Street-level implementers of population-based oral health policies: the case of water fluoridation supply in Brazil's small towns

BACKGROUND

Knowledge of conditions influencing the performance of street-level operators when implementing population-based policies could increase the understanding of local implementation dynamics.

OBJECTIVE

We analyzed how street-level operators claim to act to implement fluoridation policy in the water treatment units of small Brazilian municipalities and identified conditions shaping behavior against adherence to policy.

METHODS

A case study using narratives obtained through in-depth interviews with key informants in two pairs of municipalities with contrasting levels of implementation. Analysis identified themes in the data and in the street-level bureaucracy literature.

RESULTS

Institutional characteristics such as administrative fragility of local entities, low priority given locally to policy, poor physical structure of the water treatment plants, isolated working relations, low effectiveness of monitoring devices, and local actors' uncertainties about the policy favored the expansion of the discretionary power of street-level operators configuring important barriers for water fluoridation.

CONCLUSION

These data highlight the complexity of policy implementation and inform policymakers about the importance of inter-federal and inter-sectoral coordination when implementing population-based health policies in small towns.

[Social rights: difficult to construct, easy to destroy]

The purpose of this article is to reflect on contemporary tensions between the social protection system in Brazil - which in the past 30 years has come to be organized as a social right and has been part of the construction of democracy in the country - and the current process of its dismantling under an authoritarian populist regime. From the theoretical perspective adopted in this article, structural characteristics and circumstantial factors are examined in order to explain the difficulties that have been faced in constructing a legal and institutional architecture for social rights, and on the other hand, why at present it is so easy to destroy it in practice.

Where in the world is Florence Nightingale's medicine chest?

BACKGROUND

In the 121^st anniversary year of the birth of Florence Nightingale, and during the COVID-19 pandemic, it is both interesting and salient to be reminded of the foundational work of this famous woman who began modern nursing. Her work in nursing care and nursing, health and public policy has been a continuing strong foundation to practices in societies around the world.

METHODS

In this short communication about historical research, various aspects of Florence's life and work are described, as well as the locations, memorials and museum significant to our remembrance of her.

RESULTS

A particular focus of this paper is the description of a larger but little-known medicine chest located at the College of Nursing, University of Saskatchewan, in Saskatoon, SK, Canada, and attributed as belonging to Florence.

CONCLUSION

Best known to this point in time is a smaller medicine chest at the Florence Nightingale Museum in London.

[An Exploratory Study on the Policy for Facilitating of Health Behaviors Related to Particulate Matter: Using Topic and Semantic Network Analysis of Media Text]

PURPOSE

This study aimed to analyze the mass and social media contents and structures related to particulate matter before and after the policy enforcement of the comprehensive countermeasures for particulate matter, derive nursing implications, and provide a basis for designing health policies.

METHODS

After crawling online news articles and posts on social networking sites before and after policy enforcement with particulate matter as keywords, we conducted topic and semantic network analysis using TEXTOM, R, and UCINET 6.

RESULTS

In topic analysis, behavior tips was the common main topic in both media before and after the policy enforcement. After the policy enforcement, influence on health disappeared from the main topics due to increased reports about reduction measures and government in mass media, whereas influence on health appeared as the main topic in social media. However semantic network analysis confirmed that social media had much number of nodes and links and lower centrality than mass media, leaving substantial information that was not organically connected and unstructured.

CONCLUSION

Understanding of particulate matter policy and implications influence health, as well as gaps in the needs and use of health information, should be integrated with leadership and supports in the nurses' care of vulnerable patients and public health promotion.

Option-based guarantees to accelerate urgent, high-risk vaccines: a new market-shaping approach

Accelerating the availability of COVID-19 vaccines is critical to preventing further waves and mitigating the impact on society. However, preparations for large-scale manufacturing, such as building production facilities, are typically delayed until a vaccine is proven safe and effective. This makes sense from a commercial perspective, but incurs great costs in terms of lives lost and damage to the economy. Several policy options are available to reduce this delay, all of which involve incentives or subsidies to invest in production facilities. We review existing approaches, then propose a novel alternative using "option-based guarantees" in which the government commits to paying a proportion of the manufacturer's preparation costs should the product turn out not to be viable. Counterintuitively, this "payment for failure" is appropriate because in the case of success, a company makes a profit from the product itself, and does not need additional money from the government. While other approaches have critical roles, we argue that option-based guarantees are the most promising approach to ensuring a rapid vaccine for COVID-19. Compared to the alternative approaches, they reduce both costs to the government and risk to the companies, while maintaining an incentive to produce a high-quality product quickly and at scale.

Option-based guarantees to accelerate urgent, high-risk vaccines: a new market-shaping approach

Accelerating the availability of COVID-19 vaccines is critical to preventing further waves and mitigating the impact on society. However, preparations for large-scale manufacturing, such as building production facilities, are typically delayed until a vaccine is proven safe and effective. This makes sense from a commercial perspective, but incurs great costs in terms of lives lost and damage to the economy. Several policy options are available to reduce this delay, all of which involve incentives or subsidies to invest in production facilities. We review existing approaches, then propose a novel alternative using "option-based guarantees" in which the government commits to paying a proportion of the manufacturer's preparation costs should the product turn out not to be viable. Counterintuitively, this "payment for failure" is appropriate because in the case of success, a company makes a profit from the product itself, and does not need additional money from the government. While other approaches have critical roles, we argue that option-based guarantees are the most promising approach to ensuring a rapid vaccine for COVID-19. Compared to the alternative approaches, they reduce both costs to the government and risk to the companies, while maintaining an incentive to produce a high-quality product quickly and at scale.

Interdisciplinary Information for Infectious Disease Response: Exercising for Improved Medical/Public Health Communication and Collaboration

Infectious disease threats like the novel coronavirus that emerged in late 2019 continue to demand an increase in preparedness and response capabilities. One capability that is both essential and consistently challenging is information sharing between responding organizations, particularly between public health agencies and health care providers. This policy analysis reviews the threat that infectious diseases continue to pose to the United States, and the role that the Hospital Preparedness Program can play in countering such threats. Current strategies for preparing for, and responding to, infectious disease outbreaks are also reviewed, noting some gaps that need to be addressed. Particular attention is given to challenges in information sharing that continue to hinder effective surveillance and response, despite advances in technology. The study looks at recommendations from biodefense organizations and experts in the field. It concludes with our recommendation that regulatory requirements and funding opportunities for health care institutions emphasize the importance of communication and training in relation to high consequence pathogens. We further recommend that providers in Ebola treatment hospitals be employed to train and educate providers in frontline hospitals in a 'train-the-trainer' model.

["Irrigated land" and the commodification of water in a new waterscape of Pampean agriculture: the case of the seed cluster]

Since the mid-1990s extensive agriculture using irrigation has grown rapidly in Argentina. Where farming on dry land was traditionally carried out, technological change has created a new waterscape: "irrigated land." To understand the creation of this conceptual category and how it is anchored in a specific production model, in this paper I contextualize the spread of mechanized irrigation in the north of the province of Buenos Aires by examining the main public policies that intervene in this territorial transformation: the Competitive Improvement Plan of the Seed Cluster, the National Irrigation Plan, and the management of groundwater for productive irrigation. Integrating contributions from Political Ecology and Science and Technology Studies, I argue that the exploitation of groundwater for irrigation implies the privatization of a resource that remains invisible. "Irrigated land" contains two of the fundamental resources for food production that, jointly, resignify each other. Water acquires productive meaning as a commodity to which it is feasible to assign a monetary value, and becomes privatized de facto at the moment of its productive consumption; while the land - thanks to water - is valorized economically by allowing for new exploitation alternatives with higher profit margins. Thus, water acts as the "lubricant" that reinforces the accumulation process.

[Drug policies in the Brazilian context: an intersectional analysis of "Cracolândia" in São Paulo, Brazil]

From the analysis of a specific conjuncture, "Cracolândia" in São Paulo, Brazil, and the "De Braços Abertos" program, this article discusses the complex relationships between drug use and the formulation of public policies directed to the care of users. In methodological terms, this work is based on the qualitative research by using semi-structured interviews with thirteen key informants. The empirical material was analyzed from the content thematic analysis and the intersectionality perspective, especially from the theoretical contributions of the "difference" category. The results point out that "differences" are marked by gender, race and social position in the society, reinforcing stigmas and their different impacts on social relations. This paper contributes to the debate on the need to formulate different approaches to the specific needs and demands of populations or social classification categories regarding drug public policy.

[En defensa del pensamiento de Ramón Carrillo: "La libertad en todas las formas es un derecho del pueblo"]

In the midst of the COVID-19 pandemic, images of a potential new banknote that may be introduced in Argentina have circulated, which depict Ramón Carrillo (the country's first Minister of Public Health) and Cecilia Grierson (the country's first female physician). In response, the Embassies of world powers such as the United Kingdom and Israel have released statements defaming Ramón Carrillo. The National University of Lanús expresses its support for the public health expert who taught us the importance of training physicians in public health, and that the true problem is not disease at an individual level, but rather that health must be addressed in collective terms.

New problems of a new health system: the creation of a national public policy of rare diseases care in Brazil (1990s-2010s)

This study discusses actors and institution movements leading to the disclosure in 2014 of Resolution 199 by the Brazilian Ministry of Health, which establishes the National Policy for the Comprehensive Care of Persons with Rare Diseases. Taking as sources the mainstream newspapers, drafts law, and secondary literature on the subject, we begin our analysis in the early 1990s when the first patient associations were created in Brazil - mainly for claiming more funds for research on genetic diseases - and arrive at the late 2010s when negotiations for a national policy are taking place in the National Congress. Resolution 199 is part of an ongoing process and the path towards its disclosure and the complications that followed have given us elements to discuss contemporary aspects of the Brazilian public health. Based on the references of the history of the present time and the social studies of science, we argue that two aspects have been fundamental to creating a national policy: framing different illnesses within the terminology "rare diseases" and the construction of a public perception about the right of health which is guaranteed by the 1988 Brazilian Constitution.

Insurance for economic losses caused by pandemics

Private insurance coverage for economic losses caused by pandemics is limited. While many factors contribute to reduced demand and supply, we attribute the low amount of coverage to the high levels of capital that would be required to credibly insure pandemic economic losses with cross-sectional pooling mechanisms. Pooling over time significantly reduces the required capital and therefore the cost of insurance, but as a practical matter likely requires a government with the ability to borrow and tax. We also argue that insurance for economic losses due to pandemics likely generates positive externalities for the macroeconomy. We therefore analyze the general tradeoffs associated with different ways that a government can promote such insurance.

The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research

The conditions in which we are born, grow, live, work and age are key drivers of health and inequalities in life chances. To maximise health and wellbeing across the whole population, we need well-coordinated action across government sectors, in areas including economic, education, welfare, labour market and housing policy. Current research struggles to offer effective decision support on the cross-sector strategic alignment of policies, and to generate evidence that gives budget holders the confidence to change the way major investment decisions are made. This open letter introduces a new research initiative in this space. The SIPHER ( Systems Science in Public Health and Health Economics Research) Consortium brings together a multi-disciplinary group of scientists from across six universities, three government partners at local, regional and national level, and ten practice partner organisations. The Consortium’s vision is a shift from health policy to healthy public policy, where the wellbeing impacts of policies are a core consideration across government sectors. Researchers and policy makers will jointly tackle fundamental questions about: a) the complex causal relationships between upstream policies and wellbeing, economic and equality outcomes; b) the multi-sectoral appraisal of costs and benefits of alternative investment options; c) public values and preferences for different outcomes, and how necessary trade-offs can be negotiated; and d) creating the conditions for intelligence-led adaptive policy design that maximises progress against economic, social and health goals. Whilst our methods will be adaptable across policy topics and jurisdictions, we will initially focus on four policy areas: Inclusive Economic Growth, Adverse Childhood Experiences, Mental Wellbeing and Housing.

Ethics of organ procurement from the unrepresented patient population

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act (RUAGA) of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion.

Opening the Policy Window to Mobilize Action Against Corruption in the Health Sector Comment on "We Need to Talk About Corruption in Health Systems"

Corruption in the health sector has been a "dirty secret" in the health policy and international development community, but recent global activities point to a day when it will no longer be neglected as a key determinant of health. To further explore next steps forward, this commentary applies the Kingdon's multiple-streams framework (MSF) to assess what opportunities are available to mobilize the global agenda to combat health corruption. Based on this analysis, it appears that Kingdon's problem, policy, and political streams are coalescing to create a policy window opportunity that can be leveraged based on recent developments in the global health and international development community around corruption. This includes the recent formation of the Global Network on Anti-Corruption, Transparency and Accountability (GNACTA) led by the World Health Organization (WHO), the Global Fund, and the United Nations Development Programme in 2019. It also includes bridging shared goals of addressing corruption in order to make progress towards health-specific goals in the United Nations (UN) Sustainable Development Goals (SDGs) and for achieving universal health coverage.

Body mass index and lifetime healthcare utilization

BACKGROUND

Overweight and obesity is a major global public health challenge, and understanding the implications for healthcare systems is essential for policy planning. Past studies have typically found positive associations between obesity and healthcare utilization, but these studies have not taken into consideration that obesity is also associated with early mortality. We examined associations between body mass index (BMI, reported as kg/m2) and healthcare utilization with and without taking BMI-specific survival into consideration.

METHODS

We used nationally representative data on 33 882 adults collected between 2002 and 2015. We computed BMI- and age-specific primary and secondary care utilization and multiplied the estimated values with gender-, age-, and BMI-specific probabilities of surviving to each age. Then, we summed the average BMI-specific utilization between 18 and 85 years.

RESULTS

During a survival-adjusted lifetime, males with normal weight (BMI: 18.5-24.9) had, on average, 167 primary care, and 77 secondary care contacts. In comparison, males with overweight (BMI: 25.0-29.9), category I obesity (BMI: 30.0-34.9), and category II/III obesity (BMI ≥35.0) had 11%, 41%, and 102% more primary care, and 14%, 29%, and 78% more secondary care contacts, respectively. Females with normal weight had, on average, 210 primary care contacts and 91 secondary care contacts. Females with overweight, category I obesity, and category II/III obesity had 20%, 34%, and 81% more primary care contacts, and 26%, 16%, and 16% more secondary care contacts, respectively.

CONCLUSION

The positive association between BMI and healthcare utilization was reduced, but not offset, when BMI-specific survival was taken into consideration. Our findings underpin previous research and suggest that interventions to offset the increasing prevalence of overweight, and especially obesity, are warranted.

[Effect of risk factor control policies on oral cancer mortality in Latin America]

OBJECTIVE

Mortality from oral cancer, the prevalence of the main risk factors and the implementation of policies to control current trends and the distribution of data among the countries of Latin America. The objective of this study was to describe the trends of mortality from oral cancer between 2000 and 2017, by sex, in 20 countries in Latin America, and to know the effect of measures to control tobacco consumption and alcohol consumption on the Mortality from oral cancer.

METHODS

Ecological study that evaluates the relationship between the rates standardized by the age of cancer by oral sex, the prevalence of tobacco consumption and alcohol consumption, and the implementation of control policies. To calculate the annual percentage change of the rates, the Prais-Winsten regression was used; and the effect of measures of control of risk factors on oral cancer mortality is assessed by Spearman correlations.

RESULTS

The greatest decreases in oral cancer mortality were in men in Brazil (APC -7.83, -14.25,-0.93). Mortality from cancer the oral relationship between men and the prevalence of tobacco consumption and alcohol consumption (r = 0.358, r 0.537) (p <0.01), and between the non-implementation of control policies of smoking (r = 0.738) (p= 0.003), the restrictions on the hours and days of sale of alcohol (r = 0.777, p = 0.001), and the states on sponsorship and promotion of alcohol sales (r =0.739 , p =0.040).

CONCLUSIONS

The effect of the implementation of control policies is evidenced by a greater relationship with oral cancer mortality in the countries with the least progress in their execution.

The Future of Health Equity in America: Addressing the Multiple, Intersecting Determinants of Health

Even though health equity is a key component of the transforming journey of health that our nation is embarking on, little has been done to trans-disciplinarily coordinate health policy research and collaboratively address issues driving health inequities. This article examines the past and present health policy issues affecting health equity in the United States and discusses the need to address the multiple, intersecting determinants of health in order to fully realize health equity and eliminate health disparities in the future.

Characteristics and Red Flag Correlates of Psychiatric Outpatients in a Mandated-Use Prescription Drug Monitoring Program State: A PBRN Card Study

Objectives

All 50 states have implemented a Prescription Drug Monitoring Program (PDMP) in efforts to control prescription drug abuse. Many now mandate PDMP checks before clinicians prescribe controlled substances. The aim of this study was to characterize the associations between patient characteristics, red flags found on PDMP reports, and prescriber behavior at community mental health agencies.

Methods

Prescribers at 9 practice sites, in five regional community mental health centers, were recruited by a practice-based research network (PBRN) to participate in a Card Study. Prescribers completed a PDMP attitudes survey, and cards were completed for patients who had PDMP reports checked. Data were analyzed using descriptive and inferential statistics.

Results

Thirty nine providers completed cards for n=249 unique patient encounters. Over 1/3 of all patients reported an addiction disorder (38%) or a diagnosis of chronic pain (34%). Twenty percent of PDMP reports were found to have red flags, most commonly multiple prescribers or multiple pharmacies. Red flags were associated with race (p<.0.05), presence of chronic pain (p<0.01), presence of an addiction diagnosis (p<0.05), use of opioids (p<0.001), and non-adherence with treatment (p<0.006). Among prescribers, red flags were associated with lower prescribing rates (p<0.01), and decisions to decrease dosage (p<0.002).

Conclusions

Red flags were commonly found on PDMP reports done in community mental health settings, and were associated with important patient characteristics and diagnostic factors. PBRN research methods can be leveraged to obtain real-time observational data about psychiatric prescribers' use of PDMP reports in clinical decision-making in different settings.

Memoranda of understanding: a tobacco industry strategy to undermine illicit tobacco trade policies

OBJECTIVE

Analyse the transnational tobacco companies' (TTCs) memoranda of understanding (MoUs) on illicit trade and how they could undermine the WHO Framework Convention on Tobacco Control (FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products (Protocol).

METHODS

Review of tobacco industry documents and websites, reports, news and media items using standard snowball search methods.

RESULTS

Facing increasing pressure from governments and the FCTC to address illicit tobacco trade during the late 1990s, TTCs entered into voluntary partnerships embodied in MoUs with governments' law enforcement and customs agencies. One of the earliest known MoUs was between Philip Morris International and Italy in 1999. TTCs agreed among themselves to establish MoUs individually but use the Italian MoU as a basis to establish similar connections with other governments to pre-empt more stringent regulation of illicit trade. TTCs report to have signed over 100 MoUs since 1999, and promote them on their websites, in Corporate Social Responsibility reports and in the media as important partnerships to combat illicit tobacco trade. There is no evidence to support TTCs' claims that these MoUs reduce illicit trade. The terms of these MoUs are rarely made public. MoUs are non-transparent partnerships between government agencies and TTCs, violating FCTC Article 5.3 and the Protocol. MoUs are not legally binding so do not create an accountability system or penalties for non-compliance, rendering them ineffective at controlling illicit trade.

CONCLUSION

Governments should reject TTC partnerships through MoUs and instead ratify and implement the FCTC and the Protocol to effectively address illicit trade in tobacco products.

Observed retail price of Australia's market-leading cigarette brand before and up to 3 years after the implementation of plain packaging

OBJECTIVE

Despite claims by tobacco companies that plain packaging would lead to lower cigarette prices, recommended and observed real cigarette prices in Australia rose in the 9-11 months after plain packaging was introduced. However, little is known about trends in prices longer term. In this report, we assess whether inflation (Consumer Price Index; CPI) and tax adjusted ('CPI-tax-adjusted') prices of the market-leading Australian cigarette brand changed in the 3-year period after plain packaging, and whether price changes were associated with retailer characteristics.

METHOD

Cigarette prices were ascertained from a panel of tobacco retailers at three time points: (1) in November 2012 (n=857) (before full implementation of plain packaging, compulsory in retail outlets from December 2012), (2) between October 2014 and February 2015 (n=789) and (3) between November 2015 and March 2016 (n=579). Generalised estimating equations were used to estimate percentage change in mean CPI/tax-adjusted cigarette prices over time.

RESULTS

CPI/tax-adjusted adjusted mean stick prices rose by 13.7% (95% CI 13.0 to 16.0) and 15.2% (95% CI 14.3 to 16.0) at 2.1 and 3.1 years after plain packaging was introduced, respectively. Increases in mean CPI/tax-adjusted stick prices varied by outlet type (p<0.001), socioeconomic status (p=0.013) and remoteness of retailer's area (p=0.028) and whether twin packs were sold (p=0.009).

CONCLUSIONS

Contrary to tobacco company predictions of a fall in prices, the price of the market-leading Australian cigarette brand increased significantly in the 3 years after plain packaging was introduced, and these increases were above the combined effects of inflation and increases in excise/customs duty.

Challenging Institutional Norms to Improve Local-Level Policy for Health and Health Equity Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups"

The article by Susanne Hagen and colleagues on Health Promotion at Local Level in Norway discusses actions by municipal governments to assess and address heath inequities within their respective regions, as required under the Norwegian Public Health Act (PHA). Although the broad intent of the Norwegian government is to encourage action on social determinants of health (SDH), Hagen et al find that many of the initiatives undertaken by municipalities 'tend to cash out as single, targeted initiatives,' and focus on individual behaviours. In this commentary, I use the concept of place-based policy and ideas from policy theory on the institutional behaviours of public policy agencies and services, to discuss reasons behind this narrowing of perspective and policy action. I argue in favour of an alternative approach involving public agencies and services supporting processes of community-led action and social change.

Researching Healthy Public Policy: Navigating the 'Black Box' Means Thinking More About Power Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

Lawless et al provide a valuable narrative of using program logic to develop an evaluation of Health in All Policies (HiAP) in South Australia. In this commentary I argue that the paper and analysis is an extremely useful example of navigating the supposed black box of policy-making. However the original makes the reader work too hard and is distracting from the main narrative of explaining the logic behind the HiAP approach in South Australia. My response covers avoiding epistemological traps and weighing up the pragmatics of collaborative policy research with more complex institutional policy issues like power.