Evolution of public health policy on healthcare self-management: the case of Ontario, Canada

BACKGROUND

As people live longer, they are at increased risk for chronic diseases and disability. Self-management is a strategy to improve health outcomes and quality of life of those who engage in it. This study sought to gain a better understanding of the factors, including digital technology, that affect public health policy on self-management through an analysis of government policy in the most populous and multicultural province in Canada: Ontario. The overarching question guiding the study was: What factors have influenced the development of healthcare self-management policies over time?

METHODS

Archival research methods, combining document review and evaluation, were used to collect data from policy documents published in Ontario. The documents were analyzed using the READ approach, evaluated using a data extraction table, and synthesized into themes using the model for health policy analysis.

RESULTS

Between January 1, 1985, and May 5, 2022, 72 policy documents on self-management of health were retrieved from databases, archives, and grey literature. Their contents largely focussed on self-management of general chronic conditions, while 47% (n = 18/72) mention diabetes, and 3% (n = 2/72) focussed solely on older adults. Digital technologies were mentioned and were viewed as tools to support self-management in the context of healthcare delivery and enhancing healthcare infrastructure (i.e., telehealth or software in healthcare settings). The actors involved in the policy document creation included mostly Ontario government agencies and departments, and sometimes expert organizations, community groups and engaged stakeholders. The results suggest that several factors including pressures on the healthcare system, hybrid top-down and bottom-up policymaking, and political context have influenced the nature and implementation timing of self-management policy in Ontario.

CONCLUSIONS

The policy documents on self-management of health reveal a positive evolution of the content discussed over time. The changes were shaped by an evolving context, both from a health and political perspective, within a dynamic system of interactions between actors. This research helps understand the factors that have shaped changes and suggests that a critical evidence-based approach on public health policy is needed in understanding processes involved in the development of healthcare self-management policies from the perspective of a democratic governing system.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam

OBJECTIVE

To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).

DESIGN

Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy.

SETTING

Argentina, Mongolia, South Africa and Vietnam.

PARTICIPANTS

Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.

RESULTS

Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.

CONCLUSIONS

Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation

BACKGROUND

There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific.

METHODS

Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions.

DISCUSSION

The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

An analysis of the impact of newborn survival policies in Pakistan using a policy triangle framework

Introduction

Pakistan has made slow progress towards reducing the newborn mortality burden; as a result, it has the highest burden of newborn mortality worldwide. This article presents an analysis of the current policies, plans, and strategies aimed at reducing the burden of newborn death in Pakistan for the purpose of identifying current policy gaps and contextual barriers towards proposing policy solutions for improved newborn health.

Methods

We begin with a content analysis of federal-level policies that address newborn mortality within the context of health system decentralization over the last 20 years. This is then followed by a case study analysis of policy and programme responses in a predominantly rural province of Pakistan, again within the context of broader health system decentralization. Finally, we review successful policies in comparable countries to identify feasible and effective policy choices that hold promise for implementation in Pakistan, considering the policy constraints we have identified.

Results

The major health policies aimed at reduction of newborn mortality, following Pakistan’s endorsement of global newborn survival goals and targets, lacked time-bound targets. We found confusion around roles and responsibilities of institutions in the implementation process and accountability for the outcomes, which was exacerbated by an incomplete decentralization of healthcare policy-making and health service delivery, particularly for women around birth, and newborns. Such wide gaps in the areas of target-setting, implementation mechanism, and evaluation could be because the policy-making largely ignored international commitments and lessons of successful policy-making in comparable regional counties.

Conclusions

Inclusion of clear goals and targets in newborn survival policies and plans, completion of the decentralization process of maternal and child healthcare service delivery, and policy-making and implementation by translating complex evidence and using regional but locally applicable case studies will be essential to any effective policy-making on newborn survival in Pakistan.

Analyzing the cost-effectiveness of Lyme disease risk reduction approaches

Lyme disease (LD) is endemic in many regions of the Northeastern United States. Given the elusive nature of the disease, a systematic approach to identify efficient interventions would be useful for policymakers in addressing LD. We used Markov modeling to investigate the efficiency of interventions. These interventions range from awareness-based to behavioral-based strategies. Targeting animal reservoirs of LD using fungal spray or bait boxes did not prove to be an effective intervention. Results of awareness-based interventions, including distribution of signage, fliers, and presentations, implementable in different geographical scales, suggest that policymakers should focus on these interventions, as they are both cost-effective and have the highest impact on lowering LD risk. Populations may lose focus of LD warnings over time, thus quick succession of these interventions is vital. Our modeling results identify the awareness-based intervention as the most cost-effective strategy to lower the number of LD cases. These results can aid in the establishment of effective LD risk reduction policy at various scales of implementation.

Understanding Government Decisions to De-fund Medical Services Analyzing the Impact of Problem Frames on Resource Allocation Policies

Many medical services lack robust evidence of effectiveness and may therefore be considered "unnecessary" care. Proactively withdrawing resources from, or de-funding, such services and redirecting the savings to services that have proven effectiveness would enhance overall health system performance. Despite this, governments have been reluctant to discontinue funding of services once funding is in place. The focus of this study is to understand how the framing of an issue or problem influences government decision-making related to de-funding of medical services. To achieve this, a framework describing how problem frames, or explanatory naratives, influence government policy decisions was developed and applied to actual cases. The two cases selected were the Ontario government's decisions to de-fund the drug Oxycontin and blood glucose test strips used by patients with diabetes. A qualitative content analysis of public discourse (political debate and media coverage) surrounding these two resource withdrawal examples was conducted and described using the framework. In the framework, government decision-making is a partial reflection of the visibility of the policy issue and complexity of the causal story told within a problem frame. By applying this framework and considering these two key characteristics of problem frames, we can better understand, and possibly predict, the shape and timing of government policy decisions to withdraw resources from medical services.

Systemic Racism and the Family Medical Leave Act (FMLA): Using Critical Race Theory to Build Equitable Family Leave Policies

Past and current policies have led to the creation and sustainment of systemic racism. The Family and Medical Leave Act (FMLA) is a key contributor to sustaining health disparities for working Black women in the USA. Black women have a longstanding history of disadvantage and the current family leave policies make this demographic more vulnerable to economic hardship and eventually disparate health outcomes. Using data from the Family and Medical Leave Act in 2012 - Employee Survey (N = 1266), this study conducts logistic regression analyses to examine if this policy disparately benefits white men and white women compared to women of color. Respondents were categorized into leave takers (those who took family and medical leave as needed), leave needers (those who had an unmet need for leave), and employed only (those who neither needed nor took leave). As hypothesized, Black working women (vs. White working men) have the highest odds of having an unmet need for taking a leave followed by Latina women. In addition, Black working women (vs. White working men) had the highest odds of difficulty in making ends meet when they did take leave. The authors also conduct a policy analysis of the FMLA through a critical race theory (CRT) lens to offer policy recommendations, which deconstruct the role structural racism plays in the structure and implementation of the FMLA.

Toward universal human papillomavirus vaccination for adolescent girls in Hong Kong: a policy analysis

Studies have assessed early population-level impact of human papillomavirus (HPV) vaccination programs for preventing cervical cancer. Through a case study in Hong Kong we examined stakeholder engagement and interactions to promote a universal HPV vaccination program using the Health Policy Triangle framework for structured health policy analysis. Using data from a document review and semi-structured in-depth interviews, we used thematic and stakeholder analyses to describe the process of policy formation. Given Hong Kong’s political and health system, and a mix of Chinese and Western values, stakeholders judged legitimacy of the process differently. We discuss their varied ethical stances and the role of research evidence for informing policy-making. For effective HPV vaccination policy and promotion of universal free HPV vaccination among adolescent girls, new strategies are needed to broaden acceptance of the process, to frame policies in terms of facts and values, and to connect research to policy-making and improve coalition-building.

Assessment of the multi-sectoral approach to tobacco control policies in South Africa and Togo

Background

Tobacco use is the world’s leading preventable cause of illness and death and the most important risk factor for non-communicable diseases (NCDs), particularly cardiovascular and chronic respiratory diseases (heart attack, stroke, congestive obstructive pulmonary disease, and lung cancer). Tobacco control is one of the World Health Organization’s “best-buys” interventions to prevent NCDs. This study assessed the use of a multi-sectoral approach (MSA) in developing and implementing tobacco control policies in South Africa and Togo.

Methods

This two-country case study consisted of a document review of tobacco control policies and of key informant interviews (N = 56) about the content, context, stakeholders, and strategies employed throughout policy formulation and implementation in South Africa and Togo. To guide our analysis, we used the Comprehensive Framework for Multi-Sectoral Approach to Health Policy, which is built around four major constructs of context, content, stakeholders and strategies.

Results

The findings show that the formulation of tobacco control policies in both countries was driven locally by the political, historical, social and economic contexts, and globally by the adoption WHO Framework Convention on Tobacco Control (FCTC). In both countries, the health department led policy formulation and implementation. The stakeholders involved in South Africa were more diverse, proactive and dynamic than those in Togo, whereas the strategies employed were more straightforward in Togo than in South Africa. The extent of understanding and use of MSA in both countries consisted of an inter-sectoral action for health, whereby the health department strove to collaborate with other sectors within and outside the government. Consequently, information sharing was identified as the main outcome of the interactions between institutions and interest groups within and across three critical sectors of the state, namely the public (government), the private and the civil society.

Conclusion

Tobacco control policies in South Africa and Togo were formulated and implemented from an inter-sectoral approach perspective, which relied heavily on information transfer between stakeholders and less on collaborative problem-solving approach. Incorporation of multiple stakeholders allowed both countries to formulate policies to meet FCTC goals for tobacco control and NCD reduction.

Two decades of tobacco use prevention and control policies in Cameroon: results from the analysis of non-communicable disease prevention policies in Africa

BACKGROUND

Tobacco use is the leading cause of preventable death in the world today. In 2010, the World Health Organization (WHO) proposed efficient and inexpensive "best buy" interventions for prevention of tobacco use including: tax increases, smoke-free indoor workplaces and public places, bans on tobacco advertising, promotion and sponsorship, and health information and warnings. This paper analyzes the extent to which tobacco use prevention policies in Cameroon align with the WHO tobacco "best buy" interventions. It further explores the context, content, formulation and implementation level of these policies.

METHODS

This was a case study combining a structured review of 19 government policy documents related to tobacco use and prevention, in-depth interviews with 38 key stakeholders and field observations. The Walt and Gilson's policy analysis triangle was used to describe and interpret the context, content, processes and actors during the formulation and implementation of tobacco prevention and control policies. Direct observations ascertained the level of implementation of some selected policies.

RESULTS

Twelve out of 19 policies for tobacco use and prevention address the WHO "best buy" interventions. Cameroon policy formulation was driven locally by the social context of non-communicable diseases, and globally by the adoption of the WHO Framework Convention on Tobacco Control. These policies incorporated at a certain level all four domains of tobacco use "best buy" interventions. Formulating policy on smoke-free areas was single-sector oriented, while determining tobacco taxes and health warnings was more complex utilizing multisectoral approaches. The main actors involved were ministerial departments of Health, Education, Finances, Communication and Social Affairs. The level of implementation varied widely from one policy to another and from one region to another. Political will, personal motivation and the existence of formal exchange platforms facilitated policy formulation and implementation, while poor resource allocation and lack of synergy constituted barriers.

CONCLUSIONS

Despite actions made by the Government, there is no real political will to control tobacco use in Cameroon. Significant shortcomings still exist in developing and/or implementing comprehensive tobacco use and prevention policies. These findings highlight major gaps as well as opportunities that can be harnessed to improve tobacco control in Cameroon.

Frameworks for self-management support for chronic disease: a cross-country comparative document analysis

BACKGROUND

In a number of countries, frameworks have been developed to improve self-management support (SMS) in order to reduce the impact of chronic disease. The frameworks potentially provide direction for system-wide change in the provision of SMS by healthcare systems. Although policy formulation sets a foundation for health service reform, little is currently known about the processes which underpin SMS framework development as well as the respective implementation and evaluation plans.

METHODS

The aim of this study was to conduct a cross-country comparative document analysis of frameworks on SMS for chronic diseases in member countries of the Organisation for Economic Cooperation and Development. SMS frameworks were sourced through a systematic grey literature search and compared through document analysis using the Health Policy Triangle framework focusing on policy context, contents, actors involved and processes of development, implementation and evaluation.

RESULTS

Eight framework documents published from 2008 to 2017 were included for analysis from: Scotland, Wales, Ireland, Manitoba, Queensland, Western Australia, Tasmania and the Northern Territory. The number of chronic diseases identified for SMS varied across the frameworks. A notable gap was a lack of focus on multimorbidity. Common courses of action across countries included the provision of self-management programmes for individuals with chronic disease and education to health professionals, though different approaches were proposed. The 'actors' involved in policy formulation were inconsistent across countries and it was only clear from two frameworks that individuals with chronic disease were directly involved. Half of the frameworks had SMS implementation plans with timelines. Although all frameworks referred to the need for evaluation of SMS implementation, few provided a detailed plan.

CONCLUSIONS

Differences across frameworks may have implications for their success including: the extent to which people with chronic disease are involved in policy making; the courses of action taken to enhance SMS; and planned implementation processes including governance and infrastructure. Further research is needed to examine how differences in frameworks have affected implementation and to identify the critical success factors in SMS policy implementation.

Developing the National Knowledge Platform in India: a policy and institutional analysis

BACKGROUND

The importance of strong engagement between researchers and decision-makers in the improvement of health systems is increasingly being recognised in low- and middle-income countries (LMICs). In 2013, in India, the Ministry of Health and Family Welfare began exploring the formation of a National Knowledge Platform (NKP) for guiding and supporting public health and health systems research in the country. The development of the NKP represents an important opportunity to enhance the linkage between policy-makers and researchers from the health policy and systems research field in India. However, the development process also reflects the highly complex reality of policy-making in the Indian health sector. Our objective is to provide insight into the policy-making process for establishing a health sector knowledge platform in India, and in doing so, to analyse the enabling contextual factors, the interests and actions of stakeholders, and the varying institutional arrangements explored in the development of the NKP.

METHODS

We used a qualitative case study methodology, conducting 16 in-depth interviews and reviewing 42 documents. We utilised General Thematic Analysis to analyse our data. Our research team combined perspectives from both outsiders (independent researchers with no prior or current involvement with the policy) and insiders (researchers involved in the policy-making process).

RESULTS

We found that enabling contextual factors, and a combination of government and non-governmental stakeholders with core interests in public health and health systems, were able to gain considerable momentum in moving the idea for the NKP forward. However, complex evidence-to-policy processes in the Indian health sector resulted in complications in determining the right institutional arrangement for the platform. Establishing the appropriate balance between legitimacy and independence, as well as frequent changes in institutional leadership, were found to be additional issues that stakeholders contended with in building the NKP.

CONCLUSION

As interest in platforms linking health sector policy-makers and researchers grows in LMICs, our findings may allow stakeholders to learn from the Indian experience thus far, and to anticipate some of the facilitators and barriers that could potentially arise in establishing such mechanisms.

Mapping the existing body of health policy implementation research in lower income settings: what is covered and what are the gaps?

This article uses 85 peer-reviewed articles published between 1994 and 2009 to characterize and synthesize aspects of the health policy analysis literature focusing on policy implementation in low- and middle-income countries (LMICs). It seeks to contribute, first, to strengthening the field of LMIC health policy analysis by highlighting gaps in the literature and generating ideas for a future research agenda and, second, to thinking about the value and applicability of qualitative synthesis approaches to the health policy analysis field. Overall, the article considers the disciplinary perspectives from which LMIC health policy implementation is studied and the extent to which the focus is on systems or programme issues. It then works with the more specific themes of the key thrusts of the reviewed articles, the implementation outcomes studied, implementation improvement recommendations made and the theories used in the reviewed articles. With respect to these more specific themes, the article includes explorations of patterns within the themes themselves, the contributions of specific disciplinary perspectives and differences between systems and programme articles. It concludes, among other things, that the literature remains small, fragmented, of limited depth and quite diverse, reflecting a wide spectrum of health system dimensions studied and many different suggestions for improving policy implementation. However, a range of issues beyond traditional 'hardware' health system concerns, such as funding and organizational structure, are understood to influence policy implementation, including many 'software' issues such as the understandings of policy actors and the need for better communication and actor relationships. Looking to the future, there is a need, given the fragmentation in the literature, to consolidate the existing body of work where possible and, given the often broad nature of the work and its limited depth, to draw more explicitly on theoretical frames and concepts to deepen work by sharpening and focusing concerns and questions.

The use of street-level bureaucracy theory in health policy analysis in low- and middle-income countries: a meta-ethnographic synthesis

This article presents a synthesis of studies that explicitly use the theory of street-level bureaucracy to illuminate health policy implementation in low- and middle-income countries. Street-level bureaucrats are frontline workers in bureaucracies, e.g. nurses, who regularly interact directly with citizens in discharging their policy implementation duties and who have some discretion over which services are offered, how services are offered and the benefits and sanctions allocated to citizens. This synthesis seeks to achieve the dual objectives of, first, reflecting on how street-level bureaucracy theory has been used in the literature and, second, providing an example of the application of the synthesis methodology of meta-ethnography to the health policy analysis literature. The article begins by outlining meta-ethnography and providing more information on the papers on which the synthesis is based. This is followed by a detailed account of how the synthesis was achieved and by an articulation of the synthesis. It then concludes with thoughts and questions on the value and relevance of the synthesis, the experience of conducting the synthesis and the partial way in which street-level bureaucracy theory has been used in the literature examined.

The First Stages of Liberalization of Public Hospitals in Iran: Establishment of Autonomous Hospitals and the Barriers

BACKGROUND

Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms.

METHODS

Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase.

RESULTS

Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments".

CONCLUSION

The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.