Fences and ambulances: Governance for intersectoral action on health

The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018-2023

BACKGROUND

Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation.

METHODS

This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis.

RESULTS

The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes.

CONCLUSIONS

Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.

COVID-19 and healthcare worker mental well-being: Comparative case studies on interventions in six countries

Healthcare worker (HCW) mental well-being has become a global public health priority as health systems seek to strengthen their resilience in the face of the COVID-19 pandemic. Analysing data from the Health System Response Monitor, we present six case studies (Denmark, Italy, Kyrgyzstan, Lithuania, Romania, and the United Kingdom) as a comparative review of policy interventions supporting HCW mental health during the pandemic. The results illustrate a wide range of interventions. While Denmark and the United Kingdom built on pre-existing structures to support HCW mental wellbeing during the pandemic, the other countries required new interventions. Across all cases, there was a reliance on self-care resources, online training tools, and remote professional support. Based on our analysis, we develop four policy recommendations for the future of HCW mental health supports. First, HCW mental health should be seen as a core facet of health workforce capacity. Second, effective mental health supports requires an integrated psychosocial approach that acknowledges the importance of harm prevention strategies and organisational resources (psychological first aid) alongside targeted professional interventions. Third, personal, professional and practical obstacles to take-up of mental health supports should be addressed. Fourth, any specific support or intervention targeting HCW's mental health is connected to, and dependent on, wider structural and employment factors (e.g. system resourcing and organisation) that determine the working conditions of HCWs.

Preventive health resource allocation decision-making processes and the use of economic evidence in an Australian state government—A mixed methods study

Context

Recommended best practice for resource allocation decisions by governments include a stepwise process guided by economic evidence. However, the use of economic evidence in preventive health decision-making, which often impacts on multiple sectors of government, is under-researched. This study aimed to explore the resource allocation decision-making processes for preventive health interventions in the New South Wales (NSW) Government in Australia, and specifically examined the barriers and facilitators to the use of economic evidence from the perspective of multiple government departments.

Methods

This mixed methods study was conducted using semi-structured interviews with NSW Treasury representatives (n = 4), a focus group of NSW Ministry of Health representatives (n = 9), and a quantitative questionnaire of all participants. The schedule for the interviews and focus group was based on resource allocation guidance documents from Australian government agencies. Deductive content analysis was undertaken, guided by the Multiple Streams Framework.

Findings

NSW Treasury participants believed that decision-making processes where economic efficiency was the key guiding principle was the ideal approach. However, the NSW Ministry of Health participants identified that for preventive health decision-making, economic evidence was not used to inform their own choices but was typically only used to convince other agencies of the merits of proposed initiatives when seeking approval. The key barriers to the use of economic evidence were the lack of capacity within the NSW Ministry of Health to understand and undertake economic evaluations; a lack of collaboration between NSW Treasury and preventive health decision-makers within the NSW Ministry of Health; and deficient processes and governance mechanisms that do not facilitate or incentivise effective inter-sectoral decision-making.

Conclusions

Institutional structures for resource allocation decision-making regarding preventive health result in processes that contrast with best practice recommendations. The multiple challenges to collaborative decision-making across agencies require organisational change to promote a whole-of-government approach.

The contribution of professions to the governance of integrated care: Towards a conceptual framework based on case studies from Denmark

OBJECTIVE

Good governance of integrated care is key to better health care, but we know little about how professions can help make this happen. Our aim is to introduce a conceptual framework to analyse how professions contribute to the governance of integrated care, and to apply the framework to a secondary analysis of selected case studies from Denmark.

METHODS

We developed a framework, which identified the what, how and why of the contribution professions make to the governance of integrated care. We included five qualitative Danish studies, using coordination as an indicator of integrated care. We adopted a thematic approach in our analysis, combining deductive and inductive elements.

RESULTS

Health professions engage in highly diverse activities, which fall into closely connected clusters of more formal or more informal coordination. Professions apply many different adaptive mechanisms at different levels to fit coordination into local contexts. Professions are driven by interlocking rationales, where a common focus on patients connects organizational and professional concerns.

CONCLUSIONS

Our analytical framework emerges as a useful tool for analysis. The contribution of professions to the governance of integrated care needs greater attention in health policy implementation as it can promote more effective governance of integrated care.

[Können wir uns das Neben- und Gegeneinander noch leisten?]

Kein Medikament war je so wirksam wie die Antibabypille. Sie hat wesentlichen Anteil an zwei der größten Herausforderungen unseres Gesundheitswesens. Erstens dem Glauben, alle Medikamente würden so gut wirken und zweitens dem demographischen Wandel. Unsere Kultur ist von der Idee geleitet, dass man letztlich durch Investition in Forschung und Technik alle Probleme lösen und alle Unsicherheit des Lebens beseitigen kann. Dies hat zu einer Flut diagnostischer und therapeutischer Möglichkeiten geführt, deren unkritischer oder gewinnorientierter Einsatz sich am besten mit dem Begriff Überversorgung beschreiben lässt. Vor allem binden sie unsere teuerste und knappste Ressource, das medizinische Personal, das an anderer Stelle fehlt. Ein Gesundheitswesen, das schon in normalen Zeiten an der Grenze seiner Belastbarkeit steht, kommt in Krisenzeiten schnell an die Grenzen seiner Resilienz. Die Politik der vergangenen 20 Jahre hat Wettbewerb und Konkurrenz im Gesundheitswesen gefördert. Hat dieser Ansatz wirklich zu einer effizienteren, kostengünstigeren und besseren Medizin geführt? Werden Innovation und Wettbewerb die richtigen Antworten sein, wenn es darum geht das Problem des demographischen Wandels zu lösen? Wir glauben beides nicht und fordern deshalb zu Diskussion und Kooperation auf.

Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness

CONTEXT

Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems.

METHODS

We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation.

FINDINGS

Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid.

CONCLUSIONS

Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.

Brexit and trade policy: an analysis of the governance of UK trade policy and what it means for health and social justice

BACKGROUND

There is an extensive body of research demonstrating that trade and globalisation can have wide-ranging implications for health. Robust governance is key to ensuring that health, social justice and sustainability are key considerations within trade policy, and that health risks from trade are effectively mitigated and benefits are maximised. The UK's departure from the EU provides a rare opportunity to examine a context where trade governance arrangements are being created anew, and to explore the consequences of governance choices and structures for health and social justice. Despite its importance to public health, there has been no systematic analysis of the implications of UK trade policy governance. We therefore conducted an analysis of the governance of the UK's trade policy from a public health and social justice perspective.

RESULTS

Several arrangements required for good governance appear to have been implemented - information provision, public consultation, accountability to Parliament, and strengthening of civil service capacity. However, our detailed analyses of these pillars of governance identified significant weaknesses in each of these areas.

CONCLUSION

The establishment of a new trade policy agenda calls for robust systems of governance. However, our analysis demonstrates that, despite decades of mounting evidence on the health and equity impacts of trade and the importance of strong systems of governance, the UK government has largely ignored this evidence and failed to galvanise the opportunity to include public health and equity considerations and strengthen democratic involvement in trade policy. This underscores the point that the evidence alone will not guarantee that health and justice are prioritised. Rather, we need strong systems of governance everywhere that can help seize the health benefits of international trade and minimise its detrimental impacts. A failure to strengthen governance risks poor policy design and implementation, with unintended and inequitable distribution of harms, and 'on-paper' commitments to health, social justice, and democracy unfulfilled in practice. Although the detailed findings relate to the situation in the UK, the issues raised are, we believe, of wider relevance for those with an interest of governing for health in the area of international trade.

Migrant carers in Europe in times of COVID-19: a call to action for European health workforce governance and a public health approach

The present study explores the situation of migrant carers in long-term care (LTC) in European Union Member States and the disruptions caused by the COVID-19 pandemic from a public health perspective. The aim is to bring LTC migrant carers into health workforce research and highlight a need for trans-sectoral and European heath workforce governance. We apply an exploratory approach based on secondary sources, document analysis and expert information. A framework comprising four major dimensions was developed for data collection and analysis: LTC system, LTC health labour market, LTC labour migration policies and specific LTC migrant carer policies during the COVID-19 crisis March to May 2020. Material from Austria, Italy, Germany, Poland and Romania was included in the study. Results suggest that undersupply of carers coupled with cash benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. COVID-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Two important policy recommendations are emerging: to include LTC migrant carers more systematically in public health and health workforce research and to develop European health workforce governance which connects health system needs, health labour markets and the individual migrant carers.

A scoping review of the implementation of health in all policies at the local level

OBJECTIVES

Health in All Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP implementation can involve engagement from multiple levels of government; however, factors contributing or hindering HiAP implementation at the local level are largely unexplored. Local is defined as the city or municipal level, wherein government is uniquely positioned to provide leadership for health and where many social determinants of health operate. This paper presents the results of a scoping review on local HiAP implementation.

METHODS

Peer reviewed articles and grey literature were systematically searched using the Arksey and O'Malley framework. Characteristics of articles were then categorized, tallied and described.

RESULTS

23 scholarly articles and four government documents were identified, ranging in publication year from 2002 to 2016 and originating from 14 countries primarily from North America and Europe. A wide range of themes emerged relating to HiAP implementation locally including: funding, shared vision, national leadership, ownership and accountability, local leadership and dedicated staff, Health Impact Assessment, and indicators.

CONCLUSION

Common themes were found in the literature regarding HiAP implementation locally. However, to better clarify these factors to contribute to theory development on HiAP implementation, further research is needed that specifically investigates the facilitators and barriers of HiAP locally within their political and policy context.