Health systems frameworks in their political context: framing divergent agendas

Factors Associated with Communities' Satisfaction with Receiving Curative Care Administered by Community Health Workers in the Health Districts of Bousse and Boussouma in Burkina Faso, 2024

BACKGROUND

Since 2010, Burkina Faso has developed and initiated community-based management of childhood illnesses. Following the increased presence of community health workers and the adoption of free community health care, this study aims to assess community satisfaction with curative care administered by community health workers.

METHODOLOGY

This was a descriptive and analytical cross-sectional study. Data were collected in the health districts of Boussé and Boussouma from 20 February to 30 March 2023 for quantitative data and from 12 to 30 January 2024 for qualitative data using a questionnaire (household survey) and an interview grid (focus groups). Analyses were conducted using SPSS IBM 25 and Nvivo 14.

RESULTS

Households benefit from oral curative care when using Community health workers, but are not satisfied with the temporal accessibility of these community health workers. Temporal accessibility and awareness during care have a significant influence on household satisfaction.

CONCLUSIONS

Curative care by community health workers is effective, but its use could be improved by addressing the unavailability of community health workers, inputs and better communication during care.

An international comparative policy analysis of opioid use disorder treatment in primary care across nine high-income jurisdictions

BACKGROUND

Opioid use disorder (OUD) and opioid-related harms are current health priorities in many high-income countries such as Canada. Opioid agonist therapy (OAT) is an effective evidence-based treatment for OUD, but access is often limited.

AIMS

To describe and compare OUD treatment policies across nine international jurisdictions, and to understand how they are situated within their primary care and health systems.

METHODS

Using policy documents, we collected data on health systems, drug use epidemiology, drug policies, and OUD treatment from Australia, Canada, France, Germany, Ireland, Portugal, Sweden, Switzerland, and Taiwan. We used the health system dynamics framework and adapted definitions of low- and high-threshold treatment to describe and compare OUD treatment policies, and to understand how they may be shaped by their health systems context.

RESULTS

Broad similarities across jurisdictions included the OAT pharmacological agents used and the need for supervised dosing; however, preferred OAT, treatment settings, primary care and specialist physicians' roles, and funding varied. Most jurisdictions had elements of lower-threshold treatment access, such as the availability of treatment through primary care and multiple OAT options, but the higher-threshold criteria of supervised dosing.

CONCLUSIONS

From the Canadian perspective, there are opportunities to improve accessibility of OUD care by drawing on how different jurisdictions incorporate multidisciplinary care, regulate OAT medications, remunerate healthcare professionals, and provide funding for services.

Investigating the citing communities around three leading health-system frameworks

Of numerous proposed frameworks for analyzing and impacting health systems, three stand out for the large number of publications that cite them and for their links to influential international institutions: Murray and Frenk (Bull World Health Organ 78:717-31, 2000) connected initially to the World Health Organization (WHO) and then to the Global Burden of Disease Project; Roberts et al. (Getting health reform right: a guide to improving performance and equity, Oxford University Press, Oxford, 2004) sponsored by the World Bank/Harvard Flagship Program; and de Savigny and Adam (Systems thinking for health systems strengthening, WHO, 2009) linked to the WHO and the Alliance for Health Policy and Systems Research. In this paper, we examine the citation communities that form around these works to better understand the underlying logic of these citation grouping as well as the dynamics of Global Health research on health systems. We conclude that these groupings are largely independent of one another, reflecting a range of factors including the goals of each framework and the problems that it was meant to explore, the prestige and authority of institutions and individuals associated with these frameworks, and the intellectual and geographic proximity of the citing researchers to each other and to the framework authors.

Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi

BACKGROUND

Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings.

METHODS AND FINDINGS

To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework.

CONCLUSIONS

By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.

What Are Healthy Societies? A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

While support for the idea of fostering healthy societies is longstanding, there is a gap in the literature on what they are, how to beget them, and how experience might inform future efforts. This paper explores developments since Alma Ata (1978) to understand how a range of related concepts and fields inform approaches to healthy societies and to develop a model to help conceptualize future research and policy initiatives.

METHODS

Drawing on 68 purposively selected documents, including political declarations, commission and agency reports, peer-reviewed papers and guidance notes, we undertook qualitative thematic analysis. Three independent researchers compiled and categorised themes describing the domains of a potential healthy societies approach.

RESULTS

The literature provides numerous frameworks. Some of these frameworks promote alternative endpoints to development, eschewing short-term economic growth in favour of health, equity, well-being and sustainability. They also identify values, such as gender equality, collaboration, human rights and empowerment that provide the pathways to, or underpin, such endpoints. We categorize the literature into four "components": people; places; products; and planet. People refers to social positions, interactions and networks creating well-being. Places are physical environments-built and natural-and the interests and policies shaping them. Products are commodities and commercial practices impacting population health. Planet places human health in the context of the 'Anthropocene.' These components interact in complex ways across global, regional, country and community levels as outlined in our heuristic.

CONCLUSION

The literature offers little critical reflection on why greater progress has not been made, or on the need to organise and resist the prevailing systems which perpetuate ill-health.

How to Build Healthy Societies: A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

As the Sustainable Development Goals deadline of 2030 draws near, greater attention is being given to health beyond the health sector, in other words, to the creation of healthy societies. However, action and reform in this area has not kept pace, in part due to a focus on narrower interventions and the lack of upstream action on health inequity. With an aim to guide action and political engagement for reform, we conducted a thematic analysis of concepts seeking to arrive at healthy societies.

METHODS

This paper drew on a qualitative thematic analysis of a purposive sample of 68 documents including political declarations, reports, peer reviewed literature and guidance published since 1974. Three independent reviewers extracted data to identify, discuss and critique public policy levers and 'enablers' of healthy societies, the "how."

RESULTS

The first lever concerned regulatory and fiscal measures. The second was intersectoral action. The final lever a shift in the global consensus around what signifies societal transformation and outcomes. The three enablers covered political leadership and accountability, popular mobilization and the generation and use of knowledge.

CONCLUSION

Documents focused largely on technical rather than political solutions. Even as the importance of political leadership was recognized, analysis of power was limited. Rights-based approaches were generally neglected as was assessing what worked or did not work to pull the levers or invest in the enablers. Frameworks typically failed to acknowledge or challenge prevailing ideologies, and did not seek to identify ways to hold or governments or corporations accountable for failures. Finally, ideas and approaches seem to recur again over the decades, without adding further nuance or analysis. This suggests a need for more upstream, critical and radical approaches to achieve healthy societies.

One Health Surveillance System in Gujarat, India: A Health Policy and Systems Research Protocol for Exploring the Cross-Sectoral Collaborations to Detect Emerging Threats at the Human-Animal-Environment Interface

The close interaction between humans, animals and the ecosystem has been a reason for the emergence and re-emergence of zoonotic diseases worldwide. Zoonoses are estimated to be responsible for 2.5 billion human illnesses and 2.7 million deaths worldwide. Gujarat is a western state in India with more than 65 million people and 26 million livestock, and includes surveillance systems for humans and animals; however, more evidence is needed on joint collaborative activities and their effect on the early warning response for zoonoses. Thus, this study aims to investigate sectoral collaborations for early warning and response systems for emerging and re-emerging zoonoses, aiming to develop a One Health surveillance (OHS) system in Gujarat, India. This case study uses policy content analysis followed by qualitative and quantitative data collection among state- and district-level surveillance actors to provide insight into the current cross-sectoral collaborations among surveillance actors. It helps identify triggers and documents factors helpful in strengthening cross-sectoral collaborations among these systems and facilitates the establishment of an OHS system in Gujarat, India.

Retracing loss of momentum for primary health care: can renewed political interest in the context of COVID-19 be a turning point?

The COVID-19 pandemic has revealed major weaknesses in primary health care (PHC), and how such weaknesses pose a catastrophic threat to humanity. As a result, strengthening PHC has re-emerged as a global health priority and will take centre stage at the 2023 United Nations High Level Meeting (UNHLM) on Universal Health Coverage (UHC). In this analysis, we examine why, despite its fundamental importance and incredible promise, the momentum for PHC has been lost over the years. The portrayal of PHC itself (policy image) and the dominance of global interests has undermined the attractiveness of intended PHC reforms, leading to legacy historical policy choices (critical junctures) that have become extremely difficult to dismantle, even when it is clear that such choices were a mistake. PHC has been a subject of several political declarations, but post-declarative action has been weak. The COVID-19 provides a momentous opportunity under which the image of PHC has been reconstructed in the context of health security, breaking away from the dominant social justice paradigms. However, we posit that effective PHC investments are those that are done under calm conditions, particularly through political choices that prioritise the needs of the poor who continue to face a crisis even in non-pandemic situations. In the aftermath of the 2023 UNHLM on UHC, country commitment should be evaluated based on the technical and financial resources allocated to PHC and tangible deliverables as opposed to the formulation of documents or convening of a gathering that simply (re) endorses the concept.

Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance?

Background

Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.

Methods

Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.

Results

Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.

Conclusion

The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.

Health System Governance Evaluation: A Scoping Review

Background

Governance is one of the critical functions of the health system. Good governance of the health system leads to better performance and outcomes. Evaluation is the first step to improving health system governance. Therefore, this research aimed to identify evaluation tools for health system governance.

Methods

In the current scoping review, we searched all documents related to health system governance evaluation indexed in Medline, EMBASE, ProQuest, Scopus, Cochrane Library, Science Direct databases, and Google Scholar search engines to 2022, extracted, and assessed. Finally, documents were selected and analyzed by thematic analysis.

Results

Thirty tools were found to evaluate health system governance. Among the proposed tools, 11 specific tools have been designed just for health system governance evaluation, while others have governance as a component of health system evaluation. Health system governance's significant components are health policy-making, strategic planning, organizing, stewardship, and control. Indicators such as accountability, participation, transparency, equity, efficiency, accountability, corruption control, effectiveness, ethic, the rule of law, and sustainability could be used to evaluate the health system governance.

Conclusion

Different tools have been used to evaluate governance worldwide, and each governance evaluation tool has different components suitable for governance evaluation. However, these tools cannot fully evaluate governance and have shortcomings. A comprehensive evaluation of governance and sharing lessons denrael will affect the health system's capacity and ability to provide quality, safe and effective health services. It will lead to the stability of the health system.

Coping with in-locus factors and systemic contradictions affecting antibiotic prescription and dispensing practices in primary care-A qualitative One Health study in Brazil

Antimicrobial resistance (AMR) is an increasing threat to global health. The risks and sanitary consequences of AMR are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). While addressing antibiotic use has largely been documented in hospital settings, the understanding of social drivers affecting antibiotic prescribing and dispensing practices in the context of human and animal health in primary care (PC) in LMICs remains extremely limited. We seek to explore how in-locus and multi-level social factors influence antibiotic prescriptions and dispensing practices in the context of human and animal health in primary care in Brazil. This is a baseline qualitative One Health study; semi-structured interviews and field observations were undertaken in primary care sites located in a socioeconomically vulnerable area in the city of São Paulo, the most populated city of Brazil. Twenty-five human and animal healthcare professionals (HP) were purposely sampled. Interview data were subject to thematic analysis. Three overlapping social drivers were identified across HPs' discourses: individual and behavioral challenges; relational and contextual factors influencing the overprescription of antibiotics (AB); and structural barriers and systemic contradictions in the health system. As a result of the interaction between multilevel in-locus and structural and contextual factors, HPs experience contextual and territorial challenges that directly influence their risk perception, diagnosis, use of laboratorial and image exams, time and decision to undergo treatment, choice of AB and strategies in coping with AB prescriptions. Additionally, in-locus factors influencing antibiotic prescriptions and dispensing practices are intertwined with individual accounts of risk management, systemic contradictions and ambivalences in the national health system. Our findings suggest interventions tackling AB use and AMR in Brazil should consider the social context, the complex health system structure and current integrated programs and services in PC.

Comparison of Health Status Indicators in Iran with the Eastern Mediterranean Countries Using Multiple Attribute Decision-Making Methods

BACKGROUND

Improving public health is the main goal of healthcare systems across the world. Healthcare policymakers often use comparisons between different healthcare systems to better position their country and use the outcome to develop novel strategies to improve their own public health. The present study aimed to compare the health status indicators in Iran with those of the Eastern Mediterranean (EM) countries using the multiple attribute decision-making (MADM) methods.

METHODS

A descriptive-analytical study was conducted in 2021 at Shiraz University of Medical Sciences, Shiraz, Iran. Data on the ranking of health status indicators in EM countries were obtained from the annual publications of the World Health Organization, World Health Statistics (2016-2020). As part of the MADM mathematical models, the "criteria importance through intercriteria correlation" (CRITIC) model was used to assign weights to health status indicators. In addition, the "multi-criteria optimization and compromise solution" (VIKOR) model was used to rank the EM countries.

RESULTS

The results showed that Bahrain and Somalia ranked first and last on health status indicators, respectively. Iran was ranked fifth among the EM countries. However, while Iran has a better status on all indicators than the mean value of all EM countries, there is a significant gap between the health status in Iran compared to the top-ranked countries.

CONCLUSION

Health care strategies adopted by top-ranked countries, such as Bahrain and Qatar, can be used by Iran and other EM countries as a model to improve their healthcare system.

The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic

BACKGROUND

Coronavirus disease 2019 (COVID-19) has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children's Hospitals Network (SCHN), the largest provider of children's health services in the Southern hemisphere.

METHODS

We used ethnographic methods, guided by the CSSF, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the emergency operations centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN's response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN.

RESULTS

The CSSF captured SCHN's complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN's response to the pandemic included principles of equity of healthcare delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN's resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision.

CONCLUSION

Using the CSSF, we found that SCHN's ability to innovate was key to ensuring its resilience during the pandemic.

A missing piece in the Health for Peace agenda: gender diverse leadership and governance

The purpose of this paper is to explore how gender diverse leadership and governance of health systems may contribute to the Health for Peace Agenda. Despite recent momentum, the evidence base to support, implement and evaluate ‘Health for Peace’ programmes remains limited and policy-makers in conflict settings do not consider peace when developing and implementing interventions and health policies. Through this analysis, we found that gender diverse leadership in health systems during active conflict offers greater prospects for sustainable peace and more equitable social economic recovery in the post-conflict period. Therefore, focusing on gender diversity of leadership and governance in health systems strengthening offers a novel way of linking peace and health, particularly in active conflict settings. While components of health systems are beginning to incorporate a gender lens, there remains significant room for improvement particularly in complex and protracted conflicts. Two case studies are explored, north-west Syria and Afghanistan, to highlight that an all-encompassing health systems focus may provide an opportunity for further understanding the link between gender, peace and health in active conflict and advocate for long-term investment in systems impacted by conflict. This approach may enable women and gender minorities to have a voice in the decision-making of health programmes and interventions that supports systems, and enables the community-led and context-specific knowledge and action required to address the root causes of inequalities and inequities in systems and societies.

Strategies to adapt and implement health system guidelines and recommendations: a scoping review

BACKGROUND

Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries.

METHODS

We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level.

CONCLUSIONS

The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.

Zooming in and out: a holistic framework for research on maternal, late foetal and newborn survival and health

Research is needed to understand why some countries succeed in greater improvements in maternal, late foetal and newborn health (MNH) and reducing mortality than others. Pathways towards these health outcomes operate at many levels, making it difficult to understand which factors contribute most to these health improvements. Conceptual frameworks provide a cognitive means of rendering order to these factors and how they interrelate to positively influence MNH. We developed a conceptual framework by integrating theories and frameworks from different disciplines to encapsulate the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. We developed our framework iteratively, combining our interdisciplinary research team's knowledge, experience and review of the literature. We present a framework that includes health policy and system levers (or intentional actions that policy-makers can implement) to improve MNH; service delivery and coverage of interventions across the continuum of care; and epidemiological and behavioural risk factors. The framework also considers the role of context in influencing for whom and where health and non-health efforts have the most impact, to recognize 'the causes of the causes' at play at the individual/household, community, national and transnational levels. Our framework holistically reflects the range of interrelated factors influencing improved MNH and survival. The framework lends itself to studying how different factors work together to influence these outcomes using an array of methods. Such research should inform future efforts to improve MNH and survival in different contexts. By re-orienting research in this way, we hope to equip policy-makers and practitioners alike with the insight necessary to make the world a safer and fairer place for mothers and their babies.

Taking Systems Thinking to the Global Level: Using the WHO Building Blocks to Describe and Appraise the Global Health System in Relation to COVID-19

Adequately preparing for and containing global shocks, such as COVID-19, is a key challenge facing health systems globally. COVID-19 highlights that health systems are multilevel systems, a continuum from local to global. Goals and monitoring indicators have been key to strengthening national health systems but are missing at the supranational level. A framework to strengthen the global system-the global health actors and the governance, finance, and delivery arrangements within which they operate-is urgently needed. In this article, we illustrate how the World Health Organization Building Blocks framework, which has been used to monitor the performance of national health systems, can be applied to describe and appraise the global health system and its response to COVID-19, and identify potential reforms. Key weaknesses in the global response included: fragmented and voluntary financing; non-transparent pricing of medicines and supplies, poor quality standards, and inequities in procurement and distribution; and weak leadership and governance. We also identify positive achievements and identify potential reforms of the global health system for greater resilience to future shocks. We discuss the limitations of the Building Blocks framework and future research directions and reflect on political economy challenges to reform.

COVID-19 vaccine equity: a health systems and policy perspective

Introduction

The global COVID-19 vaccine rollout has highlighted inequities in the accessibility of countries to COVID-19 vaccines. Populations in low- and middle-income countries have found it difficult to have access to COVID-19 vaccines.

Areas covered

This perspective provides analyses on historical and contemporary policy trends of vaccine development and immunization programs, including the current COVID-19 vaccination drive, and governance challenges. Moreover, we also provide a comparative health system analysis of the COVID-19 vaccine deployment in some countries from different continents. It recommends that the international Access to COVID-19 Tools Accelerator (ACT-A) partnership requires a strong governance mechanism and urgent financial investment.

Expert opinion

All WHO member states should agree on technology transfer and voluntary license-sharing via a commonly governed technology access pool and supported by a just Intellectual Property regime. Contextualized, dynamic understandings and country-specific versions of health systems strengthening are needed to improve vaccine equity in a sustainable matter.

Evaluation of the World Countries Health Referral System Performance Based on World Health Organization Indicators Using Hybrid Multi-Criteria Decision-Making Model

OBJECTIVES

Primary healthcare will not be effective unless there is a proper referral system. In contrast, comparing the performance of healthcare systems provides an opportunity for policy makers to determine the status of the country's healthcare system compared with their international counterparts. Therefore, we ranked the countries in terms of indicators affected by the referral system.

METHODS

This study was conducted in 2020. In the first phase, which was to determine the indicators affected by a country's referral system, data were collected by the Delphi method, and therefore, 13 indicators with a content validity ratio equal to or greater than 0.42 were selected. In the second phase, the data of 13 indicators selected in the first phase were extracted from the 2018 and 2019 World Health Organization reports. The weight of the indicators was calculated based on the Decision-Making Trial and Evaluation Laboratory method-based Analytic Network Process (DANP) and Shannon's entropy, and the VIekriterijumsko KOmpromisno Rangiranje (VIKOR) method was used to rank the countries. SPSS 24 and Excel 2013 software were used for data analysis.

RESULTS

Switzerland, Germany, and Sweden ranked first, second, and third, respectively. In all the 3 countries, there are no mandatory gatekeeping systems. Physicians, especially general practitioners, are the core of primary healthcare, and in all the 3 countries, there is a uniform and coherent health financing system that is either based on mandatory health insurance (Switzerland and Germany) or taxes (Sweden). India had the lowest ranking.

CONCLUSIONS

It seems that the study of the health system of the countries that have obtained higher rankings can indicate their efforts in establishing a gatekeeping system, family physician program, and appropriate financing system. Therefore, other countries can study successful countries and copy them as a model to improve their health system.

Addressing Gaps for Health Systems Strengthening: A Public Perspective on Health Systems' Response towards COVID-19

Strengthening the health systems through gaps identification is necessary to ensure sustainable improvements especially in facing a debilitating outbreak such as COVID-19. This study aims to explore public perspective on health systems’ response towards COVID-19, and to identify gaps for health systems strengthening by leveraging on WHO health systems’ building blocks. A qualitative study was conducted using open-ended questions survey among public followed by in-depth interviews with key informants. Opinions on Malaysia’s health systems response towards COVID-19 were gathered. Data were exported to NVIVO version 12 and analysed using content analysis approach. The study identified various issues on health systems’ response towards COVID-19, which were then mapped into health systems’ building blocks. The study showed the gaps were embedded among complex interactions between the health systems building blocks. The leadership and governance building block had cross-cutting effects, and all building blocks influenced service deliveries. Understanding the complexities in fostering whole-systems strengthening through a holistic measure in facing an outbreak was paramount. Applying systems thinking in addressing gaps could help addressing the complexity at a macro level, including consideration of how an action implicates other building blocks and approaching the governance effort in a more adaptive manner to develop resilient systems.

The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique

Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.

Moral distress in community health nursing practice

Contemporary sociopolitical circumstance impedes the delivery of primary health care in keeping with its underlying philosophy and tenets. Skills to negotiate the maintenance of best practice and quality care in an evolving practice environment are fundamental to nursing. Nurse education needs to incorporate the ideals of best practice ideology to ensure that all are prepared to negotiate the realities of nursing practice. In this discussion paper the experience of moral distress by community health nurses is used to illustrate why skills in political advocacy and action are equally essential as clinical skills in nurse education and professional practice.

Transitioning health workers from PEPFAR contracts to the Uganda government payroll

Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis

BACKGROUND

Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.'

METHODS

We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory.

RESULTS

We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups.

CONCLUSION

We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Agenda setting for essential medicines policy in sub-Saharan Africa: a retrospective policy analysis using Kingdon's multiple streams model

BACKGROUND

Lack of access to essential medicines presents a significant threat to achieving universal health coverage (UHC) in sub-Saharan Africa. Although it is acknowledged that essential medicines policies do not rise and stay on the policy agenda solely through rational deliberation and consideration of technical merits, policy theory is rarely used to direct and guide analysis to inform future policy implementation. We used Kingdon's model to analyse agenda setting for essential medicines policy in sub-Saharan Africa during the formative phase of the primary healthcare (PHC) concept.

METHODS

We retrospectively analysed 49 published articles and 11 policy documents. We used selected search terms in EMBASE and MEDLINE electronic databases to identify relevant published studies. Policy documents were obtained through hand searching of selected websites. We also reviewed the timeline of essential medicines policy milestones contained in the Flagship Report, Medicines in Health Systems: Advancing access, affordability and appropriate use, released by WHO in 2014. Kingdon's model was used as a lens to interpret the findings.

RESULTS

We found that unsustainable rise in drug expenditure, inequitable access to drugs and irrational use of drugs were considered as problems in the mid-1970s. As a policy response, the essential drugs concept was introduced. A window of opportunity presented when provision of essential drugs was identified as one of the eight components of PHC. During implementation, policy contradictions emerged as political and policy actors framed the problems and perceived the effectiveness of policy responses in a manner that was amenable to their own interests and objectives.

CONCLUSION

We found that effective implementation of an essential medicines policy under PHC was constrained by prioritization of trade over public health in the politics stream, inadequate systems thinking in the policy stream and promotion of economic-oriented reforms in both the politics and policy streams. These lessons from the PHC era could prove useful in improving the approach to contemporary UHC policies.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Responding to the 2018-2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches

The Democratic Republic of Congo (DRC) presents a challenging context in which to respond to public health crises. Its 2018-2020 Ebola outbreak was the second largest in history. Lessons were known from the previous West African outbreak. Chief among these was the recognition that local action and involvement are key to establishing effective epidemic-response. It remains unclear whether and how this was achieved in DRC's Ebola response. Additionally, there is a lack of scholarship on how to build resilience (the ability to adapt or transform under pressure) in crisis-response. In this article, we critically review literature to examine evidence on whether and how communities were involved, trust built, and resilience strengthened through adaptation or transformation of DRC's 2018-2020 Ebola response measures. Overall, we found limited evidence that the response adapted to engage and involve local actors and institutions or respond to locally expressed concerns. When adaptations occurred, they were shaped by national and international actors rather than enabling local actors to develop locally trusted initiatives. Communities were "engaged" to understand their perceptions but were not involved in decision-making or shaping responses. Few studies documented how trust was built or analyzed power dynamics between different groups in DRC. Yet, both these elements appear to be critical in building effective, resilient responses. These failures occurred because there was no willingness by the national government or international agencies to concede decision-making power to local people. Emergency humanitarian response is entrenched in highly medicalized, military style command and control approaches which have no space for decentralizing decision-making to "non-experts". To transform humanitarian responses, international responders can no longer be regarded as "experts" who own the knowledge and control the response. To successfully tackle future humanitarian crises requires a transformation of international humanitarian and emergency response systems such that they are led, or shaped, through inclusive, equitable collaboration with local actors.

Understanding the influence of health systems on women's experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa

We explored women's experiences of Option B+ in sub-Saharan African health facility settings through a meta-ethnography of 32 qualitative studies published between 2010 and 2019. First and second-order constructs were identified from the data and authors' interpretations respectively. Using a health systems lens, third-order constructs explored how the health systems shaped women's experiences of Option B+ and their subsequent engagement in care. Women's experiences of Option B+ services were influenced by their interactions with health workers, which were often reported to be inadequate and rushed, reflecting insufficient staffing or training to address pregnant women's needs. Women's experiences were also undermined by various manifestations of stigma which persisted in the absence of resources for social or mental health support, and were exacerbated by space constraints in health facilities that infringed on patient confidentiality. Sub-optimal service accessibility, drug stock-outs and inadequate tracing systems also shaped women's experiences of care. Strengthening health systems by improving health worker capacity to provide respectful and high-quality clinical and support services, improving supply chains and improving the privacy of consultation spaces would improve women's experiences of Option B+ services, thereby contributing to improved care retention. These lessons should be considered as universal test and treat programmes expand.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

BACKGROUND

Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.

METHODS

We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance.

DISCUSSION

The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

The political economy of universal health coverage: a systematic narrative review

The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance-even veto-of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich's framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure-federal systems, user fees, pre-existing insurance schemes-needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.

Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map

Because health systems are conceptualized as social systems, embedded in social contexts and shaped by human agency, values are a key factor in health system change. As such, health systems software-including values, norms, ideas and relationships-is considered a foundational focus of the field of health policy and systems research (HPSR). A substantive evidence-base exploring the influence of software factors on system functioning has developed but remains fragmented, with a lack of conceptual clarity and theoretical coherence. This is especially true for work on 'social values' within health systems-for which there is currently no substantive review available. This study reports on a systematic mixed-methods evidence mapping review on social values within HPSR. The study reaffirms the centrality of social values within HPSR and highlights significant evidence gaps. Research on social values in low- and middle-income country contexts is exceedingly rare (and mostly produced by authors in high-income countries), particularly within the limited body of empirical studies on the subject. In addition, few HPS researchers are drawing on available social science methodologies that would enable more in-depth empirical work on social values. This combination (over-representation of high-income country perspectives and little empirical work) suggests that the field of HPSR is at risk of developing theoretical foundations that are not supported by empirical evidence nor broadly generalizable. Strategies for future work on social values in HPSR are suggested, including: countering pervasive ideas about research hierarchies that prize positivist paradigms and systems hardware-focused studies as more rigorous and relevant to policy-makers; utilizing available social science theories and methodologies; conceptual development to build common framings of key concepts to guide future research, founded on quality empirical research from diverse contexts; and using empirical evidence to inform the development of operationalizable frameworks that will support rigorous future research on social values in health systems.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

BACKGROUND

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

METHODS

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

RESULTS

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

CONCLUSION

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO-academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

BACKGROUND

Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.

METHODS

We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.

RESULTS

Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations.

CONTEXT

Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.

CONCLUSION

This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Assessing barriers to quality trauma care in low and middle-income countries: A Delphi study

BACKGROUND

Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system.

METHODS

A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement.

RESULTS

There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus.

CONCLUSION

11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.

Review of 128 quality of care mechanisms: A framework and mapping for health system stewards

Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.

Access to Healthcare: A Central Question within Brazilian Bioethics

This article explores the current situation regarding the importance of access to healthcare in relation to the genesis and context of bioethics developed in Brazil, a country in which healthcare is understood through the national constitution to be a universal right of its population. Since the onset of the development of Brazilian bioethics at the beginning of the 1990s, topics relating directly and indirectly to the field of public health have been a priority in the bioethics agenda. The article considers the socioeconomic context within which conflicts occur, an issue that has been addressed in other scientific articles on bioethics in Latin America. It presents the main conceptual bases of intervention bioethics, a critical approach that has been developed as a reference point in this region, with the aim of analyzing (bio)ethical issues and indicating solutions that relate specifically to the different forms of social exclusion that influence the health conditions and lives of people in Brazil, as well as in other peripheral countries in the Southern Hemisphere and of the world in general. The article calls attention to some of the problems and challenges that the Brazilian public health system has been facing. An international agenda of "universal health coverage" is one of the main global threats to implementing the universal right to healthcare as it has been understood in Brazil.

European aid and health system strengthening: an analysis of donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund

Background: In the field of international health assistance (IHA), there is a growing consensus on the limits of disease-specific interventions and the need for more health system strengthening (HSS). European donors are considered to be strong supporters of HSS. Nevertheless, little is known about how their support for HSS translates into concrete policies at partner country level. Furthermore, as development cooperation is a shared policy between the EU and its Member States, it remains unclear to what extent European donors share a similar approach.

Objective: This article reviews a PhD thesis on European aid and HSS. The thesis investigated (1) the approaches of European donors towards IHA, and (2) the extent to which there are similarities or differences between them. An original analytical framework was developed to make a fine-grained analysis of European donors’ approaches in the DRC, Ethiopia, Uganda and Mozambique. In addition, the relation of European donors with the Global Fund was investigated.

Methods: An abductive research approach was used during which literature review, data generation, analysis and research design mutually influenced each other. The research built on a wide range of empirical data, including semi-structured interviews with 123 respondents, policy documents and descriptive statistical analysis.

Results and conclusion: Four ‘types’ of European donors were identified, which vary in their focus (issue-specific versus comprehensive) and their level of support to and involvement of recipient states. Despite this heterogeneity at a specific level, there is still a general degree of ‘unity’ among European donors, especially compared with the US. Yet, there are signs that the ‘transatlantic’ divide on HSS may be converging, as European donors tend to focus more explicitly on result-oriented approaches traditionally associated with the US and Global Health Initiatives. Consequently, European donors play a limited role in bringing HSS more to the forefront in IHA.

Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis

BACKGROUND

Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment.

METHODS

The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis.

DISCUSSION

The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112990.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Health system preparedness for emerging infectious diseases: A synthesis of the literature

This review reflects on what the literature to date has taught us about how health systems of low- and middle-income countries (LMICs) respond to emerging infectious disease (EID) outbreaks. These findings are then applied to propose a conceptual framework characterising an EID prepared health system. A narrative synthesis approach was adopted to explore the key elements of LMIC health systems during an EID outbreak. Overarching themes ('core health system constructs') and sub-themes ('elements') relevant to EID preparedness were extracted from 49 peer-reviewed articles. The resulting conceptual framework recognised six core constructs: four focused on material resources and structures (i.e. system 'hardware'), including (i) Surveillance, (ii) Infrastructure and medical supplies, (iii) Workforce, and (iv) Communication mechanisms; and two focused on human and institutional relationships, values and norms (i.e. system 'software'), including (i) Governance, and (ii) Trust. The article reinforces the interconnectedness of the traditional health system building blocks to EID detection, prevention and response, and highlights the critical role of system 'software' (i.e. governance and trust) in enabling LMIC health systems to achieve and maintain EID preparedness. The review provides recommendations for refining a set of indicators for an 'optimised' health system EID preparedness tool to aid health system strengthening efforts.

A critical account of the policy context shaping perinatal survival in Nepal: policy tension of socio-cultural versus a medical approach

BACKGROUND

Nepal formulated a range of policies related to maternal and neonatal survival, especially after the year 2000. Nevertheless, Nepal's perinatal mortality remains high, particularly in disadvantaged regions. Policy analysis can uncover the underlying values, strategies and policy formulation processes that shape the potential to reduce in-country health inequities. This paper provides a critical account of the main policy documents relevant to perinatal survival in Nepal.

METHODS

Six key policy documents covering the period 2000-2015 were reviewed using an adapted framework and were analyzed through qualitative content analysis.

RESULTS

The analysis shows that the policies focused mainly on the system: improvement in provision of birthing facilities; targeting staff (Skilled Birth Attendants) and health service users by providing cash incentives to staff for bringing patients to services, and to users (pregnant women) to attend health institutions. Despite a growing focus on saving women and newborn babies, there is a poor policy focus and direction on preventing stillbirth. The policy documents were found to emphasize tensions between birthing at home and at health institutions on the one hand, and between strategies to provide culturally appropriate, woman-centered care in communities and medically orientated services on the other. Policies acknowledge the need to provide and address woman-centered care, equity, social inclusion, and a rights-based approach, and identify the community based approach as the mode of service delivery. Over and above this, all policy documents are aimed at the national level, and there is no specific policy direction for the separate ecological, cultural or geographic regions such as the mountainous region, which continues to exhibit higher mortality rates and has different cultural and demographic characteristics to the rest of Nepal.

CONCLUSIONS

To better address the continuing high perinatal mortality rates, particularly in disadvantaged areas, national health policies should pay more attention to the inequity in healthcare access and in perinatal outcomes by integrating both stillbirth prevention and neonatal survival as policy agenda items. To ensure effective translation of policy into practice, it is imperative to tailor the strategies according to acknowledged policy values such as rights, inclusion and socio-cultural identity.

Building the case for embedding global health security into universal health coverage: a proposal for a unified health system that includes public health

In the wake of the recent west African Ebola epidemic, there is global consensus on the need for strong health systems; however, agreement is less apparent on effective mechanisms for establishing and maintaining these systems, particularly in resource-constrained settings and in the presence of multiple and sustained stresses (eg, conflict, famine, climate change, and globalisation). The construction of the International Health Regulations (2005) guidelines and the WHO health systems framework, has resulted in the separation of public health functions and health-care services, which are interdependent in actuality and must be integrated to ensure a continuous, unbroken national health system. By analysing efforts to strengthen health systems towards attaining universal health coverage and investments to improve global health security, we examine areas of overlap and offer recommendations for construction of a unified national health system that includes public health. One way towards achieving universal health coverage is to broaden the definition of a health system.

Health Planning in 1960s Africa: International Health Organisations and the Post-Colonial State

This article explores the programme of national health planning carried out in the 1960s in West and Central Africa by the World Health Organization (WHO), in collaboration with the United States Agency for International Development (USAID). Health plans were intended as integral aspects of economic development planning in five newly independent countries: Gabon, Liberia, Mali, Niger and Sierra Leone. We begin by showing that this episode is treated only superficially in the existing WHO historiography, then introduce some relevant critical literature on the history of development planning. Next we outline the context for health planning, noting: the opportunities which independence from colonial control offered to international development agencies; the WHO's limited capacity in Africa; and its preliminary efforts to avoid imposing Western values or partisan views of health system organisation. Our analysis of the plans themselves suggests they lacked the necessary administrative and statistical capacity properly to gauge local needs, while the absence of significant financial resources meant that they proposed little more than augmentation of existing structures. By the late 1960s optimism gave way to disappointment as it became apparent that implementation had been minimal. We describe the ensuing conflict within WHO over programme evaluation and ongoing expenditure, which exposed differences of opinion between African and American officials over approaches to international health aid. We conclude with a discussion of how the plans set in train longer processes of development planning, and, perhaps less desirably, gave bureaucratic shape to the post-colonial state.

Swiss Learning Health System: A national initiative to establish learning cycles for continuous health system improvement

The health system in Switzerland is considered as one of the best in the world. Nevertheless, to effectively and efficiently meet current and future challenges, an infrastructure and culture are needed where the best evidence is systematically made available and used, and the system evolves on the basis of a constant exchange between research, policy, and practice. The Swiss Learning Health System institutionalizes this idea as a multistakeholder national initiative to ensure continuous improvement through ongoing research and implementation. This article presents the objectives and mechanisms of the Swiss Learning Health System in the context of international initiatives to strengthen health systems and improve population health through learning cycles.

Integrated primary health care in low- and middle-income countries: a double challenge

Background

The lack of primary healthcare integration has been identified as one of the main limits to programs’ efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a “crosswise approach” to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors.

Main body

The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011–2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions.

Conclusions

In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.

Resource Allocation Strategies to Increase the Efficiency and Sustainability of Gavi's Health System Strengthening Grants

BACKGROUND

Despite the increase in Health System Strengthening (HSS) grants, there is no consensus among global health actors about how to maximize the efficiency and sustainability of HSS programs and their resulting gains. To formally analyze and compare the efficiency and sustainability of Gavi's HSS grants, we investigated the factors, events and root causes that increased the time and effort needed to implement HSS grants, decreased expected outcomes and threatened the continuity of activities and the sustainability of the results gained through these grants in Cameron and Chad.

METHODS

We conducted 2 retrospective independent evaluations of Gavi's HSS support in Cameroon and Chad using a mixed methodology. We investigated the chain of events and situations that increased the effort and time required to implement the HSS programs, decreased the value of the funds spent and hindered the sustainability of the implemented activities and gains achieved.

RESULTS

Root causes affecting the efficiency and sustainability of HSS grants were common to Cameroon and Chad. Weaknesses in health workforce and leadership/governance of the health system in both countries led to interrupting the HSS grants, reprogramming them, almost doubling their implementation period, shifting their focus during implementation toward procurements and service provision, leaving both countries without solid exit plans to maintain the results gained.

CONCLUSIONS

To increase the efficiency and sustainability of Gavi's HSS grants, recipient countries need to consider health workforce and leadership/governance prior, or in parallel to strengthening other building blocks of their health systems.