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

Injury is a major global health problem, causing >5 800 000 deaths annually and widespread disability largely attributable to neurotrauma. 89% of trauma deaths occur in low- and middle-income countries (LMICs), however data on neurotrauma epidemiology in LMICs is lacking. In order to support neurotrauma surveillance efforts, we present a review and analysis of data dictionaries from national registries in LMICs.

We performed a scoping review to identify existing national trauma registries for all LMICs. Inclusion/exclusion criteria included articles published since 1991 describing national registry neurotrauma data capture methods in LMICs. Data sources included PubMed and Google Scholar using the terms “trauma/neurotrauma registry” and country name. Resulting registries were analyzed for neurotrauma-specific data dictionaries. These findings were augmented by data from direct contact of neurotrauma organizations, health ministries, and key informants from a convenience sample. These data were then compared to the World Health Organization (WHO) minimum dataset for injury (MDI) from the international registry for trauma and emergency care (IRTEC).

We identified 15 LMICs with 16 total national trauma registries tracking neurotrauma-specific data elements. Among these, Cameroon had the highest concordance with the MDI, followed by Colombia, Iran, Myanmar and Thailand. The MDI elements least often found in the data dictionaries included helmet use, and alcohol level. Data dictionaries differed significantly among LMICs. Common elements included Glasgow Coma Score, mechanism of injury, anatomical site of injury and injury severity scores. Limitations included low response rate in direct contact methods.

Conclusion:

Significant heterogeneity was observed between the neurotrauma data dictionaries, as well as a spectrum of concordance or discordance with the MDI. Findings offer a contextually relevant menu of possible neurotrauma data elements that LMICs can consider tracking nationally to enhance neurotrauma surveillance and care systems. Standardization of nationwide neurotrauma data collection can facilitate international comparisons and bidirectional learning among healthcare governments.

A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation.

We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospitalwide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies.

The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection.

Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature.

Background :

The rapid spread of the coronavirus disease 2019 (COVID-19) pandemic demonstrates the value of regional cooperation in infectious disease prevention and control. We explored the literature on regional infectious disease control bodies, to identify lessons, barriers and enablers to inform operationalisation of a regional infectious disease control body or network in southeast Asia.

We conducted a scoping review to examine existing literature on regional infectious disease control bodies and networks, and to identify lessons that can be learned that will be useful for operationalisation of a regional infectious disease control body such as the Association of Southeast Asian Nations (ASEAN) Center for Public Health Emergency and Emerging Diseases.

Results :

Of the 57 articles included, 53 (93%) were in English, with two (3%) in Spanish and one (2%) each in Dutch and French. Most were commentaries or review articles describing programme initiatives. Sixteen (28%) publications focused on organisations in the Asian continent, with 14 (25%) focused on Africa, and 14 (25%) primarily focused on the European region. Key lessons focused on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability. Enablers and constraints were consistent across regions/organisations. A clear understanding of the regional context, budgets, cultural or language issues, staffing capacity and governmental priorities, is pivotal. An initial workshop inclusive of the various bodies involved in the design, implementation, monitoring or evaluation of programmes is essential. Clear governance structure, with individual responsibilities clear from the beginning, will reduce friction. Secure, long-term funding is also a key aspect of the success of any programme.

Conclusion:

Operationalisation of regional infectious disease bodies and networks is complicated, but with extensive groundwork, and focus on organisational factors, diagnosis and detection, human resources, communication, accreditation, funding, and sustainability, it is achievable. Ways to promote success are to include as many stakeholders as possible from the beginning, to ensure that context-specific factors are considered, and to encourage employees through capacity building and mentoring, to ensure they feel valued and reduce staff turnover.

As a fundamental human right, the right to health (RTH) can influence state actors’ behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low- and middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and high-income countries (HICs), we sought to answer the question: “how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs?”

Methods :

We conducted a realist synthesis of evidence identified through a systematic search of peer-reviewed articles in Embase, Global Health, Medline (Ovid), ProQuest – Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar.

Results :

We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors’ concerns for their countries’ reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors’ response include financial cost and sustainability of rights’-based options.

Conclusion :

State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.

The World Health Organization (WHO) has collected information on policies on sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) over many years. Creating a global survey that works for every country context is a well-recognized challenge. A comprehensive SRMNCAH policy survey was conducted by WHO from August 2018 through May 2019. WHO regional and country offices coordinated with Ministries of Health and/or national institutions who completed the questionnaire. The survey was completed by 150 of 194 WHO Member States using an online platform that allowed for submission of national source documents. A validation of the responses for selected survey questions against content of the national source documents was conducted for 101 countries (67%) for the first time in the administration of the survey. Data validation draws attention to survey questions that may have been misunderstood or where there was a lot of missing data, but varying methods for validating survey responses against source documents and separate analysis of laws from policies and guidelines may have hindered the overall conclusions of this process. The SRMNCAH policy survey both provided a platform for countries to track their progress in adopting WHO recommendations in national SRMNCAH-related legislation, policies, guidelines and strategies and was used to create a global database and searchable document repository. The outputs of the SRMNCAH policy survey are resources whose importance will be enriched through policy dialogues and wide utilization. Lessons learned from the methodology used for this survey can help to improve future updates and inform similar efforts.

Breastfeeding is important for the health and development of the child, and for maternal health, in all country contexts. However, global sales of breast-milk substitutes (BMS), including infant, follow-up and toddler formulas, have ‘boomed’ in recent decades. This raises the importance of international food standards established by the Codex Alimentarius Commission (Codex) on the safety, composition and labelling of BMS. Such standards appear to be strongly contested by governments, industry and civil society groups, yet few studies have investigated the politics of Codex standard-setting processes. The aim of this paper is to understand who participates in decision-making, and how actors frame and contest proposals to revise the Codex Standard on Follow-up Formula (FUF).

We adopted a case study design involving two steps. First, we enumerated government, industry, civil society, and international organization stakeholders participating in standard-setting processes of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Second, we conducted a framing analysis of stakeholder inputs during the FUF standard revision in CCNFSDU meetings. Publicly available online meeting reports (2015-2019) were retrieved, analyzed using a theoretical framework, and organized thematically.

High-income country (HIC) delegates greatly outnumbered those from other country income categories. Industry representation was higher compared with other observer categories. Member state delegations included more industry representation than civil society representation, and were occasionally the only member state delegates. Industry stakeholders framed arguments in terms of trade implications, science, and flexible standards. Civil society groups used public health, science, and pro-breastfeeding frames.

Codex BMS standard-setting procedures are dominated by HICs and industry groups. Limited representation of civil society, and of low- and middle-income countries (LMICs), suggest actions are needed to substantially increase support for their involvement at Codex. Such representation may help to counteract power asymmetries and commercial influences on food standards for infants and young children

Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality.

This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy.

FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients’ mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public – rather than private – services, and are more prominent in poorer areas.

This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources – as well as the extent of public sector’s retrenchment – coincide with the wealth of the area.

As part of a global policy response for addressing malnutrition, food system actions have been proposed. Within food system interventions, policies directed to supply chains have the potential to increase the availability and affordability of a healthy diet. This qualitative study aimed to identify opportunities to integrate nutrition as a priority into the food supply policy space in Mexico.

Data were collected through analysis of 19 policy documents and 20 semi-structured stakeholder interviews. As an analytical framework, we used policy space analysis and embedded the Advocacy Coalition Framework (ACF) and the steps of the food chain of the conceptual framework of food systems for diets and nutrition.

Policy issues relevant to nutrition were viewed differently in the economic and agricultural sectors versus the health sector. Overall, the main policy objective related to nutrition within the economic and agricultural sectors was to contribute to food security in terms of food quantity. Nutrition was an objective in itself only in the health sector, with a focus on food quality. Our policy space analysis reveals an opportunity to promote a new integrated vision with the recent creation of an intersectoral group working on the public agenda for a food system transformation. This newer integrative narrative on food systems presents an opportunity to shift the existing food security narrative from quantity towards considerations of diet quality.

The political context and public agenda are favorable to pursue a food system transformation to deliver sustainable healthy diets. Mexico can provide a case study for other low- and middle-income countries (LMICs) for putting nutrition at the center of food policy, despite the ongoing constraints on achieving this.

How research findings are presented through domestic news can influence behaviour and risk perceptions, particularly during emergencies such as the coronavirus disease 2019 (COVID-19) pandemic. Monitoring media communications to track misinformation and find information gaps is an important component of emergency risk communication. Therefore, this study investigated the traditional media coverage of nine selected COVID-19 evidencebased research reports and associated press releases (PRs) published during the initial phases of the pandemic (April to July 2020) by one national agency.

NVivo was used for summative content analysis. ‘Key messages’ from each research report were proposed and 488 broadcast, print, and online media sources were coded at the phrase level. Manifest content was coded and counted to locate patterns in the data (what and how many) while latent content was analysed to further investigate these patterns (why and how). This included the coding of the presence of political and public health actors in coverage.

Coverage largely did not misrepresent the results of the reports, however, selective reporting and the variability in the use of quotes from governmental and public health stakeholders changed and contextualised results in different manners than perhaps originally intended in the PR. Reports received varying levels of media attention. Coverage focused on more ‘human-interest’ stories (eg, spread of COVID-19 by children and excess mortality) as opposed to more technical reports (eg, focusing on viral load, antibodies, testing, etc).

Our findings provide a case-study of European media coverage of evidence reports produced by a national agency. Results highlighted several strengths and weaknesses of current communication efforts.

Nepal’s national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government’s efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal.

A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses.

The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout.

In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members’ reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers’ behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area

Sugar-sweetened beverage (SSB) taxes are an effective public health policy intervention for improving nutrition and public health. Although implemented in over 50 jurisdictions worldwide, this intervention remains vastly underutilised, and in Australia political commitment for such a tax is low. The aim of this study is to understand the politics of SSB taxation in Australia, what factors have constrained political commitment for a tax, and what might enable such commitment in future.

We adopted a case study design, guided by a theoretical framework developed from the political economy of nutrition literature. Data were collected from 16 interviews with informants from multiple sectors, supported by media articles, journal articles, and grey literature. Data were coded and organized by thematic analysis, and synthesised into the final results.

Nutrition actors have made significant progress in generating commitment for a SSB tax by producing relevant evidence, raising awareness, advocating for action, employing resonating frames, collaborating with civil society organisations, and forming coalitions increasing their overall cohesion. Nevertheless, political commitment for a SSB tax is low and was found to be impeded by the powerful influence of the food, beverage, and sugar industries, opposition from both major Australian political parties, ideological resistance to regulation, a low quality monitoring and surveillance system for food and nutrition, and limited public advocacy. The influence of nutrition actors was also impeded by weak connections to key policy-makers and missed collaborative opportunities with pro-SSB tax organisations.

The identification of several impediments provides an explanation for why political commitment for a SSB tax is low in Australia and reveals several opportunities for how it might be generated in the future. Political commitment may come about through, for example, actions to limit the influence of industry in policy decision-making, and by strengthening the existing pro-SSB tax coalition.

A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.

This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period.

Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future.

Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.

Philanthropic activities play an important role in health systems. Donors contribute to financing, generating resources, and providing healthcare services in Iranian health system. However, they face many challenges. This study aimed to identify barriers to donors’ participation in the Iranian health system and to provide solutions.

This qualitative study was performed using semi-structured interviews with 38 donors and 26 policy-makers and managers in the social affairs department of health ministry and medical universities in 2018. In addition, document analysis was performed and the relevant data were extracted. Thematic analysis was used for data analysis. All ethical considerations were followed in this research.

Insufficient structures, poor communications, low trust, ineffective working processes, bureaucracy, insufficient senior managers’ support, weak legal support and poor monitoring were the most important challenges for donors’ participation in the Iranian health system. Effective donor participation in the health system requires the creation of an appropriate system including the right structures, processes, culture, and management. The necessary changes must be planned, led and monitored to promote donors’ participation in healthcare. A conceptual model was developed to strengthen donors’ participation in the health system.

Iranian donors face structural, procedural, cultural, and managerial challenges when financing the health system, generating resources, and providing health services. Policy-makers and managers should tackle these challenges and adopt strategies to reinforce donors’ participation in the health system. Planning, organizing, leading, monitoring, evaluation, transparency, accountability, and a commitment to meet donors’ needs are necessary for successful philanthropy initiatives in the health sector

To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative.

The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (ie, potential users) at the Health Technology Assessment International 2018 annual meeting.

An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology (The Stats and Projections), stakeholders to engage (The Team), potential facilitators and/or barriers within the policy context (The Playing Field), strategic use of different levers and tools (The Offensive Plays), unintended consequences (The Defensive Plays), and metrics and methods for monitoring and evaluation (Winning the Game).

The HTR playbook is intended to enhance a user’s ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question.

This study aimed to investigate the prevalence of hospital readmission for chronic obstructive pulmonary disease (COPD) at 30, 90 and 365 days, and to determine demographic and socioeconomic risk factors for 30-day and 90-day readmission and time to COPD-related readmission within 365 days in Tasmania.

Patients ≥40 years admitted for COPD between 2011 and 2015 were identified using administrative data from all major public hospitals in Tasmania, Australia. Factors associated with readmission and time to readmission were identified using logistic and Cox regression, respectively.

The rates of COPD-related readmission were 6.7% within 30 days, 12.2% within 90 days and 23.7% within 365 days. Being male (odds ratio [OR]: 1.49, CI: 1.06–2.09), Indigenous (OR: 2.47, CI: 1.31–4.66) and living in the lower socioeconomic North-West region of Tasmania (OR: 1.80, CI: 1.20–2.69) were risk factors for 30-day readmission. Increased COPD-related (OR: 1.48, CI: 1.22–1.80; OR: 1.52, CI: 1.29–1.78) and non-COPD-related (OR: 1.12, CI: 1.03– 1.23; OR: 1.11, CI: 1.03–1.21) emergency department (ED) visits in the preceding six months were risk factors for both 30-day and 90-day readmissions. Being Indigenous (hazard ratio [HR]: 1.61, CI: 1.10–2.37) and previous COPD-related ED visits (HR: 1.30, CI: 1.21–1.39) decreased, while a higher Charlson Comorbidity Index (CCI) (OR: 0.91, CI: 0.83– 0.99) increased the time to readmission within 365 days.

Being male, Indigenous, living in the North-West region and previous ED visits were associated with increased risk of COPD readmission in Tasmania. Interventions to improve access to primary healthcare for these groups may reduce COPD-related readmissions

Asian and pacific region countries are high risk countries for human immunodeficiency virus/ acquired immune deficiency syndrome (HIV/AIDS). Although the prevalence of HIV/AIDS is low in Bangladesh but women in Bangladesh have been identified as susceptible due to associated socioeconomic exposures. There are various misconceptions associated with HIV/AIDS transmission among the women in low- and middle-income countries including Bangladesh, which lead to a negative attitude towards the HIV/AIDS-infected. The purpose of this study was to assess the overall knowledge, transmission, and misconception about HIV/AIDS among the women in Bangladesh as well as its spatial distribution across the country.

The study used data from the UNICEF (United Nations Children’s Fund) Multiple Indicator Cluster Survey (MICS) 2019, with a sample of 64 346 women. This was a cross-sectional, population-based survey of Bangladeshi women aged 15–49 conducted using a multistage, cluster sampling technique. Three binary outcome variables considered were knowledge about HIV/AIDS, knowledge about HIV/AIDS transmission and knowledge on myths and misconceptions on HIV/AIDS along with 10 predictors based on past literature. Bivariable analysis using chi-square tests of association was conducted to examine the unadjusted percentage differences of the outcome variables for each of the predictor variables and their associations. Multiple binary logistic regression models were then fitted to evaluate the association between the outcome variables and the predictors after adjusting for survey cluster, strata, and weights. All analysis was conducted in R software (V 2.5.0).

The percentage of women who held knowledge about HIV/AIDS, knowledge about HIV/AIDS transmission and knowledge on misconceptions about transmission of HIV were on average 60.3%, 52.2% and 71.7% respectively. The models indicated that women regularly exposed to media were 79%, 18% and 19% significantly more likely (odds ratio, OR: [95% CI] = 1.79: [1.70, 1.89]; 1.18: [1.10 1.26] and 1.19: [1.11, 1.27]) to have heard about HIV, aware about HIV transmission, and have less misconceptions about HIV respectively compared to those who were not exposed to media. Overall results indicate that women from peripheral districts living far from metropolitan cities were most unaware of HIV and had higher misconceptions about AIDS.

The findings of this study should assist policy-makers and program implementers to focus on raising awareness to educating women about how HIV/AIDS is transmitted. Furthermore, interventions should be made by targeting the most disadvantaged groups, including younger women with low education living in rural areas, from poor households and limited access to information. Also, education on HIV transmission in Bangladesh should integrate cultural and ethnic considerations of HIV/AIDS.

A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program.

We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by in-depth interviews of 9 patients and 8 program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories.

Among the 426 patients, 9% of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit.

DBT improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for ‘DBT plus food-kit’ vs. universal cash transfers in India

The projection of levels and composition of financial resources for the healthcare expenditure (HCE) and relevant trends can provide a basis for future health financing reforms. This study aimed to project Iran’s HCEs by the sources of funds until 2030.

The structural macro-econometric modeling in the EViews 9 software was employed to simulate and project Iran’s HCE by the sources of funds (government health expenditure [GHCE], social security organization health expenditure [SOHCE], out-of-pocket [OOP] payments, and prepaid private health expenditure [PPHCE]). The behavioral equations were estimated by autoregressive distributed lag (ARDL) approach.

If there is a 5%-increase in Iran’s oil revenues, the mean growth rate of gross domestic product (GDP) is about 2% until 2030. By this scenario, the total HCE (THCE), GHCE, SOHCE, OOP, and PPHCE increases about 30.5%, 25.9%, 34.4%, 31.2%, and 33.9%, respectively. Therefore, the THCE as a percentage of the GDP will increase from 9.6% in 2016 to 10.7% in 2030. It is predicted that Iran’s THCE will cover 22.2%, 23.3%, 40%, and 14.5% by the government, social security organization (SSO), households OOP, and other private sources, respectively, in 2030.

Until 2030, Iran’s health expenditures will grow faster than the GDP, government revenues, and non-health spending. Despite the increase in GHCE and total government expenditure, the share of the GHCE from THCE has a decreasing trend. OOP payments remain among the major sources of financing for Iran’s HCE.

Front-of-pack nutrition labels (FoPLs) aim at increasing transparency and consumers’ awareness of the nutritional composition of pre-packed food products in order to improve the nutritional quality of their food choices. Nevertheless, the legitimacy of the Nutri-Score - the FoPL officially adopted in France and several other European countries - is subject to both technical and political controversy, particularly in Italy. In this study, we investigated how and by whom the legitimacy of the Nutri-Score, recognized by several institutional authorities, could be deconstructed within a specific system of norms, values and beliefs among Italian stakeholders.

A netnography completed with qualitative interviews with eight Italian and French nutrition and public health experts were carried out to highlight the dimensions (pragmatic, normative and cognitive) in which the NutriScore’s legitimacy is being challenged among the stakeholders involved in FoPLs’ implementation in Italy. The degree of influence and the position of these stakeholders on the debate around the Nutri-Score were assessed through the Stakeholder Theory (SHT), using their respective level of power, legitimacy and urgency. Furthermore, we compared the Italian and the French contexts on the issue.

The direct implication of political parties and media outlets in framing the Italian debate around Nutri-Score as well as the high influence of corporate unions, led to a different political outcome than in France. Results also show that the deconstruction of the legitimacy of the Nutri-Score in Italy pertained mainly to its pragmatic dimension according to the Italian public health experts. Nevertheless, its two other dimensions (normative and cognitive) are also questioned by high-influence stakeholders.

Due to the limited mobilization of scientific expertise over the issue, the debate in Italy stayed centered around the “attack” of the Nutri-Score to the Italian way of life, mixing up concepts such as Made in Italy products and the Mediterranean diet.

As evidence grows about negative health impacts of ultra-processed foods (UPFs), nutrient-centred advice is contested, and food-based dietary guidelines are increasingly utilised. Previous analyses of dietary guidelines evaluated their potential impact on health and sustainability, but little research has been conducted to examine how the concept of UPFs is reflected in dietary advice for consumers. This paper systematically analyses whether and how UPFs are represented in dietary guidelines internationally.

Based on a systematic online search, the consumer-targeted key messages of 106 dietary guidelines were identified and a qualitative content analysis was conducted. A coding framework was developed to classify messages as ‘eat more’ or ‘eat less’ according to the language used (eg, ‘choose’ vs. ‘avoid’) and to differentiate between a focus on nutrients or food processing. Specific foods mentioned in ‘eat less’ guidelines were classified according to their level of processing using the NOVA framework.

99% of guidelines utilised some type of nutrient-based message, either promoting ‘positive’ nutrients (eg, vitamins) or discouraging the consumption of ‘negative’ nutrients (mainly salt, sugar and fat). Explicit references to food processing were present in 45% of ‘eat less’ guidelines and 5% of ‘eat more’ guidelines. Implicit references (eg, promoting ‘raw’ or discouraging ‘packaged’ foods) were found in 43% of ‘eat less’ and 75% of ‘eat more’ guidelines. 53% of the specific foods referred to in ‘eat less’ advice were UPFs.

Overall, nutrient-based messages were more common than messages about processing levels. The majority of discouraged foods were UPFs, however some minimally processed foods were discouraged, which points to tensions and contradictions between nutrient- and processing-based dietary advice. As dietary guidelines begin to include advice about food processing, it is important to consider both consumer understanding of the terms used and their capacity to act on the advice.

China started a national program in 2010 to train qualified general practitioners with compulsory services program (CSP) in rural and remote areas. While the program has shown positive effects on staffing primary healthcare (PHC) in rural areas, very little is known about how well they perform. This study aims to evaluate the job performance of medical graduates from this program and the influence of program design on job performance.

A cohort study was conducted with graduates from CSP and non-CSP (NCSP) from four medical universities in central and western China. Baseline and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements. Multivariable regressions were used to identify factors affecting job performance.

2154 medical graduates were included, with 1586 CSP and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=.153). CSP graduates reported similar job performance with NCSP graduates (CSP, 63.7; NCSP, 64.2); in the multivariable regression, CSP graduates scored 0.32 and 1.36 points lower in the total sample and graduates of 2015-2017, respectively, but not significantly. Having formally funded positions improved the job performance of CSP (β coefficient=4.87, P<.05). After controlling for Qinghai which adopted a different contracting strategy, “working in hometown” showed significant influence on job performance (β coefficient = 1.48, P<.05).

CSP graduates have demonstrated as good job performance as NCSP, proving the competency to provide high-quality care for remote and rural areas. The contracted township health centers (THCs) should provide guidance for CSP graduates, especially in the first few years after graduation. The local government should provide formally funded positions on time and prioritize signing contracts with hometowns or places nearby.

District management is emerging as a lynchpin for primary healthcare system performance. However, delivery of district-level interventions at scale is challenging, and overlooks the potential role of management at other subnational levels. From 2015-2019, Ethiopia’s Primary Healthcare Transformation Initiative (PTI), aimed to build a culture of performance management and accountability at the zonal level. This paper aims to evaluate the longitudinal change in management practice and performance in the 19 zones participating in PTI, which included 315 districts and 1617 health centers.

Using data from PTI intervention (2018 to 2019), we employed quantitative measures of management capacity at health center, district, and zonal levels, and quantified primary healthcare service performance using a summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We used multiple generalized linear regression models accounting for clustering of health centers within zones to quantify (1) change in management and performance during the two-year intervention, (2) associations between the changes in management capacity at the zonal, district, and health facility level.

Adherence to management standards at the zonal, district, and health facility level improved significantly over two years (37%, P<.001; 18%, P<.001; 18%, P<.001; respectively), as did the performance summary score (14%, P<.001). Adherence at the zonal level in year one was associated with district level adherence in year one (P=.04), and, over the two-year period (P=.002), and district management mediated the relationship between management practice at zonal and health center levels (P<.001).

Improvements in zonal-level management practice were associated with significant improvements in district-level management and performance in PTI sites. Investments in managerial practices at the zonal level may provide an immediate way to energize primary healthcare system performance at scale in low-income country settings.

The World Health Organization (WHO) recommends that countries implement fiscal policies to reduce the health impacts of sugary drinks. Few studies have fully examined the responses of industry to these policies, and whether they support or undermine health benefits of sugary drinks taxes. We aimed to explore the changes that sugary drinks companies may make to their marketing, and underlying decision-making processes, in response to such a tax.

Following introduction of the UK Soft Drinks Industry Levy (SDIL) in 2018, we undertook one-to-one semi-structured interviews with UK stakeholders with experience of the strategic decision-making or marketing of soft drinks companies. We purposively recruited interviewees using seed and snowball sampling. We conducted telephone interviews with 6 representatives from each of industry, academia and civil society (total n=18), which were transcribed verbatim and thematically analysed. Four transcripts were double-coded, three were excluded from initial coding to allow comparison; and findings were checked by interviewees.

Themes were organised into a theoretical framework that reveals a cyclical, iterative and ongoing process of soft drinks company marketing decision-making, which was accelerated by the SDIL. Decisions about marketing affect a product’s position, or niche, in the market and were primarily intended to maintain profits. A product’s position is enacted through various marketing activities including reformulation and price variation, and non-marketing activities like lobbying. A soft drinks company’s selection of marketing activities appeared to be influenced by their internal context, such as brand strength, and external context, such as consumer trends and policy. For example, a company with low brand strength and an awareness of trends for reducing sugar consumption may be more likely to reformulate to lower-sugar alternatives.

The theoretical framework suggests that marketing responses following the SDIL were coordinated and context-dependent, potentially explaining observed heterogeneity in responses across the industry.

Nursing home (NH) residents accounted for half of the deaths during the 2020 spring wave of the coronavirus disease 2019 (COVID-19) epidemic in France. Our objective was to identify structural and managerial factors associated with COVID-19 outbreaks in NHs.

We conducted in July 2020 a retrospective study by questionnaire addressed to NH directors in the Brittany region of France. The questions related to structural characteristics of the establishment, human resources, and crisis management decisions. The primary endpoint was the occurrence of at least one confirmed case of COVID-19 among residents between March 1, 2020 and May 31, 2020. The secondary endpoint was total mortality during this period. We used multivariate regressions to identify factors associated with these outcomes.

Responses were collected from 231 NHs hosting 20,881 residents, representing a participation rate of 47%. In 24 (10%) NHs, at least one resident presented confirmed COVID-19. NHs often implemented stringent protective measures, with 65% of them choosing to confine residents to their rooms. In multivariate analysis, factors associated with a reduced risk of case occurrence were in-room meal service, early ban of family visits, and daily access to an outdoor space. No association was found between mortality and the factors studied. Our results show an early and strict implementation of lockdown measures, with good epidemiological results in a context of shortage of personal protective equipment (PPE) and non-vaccination. Nevertheless, it raises ethical questions concerning respect of residents’ wellbeing and rights.

Cessation of communal dining seems to be the main measure likely to be effective in preventive terms. It does not seem that room lockdown and cessation of group activities should be recommended, particularly if mask wearing is possible

Deliberative dialogues (DDs) are used in policy-making and healthcare research to enhance knowledge exchange and research implementation strategies. They allow organized dissemination and integration of relevant research, contextual considerations, and input from diverse stakeholder perspectives. Despite recent interest in involving patient and public perspectives in the design and development of healthcare services, DDs typically involve only professional stakeholders. A DD took place in May 2019 that aimed to improve the social environment (eg, safety, social inclusion) and decrease social isolation in a rent-geared-to-income housing complex in a large urban community. Tenants of the housing complex, public health, primary care, and social service providers participated. This study aimed to determine how including community tenants impacted the planning and execution of a DD, including adjustments made to the traditional DD model to improve accessibility.

A Core Working Group (CWG) and Steering Committee coordinated with researchers to plan the DD, purposefully recruit participants, and determine appropriate accommodations for tenants. A single mixed-methods case study was used to evaluate the DD process. Meeting minutes, field notes, and researchers’ observations were collected throughout all stages. Stakeholders’ contributions to and perception of the DD were assessed using participant observation, survey responses, and focus groups (FGs).

34 participants attended the DD and 28 (82%) completed the survey. All stakeholder groups rated the overall DD experience positively and valued tenants’ involvement. The tenants heavily influenced the planning and DD process, including decisions about key DD features. Suggestions to improve the experience for tenants were identified.

These findings demonstrate the viability of and provide recommendations for DDs involving public participants. Like previous DDs, participants found the use of engaged facilitators, issue briefs, and off-the-record deliberations useful. Similarly, professional stakeholders did not highly value consensus as an output, although it was highly valued among tenants, as was actionability.

Health in All Policies (HiAP) encompasses collaboration across government and the consideration of health in various governmental sector’s policies and decisions. Despite increasing advocacy, interest, and uptake in HiAP globally, empirical and evaluative studies are underrepresented in this growing literature, particularly literature on HiAP implementation at the local level. Finland has been a pioneer in and champion for HiAP.

A realist explanatory case study design was used to test hypotheses about how HiAP is implemented in Kuopio, Finland. Semi-structured interviews with ten government employees from various sectors were conducted. Data from interviews and literature were analyzed with the aims of uncovering explanatory mechanisms in the form of context-strategy-mechanism-outcome (CSMO) configurations related to implementation strategies. Evidence was evaluated for quality based on triangulation of sources and strength of evidence. We hypothesized that having or creating a common goal between sectors and having committed staff and local leadership would facilitate implementation.

Strong evidence supports our hypothesis that having or creating a common goal can aid in positive implementation outcomes at the local level. Common goals can be created by the strategies of having a city mandate, engaging in cross-sectoral discussions, and/or by working together. Policy and political elite leadership led to HiAP implementation success because leaders supported HiAP work, thus providing justification for using time to work intersectorally. How and why the wellbeing committee facilitated implementation included by providing opportunities for discussion and learning, which led to understanding of how non-health decisions impact community wellbeing, and by acting as a conduit for the communication of wellbeing goals to government employees.

At the municipal level, having or creating a common goal, leadership from policy and political elites, and the presence of committed staff can facilitate HiAP implementation. Inclusion of not only strategies for HiAP, but also the explanatory mechanisms, aids in elucidating how and why HiAP is successfully implemented in a local setting.

Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion – the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle.

To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semistructured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents.

The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers.

In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.

Regional cooperation on health in Africa is not new. The institutional landscape of regional cooperation for health and health research, however, has seen important changes. Recent health emergencies have focussed regional bodies’ attention on supporting aspects of national health preparedness and response. The state of national health research systems is a key element of capacity to plan and respond to health needs – raising questions about the roles African regional bodies can or should play in strengthening health research systems.

We mapped regional organisations involved in health research across Africa and conducted 18 interviews with informants from 15 regional organisations. We investigated the roles, challenges, and opportunities of these bodies in strengthening health research. We deductively coded interview data using themes from established pillars of health research systems – governance, creating resources, research production and use, and financing. We analysed organisations’ relevant activities in these areas, how they do this work, and where they perceive impact.

Regional organisations with technical foci on health or higher education (versus economic or political remits) were involved in all four areas. Most organisations reported activities in governance and research use. Involvement in governance centred mainly around agenda-setting and policy harmonisation. For organisations involved in creating resources, activities focused on strengthening human resources, but few reported developing research institutions, networks, or infrastructure. Organisations reported more involvement in disseminating than producing research. Generally, few have directly contributed to financing health research. Informants reported gaps in research coordination, infrastructure, and advocacy at regional level. Finally, we found regional bodies’ mandates, authority, and collaborations influence their activities in supporting national health research systems.

Continued strengthening of health research on the African continent requires strategic thinking about the roles, comparative advantages, and capability of regional organisations to facilitate capacity and growth of health research systems

The implementation of change in health and care services is often complicated by organisational micropolitics. There are calls for those leading change to develop and utilise political skills and behaviours to understand and mediate such politics, but to date only limited research offers a developed empirical conceptualisation of the political skills and behaviours for leading health services change.

A qualitative interview study was undertaken with 66 healthcare leaders from the English National Health Service (NHS). Participants were sampled on the basis of their variable involvement in leading change processes, taking into account anticipated differences in career stage, leadership level and role, care sector, and professional backgrounds. Interpretative data analysis led to the development of five themes.

Participants’ accounts highlighted five overarching sets of political skills and behaviours: personal and interpersonal qualities relating to self-belief, resilience and the ability to adapt to different audiences; strategic thinking relating to the ability to understand the wider and local political landscape from which to develop realistic plans for change; communication skills for engaging and influencing stakeholders, especially for understanding and mediating stakeholders’ competing interests; networks and networking in terms of access to resources, and building connections between stakeholders; and relational tactics for dealing with difficult individuals through more direct forms of negotiation and persuasion.

The study offers further empirical insight the existing literature on healthcare organisational politics by describing and conceptualising the political skills and behaviours of implementing health services change.

Stroke is one of the leading public health issues in China and imposes a heavy financial burden on patients and the healthcare system. This study assess which payment method provides the lowest hospital costs for China’s healthcare system and the lowest out-of-pocket (OOP) expense for insured patients.

This is a 4-year cross-sectional study. From the China Health Insurance Research Association (CHIRA) database, a 5% random sample of urban health insurance claims was obtained. Descriptive analysis was conducted and a generalized linear model (GLM) with a gamma distribution and a log link was estimated.

For outpatients, capitation payment had the lowest hospital cost (RMB180.9/US$28.8) and lowest OOP expenses (RMB75.6/US$12.0) per patient visit in primary hospitals compared with fee-for-service (FFS) payments. The global budget (GB) displayed the lowest total hospital costs (RMB344.7/US$54.8) in secondary hospitals, and was 27.4% (95% CI=-0.32, -0.29) lower than FFS. FFS had the lowest OOP expenses (RMB123.4/US$19.6 vs. RMB151.8/US$24.1) in secondary and tertiary hospitals. For inpatients, FFS had the lowest total hospital costs (RMB5918.7/US$941.1) per visit and capitation payments had the lowest OOP expenses (RMB876.5/US$139.4, 40.1% lower than FFS, 95% CI=-0.58, -0.15) in primary hospitals. Capitation payment had both the lowest hospital costs (RMB7342.9/US$1167.5 vs. RMB17 711.7/US$2816.2) and the lowest OOP expenses (RMB1664.2/US$264.6 vs. RMB3276.3/US$520.9) for both secondary and tertiary hospitals.

For outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest OOP expenses for patients and the lowest hospital total costs for hospitals. We recommend that health policymakers prioritize the implementation of the payment method with the lowest OOP expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest OOP expenses for patients.

Healthcare is complex with multi-professional staff and a variety of patient care pathways. Time pressure and minimal margins for errors, as well as tension between hierarchical power and the power of the professions, make it challenging to implement new policies or procedures. This paper explores five improvement cases in healthcare integrating system dynamics (SD) into action research (AR), aiming to identify methodological aspects of how this integration supported multi-professional groups to discover workable solutions to work-related challenges.

This re-analysis was conducted by a multi-disciplinary research group using an iterative abductive approach applying qualitative analysis to structure and understand the empirical material. Frameworks for consultancy assignments/client projects were used to identify case project stages (workflow steps) and socio-analytical questions were used to bridge between the AR and SD perspectives.

All studied cases began with an extensive AR-inspired inventory of problems/objectives and ended with an SDfacilitated experimental phase where mutually agreed solutions were tested in silico. Time was primarily divided between facilitated group discussions during meetings and modelling work between meetings. Work principles ensured that the voice of each participant was heard, inspired engagement, interaction, and exploratory mutual learning activities. There was an overall pattern of two major divergent and convergent phases, as each group moved towards a mutually developed point of reference for their problem/objective and solution, a case-specific multi-professional knowledge repository.

By integrating SD into AR, more favourable outcomes for the client organization may be achieved than when applying either approach in isolation. We found that SD provided a platform that facilitated experiential learning in the AR process. The identified results were calibrated to local needs and circumstances, and compared to traditional top-down implementation for change processes, improved the likelihood of sustained actualisation.

Iran considers the revision of its health insurance benefit package (HIBP) as a means to achieve universal health coverage (UHC). Yet, its decision-making process has been criticised for being weak in terms of accountability and transparency. This paper reports on the development and implementation of the HIBP revision in Iran in the period 2019-2021, employing evidence-informed deliberative processes (EDPs), a framework for benefit package design with the explicit aim of optimising the legitimacy of decision-making.

The High Council for Health Insurance (HCHI) is coordinating the HIBP revision: it planned the six steps of the EDP framework with support from World Health Organization (WHO) and Radboudumc in 2019, and conducted a pilot project on multiple sclerosis (MS) diagnosis and treatment in 2020.

Implementation of the MS pilot project concerned the installation of advisory committees (involving some 60 stakeholders in supportive task forces, a technical working group [TWG] and a national advisory committee [NAC]), the selection of decision criteria (relating to quality of care, necessity, and sustainability), the inclusion of services for evaluation (nine in total), and the assessment and appraisal of these services.

Implementation of the priority setting process for MS diagnosis and treatment services has likely improved the legitimacy of decision-making by involving stakeholders who engaged in deliberation based on available evidence in a stepwise, transparent process. It is expected to improve the quality of care for MS patients as well as its financial accessibility, at a zero net budget impact. The pilot project has served to help Iran’s health system move faster toward UHC for a broader range of essential health services

According to Lacy-Nichols and Williams, the food industry is increasingly forestalling regulation with incremental concessions and co-option of policy-making discourses and processes; bolstering their legitimacy via partnerships with credible stakeholders; and disarming critics by amending their product portfolios whilst maintaining high sales volumes and profits. Their assessment raises a number of fundamental philosophical questions that we must address in order to form an appropriate public health response: is it appropriate to treat every act of corporate citizenship with cynicism? If voluntary action leads to better health outcomes, does it matter whether profits are preserved? How should we balance any short-term benefits from industry-led reforms against the longer-term risk stemming from corporate capture of policy-making networks? I argue for a nuanced approach, focused on carefully defined health outcomes; allowing corporations the benefit of the doubt, but implementing robust binding measures the moment voluntary actions fail to meet independently set objectives.

The “Part of the Solution” article describes how the food industry has evolved its strategies to respond to critics and government regulation by co-option and appeasement to create a less hostile environment. Rather than focusing research on single industries it would be more efficient and productive to focus on corporate political activities (CPAs) that directly influence democratic institutions and processes having authority over laws, policy, rules and regulations that govern industry. The most influential and direct CPA are election campaign donations, lobbying, and the reverse revolving door (RRD). In the United States those CPA flow from rights of corporations that underlie all industry strategies. The US history of how corporations obtained their rights is described, and research about the affirmative effects of those three CPA is summarized. Health research is needed about those CPA and their effects on health law, policy and regulation in the United States and other nations.

Lacy-Nichols and Williams provide important new insights into the ongoing contest over policy space and consumer behavior. I attempt to situate these insights in relation to government mandates and governance norms and situate these norms and mandates in the prevailing economic order. This approach is necessary to understand how corporate practices persist and why governments are receptive to the approaches outlined in the analysis conducted by Lacy-Nichols and Williams. This approach can help explain why governments are often receptive to corporations positioning themselves as ‘part of the solution’. Governments want strong economies and big food positions itself as contributor to this end. The point I attempt to articulate is that we often conceive of corporate power as power over, while I suggest that corporate power is rather power within and through a system that is oriented towards profits and economic growth.

In response to growing concerns about chronic diseases, food insecurity, low-wage food labor, and global warming, the food industry has developed new strategies to respond to its critics and pursue its business and political goals. As Lacy-Nicholas and Williams described in a recent review, the food industry has expanded its repertoire from opposition to critics to appeasement, co-option, and partnerships.1 Defining themselves as “part of the solution,” the food industry seeks to disarm its opponents, shift policy debates to favor its interests, or delay decisions that jeopardize its profits or power. This commentary explores how health professionals, can respond to this changing repertoire. Lessons from previous campaigns to control harmful industry practices,2 suggest that no single strategy will counter changing food industry efforts to achieve its goals. Thus, advocates must consider a portfolio of approaches that can be deployed in response to changing circumstances, industry tactics, and threats to health.

Lacy-Nichols and Williams’ examination of the food industry illustrates how it altered its approach from mostly oppositional to regulation to one of appeasement and co-option. This reflection builds upon this by using a commercial determinants of health (CDoH) lens to understand, expose and counter industry co-option, appeasement and partnership strategies that impact public health. Lessons learned from tobacco reveal how tobacco companies maintained public credibility by recruiting scientists to produce industry biased data, co-opting public health groups, gaining access to policy elites and sitting on important government regulatory bodies. Potential counter solutions to food industry appeasement and co-option include (i) understanding corporate actions of health harming industries, (ii) applying mechanisms to minimize industry engagement, (iii) dissecting industry relationship building, and (iv) exposing the negative effects of public private partnerships (PPPs). Such counter-solutions might help to neutralise harmful industry practices, products and policies which currently threaten to undermine healthy food policies.

This paper provides a commentary on Lacy-Nichols and Williams’ analysis of the emerging tactics of the ultraprocessed food transnational corporations (TNCs). Our paper provides an overview of the growth in power and influence of TNCs in the past three decades and considers how this change impacts on health and health equity. We examine how wealth inequities have increased dramatically and how many of the health harms are externalised to governments or individuals. We argue that human interests and corporate interests differ. The article concludes with a consideration of alternative ways of organising an economy that are more human centred and health promoting. We suggest five changes are required: improved measurement of economic outputs beyond gross domestic product (GDP); improved regulation of finance and TNCs; development of localised economic models including cooperatives; reversal of privatisations; making the reduction of economic inequalities a goal of financial policy. We consider the barriers to these changes happening.

This commentary discusses an article by Broekhuizen et al which assesses policy options for scaling up the SURG-Africa surgical team mentoring program in Malawi to increase access to surgical care. In modeling these scenarios, the authors assess the cost of scaling up surgical teams mentoring and the impacts of scaling the program on district hospitals (DHs) and central hospitals (CHs). The additional costs borne by DHs when increasing surgical volume remains a significant issue identified by the authors and could ultimately determine the success of the program. The piece indirectly advocates for an increased role for task-shifting. The Ministry of Health of Malawi will have to ensure the appropriate governance and regulatory processes are in place to maintain quality and accountability.

Nearly 60% of the world’s inhabitants lack access to timely, safe, and ffordable emergency and essential surgical, anesthetic, and obstetric (SAO) services when needed. Although acknowledged as an important step in resolving this disparity, situation analysis informed development of national surgical, obstetric and anesthesia plans (NSOAPs) has not been performed widely. There are even fewer published examples of NSOAP driven SAO system vulnerability resolving policy interventions, potentially hindering broader acceptance and drafting. Thus, there is urgent need for alignment of academic global surgery activities through a common framework for SAO strengthening intervention articulation, design and reporting which can be informed by the Malawian experience and others. This is a logical next step in the evolution of surgical system science as we move towards the articulation of actionable inequity resolving interventions through stakeholder engagement embedded in a plan-do-study-act (PDSA) model for iterative refinement of strengthening policies.

The development of models that allow improving the quality to achieve person-centered care is a challenge for any health system, especially in low- and middle-income countries, due to the economic difficulties inherent to the countries and to the cost involved in its implementation, which should be assumed by the states, avoiding that the economic burden is assumed by the population, and approaching the goal of universal health coverage. The availability of human talent and efficiency in the use of basic and specialized human talent is a necessity to improve safe access to health services, in this sense, the model proposed by SURG-Africa and whose sustainability in Malawi was evaluated, is an important reference for the establishment and sustainability of these models with other specialties and in other countries. Through this article, the elements of education, care model and financing for the implementation of the strategy in family medicine in the Colombian health system are explored.

Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article “Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands” by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study’s rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study’s findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation.