International Journal of Health Policy and Management
Volume:8 Issue: 2, Feb 2019

  While responsible innovation in health (RIH) suggests that health innovations could be purposefully designed to better support health systems, little is known about the system-level challenges that it should address. The goal of this paper is thus to document what is known about health systems’ demand for innovations.

We searched 8 databases to perform a scoping review of the scientific literature on health system challenges published between January 2000 and April 2016. The challenges reported in the articles were classified using the dynamic health system framework. The countries where the studies had been conducted were grouped using the human development index (HDI). Frequency distributions and qualitative content analysis were performed.

Up to 1391 challenges were extracted from 254 articles examining health systems in 99 countries. Across countries, the most frequently reported challenges pertained to: service delivery (25%), human resources (23%), and leadership and governance (21%). Our analyses indicate that innovations tend to increase challenges associated to human resources by affecting the nature and scope of their tasks, skills and responsibilities, to exacerbate service delivery issues when they are meant to be used by highly skilled providers and call for accountable governance of their dissemination, use and reimbursement. In countries with a low and medium HDI, problems arising with infrastructure, logistics and equipment were described in connection with challenges affecting procurement, supply and distribution systems. In countries with a medium and high HDI, challenges included a growing demand for drugs and new technology and the management of rising costs. Across all HDI groups, the need for flexible information technologies (IT) solutions to reach rural areas was underscored.

Highlighting challenges that are common across countries, this study suggests that RIH should aim to reduce the cost of innovation production processes and attend not only to the requirements of the immediate clinical context of use, but also to the vulnerabilities of the broader system wherein innovations are deployed. Policy-makers should translate system-level demand signals into innovation development opportunities since it is imperative to foster innovations that contribute to the success and sustainability of health systems.

Cognitive functioning is critical as in our daily life a host of real-world complex decisions in high-stakes markets have to be made. The decision-making process can be vulnerable to environmental stressors. Summarizing the growing economic and epidemiologic evidence linking air pollution, cognition performance and real-world decision-making, we first illustrate key physiological and psychological pathways between air pollution and cognition. We then document the main patterns of air pollution affecting cognitive test performance by type of cognitive tests, gender, window of exposure, age profile, and educational attainment. We further extend to a review of real-world decision-making that has been found to be affected by air pollution and the resulting cognitive impairments. Finally, rich implications on environmental health policies are drawn based on existing evaluations of social costs of air pollution.

The 2017 prevalence of obesity among children (age 5–17 years) in the United Arab Emirates (UAE) is 13.68%. Childhood obesity is one of the 10 top health priorities in the UAE. This study examines the quality, frequency, sources, scope and framing of childhood obesity in popular social media and three leading UAE newspapers from 2014 to 2017. During the review period, 152 newspaper articles from three leading national newspapers – Gulf News, The National and Al Ittihad – met the eligibility criteria for this study. There were 57 Facebook posts, 50 Twitter posts, 14 posted YouTube videos, and 13 Media releases on related to childhood obesity between 2014 and 2017. Childhood obesity was consistently problematized, primarily in health terms, but was not strongly linked to socio-economic and geographical factors. Childhood obesity was framed as being predominantly influenced by individual and parental behaviours more frequently (n = 76) compared with structural or environmental factors such as the roles of the food and beverage industry (n = 22). Unlike findings from studies with adult obesity, articles advocating individual behavior changes to address childhood obesity were relatively few (n = 29). Social media may be an effective way to help children overcome obesity, in part through online interaction with health care providers and health conscious obese peers. Areas for improvement in social media use to reduce childhood obesity prevalence in UAE include enhancing public engagement with social media posts on childhood obesity, as reflected in the numbers of Likes and Retweets or Shares.

  Decentralisation in the health sector has been promoted in low- and middle-income countries (LMICs) for many years. Inherently, decentralisation grants decision-making space to local level authorities over different functions such as: finance, human resources, service organization, and governance. However, there is paucity of studies which have assessed the actual use of decision-making space by local government officials within the decentralised health system. The objective of this study was to analyse the exercise of decision space across four districts in Tanzania and explore why variations exist amongst them.

The study was guided by the decision space framework and relied on interviews and documentary reviews. Interviews were conducted with the national, regional and district level officials; and data were analysed using thematic approach.

Decentralisation has provided moderate decision space on the Community Health Fund (CHF), accounting for supplies of medicine, motivation of health workers, additional management techniques and rewarding the formally established health committees as a more effective means of community participation and management. While some districts innovated within a moderate range of choice, others were unaware of the range of choices they could utilise. Leadership skills of key district health managers and local government officials as well as horizontal relationships at the district and local levels were the key factors that accounted for the variations in the use of the decision space across districts.

This study concludes that more horizontal sharing of innovations among districts may contribute to more effective service delivery in the districts that did not have active leadership. Additionally, the innovations applied by the best performing districts should be incorporated in the national guidelines. Furthermore, targeted capacity building activities for the district health managers may improve decision-making abilities and in turn improve health system performance.

  This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements.

A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, four facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach.

Results based financing arrangements introduce a wide range of new institutional arrangements, roles, tasks, and ways of doing things, for facility staff, facility managers and, district and provincial health management teams. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised.

Our study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. Carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.

ct Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based approach and identification as part of standard practice, frailty is only just emerging as a concept for PC. The web-based Frailty Portal was developed to aid in the identification of, assessment and care planning for frail patients in PC practice. In this study we assess the implementation feasibility and impact of the Frailty Portal by: (1) identifying factors influencing the Frailty Portal’s use in community PC practice, and (2) examination of the immediate impact of the ‘Frailty Portal’ on frail patients, their caregivers and PC providers.

A convergent mixed method approach was implemented among PC providers in community-based practice in the NSHA, Central Zone. Quantitative and qualitative data were collected concurrently over a 9-month period. A sample of patients who underwent assessment and/or their caregiver were approached for survey participation.

Fourteen community PC providers (10 family physicians, 4 nurse practitioners) completed 48 patient assessments and completed or begun 41 care plans; semi-structured interviews were conducted among 9 providers. Nine patients and 5 caregivers participated in the survey. PC providers viewed frailty as an important concept but implementation challenges were met, primarily with respect to the time required for use and lack of fit with traditional practice routines. Additional barriers included tool usability and accessibility, training and care planning steps, and privacy. Impacts of the tools use with respect to confidence and knowledge showed early promise.

This feasibility study highlights the need for added health system supports, resources and financial incentives for successful implementation of the Frailty Portal in community PC practice. We suggest future implementation integrate the Frailty Portal to practice electronic medical records (EMRs) and target providers with largely geriatric practice populations and those practicing within interdisciplinary, collaborative primary healthcare (PHC) teams.

Patient engagement practices are increasingly incorporated in health research, governance, and care. More recently, a large number of evaluation tools and metrics have been developed to support engagement evaluation. This growing interest in evaluation reflects a maturation of the patient engagement field, moving from a “craft” to a reflective “art and science,” with more explicit expected benefits and risks, better understood conditions for success and failure, and increasingly rigorous evaluation instruments to improve engagement theories and interventions. It also supports a more critical view of engagement science, moving beyond reductionist views of engagement as a “black box technology” to a more subtle view of this broad category of complex interventions. Structured evaluation can advance patient engagement by supporting more reflective partnerships between patients, clinicians, health system leaders and citizens. This can help clarify mutual (and potentially contradictory) expectations toward engagement, provide a reality check toward claims of benefits and harms, and increase health systems’ capacity to implement effective engagement practices over time. To do so, closer collaborations are required between engagement scientists and practitioners to align the theories, practice and evaluation of patient and community engagement.

This commentary is a further discussion of a paper published in this journal on the health professional training initiative led by the Government of Rwanda since 2012 and presented as a case study. According to the authors, the partnership program with international academic institutions may serve as model for other countries to address the shortage of health professionals and to strengthen institutional capacity, based on the competency-based and innovative training programs, the numbers of graduates, the improved quality of health services and institution strengthening. However, the conditions may not be as optimal elsewhere. A supportive government policy, massive funding and an academic consortium comprised of 19 United States academic institutions have contributed to the success of the program. We also noted that the trained professionals were clinicians almost exclusively, at the expense of public health specialists and other health professionals who can better address emerging issues such as non-communicable diseases (NCDs) particularly for their prevention, which is now compelling. Among others, the training of more nutritionists as members of the health team is needed.

The Disease Control Priorities program (DCP) has pioneered the use of economic evidence in health. The theory of change (ToC) put forward by Norheim is a further welcome and necessary step towards translating DCP evidence into better priority setting in low- and middle-income countries (LMICs). We also agree that institutionalising evidence for informed priority-setting processes is crucial. Unfortunately, there have been missed opportunities for the DCP program to challenge ill-judged global norms about opportunity costs and too little respect has been shown for the wider set of local circumstances that may enable, or disable, the productive application of the DCP evidence base. We suggest that the best way forward for the global health community is a new platform that integrates the many existing development initiatives and that is driven by countries’ asks.