International Journal of Health Policy and Management
Volume:11 Issue: 12, Dec 2022

In line with the global trend, the Middle East and North Africa (MENA) region has been growing vulnerable to the direct and indirect health effects of climate change including death tolls due to climatological disasters and diseases sensitive to climate change since the industrial revolution. Regarding the limited capacity of MENA countries to adapt and respond to these effects, and also after relative failures of the previous negotiation in Glasgow, in the upcoming COP27 in Egypt, the heads of the region’s parties are determined to take advantage of the opportunity to host MENA to mitigate and prevent the worst effects of climate change. This would be achieved through mobilizing international partners to support climate resilience, a major economic transformation, and put health policy and management in a strategic position to contribute to thinking and action on these pressing matters, at least to avoid or minimize the future adverse consequences.

Background :

A ‘Health in All Policies’ (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities.

Methods :

Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model.

Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of ‘win-win’ strategies. External factors such as economic shocks and short political cycles reduced collaborative power.

This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

Background :

The health policy and systems research literature increasingly observes that knowledge translation (KT) practices are difficult to sustain. An important issue is that it remains unclear what sustainability of KT practices means and how it can be improved. The aim of this study was thus to identify and explain those processes, activities, and efforts in the literature that facilitate the sustaining of KT practices in health policy-making processes.

Methods :

We used a critical interpretive synthesis (CIS) to review the health policy and systems research and Science and Technology Studies (STS) literature. The STS literature was included as to enrich the review with constructivist social scientific perspectives on sustainability and KT. The CIS methodology allowed for creating new theory by critically combining both literatures. We searched the literature by using PubMed, Google Scholar, Web of Science, and qualitative sampling. Searches were guided by pre-set eligibility criteria and all entries were iteratively analysed using thematic synthesis.

Results :

Eighty documents were included. Our synthesis suggests a shift from sustainability as an end-goal towards sustaining as actors’ relatively mundane work aimed at making and keeping KT practices productive. This ‘sustaining work’ is an interplay of three processes: (i) translating, (ii) contexting, and (iii) institutionalising. Translating refers to activities aimed at constructing and extending networks. Contexting emphasises the activities needed to create contexts that support KT practices. Institutionalising addresses how actors create, maintain, and disrupt institutions with the aim of sustaining KT practices.

Conclusion :

The ‘sustaining work’ perspective of our CIS emphasises KT actors’ ongoing work directed at sustaining KT practices. We suggest that this perspective can guide empirical study of sustaining work and that these empirical insights, combined with this CIS, can inform training programmes for KT actors, and thereby improve the sustainability of KT practices.

Health system performance indicators are widely used to assess primary healthcare (PHC) performance. Despite the numerous tools and some convergence on indicator criteria, there is not a clear understanding of the common features of indicator selection processes. We aimed to review the literature to identify papers that document indicator selection processes for health system performance indicators in PHC.

Methods :

We searched the online databases Scopus, Medline, and CINAHL, as well as the grey literature, without time restrictions, initially on July 31, 2019 followed by an update November 13, 2020. Empirical studies or reports were included if they described the selection of health system performance indicators or frameworks, that included PHC indicators. A combination of the process focussed research question and qualitative analysis meant a quality appraisal tool or assessment of bias could not meaningfully be applied to assess individual studies. We undertook an inductive analysis based on potential indicator selection processes criteria, drawn from health system performance indicator appraisal tools reported in the literature.

Results :

We identified 16 503 records of which 28 were included in the review. Most studies used a descriptive case study design. We found no consistent variations between indicator selection processes of health systems of high income and low- or lower-middle income countries. Identified common features of selection processes for indicators in PHC include literature review or adaption of an existing framework as an initial step; a consensus building process with stakeholders; structuring indicators into categories; and indicator criteria focusing on validity and feasibility. The evidence around field testing with utility and consideration of reporting burden was less clear.

Conclusion :

Our findings highlight several characteristics of health system indicator selection processes. These features provide the groundwork to better understand how to value indicator selection processes in PHC.

Background :

Improving the quality of hospital care is an important policy objective. Hospitals operate under pressure to contain costs and might face challenges related to financial deficits. The objective of this paper was to identify and map the available evidence on the association between hospital financial performance (FP) and quality of care (Q).

Methods :

A scoping review was performed. Searches were conducted in 7 databases: Medline via PubMed, EMBASE, Web of Science, Scopus, EconLit, ABI/INFORM, and Business Source Complete. The search strategy combined multiple terms from 3 topics: hospital AND FP AND Q. The collected data were analysed using both quantitative and qualitative methods.

Results :

10 503 records were screened and 151 full text papers analysed. A total of 69 papers were included (60 empirical, 2 theoretical, 5 literature reviews, and 2 dissertations). The majority of identified studies were published within the last decade (2010-2021). Most empirical studies had been conducted in the United States (55/60), used cross-sectional approaches (32/60) and applied diverse regression models with FP measures as dependent variables, thus measuring the impact of Q on hospitals FP (34/60). The comparability of the studies’ results is limited due to differences in applied methods and settings. Yet, the general overview shows that in almost half of the cases the association between hospital FP and Q was positive, while no study showed a clear negative association.

This scoping review provides an overview of the available literature on the association between hospital FP and Q. The results highlight numerous research gaps: (1) systematic reviews and meta-analyses of existing studies with similar measures of FP and Q are unavailable, (2) further methodological/conceptual work is needed on the metrics measuring hospital FP and Q, and (3) more empirical studies should analyse the association between FP and Q in non-US healthcare settings.

Background :

The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts.

Methods :

This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of ‘simple rules’ for MSC.

Results :

Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge.

Conclusion :

Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.

Background :

Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interest (COIs). We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.

Methods :

Using documentary sources and a stakeholder survey we identified country- regulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the United Kingdom, a country with a major role in Europe’s R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data  from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.

Results :

In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a selfregulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the United Kingdom suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available companylevel data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D.

Conclusion :

The lack of full disclosure of R&D payments in countries with industry self-regulation leaves considerable sums of money unaccounted for and potentially many COIs undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.

At present, the avoidance of drug shortages mainly relies on expert experience. This study aimed to establish an evaluation index system for the risk of drug shortages in medical institutions in China and to apply the system to guide the graded management of drugs in short supply.

A two-round Delphi process was conducted to determine the indicators in the index system. The weight value of each indicator was calculated using analytic hierarchy process (AHP) methods. The data of drugs in short supply from January 1 to December 31, 2020 in Hunan province were collected and evaluated using this index system. The evaluation scores, which ranged from 0 to 100, were calculated.

A three-level index system with four first-level indicators, 11 second-level indicators, and 36 third-level indicators was constructed by the two rounds of the Delphi process. The expert authority coefficient (Cr) of the first and second rounds of consultation were 0.88 and 0.90, respectively. The Kendall’s coefficients of concordance (Kendall’s W) for the two rounds of consultation were 0.44 and 0.50, respectively (P<.05). For the first-level indicators ‘supply stability,’ ‘causes of shortage,’ ‘medicine availability in medical institution’ and ‘pharmaceutical properties,’ the weight values were 0.3253, 0.2489, 0.2398, and 0.1860, respectively. Based on the risk evaluation score, drugs (dosage strength) at high risk of shortage included sodium thiosulfate (0.64 g), posterior pituitary lobe hormones (1 mL:6 IU), protamine sulfate (5 mL:50 mg), thrombin (500 U), urokinase (10 WU), and rotundine sulfate (2 mL:60 mg).

An indexed system for the risk assessment of drug shortages in China was established to guide the graded response to drug shortages in medical institutions and the implementation of differential management strategies to address these shortages.

Community participation is central to primary healthcare, yet there is little evidence of how this works in conflict settings. In 2016, South Sudan’s Ministry of Health launched the Boma Health Initiative (BHI) to improve primary care services through community participation.

We conducted a document analysis to examine how well the BHI policy addressed community participation in its policy formulation. We reviewed other policy documents and published literature to provide background context and supplementary data. We used a deductive thematic analysis that followed Rifkin and colleagues’ community participation framework to assess the BHI policy.

The BHI planners included inputs from communities without details on how the needs assessment was conducted at the community level, what needs were considered, and from which community. The intended role of communities was to implement the policy under local leadership. There was no information on how the Initiative might strengthen or expand local women’s leadership. Official documents did not contemplate local power relations or address gender imbalance. The policy approached households as consumers of health services.

Although the BHI advocated community participation to generate awareness, increase acceptability, access to services and ownership, the policy document did not include community participation during policy cycle.

Health workers are central to health policy-making. Given health systems’ complex, dynamic and political nature, various forms of ‘hidden power’ are at play as health workers navigate health systems. This study aims to explore the dynamics of power and its sources, and how this shapes policy-making and implementation within the Nigerian health systems context.

The case study was the Global Fund grant in Nigeria, and results are based on an in-depth qualitative study involving 34 semi-structured key informant interviews (KIIs), board-meeting observations, and documentary analysis conducted in 2014 and 2016. Participants held mid to senior-level positions (eg, Director, Programme Manager) within organisations involved with Global Fund activities, particularly proposal development and implementation. Data were analysed using thematic analysis in order to gain insight into the power dynamics of health professionals in policy processes.

Medical professionals maintained dominance and professional monopoly, thereby controlling policy spaces. The structural and productive power of the biomedical discourse in policy-making encourages global actors and the local government’s preference for rapid biomedical models that focus on medications, test kits, and the supply of health services, while neglecting aspects that would help us better understand the poor uptake of these services by those in need. The voices of the repressed groups (eg, non-clinical experts, patients and community based organisations) that better understand barriers to uptake of services are relegated.

Professional monopoly theories help illustrate how medical professionals occupy and maintain an elite position in the health system of Nigeria. Structural and agential factors specific to the contexts are key in maintaining this professional monopoly while limiting the opportunities for other health occupations’ rise up the social status ladder.

Uganda’s community health worker (CHW) program experiences several challenges related to the appropriate motivation, job satisfaction, and performance of the CHW workforce. This study aims to identify barriers in the effective implementation of financial and non-financial incentives to support CHWs and to strengthen Uganda’s CHW program.

The study was implemented in Uganda’s Lira, Wakiso, and Mayuge districts in May 2019. Ten focus group discussions (FGDs) were held with 91 CHWs, 17 in-depth interviews (IDIs) were held with CHW supervisors, and 7 IDIs were held with policy-level stakeholders. Participants included stakeholders from both the Ugandan government and non-governmental organizations (NGOs). Utilizing a thematic approach, themes around motivation, job satisfaction, incentive preferences, and CHW relationships with the community, healthcare facilities, and government were analyzed.

CHWs identified a range of factors that contributed to their motivation or demotivation. Non-monetary factors included recognition from the health system and community, access to transportation, methods for identification as a healthcare worker, provision of working tools, and training opportunities. Monetary factors included access to monthly stipends, transportation-related refunds, and timely payment systems to reduce refund delays to CHWs. Additionally, CHWs indicated wanting to be considered for recruitment into the now-halted rollout of a salaried CHW cadre, given the provision of payment.

It is imperative to consider how to best support the current CHW program prior to the introduction of new cadres, as it can serve to exacerbate tensions between cadres and further undermine provision of community health. Providing a harmonized, balanced, and uniform combination of both monetary incentives with non-monetary incentives is vital for effective CHW programs.

Integrating nutrition actions into service delivery in different policy sectors is an increasing concern. Nutrition literature recognizes the discrepancies existing between policies as adopted and actual service delivery. This study applies a street-level bureaucracy (SLB) perspective to understand frontline workers’ practices that enact or impede nutrition integration in services and the conditions galvanizing them.

This qualitative exploratory study assesses the contextual conditions and practices of 45 frontline workers employed by the agriculture, health and community development departments in two Ugandan districts.

Frontline workers incur different demands and resources arising at societal, organizational, and individual level. Hence, they adopt nine co-existing practices that ultimately shape nutrition service delivery. Nutrition integration is accomplished through: (1) ritualizing task performance; (2) bundling with established services; (3) scheduling services on a specific day; and (4) piggybacking on services in other domains. Disintegration results from (5) non-involvement and (6) shifting blame to other entities. Other practices display both integrative and disintegrative effects: (7) creaming off citizens; (8) down prioritization by fixating on a few nutrition actions; and (9) following the bureaucratic ‘jobs worth’. Integrative practices are driven mostly by donors.

Understanding frontline workers’ practices is crucial for identifying policy solutions to sustain nutrition improvements. Sustaining services beyond timebound projects necessitates institutionalizing demands and resources within government systems. Interventions to facilitate effective nutrition service delivery should strengthen the integrative capacities of actors across different government levels. This includes investing in integrative leadership, facilitating frontline workers across sectors to provide nutrition services, and adjusting the nutrition monitoring systems to capture cross-sector data and support policy learning

Long work hours for physicians not only harm the health of physicians, but also endanger patient safety. Compared with resident physicians, attending physicians—especially hospital-employed attending physicians—assume more responsibilities but has not gotten enough attention. The purpose of this study was to explore whether a hospital’s geographic location and emergency care responsibility might influence the number of hours worked.

The respondents of 2365 attending physicians from 152 hospitals in the 2018 survey of Taiwan physician work hours were used as the data source. The total work hour per week and its components, the regular scheduled shift and three types of on-call shifts, were used as outcome variables. Hospital geographic location and emergency care responsibility were the independent variables. The multilevel random effect model was employed to examine the study objective after adjusting for clinical specialty, hospital teaching status, and ownership.

The average number of total working hours was 69.09 hours per week; the regular scheduled shift was account for 75% of total work hours. The results showed the total work hours were only varied by the level of hospital’s emergency care responsibility. However, the results also demonstrated the hours of duty shifts were varied by hospital’s geographic location and emergency care responsibility. The results of the multilevel random effect model revealed that the hospital’s emergency care responsibility was the factor consistently associated with attending physician’s work hour, no matter the total work hours or its composition.

In this study, we explored how a hospital’s location and its level of emergency care responsibility were associated with physicians’ work hours for each type of shift. Our findings offer an opportunity to review the rationality of physician workforce allocation, and financial incentives and administrative measures could be the next steps for balancing the work hours of attending physicians

There is limited knowledge about interventions used for the improvement of low-performing healthcare organisations and their unintended consequences. Our evaluation sought to understand how healthcare organisations in the National Health Service (NHS) in England responded to a national improvement initiative (the Special Measures for Quality [SMQ] and challenged provider [CP] regimes) and its perceived impact on achieving quality improvements (QIs).

Our evaluation included national-level interviews with key stakeholders involved in the delivery of SMQ (n=6); documentary analysis (n=20); and a qualitative study based on interviews (n=60), observations (n=8) and documentary analysis (n=291) in eight NHS case study sites. The analysis was informed by literature on failure, turnaround and QI in organisations in the public sector.

At the policy level, SMQ/CP regimes were intended to be “support” programmes, but perceptions of the interventions at hospital level were mixed. The SMQ/CP regimes tended to consider failure at an organisational level and turnaround was visualised as a linear process. There was a negative emotional impact reported by staff, especially in the short-term. Key drivers of change included: engaged senior leadership teams, strong clinical input and supportive external partnerships within local health systems. Trusts focused efforts to improve across multiple domains with particular investment in improving overall staff engagement, developing an open, listening organisational culture and better governance to ensure clinical safety and reporting.

Organisational improvement in healthcare requires substantial time to embed and requires investment in staff to drive change and cultivate QI capabilities at different tiers. The time this takes may be underestimated by external ‘turn-around’ interventions and performance regimes designed to improve quality in the short-term and which come at an emotional cost for staff. Shifting an improvement focus to the health system or regional level may promote sustainable improvement across multiple organisations over the long-term.

  Youth participation makes an essential contribution to the design of policies and with the appropriate structures, and processes, meaningful engagement leads to healthier, more just, and equal societies. There is a substantial gap between rhetoric and reality in terms of youth participation and there is scant research about this gap, both globally and in South Africa. In this paper we examine youth participation in the Adolescent and Youth Health Policy (AYHP) formulation process to further understand how youth can be included in health policy-making.

  A conceptual framework adapted from the literature encompassing Place, Purpose, People, Process and Partnerships guided the case study analysis of the AYHP. Qualitative data was collected via 30 in-depth, semi-structured interviews with policy actors from 2019-2021.

Youth participation in the AYHP was a ‘first’ and unique component for health policy in South Africa. It took place in a fragmented policy landscape with multiple actors, where past and present social and structural determinants, as well as contemporary bureaucratic and donor politics, still shape both the health and participation of young people. Youth participation was enabled by leadership from certain government actors and involvement of key academics with a foundation in long standing youth research participatory programmes. However, challenges related to when, how and which youth were involved remained. Youth participation was not consistent throughout the health policy formulation process. This is related to broader contextual challenges including the lack of a representative and active youth citizenry, siloed health programmes and policy processes, segmented donor priorities, and the lack of institutional capability for multi-sectoral engagement required for youth health.

  Youth participation in the AYHP was a step toward including youth in the development of health policy but more needs to be done to bridge the gap between rhetoric and reality.

  Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]).

Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries.

  Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers.

  Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

  In northern Australia, Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are unique members of nominally integrated teams of primary care professionals. Spurred by research documenting ongoing structural violence experienced by Indigenous health providers and more recent challenges to recruitment and retention of A&TSIHWs, this study aimed to explore whether the governance of the A&TSIHW role supports full and meaningful participation.

  The qualitative study was co-designed by a team of Aboriginal, Torres Strait Islander and non-Indigenous collaborators. Data collection comprised document review and interviews with A&TSIHWs (n = 51), clinicians (n = 19) community members (n = 8) and administrators (n = 5) in a north Queensland health district. We analysed governance at multiple levels (regulatory, organisational, and socio-cultural) and used critical race theory to deepen exploration of the role of race and racism in shaping it.

Results :

 Governance of the A&TSIHW role occurs within a health system where racism is built into, and amplified by, formal and informal rules at all levels. Racially discriminatory structures such as the previous but long-standing relegation of A&TSIHW into the same career stream as cleaners were mirrored in discriminatory rules and managerial practices such as an absence of career-specific corporate support and limited opportunities to participate in, or represent to, key leadership groups. These interacted with and helped perpetuate workplace norms permissive of disrespect and abuse by non-Indigenous professionals. Ongoing resistance to the structural violence required of, and demonstrated by A&TSIHWs speaks to the gap between rhetoric and reality of governance for A&TSIHWs.

  Strengthening governance to support A&TSIHWs requires critical attention be given to the role of race and racism in regulatory structures, organisational practice, and inter-professional relationships. Addressing all domains will be essential to achieve systemic change that recognises, supports and embeds the unique knowledge, skills and functions of the A&TSIHW role.

  The association between timing of integrated home palliative care (IHPC) enrolment and emergency department (ED) visits is still under debate, and no studies investigated the effect of the timing of IHPC enrolment on ED visits, according to their level of emergency. This study aimed to investigate the impact of the timing of IHPC enrolment on different acuity ED visits.

  A retrospective, pre-/post-intervention study was conducted from 2013 to 2019 in Italy. Analyses were stratified by IHPC duration (short ≤30 days; medium 31-90 days; long >90 days) and triage tags (white/green: low level of emergency visit; yellow/red: medium-to-high level). The impact of the timing of IHPC enrolment was evaluated in two ways: incidence rate ratios (IRRs) of ED visits were determined (1) before and after IHPC enrolment in each group and (2) post-IHPC among groups.

  A cohort of 17 983 patients was analysed. Patients enrolled early in the IHPC programme had a significantly lower incidence rate of ED visits than the pre-enrolment period (IRR = 0.65). The incidence rates of white/green and yellow/red ED visits were significantly lower post-IHPC enrolment for patients enrolled early (IRR = 0.63 and 0.67, respectively). All results were statistically significant (P < .001). Comparing the IHPC groups after enrolment versus the short group, medium and long IHPC groups had a significant reduction of ED visits (IRR = 0.37, IRR = 0.14 respectively), showing a relation between the timing of IHPC enrolment and the incidence of ED visits. A similar trend was observed after accounting for triage tags of ED visits.

  The timing of IHPC enrolment is related with a variation of the incidence of ED visits. Early IHPC enrolment is related to a high significant reduction of ED visits when compared to the 90-day pre-IHPC enrolment period and to late IHPC enrolment, accounting for both low-level and medium-to-high level emergency ED visits.

  Even in countries having nearly universal healthcare provision some individuals forgo or postpone healthcare to which they are entitled. Socioeconomic and geographic inequalities can make access to healthcare difficult for some people, such that they fail to seek it, particularly if they deem the type of care as non-essential. The need to pay at the point of care, the complexity and cost of top-up health insurance, and delays or only partial reimbursement can discourage take-up of care. This can affect the general health of the population.

To estimate the rate of forgoing healthcare in the general French population, between 2015 and 2018 we conducted a nationwide cross-sectional survey of individuals visiting French primary healthcare insurance agencies (Caisse Primaire d’Assurance Maladie, CPAM). We asked whether the person had foregone or postponed healthcare in the last 12 months, if so the types of healthcare forgone or put-off, and reasons. Individuals were stratified by the type of complementary (top-up) health insurance they had.

  Out of 164 092 individuals who responded, 158 032 were included in the analysis. Respondents had either private complementary (top-up) insurance (60%), top-up insurance subsidized by the state (29%), or no top-up health insurance (11%). Forgoers (n=40 115; 25.4%) most often lived alone (with or without children), were unemployed, and/ or female. Dental care (54%) and consultations with ophthalmologists, gynaecologists and dermatologists (41%) were most commonly forgone. The reasons were: inability to advance payment and/or to pay the uninsured part (69%), time constraints and difficulty in obtaining appointments (26%).

  We present a snapshot of forgoing healthcare in a developed country, highlighting the need for continuing review by policy-makers of payment regimens, insurance cover, availability and accessibility. While initiatives have already emerged from the results, further reforms are needed to address the problem of people forgoing preventative or perceived non-urgent healthcare, particularly for disadvantaged subgroups.

  Successful implementation of an antimicrobial stewardship program (ASP) depends on staff members’ response to it. We introduced at the Hadassah Medical Center in Israel a significant change to our long-standing handshake ASP. As before, the new ASP involved a dialogue between the treating physician and the infectious disease physician over the appropriate antibiotic therapy. The main change was that the infectious disease physician’s decision was now integrated into the patient’s electronic medical record (EMR). Our purpose in this study was to uncover the concerns and expectations of physicians and nurses towards the new ASP, before and after its implementation, and link these with their basic perceptions of the ASP and their personal values.

  We used open-ended questions and Likert-type scales to study staff members’ personal values, basic perceptions of the new system, and attitudes towards it, both before (N = 143), and one year after (N = 103) the system’s implementation. Relationships of the system’s perceptions and personal values with attitudes toward the system were tested using correlations and multiple regression analyses.

  Prior to its implementation, physicians and nurses had multiple concerns about the new ASP’s demandingness and inefficiency and its threat to physicians’ autonomy and expertise. They also had positive expectations for benefits to the hospital, the patients and society. A year later, following the system’s implementation, concerns dissipated, whereas the perceived benefits remained. Moreover, staff members’ attitudes tended to be more positive among those who value conformity.

  Introducing new ASPs is a challenging process. Our findings suggest that hospital staff ’s initial concerns about the new ASP were primarily about its ease of use and demandingness. These concerns, which diminished over time, were linked with perceived satisfaction with the system. Conformity values had an indirect effect in predicting satisfaction with the system, mediated by perceptions of the system as straightforward.

The community case management (CCM) program for malaria control is a community-based strategy implemented to regulate malaria in children in Burundi. This study compared the cost and utility of implementing the CCM program combined with health facility management (HFM) versus HFM alone for malaria control in children under five in Burundi.

  This study constructed a five-year Markov model with one-week cycles to estimate cost-utility and budget impact analysis (BIA). The model defined 10 health states, simulating the progression of the disease and the risk of recurrent malaria in children under five years of age. Cost data were empirically collected and presented for 2019. Incremental cost per disability-adjusted life year (DALY) averted, and a five-year budget was estimated. One-way and probabilistic sensitivity analyses (PSAs) were then performed.

  From provider and societal perspectives, combining the CCM program with HFM for malaria control in Burundi was more cost-effective than implementing HFM alone. The addition of CCM, using artesunate amodiaquine (ASAQ) as the first-line treatment, increased by US$1.70, and US$ 1.67 per DALY averted from the provider and societal perspectives, respectively. Using Artemether Lumefantrine (AL) as the first-line treatment, adding the CCM program to HFM increased by US$ 1.92, and US$ 1.87 per DALY averted from the provider and societal perspectives. At a willingness-to-pay of one GDP/capita, the CCM program remained a 100% chance of being cost-effective. In addition, implementing the program for five years requires a budget of US$ 15 800 486–19 765 117.

  Implementing the CCM program and HFM is value for money for malaria control in Burundi. The findings can support decision-makers in Burundi in deciding on resource allocation, especially during the program’s scale up.

  Research is central to high functioning health services alongside clinical care and health professional training. The impact of embedded research includes delivery of high-quality care and improved patient outcomes. Evaluations of research impact help health service leadership ensure investments lead to the greatest healthcare benefits for patients. This study aimed to retrospectively evaluate the impact of research investment from 2008 to 2018 at Townsville Hospital and Health Service (THHS), a regional Hospital and Health Service in Queensland, Australia. The evaluation also sought to identify contextual conditions that enable or hinder intended impacts.

A mixed-methods realist-informed evaluation was conducted using documentation, interviews with 15 staff and available databases to identify and measure research investments, impacts and contextual conditions influencing impact outcomes.

  Between 2008 and 2018, THHS increased resources for research by funding research projects, employing research personnel, building research-enabling facilities, hosting research events, and providing research education and training. Clinical practice, policy and workforce impacts were successful in isolated pockets, championed by individual researchers and facilitated by their policy and community-of-practice networks. However, there was little organisationallevel support for continuity of research and implementation into practice and policy. Availability of research supports varied geographically across THHS, and across disciplines.

Definitive steps in the development of THHS as a credible and productive research centre and leading hospital research centre in Northern Australia are evident. Continuing investments should address support for the research continuum through to translation and establish ongoing, systematic processes for evaluating research investment and impact.

  Integrated home care (IHC) is one strategy to provide care to people with multiple chronic conditions, and it contributes to the reduction of unnecessary emergency department (ED) use, but there are conflicting results on its effectiveness. In this study, we assessed the frequency and characteristics of ED visits occurring before, during, and after IHC in a large cohort of IHC patients enrolled over 6 years.

  The analysis included 39 822 IHC patients identified in Italian administrative databases. Patients were grouped in tertiles according to IHC duration (short, intermediate, and long) and the number of ED visits during IHC was compared to that the 12 months before IHC enrolment and in the 12 months after IHC discharge across IHC duration groups.

We observed a reduction in ED visits during IHC. IHC was significantly associated with a reduction in ED visits in the long and short IHC duration groups. A non-significant reduction in ED visits was observed in the intermediate IHC duration group. A 90% reduction in ED visits during IHC and a 45% reduction after IHC was observed in the short IHC duration group. Corresponding reductions were 17% and 64% during and after IHC, respectively, in the long IHC duration group.

  IHC was effective in reducing ED visits, but expansion of IHC to include additional necessary services could further reduce ED visits. Investment in the creation of a structured, effective network of engaged professionals (including community care services and hospitals) is crucial to achieving this.

  Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders’ perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation.

  In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis.

Results :

 Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors’ work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct “organizational incentives” suggested that current pay-for-performance incentives function as a “double-edged sword,” increasing family doctors’ motivation to excel while creating pressures to “game the system” among some physicians. When considering the CFIR construct “reflecting and evaluating,” policy-makers perceived the online evaluation application – which provides daily reports on family doctors’ work – to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the “network and communication” construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs.

  The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital–community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

  This paper analyses input from global interests in the policy process leading up to the passing of alcohol control legislation in Vietnam in 2019. The global alcohol industry now relies on growth in volume in emerging markets in middle-income countries such as Vietnam, a large, rapidly industrialising country with a youthful population and emerging middle class. The industry’s role in the alcohol policy process is compared with that of global health interests.

  Document analysis of letters and English language media coverage was supplemented by and triangulated with data from key informants on changes in the content of draft alcohol legislation and participant observation.

  The alcohol legislation was negotiated in the context of active engagement from the global alcohol industry and some input from global public health interests. The global alcohol industry established a partnership relationship with politicians using CSR and funded a local employee in Hanoi over the decade prior to the draft legislation being considered. Direct lobbying took place over the content of the legislation, which went through six published drafts. Trade and investment agreements provided a supportive environment and were referred to by both politicians and industry. In contrast public health resource was limited and lacked the support of a normative global policy to counter the economic imperatives. Vietnamese Ministry of Health proposals for cost effective alcohol policy were not enacted.

Global commercial interests employed their considerable resources to engage in corporate social responsibility (CSR) and build partnerships with policy-makers over a long period, contributing significantly to an environment unsupportive of enacting effective alcohol control policy. The absence of structural support from a global health treaty on alcohol and lack of an equivalent level of long-term sustained input from global health actors contributed to the legislative outcome, which excluded proposed cost-effective policies to reduce alcohol harm.

  Many countries with universal healthcare have a parallel private healthcare sector due to the waiting time in the public sector. People purchase individual health insurance to pay for private services. Past studies on the relationship between the public sector’s waiting time and the demand for health insurance have two limitations: not considering the capacity of the private sector, and subsequently, the omission of a feedback loop. These limitations are also present in the health insurance policy discussion in Hong Kong, where the public sector is overstretched. A lack of understanding of market dynamics might lead to unrealistic expectations of public policy. This study highlights these limitations, and tries to answer the research question: whether the historical dynamics between the intersectoral imbalance of burden and the demand for health insurance in Hong Kong could be quantitatively explained.

  A system dynamics model was created based on a negative feedback loop. The model’s initial input was the percentage of population with health insurance in 2009, and to simulate the percentage continuously until 2019. Results from 2015 to 2019 were compared with actual figures to examine the model’s explanatory power. Multivariable sensitivity analysis was performed.

  With initial fluctuation, the simulated result stabilized and was within the acceptable error range from 2015 to 2019. The mean absolute percentage error (MAPE) was 0.94%. At the end of 2019, the simulated percentage of population with health insurance is 36.6% versus the “real value” of 36.7%. Simulated patient admissions and occupancy rates also approximate the reality. Sensitivity analysis demonstrates the robustness of the model.

  We can quantitatively explain the feedback loop between health system burden and demand for health insurance. With local parameterization, this model should be transferable to other universal health systems for a better understanding of the system dynamics and more informed policy-making.

  With the delayed eradication of coronavirus disease 2019 (COVID-19), people with disabilities, a socially vulnerable class of individuals, face aggravated hardships caused by a pause in support services and lack of care due to stricter social distancing policies combined with the challenges of their disabilities. Given this background, we aim to investigate COVID-19 infection and mortality rates among people with disabilities, who face heightened physical and mental health threats amidst the COVID-19 pandemic.

Gender, age, health insurance premiums, the Charlson Comorbidity Index (CCI), the severity of the disability, and the type of disability were compared among people with disabilities who had been infected with or died from COVID-19 using the nationally representative National Health Insurance Service (NHIS)-COVID-19 database (DB).

  We found that the COVID-19 infection rate was higher among those with low income, those with severe disability, and those with “other” disabilities (ie, speech disabilities, hepatic dysfunction, respiratory dysfunction, facial disfigurement, intestinal fistular/urinary disability, epilepsy, intellectual disability, autistic disorder, and mental disorders). The mortality rate was markedly higher (ie, 15.90 times higher, odds ratio [OR]: 15.90, 95% confidence interval [CI]: 6.16 - 41.06) among people aged 80 years or older as compared with those aged 60 years or younger. The odds for mortality were 2.49 times higher (OR: 2.49, 95% CI: 1.33 - 4.64) among people with severe disabilities as compared with mild disabilities.

  Among people with disabilities, we found that COVID-19 infection rates differed according to income level, severity of the disability, and disability type, while the COVID-19 mortality rates differed according to age and severity of the disability.

  This article proposes a method for analysing the degree of maturity of Health in All Policies (HiAP) among World Health Organization-French Healthy Cities Network (WHO-FHCN) as part of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project. We focused on the creation or enhancement of healthpromoting environments, and more specifically, public green spaces.

We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a multiple correspondence analysis (MCA) and a hierarchical ascending classification (HAC).

Thirty-two criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies/actions of the sector studied, (2) occasional intersectoral collaboration, ie, one-off initiatives between the health department and others sectors, (3) the existence of joint projects, ie, common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.

  Four dimensions which allow to the measurement of the degree of progress in implementing healthall-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.

  Organizational culture has been widely recognized as predictive of health system performance and improved outcomes across various healthcare settings. Research on organizational culture in healthcare has been largely conducted in high-income settings, and validated scales to measure this concept in primary healthcare systems in lowand middle-income country (LMIC) settings are lacking. Our study aimed to validate a tool to measure organizational culture in the context of the Ethiopian Primary Healthcare Transformation Initiative (PTI), a collaborative of the Federal Ministry of Health (FMoH) and the Yale Global Health Leadership Initiative to strengthen primary healthcare system performance in Ethiopia.

  Following established survey development and adaptation guidelines, we adapted a 31-item US-based organizational culture scale using (1) cognitive interviewing, (2) testing with 1176 district and zonal health officials from four regions in Ethiopia, and (3) exploratory factor analysis (EFA).

Based on the results of cognitive interviewing, an adapted 30-item survey was piloted. The factor analyses of 1034 complete surveys (88% complete responses) identified five constructs of the scale which demonstrated strong validity and internal consistency: learning and problem solving, psychological safety, resistance to change, time for improvement, and commitment to the organization. Of the 30 a priori items, 26 items loaded well on the five constructs (loading values 0.40-0.86), and 4 items failed to load. Cronbach alpha coefficients were 0.86 for the scale as a whole and ranged from 0.65 to 0.90 for the subscales. The five-factor solution accounted for 62% of total variance in culture scores across respondents.

  Through validation and factor analyses, we generated a 26-item scale for measuring organizational culture in public primary healthcare systems in LMIC settings. This validated tool can be useful for managers, implementers, policy-makers, and researchers to assess and improve organizational culture in support of improved primary healthcare system performance.

 Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania.

  We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data.

  The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates.

  Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

  In 2017, the Chinese government launched a pilot project in hospice care (HC), in which Shanghai was a pioneer. Healthcare provider knowledge, attitudes, and practices in hospice care (KAPHC) may facilitate or hinder HC development. To determine how to design targeted training for healthcare providers and policies to improve their KAPHC, we conducted an original study based on an indigenized KAPHC scale to (a) comprehensively measure the KAPHC baseline of healthcare providers in Shanghai and (b) explore its influencing factors.

  A cross-sectional study was designed to evaluate healthcare providers’ KAPHC with the indigenized KAPHC scale.  Descriptive analysis, linear regression, and Pearson’s (r) correlation analysis were performed to uncover providers’ KAPHC, its influencing factors, and their correlations.

The KAPHC scale proved applicable to the knowledge, attitudes, and practices of the large sample of providers we surveyed. The 7027 KAPHC scaling results revealed that 42.44% of participants had HC experience and 57.49% were willing to provide HC. The mean accuracy of the responses related to knowledge was 59.30%. Scoring rates for attitudes, confidence, and self-reported practices were 74.20%, 73.96%, and 75.55%, respectively. The linear regression revealed that higher KAPHC scores were associated with experience and willingness and varied with professional specializations. The Pearson’s (r) correlation evidenced that HC practices were strongly correlated with confidence (r = 0.648, P < .001) and moderately correlated with attitudes (r = 0.463, P < .001).

  We uncovered that targeted training for enhancing healthcare provider KAPHC in Shanghai should focus on psychological and spiritual care, the management of pain and other symptoms, and traditional Chinese medicine (TCM). Additionally, training should be scaled up for providers with different characteristics. Meanwhile, policy should encourage providers to work enthusiastically in HC—universal high-quality HC requires well-trained, supported, and motivated providers.

An effective response to the coronavirus disease 2019 (COVID-19) pandemic entails a comprehensive strategy that ensures equitable access to all COVID-19-fighting technologies. To achieve this goal, the international community has acknowledged immunization as a public good. However, a trend of grossly unequal dose distribution emerged, owing, among other factors, to pharmaceutical companies’ profit-driven actions, jeopardizing the mechanisms built to increase vaccine access. The contradiction between public health interests and corporate discretion in determining vaccine dose distribution poses critical concerns about the health risks associated with lengthening the duration of the pandemic and the eventual liability of companies for violations of human rights.

To evaluate the risks posed to the COVID-19 immunization program, data on vaccine allocation and delivery, vaccine dose application, immunized populations, and the volume of Advanced Purchase Agreements (APAs) between countries and pharmaceutical companies were compiled and assessed. A descriptive analysis was then conducted to analyze the role of pharmaceutical companies in providing equitable access to COVID-19 vaccines.

  When the data is broken down by income (as of June 2021), it shows that high-income countries (HICs) have already crossed the COVID-19 Vaccine Global Access (COVAX) 20% immunization threshold. However, countries of all other income levels have yet to achieve this mark for fully vaccinated people. Upper-middle-income countries (UMICs) have approximately 3%, low- and middle-income countries (LMICs) have approximately 2% and low-income countries (LICs) have less than 0.1% of fully vaccinated people per hundred. The supply shortage is expected to last until the second half of 2021.

As a result of the COVAX failure, a health gap emerged with countries living in a pre-immunization period for an extended time. The existing conflict between the international response to tackle COVID-19 and corporate profitdriven behavior contributed to prolonging pandemic, especially in Africa. Accordingly, there is a need to approve an international treaty that targets the activities of all actors, including the pharmaceutical companies, in protecting human rights and the right to health realms.

Healthcare innovations emerge and develop in institutionally dense selective environments. New projects and propositions in healthcare sectoral ecosystems can be understood as product-service compacts, that is, complex solutions that dynamically integrate tangible and intangible elements in close interaction with users’ needs and the evolving regulatory context under uncertainty and ambiguity. We advance the concept of “strategic encounters” to encapsulate, capitalise and extend the contribution by Palm and Fischier’s on the key enabling managerial factors for healthcare innovation implementation under conditions of imperfect foresight. We intertwine creative assemblages that shape the formation of knowledge-intensive activities at the operators’ level with scope of sectoral level interventions to underscore how the opportunities and constraints can enhance innovation for the common good. We use the case of digital data health regulatory agendas as illustration. We argue that this broader perspective on healthcare transformation is theoretically pertinent and practically useful, for management and policy.

In their 2021 paper, Palm and Persson Fischier focus on the enabling factors that can facilitate innovation implementation, specifically the step of moving from idea generation to implementation in a healthcare context. The authors address the lack of concretisation of theoretical perspectives related to the implementation of innovations and hence propose to work holistically with six management perspectives. Our commentary provides new interdisciplinary angles to the six perspectives, from management and organisation literature to theory of change management. This provides future innovation managers with different viewpoints and inspires creative thinking and reflection. Our commentary also critiques the emphasis on the enablers and hence a constructionist-based approach to change management. We plea that a focus on the ‘good, bad, and ugly’—or rather all moods of change—is warranted in order to support holistic and successful change.

Health is not just a physiological state, it is also a relational phenomenon. This means health is a collective challenge, often a cross-border one. Diplomacy in the health sector has progressively received more attention from formal actors (national states, international organisations, etc) but after the coronavirus disease 2019 (COVID-19) challenge, this attention became a global emergency mobilising an expansive set of knowledge-seeking players (industry, research networks, civil society, etc). This paper comments on and leverages the contribution by Palm and Feschier on innovation management at the organisational level to address a complementary dimension: the internationalization process, and the need for a particular set of skills and routines to make innovations travel through different markets and regulatory contexts. Our argument is that marketing (knowing about customers) and diplomacy (understanding framing institutions) constitute a set of dynamic capabilities (soft power) that are critical for the effective internationalization of innovation.

The recent study of which enabling factors can facilitate the specific step of moving from idea generation to implementation in healthcare supports that managing innovation is a context-driven process that goes through six categories of change. While this research provides a general and rather comprehensives overview of what successful innovation work needs, it does not offer deeper insights into how categories of change can be operated in the context of accelerated openness in healthcare. I use the concepts of open innovation and open strategy to trying better understand how openness, in terms of greater inclusion and transparency, may or may not serve healthcare innovation through three theoretical questions: to whom, how and when to open up to foster innovation? Whilst diversity of knowledge, actors and systems are growing drivers of innovation, strategizing openness for more deliberate and impactful inclusion and transparency in healthcare management is key to coproducing better health.

Cervantes et al have provided an insightful addition to the policy literature by identifying the contextual, political, and policy factors that create constraints and opportunities for putting nutrition at the center of the food supply chain policy process. This commentary discusses important elements and features when aiming for reconciling nutrition goals and food supply policy, provides some examples of the salience of nutrition of non-health policies in countries with different income levels, and argues for improving governance for better nutrition outcomes and inspiring institutional interest and idea of food supply policy actors around population nutrition. Cervantes et al highlight the political context that favors nutrition outcomes, nutrition advocacy in the public agenda, and multisectoral mechanisms which can keep the nutrition objective moving forward in the food supply sector. However, a wider view on governance and institutional capacity is needed, recognizing government action by multiple sectors, with diverse sets of actors. The expanded understanding of nutrition, which includes considering nutrition as an emerging facet of food systems, by policy actors is needed. Enhancing discourse involving nutrition and food supply actors is important in order to appeal to the wider public and opinion leaders across the political spectrum. Accomplishing this also requires political will and an advocacy movement, especially by civil society and grassroots movements.

A paradigm shift is required to transform food systems, so they are more equitable, environmentally friendly, and healthy. This requires acknowledging which factors change or maintain the status quo. In this commentary, we reflect upon the Cervantes et al study findings and discuss the role of power dynamics in transforming food systems. This is directly relevant to Mexico in terms of (i) relationships between food system actors; (ii) the role of socio-economic political context; and (iii) opportunities for policy coherence and transformative food systems approaches. We suggest that the power dynamics that drive the food produced, sold, and consumed should be recognised in all (inter)national governance decision-making. The 2021 United Nations Food System Summit – when interest groups were perceived to overly influence the summit proceedings – is an example of how neglecting the role of power dynamics can undermine and slow food system transformation.

The coronavirus disease 2019 (COVID-19) pandemic has brought the need for regional collaboration on disease prevention and control to the fore. The review by Durrance-Bagale et al offers insights on the enablers, barriers and lessons learned from the experience of various regional initiatives. Translating these lessons into action, however, remains a challenge. The Association of Southeast Asian Nations (ASEAN) planned to establish a regional centre for disease control; however, many factors have slowed the realisation of these efforts. Going forward, regional initiatives should be able to address the complexity of emerging infectious diseases through a One Health approach, assess the social and economic impact of diseases on the region and study the real-world effectiveness of regional collaborations. The initiatives should seek to be inclusive of stakeholders including those from the private sector and should identify innovative measures for financing. This advancement will enable regions such as ASEAN to effectively prepare for the next pandemic.

This commentary cites a scoping review by Durrance-Bagale et al on how regional bodies have approached infectious disease control to determine if those lessons could be applied to assist the Association of Southeast Asian Nations (ASEAN). The author’s work is timely and highlights the importance of recognizing and understanding regional context, governance and operational structures to then design effective regional networks. Most factors highlighted as enablers and constraints are quite expected, including stakeholder mapping, a clear mission space with goals and objectives, outreach and advocacy to receive buy-in, political will and sustainable funding. We suggest below that there is an opportunity for further systematic and operational research of enablers and constraints for regional infectious disease control bodies, one that expands on infectious disease control while also continuing to take into account governance, legislative and organizational factors, and strongly emphasizes the development and application of clear metrics to create better measures of impact.

Fisher and colleagues carefully review the extent to which health equity goals of availability, affordability, and acceptability have been achieved in the areas of national broadband network policy and land-use policy, in addition to the more traditional areas of primary healthcare and Indigenous health in Australia. They consider the effectiveness of policies identified as either universal, proportionate-universal, targeted or residualist in these areas. In this commentary we suggest future areas of inquiry that can help inform the findings of their excellent study. These include the impacts of Australia being a liberal welfare state and how acceptance of neoliberal approaches to governance makes the achieving of health equity in these four policy areas difficult.

This commentary reflects on an important article by Fisher and colleagues who draw on four Australian policy case studies to examine how universal and targeted approaches or a combination can be deployed to improve health equity. They conclude that universal approaches are central to action to increase health equity, but that targeting can improve equity of access in some situations including in the context of proportionate universalism. However, we argue that although target services may provide benefits for some populations, they are often stigmatizing and fail to reach may people they aim to support. Instead of accepting the dominant discourse about the key role for targeted approaches, we argue that those committed to reduce social and health inequities should consider the potential of Equity Sensitive Universalism (ESU). This approach focuses on achieving proportionate outcomes with equally provided resources rather than proportionate inputs and provides a ‘cohesion dividend,’ increasing social solidarity.