Bidirectional Data Collaborations in Distributed Research

Introduction:

The need for collaborations with bidirectional data exchange within and across distributed research networks has increased.

Currently Existing Activities:

This commentary will present currently publically available activities including the Sentinel Initiative, the Patient-Centered Outcomes Research Network (PCORnet), and the NIH Research Collaboratory.

Current Technical and Governance Challenges:

Even with the advances made in this arena, several technical and governance challenges remain including the evolution of clinically rich data sources and modes of care, availability of longitudinal data resources through data linkage, and the processes to share data and link data resources while ensuring privacy and proprietary control of data.

Perspective:

These activities will require enhanced levels of trust between entities involved in the delivery of healthcare (Trust 2.0) in addition to the trust health plans and health systems have with patients (Trust 1.0). Recent public funding announcements and public access to data resources will likely improve the landscape of bidirectional data collaborations in distributed research.

Understanding cancer networks better to implement them more effectively: a mixed methods multi-case study

Background

Managed cancer networks are widely promoted in national cancer control programs as an organizational form that enables integrated care as well as enhanced patient outcomes. While national programs are set by policy-makers, the detailed implementation of networks is delegated at the service delivery and institutional levels. It is likely that the capacity to ensure more integrated cancer services requires multi-level governance processes responsive to the strengths and limitations of the contexts and capable of supporting network-based working. Based on an empirical case, this study aims to analyze the implementation of a mandated cancer network, focusing on governance and health services integration as core concepts in the study.

Methods/design

This nested multi-case study uses mixed methods to explore the implementation of a mandated cancer network in Quebec, a province of Canada. The case is the National Cancer Network (NCN) subdivided into three micro-cases, each defined by the geographic territory of a health and social services region. For each region, two local health services centers (LHSCs) are selected based on their differences with respect to determining characteristics. Qualitative data will be collected from various sources using three strategies: review of documents, focus groups, and semi-directed interviews with stakeholders. The qualitative data will be supplemented with a survey that will measure the degree of integration as a proxy for implementation of the NCN. A score will be constructed, and then triangulated with the qualitative data, which will have been subjected to content analysis. Qualitative, quantitative, and mixed methods data will be interpreted within and across cases in order to identify governance patterns similarities and differences and degree of integration in contexts.

Discussion

This study is designed to inform decision-making to develop more effective network implementation strategies by thoroughly describing multi-level governance processes of a sample of settings that provide cancer services. Although the study focuses on the implementation of a cancer network in Quebec, the rich descriptions of multiple nested cases will generate data with a degree of generalizability for health-care systems in developed countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0404-8) contains supplementary material, which is available to authorized users.

A survey of the governance capacity of national public health associations to enhance population health

BACKGROUND

National public health associations (PHAs) are key partners with governments and communities to improve, protect and promote the public's health. Governance and organizational capacity are among the key determinants of a PHA's effectiveness as an advocate for appropriate public health policies and practice.

METHODS

During 2014, the World Federation of Public Health Associations (WFPHA) conducted an on-line survey of its 82 PHA members, to identify the state of organizational governance of national public health associations, as well as the factors that influence optimal organizational governance. The survey consisted of 13 questions and focused on the main elements of organizational governance: cultivating accountability; engaging stakeholders; setting shared direction; stewarding resources; and, continuous governance enhancement. Four questions included a qualitative open-ended response for additional comments. The survey data were analyzed using Microsoft Excel. The qualitative data was analyzed using thematic content analysis

RESULTS

Responses were received from 62 PHAs, constituting a 75.6 % response rate. The two most important factors that support governance effectiveness were a high degree of integrity and ethical behavior of the PHA's leaders (77 %) and the competence of people serving on the PHA's governing body (76 %). The lack of financial resources was considered as the most important factor that negatively affected organizational governance effectiveness (73 %). The lack of mentoring for future PHA leaders; ineffective or incompetent leadership; lack of understanding about good governance practices; and lack of accurate information for strategic planning were identified as factors influencing PHA governance effectiveness. Critical elements for PHA sustainability included diversity, gender-responsiveness and inclusive governance practices, and strategies to build the future generation of public health leaders.

CONCLUSION

National PHA have a responsibility to put into place the practices and infrastructure that enhance organizational governance. This will enhance their ability to be effective advocates for policies and practices that enhance, protect and promote the public's health. The WFPHA has an important role to play in providing the technical assistance and financial resources to assist PHAs in attaining and sustaining a higher level of governance capacity.

Decentralization and collaborative disaster governance: Evidence from South Korea

Decentralized disaster governance has been gaining much attention with the rising global urbanization rate and the complex nature of the disasters occurring in densely urbanized areas today. This paper studies the case of South Korea, a highly urbanized country with relatively recent decentralization reforms, in order to analyze the evolution of its disaster management system and to draw out implications from its experience. Specifically, it traces the national-level institutional changes in its disaster management, and then closely examines a hydrofluoric gas leakage in the industrial city of Gumi. The finding is that South Korea simultaneously carried out both centralization and decentralization of disaster management, which are not contradictory but rather complementary. Nevertheless, while the country successfully set up an integrated and comprehensive national-level management system, from which disaster governance can successfully be decentralized to localities, it still requires much more developed and consolidated multilevel (vertical) and broader (horizontal) collaboration, which are the preconditions for decentralized disaster governance.

Bioethics as a Governance Practice

Bioethics can be considered as a topic, an academic discipline (or combination of disciplines), a field of study, an enterprise in persuasion. The historical specificity of the forms bioethics takes is significant, and raises questions about some of these approaches. Bioethics can also be considered as a governance practice, with distinctive institutions and structures. The forms this practice takes are also to a degree country specific, as the paper illustrates by drawing on the author's UK experience. However, the UNESCO Universal Declaration on Bioethics can provide a starting point for comparisons provided that this does not exclude sensitivity to the socio-political context. Bioethics governance practices are explained by various legitimating narratives. These include response to scandal, the need to restrain irresponsible science, the accommodation of pluralist views, and the resistance to the relativist idea that all opinions count equally in bioethics. Each approach raises interesting questions and shows that bioethics should be studied as a governance practice as a complement to other approaches.

Global Health Governance Challenges 2016 - Are We Ready?

The year 2016 could turn out to be a turning point for global health, new political realities and global insecurities will test governance and financing mechanisms in relation to both people and planet. But most importantly political factors such as the global power shift and "the rise of the rest" will define the future of global health. A new mix of health inequity and security challenges has emerged and the 2015 humanitarian and health crises have shown the limits of existing systems. The global health as well as the humanitarian system will have to prove their capacity to respond and reform. The challenge ahead is deeply political, especially for the rising political actors. They are confronted with the consequences of a model of development that has neglected sustainability and equity, and was built on their exploitation. Some direction has been given by the path breaking international conferences in 2015. Especially the agreement on the Sustainable Development Goals (SDGs) and the Paris agreement on climate change will shape action. Conceptually, we will need a different understanding of global health and its ultimate goals - the health of people can no longer be seen separate from the health of the planet and wealth measured by parameters of growth will no longer ensure health.

Governance and pharmacovigilance in Brazil: a scoping review

Background

This scoping review investigates the relationship between governance, pharmacovigilance, and Agencia Nacional de Vigilancia Sanitaria (ANVISA) in Brazil, which has authority over Brazil's national pharmaceutical policy, drug registration and coordination of the national pharmacovigilance system. The purpose is to investigate opportunities for effective pharmacovigilance.

Methods

Sixty-three terms pertaining to pharmacovigilance in Brazil and ANVISA, global institutions, pharmaceutical industry, and civil society were searched in thirteen relevant databases on November 17-18, 2013. Using a pharmacogovernance framework we analyzed ANVISA's pharmacogovernance: the manner in which governing structures, policy instruments, and institutional authority are managed to promote societal interests for patient safety due to medication use. The integration of transnational policy ideas for regulatory governance into pharmacogovernance in Brazil was also investigated.

Results

Brazil's policy, laws, and regulations support ANVISA's authority to ensure access to safe medicines and health products however ANVISA's broad mandate and gaps in pharmacogovernance account for regional disparities in monitoring and assessing drug safety. Gaps in pharmacogovernance include: equity and inclusiveness; stakeholder coordination; effectiveness and efficiency; responsiveness; and intelligence and information.

Conclusions

Pharmacogovernance that addresses 1) regional resource disparities, 2) federal and state lack of coordination of pharmacovigilance regulations, 3) asymmetric representation in the pharmaceutical regulatory agenda and which 4) disaggregates regulatory authority over health and commercial sectors would strengthen pharmacovigilance in Brazil.

Electronic supplementary material

The online version of this article (doi:10.1186/s40545-016-0053-y) contains supplementary material, which is available to authorized users.

Advancing Global Health - The Need for (Better) Social Science Comment on "Navigating Between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health"

In his perspective "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health," Ooms argues that actions taken in the field of global health are dependent not only on available resources, but on the normative premise that guides how these resources are spent. This comment sets out how the application of a predominately biomedical positivist research tradition in global health, has potentially limited understanding of the value judgements underlying decisions in the field. To redress this critical social science, including health policy analysis has much to offer, to the field of global health including on questions of governance.

Changing ideas in forestry: A comparison of concepts in Swedish and American forestry journals during the early twentieth and twenty-first centuries

By combining digital humanities text-mining tools and a qualitative approach, we examine changing concepts in forestry journals in Sweden and the United States (US) in the early twentieth and early twenty-first centuries. Our first hypothesis is that foresters at the beginning of the twentieth century were more concerned with production and less concerned with ecology than foresters at the beginning of the twenty-first century. Our second hypothesis is that US foresters in the early twentieth century were less concerned with local site conditions than Swedish foresters. We find that early foresters in both countries had broader-and often ecologically focused-concerns than hypothesized. Ecological concerns in the forestry literature have increased, but in the Nordic countries, production concerns have increased as well. In both regions and both time periods, timber management is closely connected to concerns about governance and state power, but the forms that governance takes have changed.

Understanding consistencies and gaps between desired forest futures: An analysis of visions from stakeholder groups in Sweden

Conflicting perspectives on forests has for a long time challenged forest policy development in Sweden. Disagreements about forest futures create intractable deadlocks when stakeholders talk past each other. The purpose of this study is to move beyond this situation through the application of participatory backcasting. By comparing visions of the future forest among stakeholder groups, we highlight contemporary trajectories and identify changes that were conceived as desirable. We worked with four groups: the Biomass and Bioenergy group, the Conservation group, the Sami Livelihood group and the Recreation and Rural Development group; in total representatives from 40 organizations participated in workshops articulating the groups' visions. Our results show well-known tensions such as intrinsic versus instrumental values but also new ones concerning forests' social values. Identified synergies include prioritization of rural development, new valued-added forest products and diversified forest management. The results may feed directly into forest policy processes facilitating the process and break current deadlocks.

Interdisciplinary science for future governance and management of forests

The sustainable use of forests constitutes one of the great challenges for the future due to forests' large spatial coverage, long-term planning horizons and inclusion of many ecosystem services. The mission of the Future Forests programme is to provide a scientifically robust knowledge base for sustainable governance and management of forests preparing for a future characterized by globalization and climate change. In this introduction to the Special Issue, we describe the interdisciplinary science approach developed in close collaboration with actors in the Future Forests programme, and discuss the potential impacts of this science on society. In addition, we introduce the 13 scientific articles and present results produced by the programme.

Promising waste: biobanking, embryo research, and infrastructures of ethical efficiency

Biobanks are custodial institutions that enhance the utility and value of biological materials by collecting and curating them. Their custodial functions tend to include ethical oversight and governance. This paper explores how biobanks increase the value of biological materials by standardizing routines of governance in order to engender "ethical efficiency." Focusing in particular upon banking of human embryos for research, the article offers an historical account of how human embryos came to be "waste" available for use by researchers in the US. It offers a case study of a human embryo biobank and the practices of ethical governance that the biobank employs to capture this waste and convert it into a valuable resource for research use. The article draws attention to the ways biobanks' emphasis on efficiency and resolving problems of ethical governance up front codifies otherwise contested normative relationships and authorizes uses of human biological materials that some see as ethically problematic, even as it eliminates institutionalized mechanisms of reflection in which such problems would otherwise be acknowledged and confronted.

Mental health system governance in Nigeria: challenges, opportunities and strategies for improvement

INTRODUCTION

A health systems approach to understanding efforts for improving health care services is gaining traction globally. A component of this approach focuses on health system governance (HSG), which can make or mar the successful implementation of health care interventions. Very few studies have explored HSG in low- and middle-income countries, including Nigeria. Studies focusing on mental health system governance, are even more of a rarity. This study evaluates the mental HSG of Nigeria with a view to understanding the challenges, opportunities and strategies for strengthening it.

METHODOLOGY

This study was conducted as part of the project, Emerging Mental Health Systems in Low and Middle Income Countries (Emerald). A multi-method study design was utilized to evaluate the mental HSG status of Nigeria. A situational analysis of the health policy and legal environment in the country was performed. Subsequently, 30 key informant interviews were conducted at national, state and district levels to explore the country's mental HSG.

RESULTS

The existing policy, legislative and institutional framework for HSG in Nigeria reveals a complete exclusion of mental health in key health sector documents. The revised mental health policy is however promising. Using the Siddiqi framework categories, we identified pragmatic strategies for mental health system strengthening that include a consideration of existing challenges and opportunities within the system.

CONCLUSION

The identified strategies provide a template for the subsequent activities of the Emerald Programme (and other interventions), towards strengthening the mental health system of Nigeria.

How Can a Global Social Support System Hope to Achieve Fairer Competiveness? Comment on "A Global Social Support System: What the International Community Could Learn From the United States' National Basketball Association"

Ooms et al sets out some good general principles for a global social support system to improve fairer global competitiveness as a result of redistribution. This commentary sets out to summarize some of the conditions that would need to be satisfied for it to level up gradients in inequality through such a social support system, using the National Basketball Association (NBA) example as a point of reference. From this, the minimal conditions are described that would be required for the support system, proposed in the article by Ooms et al, to succeed.

More heat, less light! The resource curse & HIV/AIDS: A reply to Olivier Sterck

We reported fairly robust results suggesting that resource rich countries did less well containing HIV/AIDS than resource poor states (de Soysa and Gizelis, 2013). We argued that public action to prevent the spread of disease was going to be weaker in resource rich states because rulers would have less incentive to fight disease. Olivier Sterck (this issue) criticizes our study on several grounds, arguing that resource rich states can provide anti-retroviral therapy (ART) and thereby fight the AIDS epidemic. He, however, finds no relationship between resource wealth and HIV/AIDS. We argue that his reanalyses do not fully address the theoretical association between resource wealth and the spread of HIV/AIDS and that his argument about ART is more wishful than a realistic expectation. Future research should probe more carefully why resource wealth has not been deployed more effectively for fighting disease-a point we can all agree on.

Politics or Technocracy - What Next for Global Health? Comment on "Navigating Between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health"

Politics play a central part in determining health and development outcomes as Gorik Ooms highlights in his recent commentary. As health becomes more global and more politicized the need grows to better understand the inherently political processes at all levels of governance, such as ideological positions, ideas, value judgments, and power. I agree that global health research should strengthen its contribution to generating such knowledge by drawing more on political science, such research is gaining ground. Even more important is - as Ooms indicates - that global health scholars better understand their own role in the political process. It is time to acknowledge that expert-based technocratic approaches are no less political. We will need to reflect and analyse the role of experts in global health governance to a greater extent and in that context explore the links between politics, expertise and democracy.

Pathways from marine protected area design and management to ecological success

Using an international dataset compiled from 121 sites in 87 marine protected areas (MPAs) globally (Edgar et al., 2014), I assessed how various configurations of design and management conditions affected MPA ecological performance, measured in terms of fish species richness and biomass. The set-theoretic approach used Boolean algebra to identify pathways that combined up to five ‘NEOLI’ (No-take, Enforced, Old, Large, Isolated) conditions and that were sufficient for achieving positive, and negative, ecological outcomes. Ecological isolation was overwhelming the most important condition affecting ecological outcomes but Old and Large were also conditions important for achieving high levels of biomass among large fishes (jacks, groupers, sharks). Solution coverage was uniformly low (<0.35) for all models of positive ecological performance suggesting the presence of numerous other conditions and pathways to ecological success that did not involve the NEOLI conditions. Solution coverage was higher (>0.50) for negative results (i.e., the absence of high biomass) among the large commercially-exploited fishes, implying asymmetries in how MPAs may rebuild populations on the one hand and, on the other, protect against further decline. The results revealed complex interactions involving MPA design, implementation, and management conditions that affect MPA ecological performance. In general terms, the presence of no-take regulations and effective enforcement were insufficient to ensure MPA effectiveness on their own. Given the central role of ecological isolation in securing ecological benefits from MPAs, site selection in the design phase appears critical for success.

Decentralizing conservation and diversifying livelihoods within Kanchenjunga Conservation Area, Nepal

To alleviate poverty and enhance conservation in resource dependent communities, managers must identify existing livelihood strategies and the associated factors that impede household access to livelihood assets. Researchers increasingly advocate reallocating management power from exclusionary central institutions to a decentralized system of management based on local and inclusive participation. However, it is yet to be shown if decentralizing conservation leads to diversified livelihoods within a protected area. The purpose of this study was to identify and assess factors affecting household livelihood diversification within Nepal's Kanchenjunga Conservation Area Project, the first protected area in Asia to decentralize conservation. We randomly surveyed 25% of Kanchenjunga households to assess household socioeconomic and demographic characteristics and access to livelihood assets. We used a cluster analysis with the ten most common income generating activities (both on- and off-farm) to group the strategies households use to diversify livelihoods, and a multinomial logistic regression to identify predictors of livelihood diversification. We found four distinct groups of household livelihood strategies with a range of diversification that directly corresponded to household income. The predictors of livelihood diversification were more related to pre-existing socioeconomic and demographic factors (e.g., more landholdings and livestock, fewer dependents, receiving remittances) than activities sponsored by decentralizing conservation (e.g., microcredit, training, education, interaction with project staff). Taken together, our findings indicate that without direct policies to target marginalized groups, decentralized conservation in Kanchenjunga will continue to exclude marginalized groups, limiting a household's ability to diversify their livelihood and perpetuating their dependence on natural resources.

Evaluating governance for sustainable development - Insights from experiences in the Dutch fen landscape

Prominent strands of discussion in the literature on governance for sustainable development debate how change can be induced to enhance sustainability, and how to evaluate the interventions aimed at prompting such change. Strikingly, there are few contributions about how prominent ideas of inducing change deal with multiple governance criteria for pursuing sustainable development. Moreover, the way ideas about inducing change relate to criteria of governance for sustainable development is not yet studied in an empirical context. This paper therefore comparatively analyses how three prominent modes of sustainable development governance - adaptive management, transition management and payments for environmental services - relate to a set of five prominent criteria reported in the literature, namely: equity, democracy, legitimacy, the handling of scale issues and the handling of uncertainty issues. It finds that the academic debates on these three modes address these criteria with varying attention and rather fragmented, while in the empirical setting of the Dutch fen landscape several aspects relating to the studied criteria were present and substantially influenced the functioning of the three modes of sustainable development. Together, the analysis of the literature debate and the empirical data are able to show that a narrow evaluation perspective may fail to diagnose and capture relevant struggles and complexities coming along with governance for sustainable development relevant issues. The study shows that in order to advance our understanding of governance for sustainable development, it is indeed important to include multiple criteria in studying these modes. Moreover, the study shows the importance of including empirical experiences which manifest when different modes for sustainable development are applied in real-world settings.

Health workforce governance and oral health: Diversity and challenges in Europe

Throughout the life course, oral diseases are some of the most common non-communicable diseases globally, and in Europe. Human resources for oral health are fundamental to healthcare systems in general and dentistry is no exception. As political and healthcare systems change, so do forms of governance. The aim of this paper is to examine human resources for oral health in Europe, against a workforce governance framework, using England as a case study. The findings suggest that neo-liberalist philosophies are leading to multiple forms of soft governance at professional, system, organisational and individual levels, most notably in England, where there is no longer professional self-regulation. Benefits include professional regulation of a wider cadre of human resources for oral health, reorientation of care towards evidence-informed practice including prevention, and consideration of care pathways for patients. Across Europe there has been significant professional collaboration in relation to quality standards in the education of dentists, following transnational policies permitting freedom of movement of health professionals; however, the distribution of dentists is inequitable. Challenges include facilitating employment of graduates to serve the needs and demands of the population in certain countries, together with governance of workforce production and migration across Europe. Integrated trans-European approaches to monitoring mobility and governance are urgently required.

Political economy and the emergence of a hybrid mode of governance of tourism planning

This paper examines how Hong Kong's political economy influences its local modes of tourism governance and development planning. The study explores how a destination can exhibit a hybrid mode of tourism governance, and also how that emerged in Hong Kong in relation to three phases of socio-economic and tourism development. The three phases are 1842-1966, 1967-1997, and post-1997. Hong Kong's present mode of tourism governance combines pro-growth and pluralist elements. It is affected by the need for capital accumulation and political legitimacy and by the relative influence of government and civil society.

Clarification of Safe Delivery by Iranian Experts Based on Clinical Governance: A Qualitative Study

OBJECTIVE

To clarify the principles of a safe delivery based on Clinical Governance Criteria, as recommended by the pertinent experts.

MATERIALS AND METHODS

The current study was part of a qualitative research conducted by content analysis method in 2013 and purposive sampling, performing 24 in-depth interviews based on semi-structured questions and analyzed using thematic content analysis. The participants in this research included midwives, obstetricians, managers, and hospital doctors. The data were under continuous consideration and comparative analysis in order to achieve data saturation.

RESULTS

The main concepts derived from interpretations of the pertinent experts include: Patient & Public involvement; Risk Management; Education; Clinical efficiency; Clinical audit; Personnel & Management.

CONCLUSION

In a safe delivery, there is a vicious cycle of causes the elimination of which is only possible through benchmarking patterns that attend to most aspects of a safe delivery. Changes to services require utilization of appropriate change management strategies.

Evaluating adaptive co-management as conservation conflict resolution: Learning from seals and salmon

By linking iterative learning and knowledge generation with power-sharing, adaptive co-management (ACM) provides a potential solution to resolving complex social-ecological problems. In this paper we evaluate ACM as a mechanism for resolving conservation conflict using a case study in Scotland, where seal and salmon fishery stakeholders have opposing and entrenched objectives. ACM emerged in 2002, successfully resolving this long-standing conflict. Applying evaluation approaches from the literature, in 2011 we interviewed stakeholders to characterise the evolution of ACM, and factors associated with its success over 10 years. In common with other ACM cases, triggers for the process were shifts in slow variables controlling the system (seal and salmon abundance, public perceptions of seal shooting), and exogenous shocks (changes in legal mandates, a seal disease outbreak). Also typical of ACM, three phases of evolution were evident: emerging local leadership preparing the system for change, a policy window of opportunity, and stakeholder partnerships building the resilience of the system. Parameters maintaining ACM were legal mechanisms and structures, legal power held by government, and the willingness of all stakeholders to reach a compromise and experiment with an alternative governance approach. Results highlighted the critical role of government power and support in resolving conservation conflict, which may constrain the extent of local stakeholder-driven ACM. The evaluation also demonstrated how, following perceived success, the trajectory of ACM has shifted to a 'stakeholder apathy' phase, with declining leadership, knowledge exchange, stakeholder engagement, and system resilience. We discuss remedial actions required to revive the process, and the importance of long term government resourcing and alternative financing schemes for successful conflict resolution. Based on the results we present a generic indicator framework and participatory method for the longitudinal evaluation of ACM applied to conservation conflict resolution.

Transforming river basins: Post-livelihood transition agricultural landscapes and implications for natural resource governance

The agricultural and livelihood transitions post globalization are redefining resource relations and redrawing landscapes in the Global South and have major implications for nascent natural resource governance regimes such as Integrated River Basin Management (IRBM). A mosaic of divergent reciprocations in resource relations were noticed due to livelihood transitions in the rural areas where previous resource uses and relations had been primarily within agriculture. The reconstitution of rural spaces and the attendant changes in the resource equations are observed to be creating new sites of conformity, contestation and conflicts that often move beyond local spaces. This paper critically reviews studies across the Global South to explore the nature and extent of changes in resource relations and agricultural landscapes post livelihood diversification and the implication and challenges of these changes for natural resource governance. Though there is drastic reduction in agricultural livelihoods throughout the Global South, changes in agricultural area are found to be inconsistent and heterogeneous in the region. Agriculture continues in the countrysides but in widely differentiated capacities and redefined value systems. The transformed agrarian spaces are characterized by a mosaic of scenarios from persistence and sustainable subsistence to differentiation and exploitative commercial practices to abandonment and speculation. The reconfigured resource relations, emergent multiple and multi-scalar interest groups, institutional and policy changes and altered power differentials in these diversified landscapes are yet to be incorporated into natural resource governance frameworks such as IRBM.

Strategic governance: Addressing neonatal mortality in situations of political instability and weak governance

Neonatal mortality is increasingly concentrated globally in situations of conflict and political instability. In 1991, countries with high levels of political instability accounted for approximately 10% of all neonatal deaths worldwide; in 2013, this figure had grown to 31%. This has generated a "grand divergence" between those countries showing progress in neonatal mortality reduction compared to those lagging behind. We present new analyses demonstrating associations of neonatal mortality with political instability (r = 0.55) and poor governance (r = 0.70). However, heterogeneity in these relationships suggests that progress is possible in addressing neonatal mortality even in the midst of political instability and poor governance. In order to address neonatal mortality more effectively in such situations, we must better understand how specific elements of "strategic governance"--the minimal conditions of political stability and governance required for health service implementation--can be leveraged for successful introduction of specific health services. Thus, a more strategic approach to policy and program implementation in situations of conflict and political instability could lead to major accelerations in neonatal mortality reduction globally. However, this will require new cross-disciplinary collaborations among public health professionals, political scientists, and country actors.

Introduction to special issue: Overview of Alzheimer's Disease Neuroimaging Initiative

The Alzheimer's Disease Neuroimaging Initiative (ADNI), designed as a naturalistic longitudinal study to develop and validate magnetic resonance, positron emission tomography, cerebrospinal fluid, and genetic biomarkers for use in AD clinical trials, has made many impacts in the decade since its inception. The initial 5-year study, ADNI-1, enrolled cognitively normal, mild cognitive impairment (MCI) and AD subjects, and the subsequent studies (ADNI-GO and ADNI-2) added early- and late-MCI cohorts. The development of standardized methods allowed comparison of data gathered across multiple sites, and these data are available to qualified researchers without embargo. ADNI data have been used in >600 publications including those describing relationships between biomarkers, improved methods for disease diagnosis and the prediction of future decline, and identifying novel genetic AD risk loci. ADNI has provided a framework for similar initiatives worldwide.

Marine governance in the English Channel (La Manche): Linking science and management

The English Channel is one of the world's busiest sea areas with intense shipping and port activity juxtaposed with recreation, communications and important conservation areas. Opportunities for marine renewable energy vie with existing activities for space. The current governance of the English Channel is reviewed and found to lack integration between countries, sectors, legislation and scientific research. Recent developments within the EU's marine management frameworks are significantly altering our approach to marine governance and this paper explores the implications of these new approaches to management of the English Channel. Existing mechanisms for cross-Channel science and potential benefits of an English Channel scale perspective are considered. In conclusion, current management practices are considered against the 12 Malawi Principles of the ecosystem approach resulting in proposals for enhancing governance of the region through science at the scale of the English Channel.

Integrated probabilistic risk assessment for nanoparticles: the case of nanosilica in food

Insight into risks of nanotechnology and the use of nanoparticles is an essential condition for the social acceptance and safe use of nanotechnology. One of the problems with which the risk assessment of nanoparticles is faced is the lack of data, resulting in uncertainty in the risk assessment. We attempt to quantify some of this uncertainty by expanding a previous deterministic study on nanosilica (5-200 nm) in food into a fully integrated probabilistic risk assessment. We use the integrated probabilistic risk assessment method in which statistical distributions and bootstrap methods are used to quantify uncertainty and variability in the risk assessment. Due to the large amount of uncertainty present, this probabilistic method, which separates variability from uncertainty, contributed to a better understandable risk assessment. We found that quantifying the uncertainties did not increase the perceived risk relative to the outcome of the deterministic study. We pinpointed particular aspects of the hazard characterization that contributed most to the total uncertainty in the risk assessment, suggesting that further research would benefit most from obtaining more reliable data on those aspects.

Governance and functionality of community water schemes in rural Ethiopia

OBJECTIVES

A key challenge for achieving universal water access in Sub-Saharan Africa is poor sustainability of water schemes. Previous studies have posited factors that may lead to failed schemes; however, empirical data are lacking.

METHODS

We conducted direct observations of water sources and interviewed water committee members about governance in two regions of Ethiopia. Based on direct observation at each water point, and harmonizing previous research in the sector, we developed an ordinal measure of functionality. Among functional systems, linear regression models were used to assess changes in score or level of functionality against governance characteristics.

RESULTS

Of 89 water schemes over 5 years old, 82 had sufficient data to receive a score. Higher functionality scores were associated with having good records, meeting regularly, financial audits, higher monthly fees, a paid caretaker and water committees with capacity to perform minor repairs.

CONCLUSIONS

Our continuous measure of functionality was simple to derive, objective and may be widely applicable for further studies assessing key indicators of sustainability.

What did we learn from PEGASEAS forum "Science and Governance of the Channel Marine Ecosystem"?

As one of the busiest marine ecosystems in the world, the English Channel is subjected to strong pressures due to the human activities occurring within it. Effective governance is required to improve the combined management of different activities and so secure the benefits provided by the Channel ecosystem. In July 2014, a Cross-Channel Forum, entitled "Science and Governance of the Channel Marine Ecosystem", was held in Caen (France) as part of the INTERREG project "Promoting Effective Governance of the Channel Ecosystem" (PEGASEAS). Here we use outputs from the Forum as a framework for providing Channel-specific advice and recommendations on marine governance themes, including the identification of knowledge gaps, which may form the foundation of future projects for the next INTERREG project call (2015-2020).

The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely collected administrative data

Background

Medicolegal agencies—such as malpractice insurers, medical boards and complaints bodies—are mostly passive regulators; they react to episodes of substandard care, rather than intervening to prevent them. At least part of the explanation for this reactive role lies in the widely recognised difficulty of making robust predictions about medicolegal risk at the individual clinician level. We aimed to develop a simple, reliable scoring system for predicting Australian doctors’ risks of becoming the subject of repeated patient complaints.

Methods

Using routinely collected administrative data, we constructed a national sample of 13 849 formal complaints against 8424 doctors. The complaints were lodged by patients with state health service commissions in Australia over a 12-year period. We used multivariate logistic regression analysis to identify predictors of subsequent complaints, defined as another complaint occurring within 2 years of an index complaint. Model estimates were then used to derive a simple predictive algorithm, designed for application at the doctor level.

Results

The PRONE (Predicted Risk Of New Event) score is a 22-point scoring system that indicates a doctor's future complaint risk based on four variables: a doctor's specialty and sex, the number of previous complaints and the time since the last complaint. The PRONE score performed well in predicting subsequent complaints, exhibiting strong validity and reliability and reasonable goodness of fit (c-statistic=0.70).

Conclusions

The PRONE score appears to be a valid method for assessing individual doctors’ risks of attracting recurrent complaints. Regulators could harness such information to target quality improvement interventions, and prevent substandard care and patient dissatisfaction. The approach we describe should be replicable in other agencies that handle large numbers of patient complaints or malpractice claims.

Health system governance to support integrated mental health care in South Africa: challenges and opportunities

Background

While South Africa has a new policy framework supporting the integration of mental health care into primary health care, this is not sufficient to ensure transformation of the health care system towards integrated primary mental health care. Health systems strengthening is needed, incorporating, inter alia, capacity building and resource inputs, as well as good governance for ensuring that the relevant policy imperatives are implemented.

Objectives

To identify systemic factors within institutional and policy contexts that are likely to facilitate or impede the implementation of integrated mental health care in South Africa.

Methods

Semi-structured qualitative interviews were conducted with 17 key stakeholders in the Department of Health and Department of Social Development at national level, at provincial level in the North West Province, and at district level in the Dr Kenneth Kaunda district. Participants were purposively identified based on their positions and job responsibilities. Interview questions were guided by a hybrid of Siddiqi et al.’s governance framework principles and Mikkelsen-Lopez et al.’s health system governance approach. Data were analysed using framework analysis in NVivo.

Results

Facilitative factors included the recent mental health care policy framework and national action plan that embraces integrated care using a task sharing model and provides policy imperatives for the establishment of district mental health teams to facilitate the development and implementation of district mental health care plans; the roll out of the integrated chronic disease service delivery platform that can be leveraged to increase access and resources as well as decrease stigma; and the presence of NGOs that can assist with service delivery. Challenges included the low prioritisation and stigmatisation of mental illness; weak managerial and planning capacity to develop and implement mental health care plans at provincial and district level; poor pre-service training of generalists in mental health care; weak orientation to integrated care; high staff turnover; weak intersectoral coordination; infrastructural constraints; and no dedicated mental health budget.

Conclusion

This study identifies strategies to support and improve integrated mental health care in primary health care services.

Hegemony in the marketplace of biomedical innovation: consumer demand and stem cell science

The global political economy of stem cell therapies is characterised by an established biomedical hegemony of expertise, governance and values in collision with an increasingly informed health consumer demand able to define and pursue its own interest. How does the hegemony then deal with the challenge from the consumer market and what does this tell us about its modus operandi? In developing a theoretical framework to answer these questions, the paper begins with an analysis of the nature of the hegemony of biomedical innovation in general, its close relationship with the research funding market, the current political modes of consumer incorporation, and the ideological role performed by bioethics as legitimating agency. Secondly, taking the case of stem cell innovation, it explores the hegemonic challenge posed by consumer demand working through the global practice based market of medical innovation, the response of the national and international institutions of science and their reassertion of the values of the orthodox model, and the supporting contribution of bioethics. Finally, the paper addresses the tensions within the hegemonic model of stem cell innovation between the key roles and values of scientist and clinician, the exacerbation of these tensions by the increasingly visible demands of health consumers, and the emergence of political compromise.

Scenario analysis for biodiversity conservation: a social-ecological system approach in the Australian Alps

Current policy interventions are having limited success in addressing the ongoing decline in global biodiversity. In part, this is attributable to insufficient attention being paid to the social and governance processes that drive decisions and can undermine their implementation. Scenario planning that draws on social-ecological systems (SES) analysis provides a useful means to systematically explore and anticipate future uncertainties regarding the interaction between humans and biodiversity outcomes. However, the effective application of SES models has been limited by the insufficient attention given to governance influences. Understanding the influence governance attributes have on the future trajectory of SES is likely to assist choice of effective interventions, as well as needs and opportunities for governance reform. In a case study in the Australian Alps, we explore the potential of joint SES and scenario analyses to identify how governance influences landscape-scale biodiversity outcomes. Novel aspects of our application of these methods were the specification of the focal system's governance attributes according to requirements for adaptive capacity, and constraining scenarios according to the current governance settings while varying key social and biophysical drivers. This approach allowed us to identify how current governance arrangements influence landscape-scale biodiversity outcomes, and establishes a baseline from which the potential benefits of governance reform can be assessed.

Nursing domain of CI governance: recommendations for health IT adoption and optimization

CONTEXT

There is a lack of recommended models for clinical informatics (CI) governance that can facilitate successful health information technology implementation.

OBJECTIVES

To understand existing CI governance structures and provide a model with recommended roles, partnerships, and councils based on perspectives of nursing informatics leaders.

DESIGN, SETTING, PARTICIPANTS

We conducted a cross-sectional study through administering a survey via telephone to facilitate semistructured interviews from June 2012 through November 2012. We interviewed 12 nursing informatics leaders, across the United States, currently serving in executive- or director-level CI roles at integrated health care systems that have pioneered electronic health records implementation projects.

RESULTS

We found the following 4 themes emerge: (1) Interprofessional partnerships are essential. (2) Critical role-based levels of practice and competencies need to be defined. (3) Integration into existing clinical infrastructure facilitates success. (4) CI governance is an evolving process. We described specific lessons learned and a model of CI governance with recommended roles, partnerships, and councils from the perspective of nursing informatics leaders.

CONCLUSION

Applied CI work is highly interprofessional with patient safety implications that heighten the need for best practice models for governance structures, adequate resource allocation, and role-based competencies. Overall, there is a notable lack of a centralized CI group comprised of formally trained informaticians to provide expertise and promote adherence to informatics principles within EHR implementation governance structures. Our model of the nursing domain of CI governance with recommended roles, partnerships, and councils provides a starting point that should be further explored and validated. Not only can the model be used to understand, shape, and standardize roles, competencies, and structures within CI practice for nursing, it can be used within other clinical domains and by other informaticians.

Implementing people-centred health systems governance in 3 provinces and 11 districts of Afghanistan: a case study

Background

Previous studies show that health systems governance influences health system performance and health outcomes. However, there are few examples of how to implement and monitor good governing practices in fragile and conflict affected environments. Good governance has the potential to make the health system people-centered. More research is needed on implementing a people-centered governance approach in these environments.

Case description

We piloted an intervention that placed a people-centred health systems governance approach in the hands of multi-stakeholder committees that govern provincial and district health systems. We report the results of this intervention from three provinces and eleven districts in Afghanistan over a six month period. This mixed-methods exploratory case study uses analysis of governance self-assessment scores, health management information system data on health system performance, and focus group discussions. The outcomes of interest are governance scores and health system performance indicators.

We document the application of a people-centred health systems governance conceptual model based on applying four effective governing practices: cultivating accountability, engaging with stakeholders, setting a shared strategic direction, and stewarding resources responsibly. We present a participatory approach where health system leaders identify and act on opportunities for making themselves and their health systems more accountable and responsive to the needs of the communities they serve.

Discussion and evaluation

We found that health systems governance can be improved in fragile and conflict affected environments, and that consistent application of the effective governing practices is key to improving governance. Intervention was associated with a 20% increase in antenatal care visit rate in pilot provinces. Focus group discussions showed improvements across the four governing practices, including: establishment of new sub-committees that oversee financial transparency and governance, collaboration with diverse stakeholders, sharper focus on community health needs, more frequent presentation of service delivery data, and increased use of data for decision making.

Conclusions

Our findings have implications for policy and practice within and beyond Afghanistan. Governance is central to making health systems responsive to the needs of people who access and provide services. We provide a practical approach to improving health systems governance in fragile and conflict affected environments.

Electronic supplementary material

The online version of this article (doi:10.1186/1752-1505-9-2) contains supplementary material, which is available to authorized users.

'Wasteaware' benchmark indicators for integrated sustainable waste management in cities

This paper addresses a major problem in international solid waste management, which is twofold: a lack of data, and a lack of consistent data to allow comparison between cities. The paper presents an indicator set for integrated sustainable waste management (ISWM) in cities both North and South, to allow benchmarking of a city's performance, comparing cities and monitoring developments over time. It builds on pioneering work for UN-Habitat's solid waste management in the World's cities. The comprehensive analytical framework of a city's solid waste management system is divided into two overlapping 'triangles' - one comprising the three physical components, i.e. collection, recycling, and disposal, and the other comprising three governance aspects, i.e. inclusivity; financial sustainability; and sound institutions and proactive policies. The indicator set includes essential quantitative indicators as well as qualitative composite indicators. This updated and revised 'Wasteaware' set of ISWM benchmark indicators is the cumulative result of testing various prototypes in more than 50 cities around the world. This experience confirms the utility of indicators in allowing comprehensive performance measurement and comparison of both 'hard' physical components and 'soft' governance aspects; and in prioritising 'next steps' in developing a city's solid waste management system, by identifying both local strengths that can be built on and weak points to be addressed. The Wasteaware ISWM indicators are applicable to a broad range of cities with very different levels of income and solid waste management practices. Their wide application as a standard methodology will help to fill the historical data gap.

Rethinking vulnerability analysis and governance with emphasis on a participatory approach

This article draws on vulnerability analysis as it emerged as a complement to classical risk analysis, and it aims at exploring its ability for nurturing risk and vulnerability governance actions. An analysis of the literature on vulnerability analysis allows us to formulate a three-fold critique: first, vulnerability analysis has been treated separately in the natural and the technological hazards fields. This separation prevents vulnerability from unleashing the full range of its potential, as it constrains appraisals into artificial categories and thus already closes down the outcomes of the analysis. Second, vulnerability analysis focused on assessment tools that are mainly quantitative, whereas qualitative appraisal is a key to assessing vulnerability in a comprehensive way and to informing policy making. Third, a systematic literature review of case studies reporting on participatory approaches to vulnerability analysis allows us to argue that participation has been important to address the above, but it remains too closed down in its approach and would benefit from embracing a more open, encompassing perspective. Therefore, we suggest rethinking vulnerability analysis as one part of a dynamic process between opening-up and closing-down strategies, in order to support a vulnerability governance framework.

The "wicked problems" of governing UK health security disaster prevention: The case of pandemic influenza

PURPOSE

The purpose of this paper is to examine the governance and policy-making challenges in the context of "wicked problems" based on the case of pandemic influenza.

DESIGN/METHODOLOGY/APPROACH

The case study research is based on an analysis of official documentation and interviews with policy elites at multiple levels of UK governance.

FINDINGS

Results of this study show that policy actors regard risk communication, the dynamics of international public policy and UK territorial governance as the main governance challenges in the management of influenza at a macro-level. The paper also serves to identify that although contingencies management for epidemiological issues require technical and scientific considerations to feature in governance arrangements, equally there are key "wicked problems" in the context public policy that pervade the health security sector.

PRACTICAL IMPLICATIONS

The study indicates the need to build in resources at a national level to plan for policy coordination challenges in areas that might at first be seen as devoid of political machinations (such as technical areas of public policy that might be underpinned by epidemiological processes). The identification of the major governance challenges that emerge from the pandemic influenza case study is a springboard for a research agenda in relation to the analysis of the parallels and paradoxes of governance challenges for health security across EU member states.

ORIGINALITY/VALUE

This paper provides a novel interrogation of the pandemic influenza case study in the context of UK governance and public policy by providing a strategic policy lens from perspective of elites.

Scaling up nutrition in fragile and conflict-affected states: the pivotal role of governance

Acute and chronic undernutrition undermine conditions for health, stability and socioeconomic development across the developing world. Although fragile and conflict-affected states have some of the highest rates of undernutrition globally, their response to the multilateral 'Scaling Up Nutrition' (SUN) initiative in its first two-year period was ambivalent. The purpose of this research was to investigate factors affecting fragile and conflict-affected states' engagement with SUN, and to examine what differentiated those fragile states that joined SUN in its first phase from those that did not. Drawing on global databases (Unicef, World Bank, UNDP), and qualitative country case studies (Afghanistan, the Democratic Republic of Congo, Sierra Leone, Pakistan and Yemen) we used bivariate logistic regressions and principal component analysis to assess social, economic and political factors across 41 fragile states looking for systematic differences between those that had signed up to SUN before March 2013 (n = 16), and those that had not (n = 25). While prevalence of malnutrition, health system functioning and level of citizen empowerment had little or no impact on a fragile state's likelihood of joining SUN, the quality of governance (QOG) strongly predicted accession. SUN-signatory fragile states scored systematically better on the World Bank's Country Policy and Institutional Assessment (CPIA) and the Worldwide Governance Indicators 'effectiveness of government' indices. We conclude that strengthening governance in fragile states may enhance their engagement with initiatives such as SUN, but also (recognising the potential for endogeneity), that the way aid is structured and delivered in fragile states may be an underlying determinant of whether and how governance in such contexts improves. The research demonstrates that more nuanced analysis of conditions within and among countries classed as 'fragile and conflict-affected' is both possible and necessary if aid policies are to be shaped in ways that support rather than undermine growth in governance capacity.

Precaution, governance and the failure of medical implants: the ASR((TM)) hip in the UK

Hip implants have provided life-changing treatment, reducing pain and improving the mobility and independence of patients. Success has encouraged manufacturers to innovate and amend designs, engendering patient hopes in these devices. However, failures of medical implants do occur. The failure rate of the Articular Surface Replacement metal-on-metal hip system, implanted almost 100,000 times world-wide, has re-opened debate about appropriate and timely implant governance. As commercial interests, patient hopes, and devices' governance converge in a socio-technical crisis, we analyse the responses of relevant governance stakeholders in the United Kingdom between 2007 and 2014. We argue that there has been a systemic failure of the governance system entrusted with the safety of patients fitted with medical implants. Commercial considerations of medical implants and the status quo of medical implant governance have been given priority over patient safety despite the availability of significant failure data in an example of uncertainty about what constitutes appropriate precautionary action.

Institutionalization of deinstitutionalization: a cross-national analysis of mental health system reform

Background

Policies generate accountability in that they offer a standard against which government performance can be assessed. A central question of this study is whether ideological imprint left by policy is realized in the time following its adoption. National mental health policy expressly promotes the notion of deinstitutionalization, which mandates that individuals be cared for in the community rather than in institutional environments.

Methods

We investigate whether mental health policy adoption induced a transformation in the structure of mental health systems, namely psychiatric beds, using panel data on 193 countries between 2001 and 2011.

Results

Our striking regression results demonstrate that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.

Conclusions

It can be inferred late adopters are motivated to implement deinstitutionalization for technical efficiency rather than social legitimacy reasons.

Electronic supplementary material

The online version of this article (doi:10.1186/1752-4458-8-47) contains supplementary material, which is available to authorized users.

[Governance of tertiary referral hospitals in the Democratic Republic of the Congo: a critical interpretive synthesis of the literature]

INTRODUCTION

Because hospitals are complex enterprises requiring adaptive systems, it is appropriate to apply the theory and terminology of governance or even better adaptive governance to the interpretation of their management. This study focused on understanding hospital governance in Logo, Bunia, and Katana, three hospitals in two regions of the eastern DRC, which has been characterized by intermittent armed conflict since 1996. In such a context of war and continuous insecurity, how can governance be interpreted for hospitals required to adapt to a constantly changing environment to be able to continue to provide health care?

METHODOLOGY

A critical interpretive synthesis of the literature, identified by searching for keywords related to governance.

RESULTS

The concepts of governance, adaptive governance, performance, leadership, and complex adaptive system concepts are defined. The interpretation of the concepts helps us to better understand (1) the hospital as a complex adaptive system, (2) the governance of tertiary referral hospitals, (3) analysis of hospital performance, and (4) leadership for good governance of these hospitals.

DISCUSSION

The interpretation of these concepts raises several questions about their application to the eastern DRC. Conclusion. This critical interpretive synthesis opens the door to a new way of exploring tertiary hospitals and their governance in the eastern DRC.

Same law-same rights? Analyzing why Sweden's disability legislation failed to create equal rights in mental health

This article analyzed the apparent paradox of disability rights in Sweden. Despite strong welfare state traditions and stated Government ambitions to create generous statutory entitlements for all disabled people using a single, comprehensive Disability Act, psychiatric disabilities were principally excluded from the Disability Act's rights and provisions. The study focused on Sweden's Mental Health Reform and Disability Reform using governance perspectives that traced and analyzed the policy-processes of both reforms. Theoretically guided analytical frameworks were developed to help understand the divergent reform outcomes. The first focused on legislative arguments of regulatory specificity and legal enforcement mechanisms to consider whether the Disability Act was formulated in a manner that was easier to apply to certain disabilities. The second analyzed ideological arguments and the influence of Government political beliefs that signaled specific reform 'visions' to implementers and thereby influenced policy implementation. The main findings are that both perspectives matter as the dual influences of legislative and ideological differences tended to exclude mental health service users from the Act's generous disability rights. The overall conclusion was that while legislation was an important regulatory mechanism, the Government's underlying ideological reform vision was also an essential governance instrument that signaled Government intentions to implementing agencies and thus influenced the creation of enduring disability rights.

Marine legislation--the ultimate 'horrendogram': international law, European directives & national implementation

The EU is a pre-eminent player in sustainable development, adopting more than 200 pieces of legislation that have direct repercussions for marine environmental policy and management. Over five decades, measures have aimed to protect the marine environment by tackling the impact of human activities, but maritime affairs have been dealt with by separate sectoral policies without fully integrating all relevant sectors. Such compartmentalisation has resulted in a patchwork of EU legislation and resultant national legislation leading to a piecemeal approach to marine protection. These are superimposed on international obligations emanating from UN and other bodies and are presented here as complex 'horrendograms' showing the complexity across vertical governance. These horrendograms have surprised marine experts despite them acknowledging the many uses and users of the marine environment. Encouragingly since 2000, the evolution in EU policy has progressed to more holistic directives and here we give an overview of this change.

Does more equitable governance lead to more equitable health care? A case study based on the implementation of health reform in Aboriginal health Australia

There is growing evidence that providing increased voice to vulnerable or disenfranchised populations is important to improving health equity. In this paper we will examine the engagement of Aboriginal community members and community controlled organisations in local governance reforms associated with the Aboriginal Health National Partnership Agreements (AHNPA) in Australia and its impact on the uptake of health assessments. The sample included qualitative and quantitative responses from 188 people involved in regional governance in Aboriginal health. The study included data on the uptake of Aboriginal health assessments from July 2008 to December 2012. The study population was 83190 in 2008/9, 856986 in 2009/10, 88256 in 2010/11 and 90903 in 2011/12. Logistic regression was used to examine the relationships between organisations within forums and the regional uptake of Aboriginal health assessments. The independent variables included before and after the AHNPA, state, remoteness, level of representation from Aboriginal organisations and links between Aboriginal and mainstream organisations. The introduction of the AHNPA was associated with a shift in power from central government to regional forums. This shift has enabled Aboriginal people a much greater voice in governance. The results of the analyses show that improvements in the uptake of health assessments were associated with stronger links between Aboriginal organisations and between mainstream organisations working with Aboriginal organisations. Higher levels of community representation were also associated with improved uptake of health assessments in the AHNPA. The findings suggest that the incorporation of Aboriginal community and community controlled organisations in regional planning plays an important role in improving health equity. This study makes an important contribution to understanding the processes through which the incorporation of disadvantaged groups into governance might contribute to health equity.

Impairment and sanction in Medical Practitioners Tribunal Service fitness to practise proceedings

The principal aims of this research were to assess whether, when imposing sanctions, the aggravating and mitigating circumstances considered by the General Medical Council are first considered when determining impairment of fitness to practise and to determine whether the circumstances described by the General Medical Council in their Indicative Sanctions Guidance as warranting erasure from the Medical Register will lead to that outcome. The consideration of specific aggravating circumstances or points of mitigation when determining impairment of fitness to practise was compared to their subsequent consideration by the General Medical Council when deciding on the severity of sanction to be applied. Additionally, the proportion of cases that highlighted aggravating circumstances the General Medical Council deemed sufficiently serious to warrant erasure and the actions taken were monitored. One hundred forty-six cases heard by the General Medical Council between 1 October 2011 and 30 September 2012 met with the inclusion criteria. Fisher's exact test was used to detect a variation from the expected distribution of data. Three of the four aggravating/mitigating circumstances were more likely to be considered when determining sanction having first been factored into the consideration of impairment. There was a statistically significant correlation between both a risk of harm and dishonesty as aggravating factors and the sanction of erasure from the Medical Register. In general, the General Medical Council consider relevant factors at all stages of their deliberations into practitioner misconduct, as required by the determinations in the cases of Cohen, Zygmunt and Azzam; and subsequently follow the guidance within their Indicative Sanctions Guidance document when determining which sanction to apply.

Peer, professional, and public: an analysis of the drugs policy advocacy community in Europe

BACKGROUND

In recent decades a range of advocacy organisations have emerged on the drugs policy landscape seeking to shape the development of policy at national and international levels. This development has been facilitated by the expansion of 'democratic spaces' for civil society participation in governance fora at national and supranational level. However, little is known about these policy actors - their aims, scope, organisational structure, or the purpose of their engagement.

METHODS

Drug policy advocacy organisations were defined as organisations with a clearly stated aim to influence policy and which were based in Europe. Data on these organisations was collected through a systematic tri-lingual (English, French and Spanish) Internet search, supplemented by information provided by national agencies in the 28 EU member states, Norway and Turkey. In order to differentiate between the diverse range of activities, strategies and standpoints of these groups, information from the websites was used to categorise the organisations by their scope of operation, advocacy tools and policy constituencies; and by three key typologies - the type of advocacy they engaged in, their organisational type, and their advocacy objectives and orientation.

RESULTS

The study identified over two hundred EU-based advocacy organisations (N=218) which included civil society associations, NGOs, and large-scale alliances and coalitions, operating at local, national and European levels. Three forms of advocacy emerged from the data analysis - peer, professional and public policy. These groups focused their campaigns on practice development (harm reduction or abstinence) and legislative reform (reducing or strengthening drug controls).

CONCLUSION

The findings from this study provide a nuanced profile of civil society advocacy as a policy community in the drugs field; their legitimacy to represent cases, causes, social values and ideals; and their focus on both insider and outsider strategies to achieve their goals. The level of convergence and divergence in Europe in relation to policy positions on service provision ethos and drug control regulation is indicated.

Core attributes of stewardship; foundation of sound health system

Stewardship is not a new concept for public policy, but has not been used to its optimum by the health policy-makers. Although it is being practiced in most successful models of health system, but the onus to this function is still due till date. Lately, few experts in World Health Organization (WHO) have realized its importance and have been raising the issue at different platforms to pursue the most important function of the health system i.e. stewardship. The core attributes of stewardship need to be understood in totality for better understanding of the concept. These core attributes, required for hassle free functioning of a health system, include responsible manager, political will, normative dimension, balanced interventionist and proponents of good governance.