal health coverage (UHC) and equity. This commentary builds on two of the lessons they highlight: the importance of ideas in determining how exactly UHC advances equity, and the political difficulties of addressing the commercial determinants of health. I argue that equity in UHC can be advanced through interventions that address popular prejudices against public health systems, greater emphasis on structural and commercial drivers of ill-health in health professionals’ training, and by ensuring meaningful public participation in decision-making about the institutionalisation and management of UHC. These strategies are important for ensuring that the political, power-laden nature of concepts such as “universality”, “health” and “care” are explicitly acknowledged and publicly debated – rather than continuing the current trend of allowing technocrats to reduce UHC to a matter of efficiently and expeditiously financing curative healthcare services.

This commentary refers to the article by Fisher et al on lessons from Australian primary healthcare (PHC), which highlights the role of PHC to reduce non-communicable diseases (NCDs) and promote health equity. This commentary discusses important elements and features when aiming for health equity, including going beyond the healthcare system and focusing on the social determinants of health in public health policies, in PHC and in the healthcare system as a whole, to reduce NCDs. A wider biopsychosocial view on health is needed, recognizing the importance of social determinants of health, and inequalities in health. Public funding and universal access to care are important prerequisites, but regulation is needed to ensure equitable access in practice. An example of a PHC reform in Sweden indicates that introducing market solutions in a publicly funded PHC system may not benefit those with greater needs and may reduce the impact of PHC on population health.

Fisher et al have provided a solid addition to health policy literature in their finding that universal health coverage supports equitable access to Australian primary healthcare (PHC), despite factors such as episodic care and poor distribution of services. Their definition of PHC was comprehensive, extending beyond medical care to include social determinants of health and public policy. However, they limited their operational definition for purposes of the study to general practice, community health and allied health. Applying a narrower definition risks lost opportunities to identify policy implications for equity beyond financial accessibility. The populations most at risk of noncommunicable diseases also face significant language, culture, and individual and systemic discrimination barriers to access. Future policy research should consider using a comprehensive PHC definition in determining variables of interest and designing research methodologies, to avoid missing important knowledge that allows existing biases within primary care to continue.