Health policy and planning最新文献

Stories and storytelling stimulate inquiries in health policy, and initiate and become an integral part of policy dialogues. They can also be used as a health policy advocacy tool. Storytelling is a compelling way to engage with various actors in the health policy realm, co-creating knowledge and action in the social world of health systems. Playback Theatre (PT) is an improvisational form of theatre in which audience members share their life stories, which are then enacted on the spot by a group of citizen actors. Citizen actors are everyday people who are not necessarily professional performers but are trained in PT. PT's emphasis on emotional expression and representation allows individuals to deeply engage with the stories of others, leading to greater empathy and understanding across diverse social groups. If applied with a critical consciousness, we argue that PT methodology can illuminate health policy and systems research storytelling processes, given its ontological and epistemological alignment with social constructivism and its orientation towards values such as human dignity and social justice. In this article, we explore the possibilities and the limits of PT for storytelling in the field of Health Policy and Systems Research, as it emphasises stories as much as the storyteller.

Global consensus has shifted to focus on how children can be supported to not only 'survive' but to 'thrive'. Blindness and visual loss in early childhood undermine a child's ability to thrive, affecting psychomotor, cognitive, and social development leading to life-long consequences for educational attainment, employment, economic and social status, and wellbeing. Despite this, eye health for children under the age of 5 years has been neglected, and not politically prioritized. In Tanzania, policy makers decided in 2019 to include eye conditions in the national Integrated Management of Newborn and Childhood Illness (IMNCI) programme, despite eye health not being part of the global World Health Organization/UNICEF IMNCI strategy. We conducted a qualitative policy analysis to explore enabling factors and barriers to this policy change. The interviews were semi-structured with key actors selected purposively and by snowball sampling, including those with a role in child and eye health at national and global levels. We used an adapted Shiffman and Smith framework (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007;370:1370-9) to guide the interviews and analysis, and the Consolidated Criteria for Reporting Qualitative Research for planning and reporting. This study shows how rapidly one country altered its overall child health policy to include eye health, driven by good quality collaborative research and collective action (cohesive policy community) which importantly included co-design with the decision makers (Ministry of Health actors). These developments coincided with the shift in the international agenda moving from 'survive to thrive' in child health which was leveraged to include eye care in the national strategy.

There is a growing need for healthcare professionals to ensure that their practices are inclusive and that they are considerate of the needs of marginalised communities. Inclusion health seeks to correct the imbalances that result in health inequities and requires health practitioners to have an adequate understanding and knowledge of the needs of marginalised and vulnerable population groups. The aim of this systematic review was to synthesise and critically appraise evidence from studies that explored healthcare professionals' knowledge and/or awareness of inclusion health. Academic Search Complete, CINAHL Plus with Full Text, MEDLINE, APA PsycArticles, APA PsycInfo, SocINDEX, were systematically searched without any year or language limits. The last search was conducted 16th of December 2024. A total of 4,870 studies were identified; of which, 37 were included (21 qualitative studies, 7 quantitative studies, 6 mixed-methods studies, 2 cross-sectional studies, and 1 quasi-experimental study). The methodological quality of the studies was appraised. Most studies were from the United States and Australia and focused on inclusion health knowledge regarding members of the Lesbian, Gay, Bisexual, Trans and Queer community, people with disabilities, and culturally diverse populations. Studies examining healthcare professionals' knowledge and awareness were not homogenous in nature resulting in a wide variety of studies and types of data. Different minority groups require varied levels of insights and understanding from their healthcare professionals. There is therefore no one-size-fits-all solution. We recommend targeted interventions throughout the training and education of healthcare professionals, informed and designed by the participation of members of those marginalised communities.

First referral hospitals (FRHs) have an important role to play in helping many countries achieve 'Health for All'. However, their specific role and the clinical services they are expected to provide to achieve this are evolving. To explore this issue further, we undertook a narrative review to examine the clinical service expectations of FRHs outlined in academic and policy literature, which identified a total of 404 FRH service expectations. At a global level, some categories of services provide extensive specific service recommendations, likely resulting from historical priorities and the influence of vertical programming and professional interests. However, in several important areas we identified few or no recommendations. At the level of individual country case studies undertaken through this review, FRH clinical service recommendations within available policy documents vary considerably. Our findings suggest a disconnect between the ambition for FRH and the difficult, context-specific decision-making needed at the national level on the role of FRHs as a service delivery platform within integrated health systems helping countries achieve universal health coverage.

Dementia has been regarded as a priority in public health for healthy ageing. Mild cognitive impairment (MCI) detection and management is one of the strategies to confront the challenge of increasing burden of dementia. However, MCI is not well recognized or managed in primary care. This study aimed to assess system barriers relating to MCI detection and management in the community. A mixed-methods study was undertaken over the period from October 2020 to October 2022. First, a focus group study (n = 124) in Shanghai explored the experiences of general practitioners (GPs), people with MCI and their informal caregivers, and community health managers using thematic analysis. This was followed by 2 rounds of national Delphi surveys among 22 eligible experts to solicit their consensus on the system conditions needed for community detection and management of MCI. A questionnaire survey based on the Delphi consultations was conducted with GPs (n = 1253) recruited from 56 community health centres (CHCs) in Shanghai to quantify their knowledge, attitudes, and practice (KAP) toward community detection and management of MCI and perceived system barriers. The results were mapped and triangulated in line with the chronic care model (CCM) and the health system building blocks articulated by the World Health Organization. Potential system barriers were identified from eight themes: (i) lack of self-management skills and enablement; (ii) lack of family support; (iii) lack of community support; (iv) unprepared healthcare system; (v) health service delivery deterrence; (vi) inadequate clinical decision support; (vii) lack of case management; and (viii) misaligned clinical information systems. The primary care system in Shanghai is not adequately equipped to handle the task of detecting and managing MCI. Both intrinsic and extrinsic obstacles impede the successful conversion of MCI knowledge into desired actions. A systems approach is needed to confront the challenge of MCI detection and management in China.

The establishment of long-term care insurance (LTCI) has become one of the key measures adopted by countries worldwide to address growing care needs associated with population aging. While existing studies focus on LTCI's impact on medical expenditure and healthcare utilization, its effects on living arrangements of older adults, a core component of long-term care, remain underexplored in China. Living arrangements reflect both the well-being of older adults and their approaches to aging. This study examines the effects of China's LTCI pilots on living arrangements of older adults. Using three-wave panel data from the Chinese Longitudinal Healthy Longevity Survey, we analyzed the rollout of LTCI pilots across different cities from 2014 to 2021, employing a time-varying difference-in-differences approach. Our findings indicate that LTCI significantly increases the likelihood of older adults living alone or only with their spouse and decreases their preference for living with adult children. We provide two explanations for the observed effects: LTCI facilitates aging in place through the provision of home- and community-based services and enhances older adults' health by reducing the incidence of severe illnesses. The effects of LTCI are shaped by policy design, specifically reimbursement structures. These findings offer valuable insights for developing a universal LTCI system in China and other developing countries.

This study aims to investigate the implementation strategy, unintended consequences, and underlying barriers to mandatory antimicrobial stewardship (AMS) programs in China. Face-to-face, in-depth qualitative interviews were conducted in 16 public hospitals in eastern, central, and western China. Hospitals were purposely selected with full consideration to represent both economically developing and developed areas and both secondary and tertiary care hospitals. A total of 111 respondents were interviewed, including 38 doctors, 28 clinical pharmacists, 15 microbiologists, 14 infection prevention and control specialists, 10 experts from medical service departments, and 6 quality improvement experts. A thematic framework analysis was conducted. A common implementation strategy was found among the surveyed hospitals in response to the AMS programs mandated by healthcare authorities. The hospital leadership empowered an AMS team to set AMS-related indicators for each clinical department and each doctor, and adopted core elements of AMS to optimize antimicrobial prescribing. However, the mandatory AMS approach also caused unintended consequences including regulatory circumvention, shift of risk to doctors and patients, and demotivation of healthcare workers. Two key barriers to AMS implementation were identified: (i) poor communication and cooperation between the AMS team and doctors, characterized by a high-power-low-power dynamic within hospital disciplines; and (ii) the profit-driven compensation system, which discourages collaboration and resource distribution for AMS implementation. Mandatory AMS programs should intensify AMS training, promote communication and cooperation between the AMS team and doctors, adjust the compensation system to facilitate better AMS implementation, and offer supportive measures that enable the adoption of strict regulations.

Healthcare costs are a major driver of poverty, accounting for 44.1% of poverty cases in China. By 2015, nearly 20 million people fell into or returned to poverty due to health issues. In response, the Chinese government launched the national health poverty alleviation project in 2016. This study aims to evaluate the distribution and trends of healthcare-induced poverty from 2013 to 2019. Using data from the China Household Finance Survey (CHFS), we estimated the incidence of household catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) and analyzed their determinants through multi-level logistic regression models. Subgroup analyses were conducted based on rural/urban location, geographic region, and province. In 2013, 31.83% of households experienced CHE, while 9.56% faced IHE. CHE incidence declined significantly after 2016 [adjusted odds ratio (AOR)  = 0.493-0.766, P < 0.001]. IHE incidence initially increased in 2015 (AOR = 1.580, P < 0.001) before declining from 2017 onward (AOR = 0.465-0.607, P < 0.001). The most significant reduction (9.99%-10.95%) occurred among the highest income quartile. CHE and IHE shared similar determinants. Higher odds of CHE and IHE were associated with older age of the household head (AOR = 1.225-2.175, P < 0.001), rural residency (AOR = 1.093-1.199, P < 0.05), the presence of an elderly household member (AOR = 1.237-1.336, P < 0.001), and having more household members in poor self-rated health (AOR = 2.455-4.137, P < 0.001). Conversely, lower odds of CHE and IHE were associated with higher educational attainment (AOR = 0.681-0.879, P < 0.001) and employment (AOR = 0.610-0.708, P < 0.001) of the household head, higher household income per capita (AOR = 0.017-0.860, P < 0.001), and larger household size (AOR = 0.335-0.684, P < 0.001). Households in urban areas and the eastern developed region had lower incidences of CHE and IHE compared to others. In conclusion, China has seen a significant decline in CHE and IHE, particularly after implementing the national poverty alleviation project. However, regional, urban-rural, and income-related disparities persist, underscoring the need for equity-focused interventions.

Supportive supervision (SS) programs aim to enhance the quality of care by strengthening the performance of health providers. Commonly part of broader quality improvement efforts, SS programs are increasingly used in low-and middle-income countries to improve malaria case management. Despite substantial investments and some positive outcomes, little is known about what drives their effectiveness. A realist evaluation was conducted in Tanzania and Benin to explain how, why, and under what circumstances SS programs can improve the facility-based management of uncomplicated malaria in children <5 years. A program theory was developed through a team-based analysis of empirical data collected in both countries at two time points. Data included 218 in-depth and 12 structured interviews with stakeholders, 154 audits of febrile case management decisions, and 4 health facility audits. Stakeholder perspectives identified three acceptability mechanisms driving SS program outcomes in the studied contexts: the affective attitude, self-efficacy, and burden of the program as perceived by key actors. The pathway through which these mechanisms were perceived to shape malaria case management (diagnosis and treatment) practices was defined by the (i) extent to which the program was integrated into the public health system; (ii) frequency with which SS visits were conducted by appropriate supervisors; (iii) degree to which supervisors coached, rather than policed, supervisees; and (iv) level of collaboration achieved between supervisees and supervisors. The program actors' perception of the program's effectiveness was also found to be crucial to its sustainability. This study explains the dynamics driving SS program outcomes and underscores the role played by the cognitive and emotional responses of program actors. These insights are likely to be transferable to other settings with similar contexts and can help inform the design, implementation, monitoring, and evaluation of new and ongoing SS programs.

Intersectoral collaboration (ISC) is a critical strategy in global health for addressing complex challenges requiring multi-sectoral engagement. Although studies examined ISC in low- and middle-income countries (LMICs), gaps remain in understanding how power dynamics between stakeholders influence the effectiveness of ISC in these settings. This realist synthesis examines how, why, for whom, under what context, and to what extent power dynamics shape ISC in LMIC health programmes and policies, offering insights crucial for improving health policy implementation. Five initial programme theories were developed through a scoping review, document analysis, and qualitative study. A systematic search of Medline, Embase, CINAHL, Web of Science, and grey literature (2012-23) yielded 2850 records, with 23 included after screening. This period was chosen to capture contemporary shifts in ISC, following the 2012 UN Political Declaration on NCDs and the WHO's 2013 Health in All Policies (HiAP) framework, which strengthened multi-sectoral governance in LMICs. It also builds on prior reviews, ensuring an up-to-date synthesis of power dynamics in ISC. Data were synthesized using the context-mechanism-outcome framework, generating demi-regularities to refine programme theories (PTs). Findings reveal that power imbalances frequently manifest through hierarchical governance structures, resource disparities, and historical inequities, shaping ISC outcomes. Six refined PTs highlight: (i) inclusive policy development processes mitigate power asymmetries but require intentional facilitation to prevent marginalization of less dominant sectors. (ii) Leadership commitment and shared goal alignment enhance collaboration, yet competing institutional priorities often reinforce power struggles. (iii) Equitable resource allocation acts as both a catalyst for trust and a source of conflict, with donor influence exacerbating dependency dynamics. (iv) Hierarchical communication norms in LMICs undermine transparency, though informal interpersonal networks can circumvent bureaucratic barriers. (v) Ambiguity in roles and mandates amplifies power vacuums, enabling dominant actors to disproportionately influence agendas. Additionally, a sixth PT emerged: (vi) sustained interpersonal relationships counterbalance structural power imbalances, fostering accountability and adaptive problem-solving. These findings demonstrate that power dynamics in ISC within LMICs are mediated by both structural factors (e.g. funding models and institutional hierarchies) and relational mechanisms (e.g. trust and negotiation). Successful collaboration hinges on recognizing and addressing these dual dimensions of power. This synthesis advances the theoretical and practical understanding of ISC, offering policymakers actionable insights to navigate power-related challenges in intersectoral health initiatives.