Health policy and planning最新文献

One in five adolescents (aged 10-19 years) live in sub-Saharan Africa. Despite the availability of policies targeted at this age group, policy formulation, implementation, and gains in adolescent health continue to be underwhelming. Stakeholders or actors are architects of policy, bringing their ideological values, interests, power, and positions to policy formulation and implementation and thus influencing the policy process. We analysed multilevel stakeholder interests, positions, power, and their influence on adolescent mental, sexual, and reproductive health policy formulation and implementation in Ghana, West Africa, using a single-case study design with multiple embedded subunits of analysis. The case was defined as actors, their power, interests, positions, and their influence on policy formulation and implementation processes in adolescent mental, sexual, and reproductive health. A conceptual framework of conflict and synergies between stakeholder interests, power, and positions and their influence on policy formulation and implementation was used to guide the analysis. Data were obtained from key informant in-depth interviews with 19 global and national level and 16 subnational level stakeholders. Focus group discussions were also conducted with 4 district health management teams, 9 groups of frontline health workers, and 20 groups of in and out of school adolescents in four districts in the Greater Accra region of Ghana. The multiple stakeholders in adolescent health, including adolescents themselves, had sometimes synergistic and sometimes divergent and conflicting views on policy agendas, formulation, and approaches to implementation. Unresolved conflicts between powerful stakeholders in the public or bureaucratic arena stalled or hampered policy formulation and implementation, whereas consensus and adequate resourcing moved processes forward. It is important to invest effort in understanding actors, their power, positions, and interests in context to inform policy content and framing to increase the chances of consensus and effective policy formulation and implementation processes.

Neonatal deaths remain a critical public health challenge in many low- and middle-income countries (LMICs), including Kenya. Affordable technologies such as Comprehensive Positive Airway Pressure (CPAP) and phototherapy machines can reduce neonatal mortality and are used in these settings. However, their introduction and implementation in resource-constrained health system contexts are poorly understood. This study investigates how communication among health professionals influences decisions to use CPAP and phototherapy devices in Kenyan newborn units. Using a focused ethnographic approach, we conducted unstructured non-participatory observations, semistructured interviews, and document reviews in two newborn units in level five Kenyan referral hospitals. The study participants were all health professionals working in the newborn units. We gathered data in two phases, 6 months apart, and analyzed the data thematically. Data collection and analysis were informed by The Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework. We found four interconnected contextual factors that influenced health professionals' communication on the initiation, maintenance, discontinuation, and repair of neonatal technologies. These factors are as follows: First, physical environment, including space availability, newborn unit layout, and the arrangement of cots and incubators. Second, socio-organizational dynamics, such as the team composition, workload, management approach, and workplace culture. Third, technology-specific attributes, particularly the perceived complexity of CPAP and phototherapy's features and functions. Finally, the wider system encompasses administrative burdens from research and donor-supported programs as well as political, financial, and regulatory factors. Stakeholders, including funders, policymakers, local governments, and health professionals, must recognize that interconnected physical, organizational, technological, and wider contexts shape communication, decision-making, and use of life-saving technologies. A tailored approach that considers these complex realities, rather than a one-size-fits-all approach, should contribute to better integration and sustainability of these technologies, leading to improved outcomes in newborn care.

This innovation and practice report examines the achievements and challenges of the development and implementation of two policies guiding climate adaptation and mitigation action in Thailand's healthcare system, namely (i) The GREEN and CLEAN hospitals policy and (ii) The Health National Adaptation Plan. Based on key informant interviews and focus groups it was found that at the government level adaptation and mitigation planning was well developed. However, adaptation planning could be strengthened at the organizational level. Social values such as strong leadership and a sense of shared ownership significantly influenced initiative outcomes. Sub-district public health officials also served as crucial intermediaries between the government and local communities however, strengthening the coupling of environmental monitoring data with health impact analysis could further policy progression in the adaptation space. Participants also highlighted the need for increased funding, improved training, and greater knowledge sharing. Other healthcare systems could learn much from Thailand's approach to tackling climate change and health, particularly in the benefits of a detailed health-focused national mitigation and adaptation policy; establishment of local public health units; encouraging a sense of shared ownership; and, conceptualizing environmental sustainability as core to healthcare.

Many low- and middle-income countries are affected by catastrophic health expenditures due to overstretched public health financing, indicating need for complementary inclusive health insurance solutions. Promoting these solutions requires understanding drivers, including psychological determinants, of health insurance purchase. Yet, relevant evidence is lacking. We employed hybrid choice models to analyze discrete choice experiment data and examine preferences for Huimin Insurance, a widely diffused complementary inclusive health insurance in China. We relied on KuRunData to collect our discrete choice experiment data. We found that people who regarded themselves to be at greater health risk preferred more generous benefits, while they did not value strong government involvement in product operation, design, and publicity. Higher scheme awareness was associated with a greater propensity to purchase coverage, to be willing to pay higher premium, and to accept lower reimbursement rates. High awareness coupled with a low perception of the scheme value resulted in a preference for an expanded package covering prevention and screening services. Stronger value was attributed to the Huimin Insurance among population groups that lack access to other insurance products, such as women and rural residents. By integrating psychological constructs in the decision-making analysis, we provide new evidence to guide design and promotion of appropriate health insurance schemes, especially catastrophic diseases.

International research partnerships are crucial to strengthening research capacity (RCS) efforts. However, little is known about how such partnerships work to enhance the capacity of postgraduate trainees. We applied an Indigenous realist evaluation (RE) approach to examine how the 'African Research Initiative for Scientific Excellence' (ARISE) programme works to strengthen the capacity for trainees. The Indigenous RE integrates critical and scientific realism paradigms with the Postcolonial Indigenous paradigm, focusing strongly on power, relationality, and decolonization. We used a multi-case study design to investigate two cases of innovation- and laboratory-based research projects led by African principal investigators (PIs). We conducted realist-informed interviews and observations with PIs, interviews with collaborators and partners, and storytelling with students. Realist thematic analysis helped to identify context, intervention, mechanism, and outcomes (CIMO). Deductive, inductive, abductive, and retroductive reasoning were applied to generate programme theories through an iterative and rigorous theory-building process. Findings show that trainees who are committed and self-driven, based in a research-intensive university that provides complementary opportunities and where there is demand for multidisciplinary research, will improve their skills, secure additional funding, and transition from master's to PhD programmes. This is because the RCS resources would inspire, challenge, empower, activate a sense of agency, and provide the trainees with eye-opening experiences. However, trainees would secure jobs outside Africa (brain drain) if career opportunities in specialized fields are limited locally. If trainees are junior faculty staff and fully funded, and their university provides protected time, RCS resources would inspire, motivate, and empower them, resulting in increased research outputs and career growth. RCS efforts targeting (post)graduate trainees need to consider 'inter alia' the university contexts (e.g. availability of complementary resources and protected time), the individual traits and readiness for postgraduate training, and the broader ecosystem, which determines if the trainees' skills benefit Africa's research and development.

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.

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.