Health policy and planning最新文献

The Maternal and Newborn Health (MNH) Service Delivery Redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery care at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by neither full endorsement nor resistance, highlighting the need for clearer communication and participation to build ownership. The interaction between formal institutions (county health governance and partnership frameworks) and informal norms (trust, shared interpretation, and relational coordination) created early momentum for implementation, particularly among health system actors. However, limited financial capacity and unclear alignment with national policy priorities undermined progress and long-term viability. Kakamega's experience demonstrates how political incentives, devolved autonomy, and local institutional context jointly shape reform outcomes. Achieving successful implementation of system level reforms requires integrating local political leadership, strengthening community engagement, aligning with evolving national policies, and securing predictable financing. This study provides practical lessons for future MNH and system-level reforms in Kenya and similar decentralized, resource-constrained settings. Lessons include the importance of balancing formal and informal institutions to ensure both political feasibility and enduring impact.

Gender-based violence (GBV) is a major public health issue, further intensified in humanitarian crises. In Ethiopia's northern conflict (2021-ongoing), the scale of GBV underscores the urgent need for context-sensitive policy and service delivery. We conducted a policy analysis of national GBV-related policies within the context of the Northern Ethiopia conflict. This was complemented by nine focus group discussions with relevant stakeholders; community representatives and ten key informant interviews with key policy makers at sub-national and national levels. Data were analyzed thematically using the Health Policy Triangle framework. No reviewed policies were contextualized for humanitarian emergencies or inclusive of all GBV forms. Most focused exclusively on sexual violence against women, overlooking other GBV types and male survivors. Policy development was largely top-down, involving government bodies and international actors, with minimal input from frontline providers or affected communities. There was also a lack of consensus on which policies are being implemented, driven by poor dissemination, resource constraints, limited prevalence data, and weak coordination. Ethiopia lacks a government-led, humanitarian-specific GBV policy. This hinders a coordinated health response. Strengthening community participation in policy formulation, ensuring inclusive and context-relevant policy content, improving coordination among all governmental and non governmental GBV actors, and addressing funding gaps are critical for effective GBV response in humanitarian settings.

As global framings of health continue to expand their reach, the Philippines, like many other countries, must navigate the overlapping pressures of donors, international institutions, and domestic political agendas in setting priorities. One such framing is the framing of health as a security issue. This study examines how health security framing - how it is interpreted and operationalised - influences priority-setting in the Philippines. Drawing on 25 interviews with government (at national and sub-national levels) and non-government actors, and using a realist approach, this study sought to identify the outcomes of health security framing (as triggered or reinforced by mechanisms such as uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) and the context in which the outcomes manifest. Findings show that health security framing reshapes priorities by reinforcing centralized, top-down approaches at both international and national levels. These framings influence not only what is prioritised, but also which actors make decisions and how those decisions are justified. At the implementation level, it manifests in health workers facing misaligned operational frameworks, vertical programming, and burdensome reporting requirements tied to donor funding. Security norms become institutionalized with the involvement of military and security actors in health. The study demonstrates that health security is not a static concept, but a dynamic phenomenon co-constructed through global discourses, donor agendas, and domestic governance practices, all of which are shaped by power relations and history. While health security mobilizes resources and political attention, it also introduces trade-offs that risk exacerbating inequities and diverting attention from the structural determinants of health.

The global health landscape is undergoing a significant transformation as traditional frameworks of cooperation face fragmentation amid geopolitical tensions. Declining support from Western nations, exemplified by US withdrawal from the WHO and cuts to programmes like PEPFAR, has exposed the profound instability of an aid architecture built on colonial dependencies. The COVID-19 pandemic, marked by vaccine nationalism, was a stark litmus test of this systemic failure for low- and middle-income countries (LMICs). This commentary argues that the current geopolitical fragmentation, while a crisis, also presents a critical opportunity to dismantle colonial legacies and reimagine global health equity not as a donor-driven ideal, but as a practice of shared power and sovereignty. We first document the rise of alternative pathways, critically examining China's health diplomacy and India's pharmaceutical disruption, while highlighting robust, LMIC-led initiatives like the African Medicines Agency and local mRNA vaccine production in Rwanda and Thailand. In response to the fractured status quo, we then propose a new global health compact built on four interdependent pillars: 1) Epistemic Justice, valuing local knowledge systems; 2) Structural Audacity in Financing, such as taxing multinational corporations for reparative funding; 3) Governance for Agency, ceding decisive power to LMICs; and 4) Open Knowledge and Innovation, by dismantling restrictive intellectual property regimes. Achieving this decolonized future requires concrete action from all stakeholders. We conclude with a blueprint urging high-income countries to cede power, LMICs to invest in local capacity, funders to provide untied financing, and researchers to practice equitable collaboration. This actionable agenda is the foundation for a truly equitable global health system capable of achieving Universal Health Coverage.

Out-of-pocket health expenditures (OOPE) represent a financial strain that can increase the risk of impoverishment, especially in older people. Universal health coverage is the primary strategy to ensure financial protection. The Mexican health system is based on social security. Therefore, the objective of this research is to analyze the relationship between out-of-pocket health expenditures and social security status over time among Mexican adults aged 50 and older. A secondary analysis using data from the 2012, 2015, 2018, and 2021 waves of the Mexican Health and Aging Study. Multivariable linear regression models were performed to identify the relation between social security and OOPE. Individuals without social security reported the lowest mean expenditures. In contrast, older people with social security stability showed a steady increase in spending throughout the period, reporting the highest mean expenditures on total OOPE. Other variables, such as education, work, economic situation, multimorbidity, disability, and self-rated health status, show a greater relation with OOPE in contrast with social security. Our findings indicate that older adults with stable social security coverage reported the highest OOPE. This finding contrasts with international evidence on the protective role of health insurance. These findings may be attributed to four factors: 1) the challenging epidemiological profile of older adults characterized by chronic diseases and disability, 2) the structural and organizational changes in the Mexican health system following the political transition in 2018, 3) a decline in healthcare access among older adults during the COVID-19 outbreak; and 4) the longstanding oversaturation and low health resources in the health system.

In recent years, low- and middle-income countries (LMICs) have received substantial amounts of Official Development Assistance for Health (DAH) to address domestic health funding gaps and improve access to universal healthcare. However, the effectiveness of DAH in improving health outcomes remains contested, with varying findings across studies due to differences in methodologies, data sources, and target populations. This systematic review synthesises the existing evidence on the impact of DAH on health outcomes in LMICs, highlighting both the positive and negative effects, and identifying key mechanisms through which aid influences health. A total of 61 studies were included in the review, with a primary focus on maternal and child health outcomes. Despite methodological differences, the weight of evidence indicates a generally positive impact of DAH, particularly in countries with higher governance standards and better economic conditions. Our findings underscore the importance of contextual factors, such as governance and proximity to aid-funded projects, in shaping the effectiveness of health aid. To maximise the impact of DAH, policymakers need to strengthen donor coordination, align aid with national health priorities, and reinforce domestic health systems. Future research should focus on refining causal inference methods and exploring innovative aid-delivery mechanisms to sustain long-term health improvements.

In South-East Asia, government implementation of policies recommended for addressing unhealthy diets has generally been slow and fragmented, largely due to food industry opposition and a lack of effective cross-sectoral coordination and policy action. To help government policy-makers and other interest-holders address these issues, this study aimed to identify key arguments that undermine implementation of policies for addressing unhealthy diets in the region, and to propose a set of counter-strategies. We conducted semi-structured interviews with 15 interest-holders based in India, Indonesia, Sri Lanka, and Thailand, and performed a scoping review of diverse literature. Data analysis was guided by the 'Policy Dystopia Model', initially used to study the corporate political activity of the tobacco industry. Identified arguments were categorised into six themes: i) questioning the policy design and development process; ii) misrepresenting or distorting the supporting evidence, and/or presenting counter evidence; iii) exaggerating and/or fabricating unintended consequences on health and equity; iv) raising concerns about effects on the economy; v) querying the policy's compatibility with trade and investment agreements and national laws; and vi) raising concerns about restrictions on personal 'freedom'. To help counter these arguments, along with key material and structural factors that may increase their salience, we proposed the following set of counter-strategies: i) develop a communication strategy to counter opposing arguments; ii) implement governance measures to mitigate corporate influence on public health policy, research, and practice; iii) implement governance measures to enable effective health-promoting intersectoral and interdepartmental coordination; and iv) strengthen research, advocacy, and capacity building on the determinants of health. Successful implementation of these counter-strategies will require extensive organising and collaborating among diverse interest-holders in South-East Asia and beyond.

Raising taxes on tobacco is considered the most effective measure for reducing tobacco consumption. Although Uganda ratified WHO's Framework Convention on Tobacco control which recommends levying taxes on tobacco products by up to 75% of their retail price, in Uganda taxes on tobacco stagnated at 35% between 2017 and 2024. There is little in-depth research interrogating the political economy underpinning tobacco tax policy in Uganda. The aim of this study is to apply political economy analysis in exploring barriers to implementing WHO's recommended tobacco tax rates in Uganda. Our qualitative study entailed key informant and in-depth interviews with 34 purposively selected participants. Data were analyzed by thematic approach. Tobacco industry narratives are dominant among policy elite with a strongly entrenched notion that raising taxes will bring economic harm such as 'killing off' the tobacco industry and by implication diminish government tax revenue. Participants identified tobacco industry interference in tobacco tax policy in Uganda through both 'soft' tactics such as sustained lobbying of policy elite in the executive and legislative arms of government and 'hard' tactics through litigation. Contrary to recommendations of having a 'single spine' or uniform tax on tobacco, Uganda continues to implement a differential tax structure for tobacco products. The paucity of non-industry-funded - research on effects of raising tobacco taxes was observed while the attrition of civil society champions in advocacy campaigns for raising taxes ensured that there was no sustained counterbalance to the tobacco industry in Uganda which the later exploited to promote the narrative that taxes needed to be maintained at a low level where they would not cause 'economic harm'. Our findings highlight the need for strengthening civil society advocacy in order to sustain the momentum on raising tobacco taxes in Uganda.

Intervention evaluation is critical for determining the value of health interventions; however, real-world implementation frequently falls short of achieving anticipated large-scale impacts. This evidence-to-practice gap often arises from challenges in capturing the complexity inherent in intervention implementation. This complexity may stem from the intervention itself, the dynamic and interrelated processes of dissemination, implementation, and sustainment, or the constraints of real-world settings characterized by interconnected systems. Integrating implementation science, which employs theories, models, and frameworks to understand the adoption and integration of evidence-based interventions, with systems science, which provides tools to model and analyze complex systems, offers a promising pathway for addressing these challenges. However, practical guidance on combining these approaches to evaluate dynamic interactions between interventions and implementation contexts, while simultaneously capturing system-level learnings, remains limited. In this methodological musing, we reflect on our experience integrating systems and implementation science to develop a conceptual and quantitative model for scenario evaluation of a maternal health service delivery redesign initiative in Kakamega, Kenya. We use four research objectives as a touchstone for organizing our reflections, explicated by three steps of an evaluation process: (1) developing a qualitative systems model using implementation frameworks and causal loop diagrams; (2) constructing and parameterizing a quantitative computational model; and (3) conducting scenario analyses to explore "what-if" strategies and inform adaptive planning. These reflections highlight the potential strengths of an integrated approach and offer practical considerations for researchers and practitioners evaluating complex health interventions through quantitative modelling and scenario development.

Distributed leadership has been proposed to offer value for health systems - by enabling people to work towards collective goals within settings such as hospitals. Yet, there is still limited empirical exploration of its dynamics in practice, especially in low- and middle-income contexts. To address this knowledge gap, this case study draws on conceptual work in empirically examining leadership in one district hospital in the Western Cape province, South Africa, seeking to identify evidence of distributed leadership and the factors influencing its emergence. Data were extracted from 28 academic theses, policies and strategic documents relating to health leadership, management and governance in the provincial health system (Phase 1) and 12 semi-structured, in-person interviews were conducted with hospital personnel (Phase 2). Phase 1 data provided the context of the case and guided the collection of data in Phase 2. All data were thematically analysed. The analysis reveals that there were pockets of distributed leadership within the hospital, as characterised by chains of multiple leaders working together to co-create shared meaning, take collective decisions and achieve common goals, enabled by relational leadership practices. These pockets supported both routine service delivery and bottom-up service improvement action. However, the unequal distribution of decision-making power, in the context of bureaucratic and professional hierarchies, limited the widespread emergence of distributed leadership. The case study suggests that distributed leadership can emerge in district hospitals with positive consequences for health service delivery, but that efforts to nurture its emergence should both bolster the leadership capabilities of individual leaders and address the bureaucratic and professional hierarchies that characterise the context within which hospital leadership unfolds. To aid the future practice of, and research about, distributed leadership the paper proposes a comprehensive definition of the concept, derived from the combination of wider literature and this study's empirical findings.