International Journal of Health Policy and Management
Volume:11 Issue: 10, Oct 2022

This article addresses transparency in the current era of digital co-creation between healthcare professionals and patients. The concept of reasoned transparency is presented as a potential tool to guide the development of digital co-creation that is rapidly growing. The aim was to reflect on how doctors can apply transparency in their daily practice, following the shift from paternalistic to more collaborative relationships. On the one hand, our contribution indicates ways to take advantage of the existing digital tools to improve efficiency and increase patient trust, including the latest trend of artificial intelligence. On the other hand, this article identifies pitfalls of digitization and proposes reasoned transparency as remedy for the challenges rose by artificial intelligence. As a result, this perspective article tackles the issue of maintaining trustful and high-quality relationships between doctors and patients, increasingly challenged by the dissemination of online information and the pressures on healthcare professionals’ accountability towards patients and the general public.

Across most healthcare systems, patients are the primary focus. Patient involvements enhance their adherence to treatment, which in return, influences their health. The objective of this study was to determine the characteristics (ie, attributes) and associated levels (ie, values of the characteristics) that are the most important for patients regarding telerehabilitation (TR) healthcare to support a future discrete choice experiment (DCE) study design.

A mixed-methods systematic review was conducted from January 2005 to the end of July 2020 and the search strategy was applied to five different databases. The initial selection of articles that met the eligibility criteria was independently made by one researcher, two researchers verified the accuracy of the extracted data, and all researchers discussed about relevant variables to include. Reporting of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the study. A qualitative synthesis was used to summarize findings.

From a total of 928 articles, 11 (qualitative [n = 5], quantitative [n = 3] and mixed-methods [n = 3] design) were included, and 25 attributes were identified and grouped into 13 categories: Accessibility, Distance, Interaction, Technology experience, Treatment mode, Treatment location, Physician contact mode, Physician contact frequency, Cost, Confidence, Ease of use, Feeling safer, and Training session. The attributes levels varied from two to five. The DCE studies identified showed the main stages to undertake these types of studies.

This study could guide the development of interview grid for individual interviews and focus groups to support a DCE study design in the TR field. By understanding the characteristics that enhance patients’ preferences, healthcare providers can create or improve TR programs that provide high-quality and accessible care. Future research via a DCE is needed to determine the relative importance of the attributes.

The aim of this research was to synthetise the existing evidence on the impact of epidemic-related lockdown measures on women and children’s health in low- and lower-middle-income countries (LLMICs).

A mixed-methods systematic review was conducted of qualitative, quantitative and mixed-methods evidence. Between 1st and 10th of November 2021, seven scientific databases were searched. The inclusion criteria were that the paper provided evidence on the impact of lockdown and related measures, focused on LLMICs, addressed impacts on women and child’s health, addressed epidemics from 2000-2020, was peer-reviewed, provided original evidence, and was published in English. The Joanne Briggs Institute’s critical appraisal tools were used to assess the quality of the studies, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. The evidence from the papers was grouped by type of lockdown measure and categories of impact, using a narrative databased convergent synthesis design.

The review process identified 46 papers meeting the inclusion criteria from 17 countries that focussed on the coronavirus disease 2019 (COVID-19) and Ebola epidemics. The evidence on the decrease of utilisation of health services showed plummeting immunisation rates and faltering use of maternal and perinatal services, which was linked to a growth of premature deaths. Impacts on the mental health of children and women were convincingly established, with lockdowns associated with surges in depression, anxiety and low life satisfaction. Vulnerability may be compounded by lockdowns, as livelihoods were disrupted, and poverty levels increased.

Limitations included that searches were conducted in late-2020 as new research was being published, and that some evidence not published in English may have been excluded. Epidemic-related lockdown measures carry consequences for the health of women and children in lower-income settings. Governments will need to weigh the tradeoffs of introducing such measures and consider policies to mitigate their impacts on the most vulnerable.

Medical workforce shortages in rural and remote areas are a global issue. Highincome countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs.

The Arksey and O’Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. PRISMA-P guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates.

Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in high-income countries, with only eight studies from low and middle-income countries. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce.

This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.

To assess the impact of trials with potential financial conflict of interests (FCOIs) on evidence synthesis in meta-analyses (MAs).

A total of 96 MAs from the Cochrane Library about drug trials were investigated. The primary outcomes examined the proportion of conclusions that would change with the exclusion of trials with potential FCOIs. If the proportion of changed conclusions was below the non-inferiority margin of 10%, we considered that it was not inferior to include the trials with potential FCOIs in the MAs.

Only 54.17% of MAs reported the funding sources of each included trial, and in 21.88% of MAs, the authorindustry- related financial ties of each included trial were reported. When trials with FCOIs were excluded, the changed conclusions of effectiveness and major adverse events were 13.16% and 11.11%, respectively, and the I2 decreased by 13.56% and 10.09%, respectively. For serious adverse events, the exclusion of FCOIs trials did not lead to any change in conclusions; however, the I2 decreased by 24.24%. The impact of trials without reported FCOIs was also examined on evidence synthesis, and the results showed that the changed conclusions of effectiveness and major adverse events were 5.26% and 6.25%, respectively, indicating non-inferiority. However, the I2 increased by 13.60% and 12.37%, respectively.

In this meta-epidemiological study, we demonstrated that trials with FCOIs may not only influence the final outcome of MAs but may also increase the heterogeneity of results. It is suggested that all MAs fully report the FCOIs involved in evidence-based research and explore the impact of its FCOIs to better provide a more valuable reference for patients, clinicians, and policy-makers.

Given the increasing role of patient groups in pharmaceutical policy-making in Canada, this observational study was undertaken to determine whether companies that are members of Innovative Medicines Canada (IMC) list, on their publicly available websites, the names of patient groups that they make donations to and reciprocally, whether patient groups publicly list the names of the companies that they receive donations from. Websites of IMC members were searched for the names of the patient groups receiving donations, value of the donations and year the donations were made. The website of each patient group that was listed as receiving a donation was then searched for information about the name of companies making donations along with the value of the donations, year the donations were made and percent of the patient groups’ income represented by the donation. For donations over $50 000, an attempt was made to match donations that companies made to donations that patient groups received. Eleven of 44 IMC members reported making 165 donations to 114 different patient groups. Seventy-nine of these 114 groups reported receiving 373 donations from IMC members. Information about the value of donations, the year that they were given and received and the percent of patient groups’ income that they represented was limited. Donations made and received could not be matched because of the absence of information about the donations. Reporting on websites about donations by both companies and patient groups in Canada is haphazard, inconsistent and incomplete. Reforms are need to both the way that companies and patient groups report donations.

Health security funding is intended to improve capacities for preventing, detecting, and responding to public health emergencies. Recent years have witnessed substantial increases in the amounts of donor financial assistance to health security from countries, philanthropies, and other development partners. To date, no work has examined the effects of assistance on health security capacity development over time. This paper presents an analysis of the timelagged effects of assistance for health security (AHS) on levels of capacity.

We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial AHS. Using validated methods, we rescaled assessment scores on analogous scales to enable comparison and binned them in quartiles. We then used a distributed lag model (DLM) in a Bayesian ordinal regression framework to assess the effects of AHS on capacity development over time.

Strong evidence exists for associations between financial assistance and select capacities on a variety of lagged time intervals. Financial assistance had positive effects on zoonotic disease capacities in the year it was disbursed, and positive effects on legislation, laboratory, workforce, and risk communication capacities one year after disbursal. Financial assistance had negative effects on laboratory and emergency response capacities two years after it was disbursed. Financial assistance did not have measurable effects on coordination, antimicrobial resistance (AMR), food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered.

Financial AHS is associated with positive effects for several core health security capacities. However, for the majority of capacities, levels of funding were not significantly associated with capacity level, though we cannot fully exclude endogeneity. Future work should continue to investigate these relationships in different contexts and examine other factors that may contribute to capacity development.

Universal health coverage (UHC) is part of the global health agenda to tackle the lack of access to essential health services (EHS). This study developed and tested models to examine the individual, neighbourhood and countrylevel determinants associated with access to coverage of EHS under the UHC agenda in low- and middle-income countries (LMICs).

 Methods 

We used datasets from the Demographic and Health Surveys (DHSs) of 58 LMICs. Suboptimal and optimal access to EHS were computed using nine indicators. Descriptive and multilevel multinomial regression analyses were performed using R and STATA.

The prevalence of suboptimal and optimal access to EHS varies across the countries, the former ranging from 5.55% to 100%, and the latter ranging from 0% to 90.36% both in Honduras and Colombia, respectively. In the fully adjusted model, children of mothers with lower educational attainment (relative risk ratio [RRR] 2.11, 95% credible interval [CrI] 1.92 to 2.32) and those from poor households (RRR 1.79, 95% CrI 1.61 to 2.00) were more likely to have suboptimal access to EHS. Also, those with health insurance (RRR 0.72, 95% CrI 0.59 to 0.85) and access to media (RRR 0.59, 95% CrI 0.51 to 0.67) were at lesser risk of having suboptimal EHS. Similar trends, although in the opposite direction, were observed in the analysis involving optimal access. The intra-neighbourhood and intra-country correlation coefficients were estimated using the intercept component variance; 57.50%% and 27.70% of variances in suboptimal access to EHS are attributable to the neighbourhood and country-level factors.

Neighbourhood-level poverty, illiteracy, and rurality modify access to EHS coverage in LMICs. Interventions aimed at achieving the 2030 UHC goals should consider integrating socioeconomic and living conditions of people.

The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.

Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.

Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decisionmaking and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.

To assess whether the imposition of the coronavirus disease 2019 (COVID-19) national quarantine (March 10, 2020) resulted in a shift in the proportion of patients operated for hip fracture on the day of admission, the following day and two days after admission in the region of Piedmont, northern Italy.

Interrupted time-series analysis (ITSA) comparing hospitalization rate and timing of hip-fracture surgeries between pre- and post-quarantine period. The same data observed in Piedmont the year before were included as a control time series with no “intervention” (quarantine) in the middle of the observation period.

We found that 70.3% and 69.4% of hip-fracture patients received surgery within 2 days of hospital admission in the 16 weeks before and after the national quarantine, respectively. One-day surgery went from 46.0% to 46.5%, and same- day surgery from 13.3% to 12.4%. Unchanged trends were confirmed by ITSA after controlling for the 32-week time- series observed the year before. In the second week of March 2020, there was a borderline significant decrease in weekly hospital admissions for hip fractures as compared with that of the same week of March 2019 (–1.95 per 100 000, 95% CI = –4.10 to 0.21, P value = .075), followed by a weekly significant increase in the hospitalization rate (+0.14 per 100 000, 95% CI = 0.01 to 0.27, P value = .039), although the difference-in-differences of slopes failed to achieve statistical significance (0.19 per 100 000, 95% CI = –0.03 to 0.41, P value = .090).

 Conclusion: 

Our study shows that the timing of hip-fracture surgery was unchanged during the lockdown period. This suggests that  the healthcare systems can be resilient and able to guarantee a high-quality and safe healthcare to hipfracture patients, even in the most challenging working conditions.

South Korea has the highest out-of-pocket burden for medical expenses among the Organisation for Economic Co- operation and Development (OECD) member countries and has no formal sickness benefit system, along with United States and Switzerland, greatly increasing the risk of poverty due to a sudden illness.

We identify the causal effect of health shocks on poverty status and explore the mechanisms of medical impoverishment by analyzing longitudinal data from 13 670 households that participated in the representative Korean Welfare Panel Study (KOWEPS) from 2007 to 2016. In this study, we define a health shock as a case in which no household members were hospitalized in the previous year, but together they had more than 30 days of hospitalization in this year. The propensity score matching method was combined with a mediation analysis in this work.

The proportion of households in absolute poverty increased by 4.6–8.0 percentage points among households that experienced a health shock compared with matched controls. The selection effects due to health shock were estimated to be 5.6–8.2 percentage points. On average, a sudden hospitalization reduces annual non-medical expenditures and equivalized disposable income by just over 3.2 million KRW (2500 USD) and 1.2 million KRW (1000 USD), respectively. Health shock induces impoverishment after one year through both the medical expense and work capacity pathways, which explain 12.8% and 12.8% of the total effect, respectively. However, when we decompose the mediation effect of a health shock on poverty status after two years, we find that a health shock leads to poverty mainly through labor force nonparticipation (9.9%).

Income stabilizing scheme to protect households that experience a health shock should be introduced as a policy alternative to confront the issue of medical impoverishment.

Networks are promoted as an organizational form that enables integrated care as well as enhanced patient outcomes. However, implementing networks is complex. It is therefore important to evaluate the quality and effectiveness of networks to ensure it is worth developing and maintaining them. This article describes the development of an evaluation tool for cancer care networks and the results of a pilot study with a regional lung cancer care network.

This study used a combination of qualitative and quantitative evaluation methods. The qualitative evaluation was based on a framework with 10 standards for the organization of an oncological (tumor-specific) care network. Data for the quantitative evaluation were obtained from the Dutch Cancer Registry. The evaluation was performed at a network of three hospitals collaborating in the field of lung oncology.

The qualitative evaluation framework consisted of 10 standards/questions which were divided into 38 subquestions. The evaluation showed that in general patients are satisfied with the collaboration in the network. However, some improvement points were found such as the need for more attention for the implementation and periodic evaluation of a regional care pathway. The start of a regional multidisciplinary meeting has been a major step for improving the collaboration.

An evaluation tool for (lung) cancer care networks was successfully developed and piloted within a cancer care network. The tool has proven to be a useful method for evaluating collaboration within an oncological network. It helped network partners to understand what they see as important and allowed them to learn about their program’s dynamics. Improvement opportunities were successfully identified. To keep the tool up to date continuous improvement is needed, following the Plan Do Check Act (PDCA) cycle.

Background :

Chronic hepatitis B (CHB) is highly prevalent among adults in rural China and better management of those populations is of vital importance for viral hepatitis elimination. Adult immunization has been the subject of much controversy in previous studies. This study estimates the cost-effectiveness of population-based hepatitis B screening, treatment, and immunization strategy (comprehensive strategy) in rural areas with high prevalence under the national policy of sharp- drop drug prices.

Methods :

We constructed a Markov model comparing 4 strategies in a 30-year horizon from the healthcare payer perspective: (1) the conventional pattern; (2) screening and treating infected (treatment); (3) screening and immunizing susceptible individuals (immunization); and (4) the comprehensive strategy. Screening intensity ranged from 50% to 100%. Outcomes were measured by costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and clinical outcomes.

The costs for the conventional pattern, treatment strategy, immunization strategy, and comprehensive strategy were US$ 341, 351, 318, and 323, respectively. In addition, effects were 17.45, 17.57, 17.46, and 17.58 QALYs, respectively. The ICER of the comprehensive strategy was US$ 35/QALY gained at 50% screening intensity and 420 US$/QALY gained at 100%. The net monetary benefit increased with increasing screening intensity and declined after 90%, with the highest value of US$40 693. All new infections and 52.5% mortality could be avoided from 2020 to 2049 if all patients were properly treated and all susceptible individuals were immunized. The results were stable within a wide range of parameters.

It was cost-effective to implement the mass hepatitis B screening, treatment, and immunization strategy in areas of rural China with high prevalence, and the strategy gained the most net monetary benefit at a screening intensity of 90%. Although it was impractical to fulfill 100% coverage, efforts should be made to obtain more people screened.

Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to ‘3Cs’ (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. 

We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the ‘three delay model’ combined with a broader literature on ‘policy mixing.’

Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues.

The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the ‘three delays’ but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.

Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams). 

The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning.

SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.

Volunteers are common within palliative care services, and provide support that enhances care quality. The support they provided, and any role changes, during the coronavirus disease 2019 (COVID-19) pandemic are unknown. The aim of this study is to understand volunteer deployment and activities within palliative care services, and to identify what may affect any changes in volunteer service provision, during the COVID-19 pandemic.

Multi-national online survey disseminated via key stakeholders to specialist palliative care services, completed by lead clinicians. Data collected on volunteer roles, deployment, and changes in volunteer engagement. Analysis included descriptive statistics, a multivariable logistic regression, and analysis of free-text comments using a content analysis approach.

458 respondents: 277 UK, 85 rest of Europe, and 95 rest of the world. 68.5% indicated volunteer use preCOVID-19 across a number of roles (from 458): direct patient facing support (58.7%), indirect support (52.0%), back office (48.5%) and fundraising (45.6%). 11% had volunteers with COVID-19. Of those responding to a question on change in volunteer deployment (328 of 458) most (256/328, 78%) indicated less or much less use of volunteers. Less use of volunteers was associated with being an in-patient hospice, (odds ratio [OR] = 0.15, 95% CI = 0.07-0.3, P < .001). This reduction in volunteers was felt to protect potentially vulnerable volunteers, with policy changes preventing volunteer support. However, adapting was also seen where new roles were created, or existing roles pivoted to provide virtual support.

Volunteers were mostly prevented from supporting many forms of palliative care which may have quality and safety implications given their previously central roles. Volunteer re-deployment plans are needed that take a more considered approach, using volunteers more flexibly to enhance care while ensuring safe working practices. Consideration needs to be given to widening the volunteer base away from those who may be considered to be most vulnerable to COVID-19.

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.

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.

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.

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

The coronavirus disease 2019 (COVID-19) pandemic resulted in radical changes in many aspects of life. To deal with this, each country has implemented continuous health measures from the beginning of the outbreak. Discovering how governmental actions impacted public behaviour during the outbreak stage is the purpose of this study.

This study uses a hybrid large-scale data visualisation method to analyse public behaviour (epidemic concerns, self- protection, and mobility trends), using the data provided by multiple authorities. Meanwhile, a content analysis method is used to qualitatively code the health measures of three countries with severe early epidemic outbreaks from different continents, namely China, Italy, and the United States. Eight dimensions are coded to rate the mobility restrictions implemented in the above countries.

(1) Governmental measures did not immediately persuade the public to change their behaviours during the COVID-19 epidemic. Instead, the public behaviour proceeded in a three-phase rule, which is typically witnessed in an epidemic outbreak, namely the wait-and-see phase, the surge phase and the slow-release phase. (2) The strictness of the mobility restrictions of the three countries can be ranked as follows: Hubei Province in China (with an average score of 8.5 out of 10), Lombardy in Italy (7.125), and New York State in the United States (5.375). Strict mobility restrictions are more likely to cause a surge of population outflow from the epidemic area in the short term, whereas the effect of mobility restrictions is positively related to the stringency of policies in the long term.

The public showed generally lawful behaviour during regional epidemic outbreaks and blockades. Meanwhile public behaviour was deeply affected by the actions of local governments, rather than the global pandemic situation. The contextual differences between the various countries are important factors that influence the effects of the different governments’ health measures.

Without consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes.

We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis.

We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor. 

Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.

Through the extensive use of public media, the government of England was heavily involved in encouraging and instructing people on how to manage their life during coronavirus disease 2019 (COVID-19). This model of health emergency governance replicates the practice of ‘calculative technologies’ and ‘bio-politics’ embedded in population management. Previous research on COVID-19 governance both in the United Kingdom and beyond provides varied revelations on broader ‘technologies of government’ and bio-politics by numerous governments. However, rarely have any studies explicitly and distinctively highlighted the unique ‘calculative technologies’ mobilised by governments within their bio-politically designed “technologies of government” to compel the populations to manage their lives under their COVID-19 guidance. The paper therefor examines how the UK government deployed “calculative technologies,” as part of its strategies of health governance and governmentality during the first wave of COVID-19 in England.

This study uses document analysis as its data collection method. Its review includes documents, press releases, social media disclosures and health guidance issued by the UK government from March to December, 2020. The data are analysed employing the Foucault’s governmentality and bio-political scholarship.

The paper’s findings reveal the UK government’s use of integrated calculative technologies of self-governance in the form of risk calculations and metrices/statistics (eg, death tolls, infection rates), performance management (eg, two metre social distancing, and hand washing for twenty seconds) and discipline and control (eg, fourteen days selfisolation), in addition to a more conventional top-down, managerial decision-making process adopted in the past. By these newly initiated “calculative technologies,” the government has “bio-politically” governed the behaviours and lifestyles of vulnerable community members, health workers and general public at a distance, inculcating selfmanagement and individualisation of responsibility.

The newly adopted calculative technologies used by the UK government created a multi-faceted discourse of obligations, entitlements and scale of engagement, and facilitated directions about what people should do to protect themselves and others from the spread of the virus. Overall, the overtly and idiosyncratically used calculative technologies resemble a unique ‘art of government’ and produce a set of ‘bio-political’ interventions enforcing the populations to manage their own wellbeing and governing them at a distance during COVID-19.

Policy-makers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea.

We constructed the longitudinal dataset from 2008-2017 for 12 904 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies’ implementation.

Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The topspending clinics showed the highest rate of increase in drug costs.

Conclusion: 

Future policy interventions can maximize their effects by targeting high-spending providers.

Low socio-economic settings are characterized by high prevalence of diabetes and difficulty in accessing healthcare. In these contexts, proximity health services could improve healthcare access for diabetes prevention. Our primary objective was to evaluate the usefulness of home screening for promoting awareness of impaired glycemic status and utilization of primary care among adults aged 18-79 in a low socio-economic setting.

Methods :

This follow-up study was conducted in 2015-2016 in Reunion Island, a French overseas department in the Indian Ocean. Enrollment and screening occurred on the same day at the home of participants (N = 907). Impaired glycemic status was defined as [glycated hemoglobin (HbA1c) ≥5.7%] OR [fasting capillary blood glucose (FCBG) ≥1.10 g/L] OR [HbA1c = 5.5-5.6% and FCBG = 1.00-1.09 g/L]. Medical, socio-cultural, and socio-economic characteristics were collected via a face- to-face questionnaire. A one-month telephone follow-up survey was conducted to determine whether participants had consulted a general practitioner (GP) for confirmation of screening results. A multinomial polytomous logistic regression model was used to identify factors independently associated with non-use of GP consultation for confirmation of screening results and nonresponse to the telephone follow-up survey.

Results :

Prevalence of glycemic abnormalities was 46.0% (95% CI = 42.7-49.2%). Among participants with impaired glycemic status (N = 417), 77.7% (95% CI = 73.7-81.7%) consulted a GP for confirmation of screening results, 12.5% (95% CI = 9.3-15.6%) did not, and 9.8% failed to respond to the follow-up survey. Factors independently associated with nonuse of GP consultation for confirmation of screening results were self-reported unwillingness to consult a GP (adjusted odds ratio [OR]: 4.86, 95% CI = 1.70-13.84), usual GP consultation frequency of less than once a year (adjusted OR: 4.13, 95% CI = 1.56-10.97), and age 18-39 years (adjusted OR: 3.09, 95% CI = 1.46-6.57).

Home screening for glycemic abnormalities is a useful proximity health service for diabetes prevention in low socio- economic settings. Further efforts, including health literacy interventions, are needed to increase utilization of primary care.

The World Health Organization (WHO) has engaged in consultations with the alcohol industry in global alcohol policy development, including currently a draft action plan to strengthen implementation of the Global strategy to reduce the harmful use of alcohol. WHO’s Framework for Engagement with Non-State Actors (FENSA) is an organization-wide policy that aims to manage potential conflicts of interest in WHO’s interactions with private sector entities, non-governmental institutions, philanthropic foundations and academic institutions.

We analysed the alignment of WHO’s consultative processes with non-state actors on “the way forward” for alcohol policy and a global alcohol action plan with FENSA. We referred to publicly accessible WHO documents, including the Alcohol, Drugs and Addictive Behaviours Unit website, records of relevant meetings, and other documents relevant to FENSA. We documented submissions to two web-based consultations held in 2019 and 2020 by type of organization and links to the alcohol industry.

WHO’s processes to conduct due diligence, risk assessment and risk management as required by FENSA appeared to be inadequate. Limited information was published on non-state actors, primarily the alcohol industry, that participated in the consultations, including their potential conflicts of interest. No minutes were published for WHO’s virtual meeting with the alcohol industry, suggesting a lack of transparency. Organizations with known links to the tobacco industry participated in both web-based consultations, despite FENSA’s principle of non-engagement with tobacco industry actors.

Conclusion:

WHO’s consultative processes have not been adequate to address conflicts of interest in relation to the alcohol industry, violating the principles of FENSA. Member states must ensure that WHO has the resources to implement and is held accountable for appropriate and consistent safeguards against industry interference in the development of global alcohol policy.

The Government of Botswana introduced user-fees for primary healthcare consultations in 1975. The policy has remained in place since then, although the fee has remained largely unaltered despite rising inflation. Early reviews of the policy pointed to problems in its implementation, but there has been no evaluation in the past 20 years. The aim of this study was to review the policy to assess whether documented issues with its implementation have been addressed. 

Methods: 

This qualitative study involved interviews with 32 key informants: 18 policy-makers and 14 front-line revenue collectors. Data were analysed thematically using a template approach with constructs from an established organizational capacity assessment framework used as predetermined categories to guide data collection and analysis.

Limited administrative and management capacity has been a major hindrance to effective implementation of the policy. The lack of infrastructure for effective revenue collection led to misappropriation of funds. Lack of clear guidelines for health facilities on how to implement the policy generated interdepartmental conflicts. Study participants believed the current policy was unlikely to be cost-effective since the cost of collecting fees probably exceeded the revenue it generated.

If the Botswana Government persists with the policy then it needs to improve organizational capacity to collect and manage revenues efficiently. However, policy thinking since the turn of the century has turned away from user-charges in healthcare as they impede the move towards universal access. It is timely therefore to consider alternative financing approaches that are more effective and a more equitable means of paying for healthcare.

SASHA, which stands for “evidence-informed health policy-making (EIHP)” in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidencebased and context-aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran.

This was a qualitative study, which was informed by a literature review of pull efforts’ capacity building programs. Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method.

We extracted data from 11 articles. The objectives of capacity building programs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. Capacity building programs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain under-researched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policy-makers incorporates strategies at three levels: capacity building program, organizational structure, and health system context.

Conclusion :

To prepare the context of Iranian healthcare organizations for capacity building programs, the conflict of interests needs to be resolved, decision-makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.

In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations.

The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country.

The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support.

Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.

There is a growing expectation that many health organisations will implement innovations. One obstacle for innovative ideas to have an impact on the healthcare system in practice seems to be difficulties in the implementation phase. There is a lack of concretization of theoretical perspectives related to implementation of innovations. The research question answered by this article is: Which enabling factors can facilitate the specific step of moving from idea generation to implementation in a healthcare context?

The research was carried out with a qualitative action research methodology where the researchers took part in the innovation implementation project. The authors of this article were part of a collaborative innovation implementation project involving approximately 54 practitioners. The project was run by five stakeholders: (1) the Division of Assistive Technology in the Dalarna County Council Regional Healthcare Administration, (2) the Habilitation Division, (3) the Division for Home Care and Social Services in the municipality of Leksand, (4) Dalarna University, and (5) Uppsala University. Through a ‘Pearl growing’ technique six implementation management perspectives were, as a framework, identified and presented for the practitioners. The practitioners worked further to concretize these six perspectives. Data was collected through five workshops and collaborations between the researchers and the practitioners. Data was clustered regarding what the managers want to achieve within these six perspectives (ideal situation) and the main means for reaching this situation.

The study underlying this article generated 35 concrete enabling factors for successful innovation implementation, distributed over the initially presented six theoretical perspectives.

Concretizing management principles into enabling factors shows, on the one hand, that the theoretical principles have practical value, but on the other that they must be adopted to the specific circumstances of each organization, and that too abstract principles can hardly be operationalized.

This paper had two aims. Firstly, to provide a broader view of the profile of non-professional caregivers in Europe, and secondly, to estimate the economic value of the non-professional caregiving.

The European Quality of Life Survey 2016/2017, carried out by Eurofound, was used. The target population of the survey was adults who care for a relative or friend in a total of 33 European countries. The opportunity cost method was used to estimate the economic value of caregiving, in which two of the activities forgone were analysed: paid activities (restricted to caregivers who were employed), for which the average gross wage of each country was used; and unpaid activities, for which the minimum gross wage of each country was used.

There were more than 76 million non-professional caregivers in Europe that provide care for a relative or friend. This figure represents 12.7% of the population in Europe. The estimated time devoted to non-professional care in Europe reached 72 301.5 million hours in 2016. Sharp differences were found among countries. The economic value of that time is estimated at 576 000 million of euros, which represented about 3.63% of Europe’s gross domestic product (GDP).

Conclusion 
This study shows the very important number of resources dedicated to the non-professional care of dependent people and their economic valuation. These results may be helpful in prospective analyses estimating future needs on professional and non-professional and for designing of long-term care (LTC) policies in Europe.

Social media can be used to engage consumers in hospital service design and quality improvement (QI) activities, however its uptake may be limited by a lack of guidance to support implementation. This article presents the perceived barriers and enablers in using social media for consumer engagement derived from an interview study with public hospital stakeholders.

Semi-structured interviews with 26 Australian hospital service providers and consumer representatives. Data were analysed using a deductive content analysis method.

Results 
Data were collected between October 2019 and April 2020. Facebook was the platform most commonly used for consumer engagement activities. Barriers and enablers to social media-based consumer engagement were identified. The barrier themes were (1) fears and concerns; (2) lack of skills and resources for social media engagement; (3) lack of organisational processes and support; and (4) problems with social media platforms and the changing social media landscape. The enabler themes were: (1) hospitals facilitating access and use; (2) making discussions safe; (3) cultivating a social media community; and (4) building on success.

Using social media to facilitate consumer engagement in hospital service design and QI activities is feasible and acceptable to service providers and consumers. Hospitals and their executives can create a supportive environment for social media-based engagement activities through developing clear governance systems and providing training and support to all users. Consumers need to be involved in co-designing social media-based activities and determining which forms of engagement are accessible and acceptable. For some consumers and service providers, barriers such as a lack of resources and distrust of social media companies might mean that social media-based engagement will be less acceptable for them. Because of this it is important that hospitals provide complementary methods of engagement (eg, face-to-face) alongside social media-based methods.

Health insurance coverage is expected to protect individuals from out-of-pocket (OOP) expenditures, potentially preventing them from falling into poverty. However, to date, the effect of health insurance on OOP spending during the coronavirus disease 2019 (COVID-19) pandemic has not been fully explored. This study aimed to estimate differences in the proportion and the amount of OOP expenditures among Peruvians during the pre- and post- mandatory lockdown response to COVID-19 in 2020 according to the health insurance coverage status.

Methods 
This study utilized repeated cross-sectional data from the National Household Survey on Living and Poverty Conditions (ENAHO) from the first quarter of 2017 until the fourth quarter of 2020. The outcomes were (i) the proportion of individuals who incurred OOP expenditures and (ii) the monetary value of OOP expenditures. An interrupted time series analysis (ITS) and a quasi-experimental difference-in-difference (DID) analysis were performed to examine the outcomes among the control (individuals without health insurance) and treatment groups (individuals with health insurance) after the COVID-19 pandemic.

ITS analysis showed that the proportion of individuals reporting OOP expenditures after implementation of mandatory lockdown due to COVID-19 in Peru decreased in both groups, but no difference in the slope trend was found (P = .916). The average quarterly amount of OOP spending increased in both groups, but no difference in the slope trend was found (P = .073). Lastly, the DID analysis showed that the mandatory lockdown was associated with a higher amount of OOP, but there was no evidence to indicate that the higher amount was different between the control and treatment groups.

Conclusion 

The mandatory lockdown in response to the COVID-19 was associated with a higher amount of OOP expenditures and a lower likelihood of incurring OOP expenditures. However, our findings suggest that health insurance coverage does not lower OOP expenditures or reduce the likelihood of incurring OOP expenditures.

Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health- related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.

We synthesised findings across case studies of policy implementation in four policy areas of primary healthcare (PHC), telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access – availability, affordability and acceptability – and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures.

Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.

While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.

Countries around the world are increasingly rethinking the design of their health benefit packages to achieve universal health coverage (UHC). Health technology assessment (HTA) bodies support governments in these decisions, but employ value frameworks that do not sufficiently account for the intrinsically complex and value-laden political reality of benefit package design.

Several years ago, evidence-informed deliberative processes (EDPs) were developed to address this issue. An EDP is a practical and stepwise approach for HTA bodies to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, and to interpret available evidence on these values. We further developed the conceptual framework and initial 2019 guidance based on academic knowledge exchange, analysing practices of HTA bodies, surveying HTA bodies and experts around the globe, and implementation of EDPs in several countries around the world.

EDPs stem from the general concept of legitimacy, which is translated into four elements – stakeholder involvement ideally operationalised through stakeholder participation with deliberation; evidence-informed evaluation; transparency; and appeal. The 2021 practical guidance distinguishes six practical steps of a HTA process and provides recommendations on how these elements can be implemented in each of these steps.

There is an increased attention for legitimacy, deliberative processes for HTA and health benefit package design, but the development of theories and methods for such processes remain behind. The added value of EDPs lies in the operationalisation of the general concept of legitimacy into practical guidance for HTA bodies.

Countries around the world are using health technology assessment (HTA) for health benefit package design. Evidence-informed deliberative processes (EDPs) are a practical and stepwise approach to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. This paper reports on the development of practical guidance on EDPs, while the conceptual framework of EDPs is described in a companion paper.

The first guide on EDPs (2019) is further developed based on academic knowledge exchange, surveying 27 HTA bodies and 66 experts around the globe, and the implementation of EDPs in several countries. We present the revised steps of EDPs and how selected HTA bodies (in Australia, Brazil, Canada, France, Germany, Scotland, Thailand and the United Kingdom) organize key issues of legitimacy in their processes. This is based on a review of literature via PubMed and HTA bodies’ websites.

HTA bodies around the globe vary considerable in how they address legitimacy (stakeholder involvement ideally through participation with deliberation; evidence-informed evaluation; transparency; and appeal) in their processes. While there is increased attention for improving legitimacy in decision-making processes, we found that the selected HTA bodies are still lacking or just starting to develop activities in this area. We provide recommendations on how HTA bodies can improve on this.

The design and implementation of EDPs is in its infancy. We call for a systematic analysis of experiences of a variety of countries, from which general principles on EDPs might subsequently be inferred.

The article by Waitzberg et al on dual agency in hospitals reports on three strategies to mitigate dilemmas arising from conflicting clinical and economic considerations. This could be further explored by using systems science methods that allow in-depth analyses of (health) system dynamics, networks, and agent-based modelling, and that take into account local context, incentives and how institutions work. Future studies may also draw on the literature of multi-criteria decision-making and evidence-informed deliberative processes (EDPs) that are increasingly being used to optimise legitimate health benefit package design. Toolkits to assist hospital professionals in improving their decision-making need to be practical, with ample attention for the process of decision-making, including transparency, use of evidence, and opportunities for health professionals (and possibly others stakeholders) to contest or formally appeal against certain decisions.

Activity-based payment systems enforce Israeli and German hospital professionals to continuously balance clinical and economic considerations. As argued this status quo is unsatisfactory due to two reasons. First, professional hybridity in hospital management is restricted to the physician versus manager dichotomy rather than a multifaceted-identity framework. Second, by depending mostly on serendipity rather than hospital professionals’ organizational leeway applied reconciliation strategies seem extremely temporarily and brittle. As concluded, alternative models of hospital funding and organization such as global budgets are urgently needed. In addition, hospital professionals have to be empowered to make effectively us from their hybrid identities.

The inherent conflict between economic and clinical considerations, between professionalism and managerialism, and between being a manager or being a clinician is widely acknowledged in the sociology of professions. The original article by Waitzberg and colleagues focused on how hospital professionals reconcile these conflicting demands. In this commentary, we argue that their assumption that the considered hospital professionals (managers, chief financial officers [CFOs], chief physicians and practising physicians) are dual agents moves on from the unproductive debates of inherent conflicts to envisage possibilities of reconciling economic and clinical considerations. We conclude that the instrumental use of the term dual agent to include “the other” (the manager or the clinician) in a superlative and inclusive category can be considered a reframing strategy to solve inherent interprofessional conflicts and to implement more collaborative models in healthcare.

Waitzberg and colleagues identified strategies that managers and physicians in hospitals apply to reconcile dilemmas between clinical and economic considerations. Contributions that actually acknowledge the institutional complexity of hospitals and describe how to deal with it are rare. This comment explains the reason behind the institutional complexity in healthcare organizations and argues that institutional complexity is a good foundation for a wellfunctioning and sustainable healthcare, as long as we are able to deal with this complexity. This point underscores the importance of their contribution. However, even if the identified strategies on how to reconcile and balance different, competing demands are important, they are not easy to apply in practice. First, the strategies require frequent and high-quality interaction between different actors adhering to different institutional logics. Second, even when the strategies are applied successfully, it is difficult to make them sustainable since they rest on a fragile balance between competing logics. However, these are important avenues for future research for researchers who want to follow the route of Waitzberg and colleagues.

Waitzberg and colleagues’ participants articulate a wide range of strategies to manage tensions between clinical and economic obligations. There are, however, three notable absences in the data. First, all strategies described by participants are underpinned by the assumption that clinical (and associated administrative) practices need to either align with economic considerations or be made more compatible with them. Second, the dual agency dilemma was framed exclusively as existing at the level of the health care institution, with little attention paid to obligations to broader health systems. Third, there was no evidence of critical questioning of the priorities of the hospitals in which participants work. These absences do not render the strategies used by Weitzberg and colleagues’ participants morally “wrong,” but they do suggest that people who are deeply embedded in a system might fail to recognise the full range of moral concerns and moral possibilities.

This commentary to Waitzberg et al draws on the research stream on organizational goals in management to examine the findings they report, point out the correspondence of their findings and interpretation with existing theory, including development beyond it. Their work discusses these considerations very well. It also suggests paths to further theoretical development and proposes how their work demonstrate the potential for further research on multiple goals in hospitals. Such research will be important both for health policy and management and for management theory and practice generally.

The complexity within healthcare typically surfaces in tensions between organizational efficiency and professional values when hospital managers and professionals face dilemmas between economic and clinical considerations. Waitzberg et al, based on interviews with managers and physicians working in Israeli and German hospitals, explore strategies to cope with such dilemmas to safeguard both financial sustainability and patient quality. This short commentary provides some follow-up questions in two ways. First, I highlight the importance of nuancing and hybridizing the dichotomies that lead to dilemmas in the hospital context. Second, I discuss how such dilemmas can be highlighted in systematic group reflection which in turn can inform decision-making.

Waitzberg and colleagues’ research explores hospital managers, chief physicians and other physicians in German and Israeli hospitals, making use of thematic analysis to explore what they call ‘dilemmas’ between the commitments to clinical needs, and their hospitals’ financial sustainability. This commentary will provide a summary of the paper, into which I will embed some items I will follow-up on in my second half. The second half will then explore these items in greater depth, considering the strengths and weaknesses of the article. I then make some suggestions for future work based around the findings the authors present in terms of managerial and clinical identity, how compromises are reached in hospital settings, and how we compare different health systems.

Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries (LMICs) has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings. Surgical team mentoring programmes require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for all.

Context matters. Therefore, efforts to develop greater conceptual clarity are important for science and practice. In this commentary, we outline some key issues that were prompted by Squires and colleagues’ contribution. Specifically, we reinforce context as an interactive concept and therefore something that is hard to ‘pin down,’ the problematic nature of conceptualising context in implementation and de-implementation, and a requirement for the development of culturally sensitive understandings. Finally, we suggest it is vital that continued investment into providing a more comprehensive list of determinants needs to be accompanied by an equal effort in developing practical methods and tools to support use and application.