Health policy and planning最新文献

High ambient temperatures affect maternal and newborn health outcomes and wellbeing. The Climate Heat and Maternal and Neonatal Health in Africa (CHAMNHA) consortium conducted formative qualitative research in rural Kilifi, Kenya, to examine perceptions of heat risks among women, household members, and community stakeholders. An intervention was co-designed together with community members. This paper presents the development, implementation, and evaluation of a behaviour-change intervention aimed at reducing the burden of heat on maternal and newborn health. The intervention used Digital Audio-Visual (DAV) storytelling (encompassing short videos and a set of photographs) and facilitated group discussions. Intervention groups included pregnant and postpartum women (n = 10), mothers-in-law (n = 10), male spouses (n = 10), and community influencers (n = 40). Researchers and local community health volunteers supported pregnant and postpartum women and their household networks weekly for 4 months. At month five, a structured interview, originally administered at baseline, was repeated to evaluate understandings of heat risks and changes in behaviour (reducing exposure to heat by changing daily schedules, reducing heavy workload, and increasing spousal support). Pregnant and postpartum women reported a better understanding of the effects of heat on their health and the newborn, including the importance of staying hydrated, breastfeeding frequently, and avoiding heavy clothing for newborns. They also reported an increase in mothers-in-law and male spouses assisting with household chores and disseminating heat-health messaging to families. However, women noted that male spouses who supported them with chores sometimes reported being stigmatized by their peers. Community approaches to support pregnant and postpartum women during heat periods are feasible, and key community influencers can be trained to include heat-health messaging in their daily routines. Additional research is needed to examine whether repeated training is required to ensure sustainability. Future heat interventions focusing on maternal and neonatal health should consider factors such as employment, age, and depth of support networks.

Global health research can either challenge or reinforce power imbalances in knowledge production, funding, agenda-setting, authorship, data access, and capacity-building. These inequities are shaped by colonial legacies, funding disparities, extractive partnerships, and Global North dominance over Global South priorities. They manifest in research conduct, procedural ethics, and ethics-in-practice. While much literature focuses on individual or project-level strategies, structural, and institutional dynamics-beyond the control of individual researchers-play a critical role. While macro-level structural change may occur slowly, in line with the pace of societal change, meso-level change within organizations is possible. Research organizations and networks are well positioned to integrate equity and influence broader change. Importantly, the meso-level offers a space to challenge Global North-South binaries and foster a shared ethics-of-practice. We reviewed 255 resources from a live Zotero inventory on equity in global health research, shortlisting 42 and identifying over 135 strategies. These were categorized into domains and organized into 14 action groups, mapped onto a three-stage implementation framework-Preparation, Establishing, and Maintaining-drawing from the literature. Our goal was to distil practices applicable across institutions, recognizing that context and resources shape prioritization. The preparation phase involves assessing current practices, reforming partnerships, and promoting inclusive leadership, with attention to gender equity, community engagement, and institutional self-assessment. The establishing phase emphasizes transparent communication, local and Indigenous participation, diverse recruitment, and culturally responsive research design. The maintaining phase focuses on sustaining equity-focused teams, incentivizing inclusive leadership, supporting under-represented researchers, and formalizing equity policies. Our findings offer a phase-wise typology of organizational reforms to embed equity in conduct of global health research. Advancing these strategies requires institutional commitment and donor engagement across all resource settings. Networked organizations and reflexive designs are key to enabling shared learning and equity-aligned transformation.

In this article, we address the conundrum of context in health policy and systems research, zooming in on research on implementation of programmes, policies, and interventions. We review how the field draws on non-linear paradigms to better take into account 'context' in causal explanation, and we compare paradigms and the way in which they can inform more context-sensitive research, policies, and programmes. We propose a theorizing praxis that is based on the principles of realist inquiry and that allows researchers to draw lessons applicable to other settings by integrating a comprehensive analysis of context in their research.

Strengthening use of high-quality data for surgical obstetrics and family planning is important for improving maternal and perinatal health outcomes. Routine health information systems (RHIS) represent an important data source for indicator tracking. This landscape analysis aims to describe and compare surgical obstetric and family planning indicators put forth by global multi-stakeholder groups and those that are currently captured in RHIS in nine low- and middle-income countries. The analysis focused on five indicator topics: (i) caesarean delivery, (ii) peripartum hysterectomy, (iii) female genital fistula care, (iv) insertion/removal of long-acting reversible contraception and male/female sterilization, and (v) the general surgical context. We examined 12 indicator lists developed by multi-stakeholder groups and RHIS documentation from the Democratic Republic of the Congo, Guinea, India, Madagascar, Mali, Mozambique, Nigeria, Rwanda, and Senegal. 29 multi-stakeholder and 104 country indicators (119 unique indicators) met our inclusion criteria, typically capturing service provision or service readiness. Indicators on post-surgical outcomes or complications were rarer. The reviewed multi-stakeholder lists did not include indicators on peripartum hysterectomy. At the country level, not all RHIS included fistula care or peripartum hysterectomy indicators and there were marked differences with regard to what indicators were included and the relative distribution of indicators across the indicator topics. Only 14 (48%) of the multi-stakeholder indicators were included in countries' RHIS, with just two being tracked by all nine countries (caesarean deliveries and family planning users by modern method of contraception). There was a lack of standardized indicators for surgical obstetrics and family planning, and we noted typical RHIS challenges such as indicator profusion, duplication, vague indicator definitions, and measurement of composite or difficult-to-quantify concepts. Our findings suggest that there are opportunities to standardize and streamline prioritized measurement of surgical obstetric and family planning data for tracking with the ultimate aim of improving health services.

Early intervention (EI) is essential for the language, social, and educational development of deaf and/or hard-of-hearing (DHH) children. In African countries, however, the implementation of EI remains significantly constrained by cost considerations and systemic service gaps. This narrative review synthesises findings from 26 peer-reviewed publications to explore how cost influences access to and sustainability of EI services in Africa. Seven interrelated themes were identified: (1) high out-of-pocket expenses that limit family access to services; (2) inadequate public funding and heavy reliance on private or donor sources; (3) cost-effectiveness of early screening and intervention when delivered at scale; (4) lack of integrated cost data in national health planning; (5) inequitable access to hearing technologies due to procurement and pricing challenges; (6) opportunities for system-level enablers such as intersectoral collaboration, task-shifting, and community-based delivery; and (7) structural cost drivers unique to African contexts, including fragmented systems and infrastructure disparities. The findings highlight the need to embed economic evidence into policy planning, establish pooled procurement and subsidy schemes to reduce device costs, and integrate EI services into national insurance and essential health benefit packages. Culturally responsive, community-delivered models, supported by sustainable public financing and regional collaboration, are critical to ensure equity and long-term impact. Addressing these cost-related barriers through coordinated policy and system reforms will be key to achieving universal, inclusive, and sustainable EI services for DHH children in Africa.

In the context of a fiscal crisis and health pressures, Ghana's government has been exploring additional pro-health taxes. The World Health Organization and World Bank support health taxes as 'win-win' policies that can, if designed effectively, simultaneously improve health and raise revenue for health spending. However, international evidence shows that health taxes can meet political and public opposition. Yet, there is little research that empirically examines public views of health taxes. We compared policy stakeholders' perceptions of Ghanaian public support for health taxes with public views, seeking to understand the basis for potential public opposition, the extent to which evidence can shape public views, and whether tax framing and design influences public support. We undertook 28 semi-structured key informant interviews with stakeholders (from government, advocacy, and business groups) and five focus groups with 38 members of the public (purposefully selected for diversity in gender, age, ethnicity, occupation, and social background). We employed an innovative deliberative design for the focus groups, which enabled us to explore how public views responded to contrasting health tax 'frames'. Stakeholders generally believed public support for health taxes was low, especially for more widely consumed products. Yet, most focus group participants expressed strong support for health taxes, especially those targeting (more widely-consumed) sugar-sweetened beverages. Support increased when health taxes were framed as measures to improve public health and/or create a fairer tax system, and when commitments were made to using resulting revenue for health spending (known as 'earmarking' or hypothecation). However, stakeholders and members of the public shared a concern that business influence in Ghanaian politics presents a key barrier to implementing effective health taxes sustainably. Overall, our findings suggest that health taxes with a clearly-framed health rationale could command strong Ghanaian public support but likely require effective advocacy to overcome political barriers.

Understanding how an integrated rehabilitation workforce can be supported and strengthened is crucial to address gaps in access and quality of rehabilitation below tertiary hospitals. We explored how physiotherapists in two provinces in Pakistan perceive enablers and constraints to their rehabilitation performance at individual, workplace, health systems, socio-cultural, and political levels. Using a qualitative approach based on social ecological theories of health-worker performance and semi-structured interviews, 31 in-depth interviews with physiotherapists were conducted at secondary care hospitals in Khyber Pakhtunkhwa and Sindh provinces. Four intersecting themes were generated. (i) The capacity to perform as a rehabilitation professional is mediated by factors operating at different levels of the worker ecology. The experience of these factors has implications for (ii) the livelihoods and wellbeing of rehabilitation workers and (iii) the quality of care these workers perceive is delivered. (iv) Respondents' insightful and diverse suggestions for positive opportunities for change, towards strengthening and expanding integration of rehabilitation services within the health system, have policy and practice implications. Findings suggest an interdependence between context, rehabilitation workers, and the quality of care they deliver. The perspectives of these workers draw attention, beyond staff numbers and distribution, to the real-world challenges of practicing effectively in the context of local and systemic constraints and facilitators. These insights will be valuable to current efforts to integrate rehabilitation into health care settings beyond tertiary hospitals.

Efforts to strengthen knowledge translation (KT) for policy-making often call for greater engagement with the policy process and its actors. Yet, existing KT approaches often focus on communication and dissemination of evidence and undertheorise the role and influence of policy actors on KT. As such, this study examines how, why, and to what effect policy actors shape KT. Our findings address a critical gap in the KT literature regarding the relational dimensions of KT for policy-making in low-middle-income countries. We utilised purposive and snowball sampling to identify participants who are involved in health policy-making and KT in Kenya. This included policy-makers, academics/researchers, knowledge intermediaries, and external partners (development and implementation partners). Data were collected through in-depth interviews (n = 32), observations (n = 52 h), and document reviews (n = 34). Data analysis was informed by a theoretical framework that combined perspectives from actor-centred institutionalism, Gaventa's PowerCube, boundary work, and coproduction. Our findings reveal how actor influence in KT is shaped by institutional mandates and roles, which, in turn, shape how actors perceive their position and authority in KT processes. While some actors viewed themselves as constrained to the role of evidence provision, others acted as boundary spanners across policy spaces, enabled by their institutional flexibility and financial resources. In addition, actor interests shaped when and how they exercised power to support or resist KT. Furthermore, access to policy spaces determined whose evidence was visible and perceived as legitimate, reflecting deeper power structures. These dynamics frame KT as a relational process mediated by political and institutional structures. As such, this study highlights the need to reconceptualise KT to integrate relational and structural dimensions, moving beyond evidence dissemination to addressing actor and power dynamics. It contributes novel insights into the interplay between actors, context, and power in shaping KT outcomes.

The underutilization of primary care (PC) presents a substantial challenge in enhancing the people-centeredness, quality, and efficiency of health services for patients with chronic diseases. Pharmaceutical copayments have been considered a key barrier to patient access in low- and middle-income countries. It is unclear whether the removal of pharmaceutical copayment can lead to better care and management of chronic diseases. This study sought to evaluate the impact on healthcare utilization and spending of a policy that waived fees for essential pharmaceuticals at PC facilities, piloted county-wide from 2014 in rural China. Using individual claims data from 2010 to 2017, we applied a synthetic difference-in-difference approach to estimate the policy's effects. Our sample included 9115 patients with hypertension and/or diabetes from the pilot county and 30 675 patients from the other counties in the same municipality. The policy led to a significant increase of 0.69 in the number of PC visits per patient per year (95% CI: 0.46-0.91), equivalent to a rise of 44.1%. Annual spending per person on outpatients at PC facilities increased significantly due to the policy, by 58 yuan (95% CI: 36-80), equivalent to a rise of 40.5%. As for outpatient visits at hospitals, there was a 25.8% significant reduction in the number of visits per year (-0.56; 95% CI: -0.95 to -0.16) and a nonsignificant increase in spending (45 yuan; 95% CI: -111 to 21). The annual number of admissions and spending on inpatients per person in all facilities remained stable. Using claims data, we have demonstrated that targeted removal of copayment for essential medicines successfully shifted outpatient visits and expenditure from hospitals to PC facilities but did not affect hospitalization and inpatient expenditure. Further research may be attempted to see if removing pharmaceutical copayments on people with less severe NCDs could reduce hospitalizations.

Cervical cancer is a significant public health issue in Nigeria and a major cause of cancer-related morbidity and mortality among women. Equitable implementation of cervical cancer control programs alongside relevant policies and strategic plans is vital to reducing the burden of cervical cancer and improving the quality of life. Considering the role of policies in guiding program implementation, we reviewed Nigeria's cervical cancer policy landscape to identify strengths, limitations, and opportunities for improvement. This policy appraisal involved a literature review to understand related policy review frameworks, developing a modified framework containing six domains, systematically searching key databases and websites to identify relevant policy documents, data extraction and analysis, and synthesizing findings from reviewed documents. A total of five documents were reviewed in this study-three integrated cancer control plans, a cervical cancer policy, and a strategic plan for cervical cancer prevention and control. Two of the reviewed documents are current (2023-7), one is outdated, and two are expired. Key strengths identified in these documents include (i) a clear articulation of goals, (ii) a collaborative development process, (iii) the adoption of a phased implementation approach for proposed interventions, (iv) detailed intervention plans, and (v) monitoring and evaluation plans with performance indicators. In contrast, key limitations include (i) poor participation of subnational level stakeholders, (ii) absence of costing and funding approach in some plans, (iii) lack of baseline data on unmet needs and outcomes of previous plans, and (iv) absence of health system resource mapping. Addressing identified limitations is critical to improving the quality of policy and policy-informing documents, strengthening implementation across all levels, lowering the cervical cancer burden, and improving women's health outcomes.