International Journal of Health Policy and Management
Volume:5 Issue: 2, Feb 2016

While many international organisations have independent evaluations, including the International Monetary Fund (IMF) and World Health organization (WHO), uniquely the World Bank in its 2015 World Development Report sought to ascertain the potential biases that influence how its staff interpret evidence and influence policy. Here, we describe the World Bank’s study design, including experiments to ascertain the impact on Bank staff’s judgements of complexity, confirmation bias, sunk cost bias, and an understanding of the wishes of those whom they seek to help. We then review the Bank’s proposed mechanisms to minimise the impact of the biases they identified. We argue that this approach, that we refer to as ‘reflective practice,’ deserves to be adopted more widely among institutions that seek to use evidence from research to inform policy and practice.

While there is currently no cure for multiple sclerosis (MS), treatment with biologic diseasemodifying drugs (bDMDs) can reduce the impact of the condition on the lives of patients. In Greece, the regulatory change in the distribution system of bDMDs, limited their administration through the designated pharmacies of the National Organization for Healthcare Services Provision (EOPYY) or the National Health System (ESY) hospitals, thus potentially impacting access to MS treatment. In this context, the aim of this paper was to assess the barriers to bDMDs, by recording MS patients’ experiences. A survey research was conducted between January and February 2014 in Athens and 5 other major Greek cities with the methods of personal and telephone interview. A structured questionnaire was used to elicit socio-economic and medical information, information related to obstacles in accessing bDMDs and medical treatment, from MS patients that visited EOPYY pharmacies during the study period. During the last year 69% of 179 participants reported that the distribution system of bDMDs has improved. Thirteen percent of participants encountered problems in accessing their medication, and 16.9% of participants in accessing their physician, with the obstacles being more pronounced for non-Athens residents. Frequent obstacles to bDMDs were the distance from EOPYY pharmacies and difficulties in obtaining a diagnosis from an EOPYY/ESY physician, while obstacles to medical care were delays in appointment booking and travel difficulties. Even though the major weaknesses of the distribution system of bDMDs have improved, further amelioration of the system could be achieved through the home delivery of medicines to patients living in remote areas, and through the development of a national MS registry.

Recently, parenting programs to address behavioural and emotional problems associated with child maltreatment in developing countries have received much attention. There is a paucity of literature on effective parent education interventions in the local context of Pakistan. This study aimed to assess the feasibility of offering a 6-week parenting program for mothers of pre-school children attending family health centres (FHCs) in Karachi, the largest metropolitan city of Pakistan. A pilot quasi-experimental trial was conducted. Two FHCs were selected, one as the intervention and the second as the control. A total of 57 mothers of pre-school children (n = 30 intervention; n = 27 control) participated in this study. Mothers in the intervention group received SOS Help for parents module, while mothers in the control group received information about routine childcare. A parenting scale (PS) was administered before the program was implemented and repeated 2 weeks after the program was completed in both groups. Statistical analysis was performed to compare participants’ attributes. Descriptive analysis was conducted to compare pre- and post-test mean scores along with standard deviation for parenting subscales in the intervention and control groups. A total of 50 mothers (n = 25 intervention; n = 25 control) completed the 6-week program. Attrition was observed as 5/30 (17%) in the intervention arm and 2/27 (2%) in the control arm. Mothers commonly reported the burden of daily domestic and social responsibilities as the main reason for dropping out. Furthermore, the majority of participants in the control group recommended increasing the duration of weekly sessions from 1 to 1.5 hours, thereby decreasing the program period from 6 to 4 weeks. Mothers in intervention group reported substantial improvement in parenting skills as indicated by mean difference in their pre- and post-test scores for laxness and over-reactivity. Parenting programs can be implemented for mothers attending FHCs in Pakistan. Mothers require positive reinforcement and constant encouragement at the participant level. Integrating such programs into primary healthcare at the population level has the potential to maximize child health benefits and to improve parenting skills at the country level.

Although medical oncologists can have an important role in controlling the cost of cancer treatment, there is little information about their attitudes toward the cost of cancer treatment and the impact of cost on their treatment recommendations, especially in low- and middle-income countries (LMICs). In this study, we assessed the attitude of Iranian medical oncologists toward some economic aspects of new cancer drugs. We translated a questionnaire that was used in similar studies in the United States and Canada into Persian and modified it according to the local setting in Iran. The face and content validity of the questionnaire were assessed by oncologists before being used in the survey. We distributed the questionnaire and collected the data from 80 oncologists who participated in the 13th Annual Congress of the Iranian Society of Medical Oncology and Hematology (ISMOH). Fifty-two oncologists participated in our study (a response rate of 65%). The majority of oncologists stated that drug costs and patient out-of-pocket (OOP) costs influence their treatment recommendations (92% and 94%, respectively). Most oncologists (70%) felt that they are ready enough to use cost-effectiveness information in their treatment decisions, and 74% believed that patients should only have access to cancer treatments that are cost-effective. Most oncologists agree that the government should have control over drug prices, and more use of cost‐effectiveness data is required for decision-making about cancer drug coverage. Ninety-one percent of oncologists said that they always or frequently discuss cancer treatment costs with their patients. Oncologists believed that academic groups (research centers and scientific societies) (81%) and the Ministry of Health (MoH) (43%) are the most eligible groups for determining whether a drug provides good value. Iranian medical oncologists are ready to participate in the health technology assessment and prioritysetting process. This situation creates a unique opportunity for the government to rely on scientific societies and find an appropriate solution for the improvement of patients’ access to high-quality care.

This commentary on Potts et al provides a critical view on their thesis that increasing the level of education among women is likely to reduce terrorism. Presence of a strong family planning program enables women to control family size resulting in women’s public participation more likely and facilitating the emergence of small birth cohorts who are less likely to become unemployed. In spite of the several theoretical insights their paper offers, they have not adequately described the multiple social and economic linkages that may exist between fertility rates and lowering frequency of wars, terrorism, etc.

The relationship between population structure and violent conflict is complex and heavily dependent on the behavior of other variables like governance, economic prospects, and urbanization. While addressing rapid population growth might be a necessary condition for peace, it is by no means sufficient. Concomitant steps must also be taken to foster inclusivity, guarantee broader rights for all, particularly women, rebuild social contracts and ensure that all citizens have equal access to economic opportunity. Measures to control family size could reduce dependency and create greater socio-economic opportunities for women and youth, By so doing, the “youth bulge” phenomenon could be a boon for rapidly growing developing countries.

The article by Potts et al, “The Pill is Mightier than the Sword,” points out that family planning has an important role to play in building peace by increasing women’s empowerment and their agency, ultimately helping peacebuilding efforts. Evidence has demonstrated that family planning programs are cost effective, produce quick results, help women and couples meet their desired fertility levels, and produce a multitude of benefits around economic productivity, community engagement, conservation, resilience, and peacebuilding. In order for policy audiences from a variety of sectors, including conflict and peacebuilding, to appreciate these benefits, it is important to find common ground and articulate co-benefits that will help them appreciate and value the role of family planning, as it were, give them sugar to help the pill go down. This commentary examines how resilience, peacebuilding and family planning efforts need to focus on co-benefits in order to build on the successful interventions and opportunities that Potts et al highlight.

In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing the politics of global health as a question of individual morality. Drawing on the theoretical works of Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception. Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we underline the opportunity for political changes, through political articulation of an issue, and collective mobilization based on such an articulation.

An important determinant of health system performance is contracting. Providers often respond to financial incentives, despite the ethical underpinnings of medicine, and payers can craft contracts to influence performance. Yet contracting is highly imperfect in both single-payer and multi-payer health systems. Arguably, in a competitive, multi-payer environment, contractual innovation may occur more rapidly than in a single-payer system. This innovation in contract design could enhance performance. However, contractual innovation often fails to improve performance as payer incentives are misaligned with public policy objectives. Numerous countries seek to improve healthcare contracts, but thus far no health system has demonstrably crafted the necessary blend of incentives to stimulate optimal contracting.

In their valuable discussion of whistleblowing in healthcare organisations, Mannion and Davies highlight the importance of organisational culture in influencing whether people raise concerns, and whether these concerns are listened to and acted upon. The role of leadership in shaping organisational culture is well-established1 and in this commentary, we will examine the influence of leaders in creating cultures of silence or cultures of voice.

The current limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system strengthening interventions and the complexity of clinical operations across settings. By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. Rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field.

In the healthcare context, whistleblowing has come to the fore of political, professional and public attention in the wake of major service scandals and mounting evidence of the routine threats to safety that patients face in their care. This paper offers a commentary and wider contextualisation of Mannion and Davies, ‘Cultures of silence and cultures of voice: the role of whistleblowing in healthcare organisations.’ It argues that closer attention is needed to the way in which whistle-blowers can become the focus and victim of raising concerns and speaking up.

Despite the mythology that the global economy with its trade rules creates a ‘level playing field,’ international trade has never involved ‘level players.’ The inequalities in outcomes generated by the more powerful winning more frequently has led to innovative ideas for ex post redistribution to make the matches between the players both fairer, and in the analogy to basketball used by the authors, more interesting and even more competitive. The proposal for a Global Social Protection Fund, financed by a small tax on the winners to enhance social protection spending for the losers, presumably increasing the latter’s capabilities to compete more effectively in the global market game, is one such idea. It has much to commend it. Several problems, however, stand in its way, apart from those inherent within nations themselves and to which the authors give some attention. First, much global trade is now intra-firm rather than international, making calculations of which nations win or lose exceedingly difficult. Second, tax havens persist without the transparency and global regulatory oversights that would allow a better rendering of where winnings are stashed. Third, pre-distribution inequalities (those arising from market activities before government tax and transfer measures apply) are still increasing as labour’s power to wrestle global capital into some ameliorative social contract diminishes. Fourth, there are finite limits to a planet on the cusp of multiple environmental crises. These problems do not diminish the necessity of alternative policy playbooks such as the proposed Fund, but point to the need to embrace the new Sustainable Development Goals (SDGs) as a single set, such that economic growth for the bottom half of humanity includes deep structural reforms to both pre-distribution and redistribution, if the targets for environmental survival are to be met.

The editorial is commendable and I agree with many of the points raised. Management is an important aspect of health system strengthening which is often overlooked. In order to build the capacity of management, we need to consider other factors such as, the environment within which managers work, their numbers, support systems and distribution. Effective leadership is an issue which cannot be overemphasized as part of management capacity in resource deprived settings as difficult settings require leadership skills in order to achieve managerial success. A primary issue of importance highlighted in the editorial is country ownership of management effectiveness initiatives, which may be very difficult when the health sector is dependent on support and funding from donors and influential partners, who drive change often without a good understanding of the context. How partners finance health programmes is another dilemma as it can distract from locally determined priorities. Further research should help us to understand better what works and under different settings.

There is increasing interest in – and debate about – the extent to which key concepts from the resource-based view (RBV) of the Firm school of strategic management can be usefully applied to study knowledge mobilization (KM) processes in healthcare and other public services settings.

I am very grateful that esteemed colleagues have taken the time to respond to my article,1 particularly engaging in the style of my original contribution. I will respond in terms of their level of agreement with me: to Rudolf Klein (largely right), Scott Greer (partly right), Ian Greener (right and wrong and right), and David Hunter (largely wrong).