Health policy and planning最新文献

In Zambia, efforts to produce a tobacco control policy have stalled for over a decade, and the country is not yet close to developing one. Limited studies have explored the dynamics in this policy process and how they affect the attainment of policy goals and outcomes. This study explored how collaborative dynamics within tobacco control policy development shaped shared motivation among stakeholders in Zambia. The study used a qualitative case study design that adopted a collaborative governance lens, comprising an in-depth exploration of the tobacco control policy working group meetings and their internal collaborative dynamics. The integrative framework for collaborative governance, which identifies mutual trust, mutual understanding, internal legitimacy and shared commitment as key elements of shared motivation, was adapted for this study. Data were collected from 27 key informants and analysed using thematic analysis. Several collaborative dynamics thwarted mutual trust among tobacco control stakeholders, including concerns about associated loyalties, fear of a ban on tobacco production, silo-mentality and lack of comprehensive dialogue. All stakeholders agreed that the limited sharing of information on tobacco control and the lack of reliable local evidence on the tobacco burden hindered mutual understanding. Diverse factors hampered internal legitimacy, including sector representatives' lack of authority and the perceived lack of contextualization of the proposed policy content. Acknowledgement of the need for multisectoral action, lack of political will from other sectors and limited local allocation of funds to the process were some of the factors that shaped shared commitment. To accelerate the development of tobacco control policies in Zambia and elsewhere, policymakers must adopt strategies founded on shared motivation that deliberately create opportunities for open discourse and respectful interactions, promote a cultural shift towards collaborative information sharing and address unequal power relations to enable shaping of appropriate tobacco control actions in respective sectors.

Our paper examines the political considerations in the intersectoral action that was evident during the SAR-COV-2 virus (COVID-19) pandemic through case studies of political and institutional responses in 16 nations (Australia, Belgium, Brazil, Ethiopia, India, New Zealand, Nigeria, Peru, South Africa, South Korea, Spain, Taiwan, Thailand, Vietnam, UK, and USA). Our qualitative case study approach involved an iterative process of data gathering and interpretation through the three Is (institutions, ideas and interests) lens, which we used to shape our understanding of political and intersectoral factors affecting pandemic responses. The institutional factors examined were: national economic and political context; influence of the global economic order; structural inequities; and public health structures and legislation, including intersectoral action. The ideas explored were: orientation of governments; political actors' views on science; willingness to challenge neoliberal policies; previous pandemic experiences. We examined the interests of political leaders and civil society and the extent of public trust. We derived five elements that predict effective and equity-sensitive political responses to a pandemic. Firstly, effective responses have to be intersectoral and led from the head of government with technical support from health agencies. Secondly, we found that political leaders' willingness to accept science, communicate empathetically and avoid 'othering' population groups was vital. The lack of political will was found in those countries stressing individualistic values. Thirdly, a supportive civil society which questions governments about excessive infringement of human rights without adopting populist anti-science views, and is free to express opposition to the government encourages effective political action in the interests of the population. Fourthly, citizen trust is vital in times of uncertainty and fear. Fifthly, evidence of consideration is needed regarding when people's health must be prioritized over the needs of the economy. All these factors are unlikely to be present in any one country. Recognizing the political aspects of pandemic preparedness is vital for effective responses to future pandemics and while intersectoral action is vital, it is not enough in isolation to improve pandemic outcomes.

Although Population-Health-Environment (PHE) approaches have been implemented and studied for several decades, there are limited data on whether, how and why they work. This study provides a process evaluation of the 'Healthy Wetlands for the Cranes and People of Rukiga, Uganda' project, implemented by an NGO-local hospital consortium. This programme involved a research design element, testing two delivery modalities to understand the added benefit of integrating conservation, livelihoods and human health interventions, compared to delivering sector support services separately (as is more usual). The process evaluation sought to understand how the programme was implemented, the mechanisms of impact, how it was shaped by the context in which it was delivered and whether there were discernable differences across the two delivery arms. Methods involved key informant interviews with implementing staff and community educators, a review of programme documents and secondary qualitative analysis of interviews and focus groups with community members. The findings include a statistically significant increase in the reach of the programme, in both service delivery and sensitization activities, when the sectors were fully integrated. It appears that this comparative advantage of integration is because of the improved acceptability and motivation among stakeholders, and increased initiative (and agency) taken by community-based peer educators and community members. We argue that the 'software' of the programme underpins these mechanisms of impact: trust-based relationships embedded in the system enabled coordinated leadership, supported local staff agency and encouraged motivation.

Leveraging the co-benefits of investments in health and climate can be best achieved by moving away from isolated financing approaches and adopting co-financing strategies, which aim to improve the outcomes of both sectors. We propose a framework for studying co-financing for health and climate that considers the degree of integration between sector funding, and whether arrangements are 'passive', when cross-sectoral goals are indirectly affected, or 'strategic', when they are pre-emptively supported to build resilience and sustainability. We conducted a rigorous, evidence-focused review to describe co-financing mechanisms according to a framework, including the context in which they have been employed, and to identify enablers and barriers to implementation. We searched the international literature using Pubmed and Web of Science from 2013 to 2023, the websites of key health and climate agencies for grey literature and consulted with stakeholders. Our review underscores the significant impact of climate change and related hazards on government, health insurance and household health-related costs. Current evidence primarily addresses passive co-financing, reflecting the financial consequences of inaction. Strategic co-financing is under explored, as are integrative co-financing models demanding cross-sectoral coordination. Current instances of strategic co-financing lack sufficient funding to demonstrate their effectiveness. Climate finance, an under used resource for health, holds potential to generate additional revenue for health. Realizing these advantages necessitates co-benefit monitoring to align health, climate mitigation and adaptation goals, alongside stronger advocacy for the economic and environmental benefits of health investments. Strategic co-financing arrangements are vital at all system levels, demanding increased cross-sectoral collaboration, additional funding and skills for climate integration within health sector plans and budgets, and mainstreaming health into climate adaptation and mitigation plans. Supporting persistent health needs post-disasters, promoting adaptive social protection for health and climate risks, and disseminating best practices within and among countries are crucial, supported by robust evaluations to enhance progress.

The health workforce (HWF) is a critical component of the health sector. Intersectoral/multisectoral collaboration and action is foundational to strengthening the HWF, enabling responsiveness to dynamic population health demands and supporting broader goals around social and economic development-such development underpins the need for health in all policies (HiAP). To identify what can be learned from intersectoral/multisectoral activity for HWF strengthening to advance HiAP, we carried out a scoping review. Our review included both peer-reviewed and grey literature. Search terms encompassed terminology for the HWF, intersectoral/multisectoral activities and governance or management. We carried out a framework analysis, extracting data around different aspects of HiAP implementation. With the aim of supporting action to advance HiAP, our analysis identified core recommendations for intersectoral/multisectoral collaboration for the HWF, organized as a 'pathway to HiAP'. We identified 93 documents-67 (72%) were journal articles and 26 (28%) were grey literature. Documents reflected a wide range of country and regional settings. The majority (80, 86%) were published within the past 10 years, reflecting a growing trend in publications on the topic of intersectoral/multisectoral activity for the HWF. From our review and analysis, we identified five areas in the 'pathway to HiAP': ensure robust coordination and leadership; strengthen governance and policy-making and implementation capacities; develop intersectoral/multisectoral strategies; build intersectoral/multisectoral information systems and identify transparent, resources financing and investment opportunities. Each has key practical and policy implications. Although we introduce a 'pathway', the relationship between the areas is not linear, rather, they both influence and are influenced by one another, reflecting their shared importance. Underscoring this 'pathway' is the shared recognition of the importance of intersectoral/multisectoral activity, shared vision and political will. Advancing health 'for' all policies-generating evidence about best practices to identify and maximize co-benefits across sectors-is a next milestone.

Resilience is crucial for a health system to better prevent and respond to public health threats and provide high-quality services. Despite the growing interest in the concept of resilience in health care, however, there is little empirical evidence of the impact of organizational resilience, especially in primary care settings. As the largest professional group in primary care, primary care nurses are taking more and more responsibilities during their daily practice, which influences both their work conditions and well-being. This study aims to examine the association between organizational resilience and primary care nurses' working conditions and well-being. Using a convenience sampling approach, we recruited 175 primary care nurses from 38 community health centres (CHCs) in four cities in China. Organizational resilience was operationalized as comprising two domains: adaptive capacity and planning capacity, and measured using a 16-item scale. The primary care nurses' working condition indicators comprised variables of psychological safety, organizational commitment, professional commitment, and self-directed learning; well-being indicators included depression and burn-out. Hierarchical linear regression models were built for analysis. We found that the sampled CHCs have a relatively high level of organizational resilience. The organizational resilience was positively associated with the four indicators of working conditions: psychological safety (β = 0.04, P < 0.01), organizational commitment (β = 0.38, P < 0.01), professional commitment (β = 0.39, P < 0.01), and self-directed learning (β = 0.28, P < 0.01). However, organizational resilience was not significantly associated with the two well-being indicators. Furthermore, we found that the adaptive capacity has stronger association compared with planning capacity. Therefore, primary care manager should build resilient organizations, especially the adaptive capacity, in order to enhance primary care nurses' psychological safety, commitment and learning behaviours. Further studies should also be conducted to understand the link between organizational resilience and primary care nurses' well-being.

The National Hospital Insurance Fund (NHIF) of Kenya was upgraded to improve access to healthcare for impoverished households, expand universal health coverage, and boost the uptake of essential reproductive, maternal, newborn and child health (RMNCH) services. However, premiums may be unaffordable for the poorest households. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) programme targets low-income women and their households to improve their access to and utilization of quality healthcare, including RMNCH services, by providing subsidized, mobile phone-based NHIF coverage in combination with enhanced, digital training of community health volunteers and upgrading of health facilities. This study evaluated whether expanded NHIF coverage increased the accessibility and utilization of quality basic RMNCH services in areas where i-PUSH was implemented using a longitudinal cluster randomized controlled trial in Kakamega, Kenya. A total of 24 pair-matched villages were randomly assigned either to the treatment or the control group. Within each village, 10 eligible households (i.e. with a woman aged 15-49 years who was either pregnant or with a child <4 years old) were randomly selected. The study applied a difference-in-difference methodology based on a pooled cross-sectional analysis of baseline, midline and endline data, with robustness checks based on balanced panels and Analysis of Covariance methods. The analysis sample included 346 women, of whom 248 had had a live birth in the 3 years prior to any of the surveys, and 424 children aged 0-59 months. Improved NHIF coverage did not have a statistically significant impact on any of the RMNCH outcome indicators at midline nor endline. Uptake of RMNCH services, however, improved substantially in both control and treatment areas at endline compared to baseline. For instance, significant increases were observed in the number of antenatal care visits from baseline to midline (mean = 2.62-2.92, P < 0.01) and delivery with a skilled birth attendant from baseline to midline (mean = 0.91-0.97, P < 0.01). Expanded NHIF coverage, providing enhanced access to RMNCH services of unlimited duration at both public and private facilities, did not result in an increased uptake of care, in a context where access to basic public RMNCH services was already widespread. However, the positive overall trend in RMNCH utilization indicators, in a period of constrained access due to the COVID-19 pandemic, suggests that the other components of the i-PUSH programme may have been beneficial. Further research is needed to better understand how the provision of insurance, enhanced community health volunteer training and improved healthcare quality interact to ensure pregnant women and young children can make full use of the continuum of care.

A health systems reform known as Service Delivery Redesign (SDR) for maternal and newborn health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions that underpin the SDR policy's theory of change. We analyse data on place of delivery, travel time and distance, out-of-pocket spending, and self-reported quality of care for 19 127 women prospectively enrolled during antenatal care (ANC) and surveyed two times after their delivery. We analyze changes in womens' delivery location preferences in recent years in Kakamega, and over the course of their most recent pregnancy. We also evaluate travel time, out-of-pocket expenditures and patient satisfaction for women who deliver in public hospitals vs primary health centres. We find substantial changes in delivery location at the population level over time and for individual women over the course of pregnancy. Facility delivery has increased from 50.4% in 2010 to 89.5% in 2019; 70% of respondents deliver at a different facility than their reported intention at ANC. Out-of-pocket delivery expenditures are on average 1351 Kenyan shillings (Ksh) in hospitals compared to 964 Ksh in PHC (primary health care)s (P < 0.01). Transport expenditures are 337 Ksh for PHC level deliveries vs 422 Ksh for hospitals (P < 0.01). Self-reported average travel time is 51 min (PHC delivery) vs 47 min (hospital delivery) (P = 0.78). The average distance to a delivery location is 15.1 km for PHC deliveries vs 15.2 km for hospitals (P = 0.99). There were no differences in overall patient-reported quality scores, while some subcomponents of quality favoured hospitals. These findings support several key assumptions of the SDR theory of change in Kakamega County, while also highlighting important challenges that should be addressed to increase the likelihood of successful implementation.