International Journal of Health Policy and Management
Volume:14 Issue: 1, Mar 2024

Many low- and middle-income countries are designing or revising their health benefit packages (HBPs), with appraisal—prioritizing services for reimbursement—being a critical phase. This occurs in a complex landscape of multiple criteria, multiple stakeholders, limited evidence, budget constraints, and tight timelines, varying across countries. Existing guidance documents do not fully address these complexities, requiring analysts to balance methodological rigor with practical constraints. This editorial highlights four key themes in organizing appraisal: decision-making structures, trade-offs between criteria, final recommendations, and the use of cost-effectiveness evidence, thresholds, and budgets. These emerged as central challenges in HBP revisions in Iran, Kyrgyzstan, Liberia, Pakistan, and Rwanda. We emphasize cross-country learning to address these challenges pragmatically, recognizing that high-quality, legitimate appraisal is as much an art as a science. More detailed documentation of appraisal processes is needed to refine HBP revision guidelines and strengthen priority-setting in health systems.

President Trump’s 2025 decision to remove the United States (US) from the World Health Organization (WHO), echoing his initial 2020 move, raises existential questions about the future of global health governance. This editorial explores the immediate and long-term potential impacts of the withdrawal, noting that it poses a significant threat to the WHO financing. This, in turn, will have adverse consequences for future pandemic preparedness, health inequities, and cross-border collaboration. We also explore the potential role of private philanthropies in bridging the funding gap, against the risk of shifting health priorities away from local needs. For the US, withdrawal means diminished influence on global health policies and weaker alignment with new international regulations. Moving forward, structural reforms within the WHO, equitable contributions from global powers, and renewed US involvement are essential to maintain strong health systems worldwide. Ultimately, a collaborative approach is necessary to uphold collective preparedness against emerging health crises.

Canada’s public healthcare system faces persistent challenges with waiting times. Prolonged delays lead to adverse physical and mental health outcomes, higher treatment costs, and economic burdens for patients and families. This editorial examines the drivers of extended wait times and policy responses at both provincial and federal levels. Contributing factors include systemic features of the Canadian healthcare system, such as shared federal–provincial jurisdiction, along with staffing shortages, population aging, structural inefficiencies, and poorly integrated health information technology. Provinces have introduced strategies such as digital health solutions, capacity expansion, workforce innovations (including Physician Assistants [PAs]), and expanded scopes of practice for pharmacists. At the federal level, a 10-year $196.1 billion investment announced in 2023 is supporting these initiatives. While such measures indicate progress, wait times remain a significant concern. Achieving equitable and timely access will require coordinated and sustained strategies that address systemic challenges and deliver long-term improvements.

Background  Public-private partnerships (PPPs) in the health sector are established to achieve health outcomes by maximising the combined resources of both public and private sectors. Good governance is core to PPP function and success. This paper explores the factors that enable and constrain governance in the delivery of PPPs for primary healthcare (PHC) in low- and lower-middle-income countries (LLMICs). Methods  A systematic search of four literature databases was conducted to identify peer reviewed articles published between 2000 and 2023 related to the governance of PPPs for PHC in LLMICs. A deductive analysis of data extracted from selected articles against the domains of Greer’s TAPIC (transparency, accountability, participation, integrity, and policy capacity) governance framework was conducted to identify commonly reported enabling and constraining factors.  Results  Of the 4290 records screened, 14 were included. Common enabling factors for governance within each domain of the framework were found: Transparency: unequal and top-down resource allocation, and opaque and resource allocation was a barrier to PPP governance; Accountability and policy capacity: monitoring and evaluation; Participation: partner engagement, covering topics of developing and managing relationships, collaborative activities, and communication; and Integrity: the design of the PPP, covering formal agreements between partners, level of policy direction, and integration within the broader health system. Conclusion  The five domains of the TAPIC governance framework provide guidance for considering governance in PPPs. The enabling factors identified in the review help facilitate the successful implementation of a PPP and thus influence the PPP’s impact on health outcomes, through establishing and maintaining healthy working relationships between partners, and defining and documenting systems and processes.

Background  Ensuring the quality and safety of service delivery extends beyond the realm of health and care professionals, necessitating collaboration among various stakeholders, including external regulatory organizations. The policy agenda of care regulators increasingly features the topic of service user involvement. Despite the extensive research on participatory healthcare, scholarly attention to service user involvement in regulatory practices has been limited. This scoping review delves into the landscape of service user involvement in the regulation of care services of all types and for all different age groups, examining the characteristics and focus of peer reviewed original research. In particular, it addresses a notable knowledge gap by examining how these studies report on the practical utilization of service user input, as well as the regulator’s perspective on service user involvement. Methods  We conducted a literature search in PubMed, Embase, CINAHL, APA PsycInfo, and Scopus from inception to July 14, 2023. Thirteen (n=13) empirical studies were included. Results  The underlying motives for service user involvement vary, ranging from legal imperatives and political pressure to enhancing institutional legitimacy and regulatory decision-making. Care regulators employ both reactive and proactive involvement methods. Empirical evidence delineates the challenges and benefits of service user involvement, highlighting concerns about bias, time investments, and the need for a distinct skillset for inspectors. Despite the valuable insights gained, there are instances where service user input is downplayed in practice. Conclusion  The findings underscore the importance of additional research on users’ preferences for involvement, optimal communication conditions to honor the collected input, and the challenges inspectors encounter in fostering meaningful involvement with service users. Addressing these challenges is crucial for aligning regulatory efforts with the genuine needs and experiences of services users.

  The 2023-2024 Gaza Genocide has generated notable scholarly discourse, influenced by various historical, political, and social contexts. These academic writings, rooted in the longstanding “war of words,” illustrate how language serves as a potent weapon in conflicts. The present study aimed to analyze the academic response to the 2023-2024 War on Gaza, focusing on the different perspectives, opinions, and lexical choices in scholarly articles. 

  A scoping review and bibliometric analysis were conducted on articles from PubMed, pertaining to the 2023- 2024 War on Gaza, spanning from October 7, 2023, to October 7, 2024. PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines were used. Individual relevant papers’ data were systematically extracted using a pre-tested form. Articles were categorized based on their stances as pro-Gaza, pro-Israel, or Neutral. Statistical analyses compared the bibliometric data of pro-Gaza and pro-Israel papers, identifying significant associated lexical fields. Factors explaining the different stances were uncovered. 

Out of 640 articles identified, 221 were included in the review. Among these, 126 (57%), pro-Gaza, 70 (31.7%), pro-Israel, and 25 (11.3%), Neutral. Pro-Gaza papers, often published in high-ranked journals with global affiliations, focused on humanitarian issues, called for a ceasefire and decried the genocide. Conversely, pro-Israel papers, often from local journals and affiliated with Israeli institutions, focused on political and psychosocial aspects, emphasizing selfdefense narratives. Terms independently associated with pro-Gaza positions included “Gaza” in the title, “occupation,” “genocide,” “punishment,” and “ceasefire.” Pro-Israel papers featured “Israel” in the title, references to “October 7,” and mentions of “Hamas.” 

This study highlights that academic narratives are profoundly influenced by historical contexts, media portrayal, official discourses, and the authors’ socio-political environments. These findings underscore the intricate connection between scholarly discourse and the broader context of chronic occupation, revealing significant limitations in current global health strategies and highlighting the need to integrate humanitarian crises into these frameworks.

The journey towards universal health coverage (UHC) began decades ago but has recently moved to centre stage in global health discourses with its inclusion in the Sustainable Development Goals (SDGs). As part of this renewed interest, 193 countries have committed to introducing UHC by 2030. However, its implementation often necessitates far-reaching health system reforms. This, coupled with the struggles countries face in relation to health financing, as well as distinct political, social and cultural contexts, means there are significant challenges to UHC implementation. This article contributes new knowledge to these discourses by identifying key contexts and mechanisms that facilitate the successful implementation of UHC reforms, as well as barriers that can impede progress. 

   This realist review identifies key contexts and mechanisms that can facilitate the successful implementation of UHC reforms. EMBASE, MEDLINE and Web of Science were searched (1995-2022), resulting in 957 articles with the protocol published through Prospero (PROSPERO 2023: CRD42023394427). Further theory-driven searches resulted in an additional 988 studies. Descriptive, inductive, deductive, and retroductive realist analysis aided the development of Context-Mechanism-Outcome Configurations (CMOCs), along with stakeholder engagement to confirm or refute results. Causal pathways, and the interplay between contexts and mechanisms that triggered outcomes, were revealed.  

   How each country goes about implementing UHC reforms depends on its context. Cohesion across all systems, as well as the functions of financing, governance and service delivery, facilitates these reforms. Implementation can also be facilitated through political commitment, communication between stakeholders in the public health system and the development of a strong primary care sector. Conversely, fragmentation across these functions pose significant barriers to UHC reforms. 

   Examining international experiences of UHC reforms supports learning around the mechanisms that support or hinder implementation processes. These learnings can empower policy-makers and health system leaders by providing roadmaps for reform implementation.

  The COVID-19 pandemic posed unprecedented public healthcare procurement challenges. The objective of this review was to identify and characterise the scope of the literature on public procurement strategies for healthcare supplies during the COVID-19 pandemic (2019–2023) in relation to the public procurement contexts, systems, and processes and methods (the public procurement ecosystem) worldwide. 

We performed a scoping review of governmental strategies for the procurement of medical equipment, personal protective equipment (PPE), or medications related to the COVID-19 pandemic. Extracted data were mapped to the fields of the public procurement ecosystem. We used inductive thematic analysis to derive within-field themes, and subsequently, cross-cutting themes through which we structured a narrative synthesis. 

  1909 unique studies were identified through a systematic search, of which 89 met the inclusion criteria. One hundred and ten themes were derived from the extracted data within the 21 fields of the public procurement ecosystem, and from these, 10 cross-cutting themes were identified which served to structure the narrative synthesis. It was clear in this literature that the scale and impact of the COVID-19 pandemic required governments to act well outside of the public procurement processes and methods themselves, to procure and distribute the required supplies. Notwithstanding the significant attention to contextual and system-level responses, there were significant responses at the procurement process and methods level, including rapid and temporary expedited procurement processes and longer-term strategic procurement responses. 

  This scoping review of public procurement strategies during the COVID-19 pandemic has demonstrated a focus of the literature not only on the public procurement processes and methods themselves, but also on governmental actions to adapt both structures of public procurement systems and conditions within broader environmental contexts to facilitate procurement goals.

Lean healthcare practices are widely used to enhance efficiency, quality, cost-effectiveness, and satisfaction in hospitals. However, no studies have synthesized their effectiveness across these dimensions. This review aims to address this gap by evaluating the impact of Lean implementation on four key themes: Efficiency, quality, cost, and satisfaction. 

  Four online databases were selected for the targeted articles: Scopus, Medline, PubMed, and Web of Science. Additionally, a comprehensive search was conducted using the Google Search Engine, along with a review of the citation list from the retrieved articles, to identify related grey literature and acquire additional articles. The search covered only the period from January 2019 to October 2024. The quality and research methodology of the articles reviewed were evaluated to determine the reliability of these findings. 

  A total of 6021 articles were screened, and 60 were included in this study. Our findings were grouped into four themes: (1) Efficiency: 49 studies identified 12 sub-dimensions of efficiency, with the most common variables being waiting time, length of stay (LOS), and patient volumes. (2) Quality: 12 studies reported quality improvements, covering 12 variables, with 30-day readmission rates, counselling sessions, and drug-related indicators being most prominent. (3) Cost: 17 studies examined Lean-driven cost reductions, with operating costs being the most frequently addressed variable, appearing in seven studies. (4) Satisfaction: Key satisfaction indicators included patient satisfaction, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, complaint rates, and nurse satisfaction.  

  This is the first review to synthesize the literature on the impacts of Lean implementation across four key themes, while also identifying existing gaps. It highlights the positive outcomes of Lean in hospitals and outlines the primary areas of improvement emphasized by healthcare institutions within each theme.

  This study aimed to systematically analyze the current research status, development trends, collaborative networks, and hot topics in the global cancer screening field using a bibliometric method. It sought to reveal the contributions and influences of different countries and institutions and explore potential directions for future research, providing a comprehensive basis for academia and policy-makers to optimize cancer screening strategies. 

  We searched the Web of Science Core Collection on October 15, 2023, using TS = (cancer screening) and DT = (Article), with no restrictions on the language or publication year. Only original research articles directly related to cancer screening were included; abstracts, comments, and non-research literature were excluded. VOSviewer was used for co-occurrence analysis to assess research status and hotspots. CiteSpace analyzed annual publication trends, collaboration networks among countries, institutions, journals, authors, and keywords. 

  A total of 5223 articles were retrieved, showing a continuous growth trend in annual publication volume. The USA had the highest output (2418), followed by the UK and the Netherlands. Harvard University was the most productive institution (183). Cancer published the most articles (120), while the New England Journal of Medicine had the most citations (7991). High-frequency keywords included screening (987), colorectal cancer (CRC) (783), mortality (680), women (671), and breast cancer (BC) (669). Cluster analysis revealed seven main research themes: CRC, cervical cancer (CC), lung cancer (LC), BC, cancer screening, human papillomavirus (HPV) vaccination, and lynch syndrome. Hot topics included LC screening and adherence. Future research may increasingly focus on artificial intelligence (AI) and deep learning (DL), aiming to introduce new technologies and optimize screening strategies to improve efficiency and early diagnosis. 

  Research on cancer screening is rapidly advancing, with the USA leading in productivity and influence. Current research mainly focuses on CRC, CC, LC, and BC.

There are relatively few studies that have measured and explained socioeconomic inequalities in the well-being of populations. Using unique information available in the 2019 Nova Scotia Quality of Life Survey (NSQLS, n = 9388), this study provides analysis of the determinants of socioeconomic inequalities in well-being of adults aged 18 and above in Nova Scotia, Canada. The population’s well-being was measured using the Canadian Index of Wellbeing (CIW), which encompasses quality of life across eight domains. The Concentration index (C) approach was utilized to quantify and identify factors explaining socioeconomic inequality in well-being. A positive value of the C (0.0294; 95% confidence interval: 0.0267 to 0.0321) indicated pro-rich inequality in well-being among Nova Scotian residents. Results of the decomposition analysis indicated that the concentration of favorable mental health, education levels, and income among high socioeconomic status (SES) groups accounted for over 86% of the observed socioeconomic inequality in the population’s well-being. Our findings demonstrated that inequalities in mental health, education, and income are significant obstacles to reducing inequality in well-being in Nova Scotia, Canada. Thus, policies aimed at alleviating inequalities in these factors may help to reduce socioeconomic inequality in well-being in Nova Scotia, Canada.

Alcohol taxation is a key policy to reduce consumption and alcohol harm but evidence on tax design and indicators to assess taxation policy are lacking. Tax design and two indicators: tax as a share of lowest retail price and affordability, were investigated in eight high-income and nine middle-income jurisdictions. Collaborators populated the International Alcohol Control (IAC) study online Alcohol Policy Tool, providing measures of tax design, tax rates; and typical lowest prices available for retail take-away alcohol. These data were used to calculate tax/share of retail price. Affordability of alcohol was assessed against gross national income (GNI) per capita. High-income jurisdictions had higher tax/share and higher affordability on average compared with middle-income jurisdictions. Over the sample as a whole there was no association between these two indicators of tax policy. The tax designs used also varied with high-income jurisdictions more likely to use specific excise tax reflecting potency and middle-income jurisdictions more likely to utilise ad valorem and specific volume based taxes and to use more than one method across a beverage. Increased alcohol taxation to reduce alcohol consumption and harm is established as a high impact policy and is believed to work by affecting affordability. However, less is known about the best taxation methods to reduce affordability or the best measures to monitor and compare alcohol taxation between countries and over time. In this sample of high- and middle-income jurisdictions tax/price share was not found to predict affordability, suggesting the need to further research indicators of alcohol affordability.

Civil society actors are widely recognized for advocating the public interest in health policy. However, their role in contributing different types of evidence to inform policy is less explored. To explore this topic, members of the Healthcare Information for All (HIFA) online forum and the Supporting Inclusive and Accountable Health Systems Decisions for Universal Health Coverage (SUPPORT-SYSTEMS) research project conducted a four-week online discussion. The discussion focused on defining civil society, its role in health policy, the types of evidence it provides, and how this evidence is used and valued. Weekly focal questions encouraged HIFA members to share experiences of civil society engagement and the use of evidence in health policy-making. The thematic analysis identified four key messages. First, defining civil society requires critical reflection, as actors differ significantly in their interests, political ties, and influence. These distinctions affect how representative their evidence is and whether it reflects vested interests. Second, policy-making structures can support meaningful civil society participation, thereby strengthening the use of evidence and the legitimacy of policy decisions. Third, civil society provides valuable local and tacit knowledge that complements scientific evidence, though safeguards are needed to prevent bias or misrepresentation. Fourth, political economy factors—such as power imbalances, gatekeeping, and funding constraints—shape the influence of civil society evidence on policy. Overall, the discussion highlighted the diverse roles civil society can play in health policy and the importance of institutional mechanisms to support responsible evidence use. Thematic discussions in communities of practice (CoPs) like HIFA offer a dynamic and inclusive approach to engaging stakeholder knowledge in research projects.

The number of drugs for orphan indications has been increasing significantly in Canada and the federal government recently announced an investment of $1.5 billion dollars over 3 years primarily directed at helping to fund the cost of these drugs. There are claims and counterclaims about what percent of Food and Drug Administration (FDA) orphan drugs are available in Canada and how delayed these drugs are in being approved by Health Canada. This study uses FDA and Health Canada databases and data from three health technology assessment agencies and one drug bulletin to provide objective data about the percent of FDA approved drugs that were also approved by Health Canada, any delays in Canadian approval and the additional therapeutic value of new orphan drugs. Decisions about what drugs should be publicly covered and how long it took to make those decisions were not investigated. From 1999 to 2022, the FDA approved 326 new drugs for an orphan indication and Health Canada approved 231 (70.9%) for the same indication. The median time between FDA and Health Canada approval was 346 days (interquartile range [IQR] 181, 785). The percent rated as major improvements declined from 50% of the total in 2004-2008 to 13.6% in 2019-2022. These findings need to be taken into account as Canada develops an orphan drug policy and decides on criteria for funding this group of drugs. Specifically, when high quality evidence about the additional therapeutic value of orphan drugs is not available at the time of approval, risk sharing funding agreements with manufacturers should be put in place. Manufacturers should understand that if the results of post-market trials do not provide convincing evidence of value, funding will be withdrawn. Finally, the quality of any research plan should be used to prioritize candidates for federal funding.

  There is increasing recognition of the role governments play in addressing the health and environmental sustainability challenges within current food systems. This study seeks to understand food system policies designed and/or implemented by selected national and local governments in Africa, and the barriers and facilitators faced when designing or implementing policies to create healthy and environmentally sustainable food systems. 

  From an evidence-based list of proposed policies with double- or triple-duty potential to achieve healthy and environmentally sustainable food systems, a policy mapping was performed in five African countries (Benin, Côte d’Ivoire, Senegal, Togo, and Uganda) and one city in each of these countries (Ouidah, Bouaké, Saint-Louis, Sokodé, and Mbale). Semi-structured interviews were then conducted with policy stakeholders. The interview data were analysed in NVivo 14 using the thematic framework analysis approach, informed by the Health Policy Triangle (HPT). 

  The mapping showed that African countries have designed and implemented policies that simultaneously address food insecurity and climate change, mainly through food production policies. Within food environments, countries are focussing on interventions to prevent obesity, mainly food provision or food pricing policies. However, many policy gaps remain. Several technical and political barriers were commonly experienced when designing and implementing food system policies, regardless of the jurisdiction, context or region, such as insufficient financial resources, lack of political will, limited data, and inadequate monitoring and enforcement mechanisms. The major facilitators perceived were supportive public opinion and awareness, international agreements, sound agenda-setting, multi-sector and multistakeholder consultations and partnerships, availability of both financial resources and data, and solid political will. 

  This article gives an overview of policies designed and implemented to achieve sustainable food systems, highlighting a strong focus through agriculture on undernutrition and climate change objectives. It also identifies their potential legislative, financial, and practical barriers and facilitators.

 Although care pathways are a response to the calls for a major change in health system redesign initiatives, very few articles have proposed an implementation method. Indeed, no method exists for large-scale projects of care pathways, as sets of interventions within health systems. Drawing on the systems thinking approach and the pragmatic sociology, we describe the implementation methodology of the Learning Care Pathways (LCP) framework, a method to implement, learn, replicate, and scale up care pathways for and with the patient.  

  The LCP was conceptually developed through a series of literature reviews on key methodological concepts. As a comprehensive, theory-informed approach, the LCP emerged by linking implementation strategies, research methods, learning mechanisms and outcomes dimensions aimed at optimising care pathways. 

  Designed around 13 steps grouped into five phases, this framework provides implementation strategies, research methods and learning mechanisms, including levers for patient involvement. The pre-implementation phase enables the selection of the pilot project’s receiving environment and the design of the project. The implementation phase is designed to co-construct and implement an optimised care pathway based on a scientific analysis of the patient journey, the care pathway perceived by professionals, the care pathway from data and integrating knowledge from international clinical practice guidelines. The post implementation phase aims to demonstrate value creation and set up a learning cycle. The replication phase is designed to repeat the method locally to develop horizontal learning and to evaluate scalability. Finally, the scale up phase aims to repeat the method in other territories to accelerate knowledge creation and develop horizontal and vertical learning. 

  This framework is of particular interest to policy-makers, healthcare managers, and researchers alike, and must be the subject of several experiments to conduct reproducible research that can lead to national Learning Health Systems (LHS).

  Cost-effectiveness (CE) is a common prioritization criterion in health benefits package (HBP) design. However, to assess CE is a time- and data-demanding process, so most HBP exercises rely wholly or partially on global evidence. Extensive investment has been made in analyses, models, and tools to support cost-effectiveness analyses (CEAs) for HBPs. However, little attention has been paid to how national HBP assessors should both understand and select CE estimates. A structured, national process to select assessment methods is essential for ensuring the accuracy, ownership, and transparency of HBP design. This can be supported by “adaptive” health technology assessment (aHTA) principles, which focus on structured methodological choices based on the time, data, and capacity available. The objective of this paper was to apply aHTA framing to CEA methods selection for HBPs, and to make recommendations on how countries may consider systematically making these choices going forward. 

  We first reviewed the definitions and categorization of different aHTA methods. We then conducted a scoping review of previous HBP assessments to understand how CEA methods used in HBPs fit into the aHTA framework, and a follow-up survey of authors to fill gaps. Results of the literature review and survey were interpreted and narratively synthesized. 

  We found that previous HBP assessments used four aHTA methods, sometimes simultaneously: expert opinion (n = 3/20), review (n = 12/20), model adaptation (n = 6/20), and new model (n = 2/20). The literature review and survey found that aHTA methods for HBPs take between 1-13 months; require different data sources depending on the method(s) used; and generally, require capacity in health economics, medicine, public health, and CE modelling. We supplement our report with a discussion of key considerations for methods selection. 

  Trading off time, data, and capacity needs for different CE assessment methods can help to support structured, local design of HBP assessments.

  Experiencing corruption when seeking health services remains a significant problem in Nigeria. An effective response requires knowledge of the individual characteristics of those impacted by corruption when seeking healthcare. This study examined the prevalence of corruption among those seeking health services in Nigeria’s public healthcare facilities and how it varies among different user groups. 

  We used a pre-tested interviewer-administered questionnaire to collect data from 1659 individuals randomly selected from households in two Nigerian states. We collected data on respondents’ socio-demographic characteristics and experiences of corrupt practices. We undertook descriptive and binomial logistic regression analyses. 

  Approximately 50% (823) of respondents experienced corrupt practices, such as using connections for faster treatment and bribery when seeking health services. 446 (27%) respondents bribed or made so-called unapproved payments to health providers to obtain health services. Gender was a strong predictor, with male healthcare service users being more likely to experience corrupt practices (%point risk difference = 24; 95% CI = 20, 29) and bribe or make an unapproved payment to obtain healthcare (%point risk difference = 20; 95% CI = 15, 25). Residents in the northern state were (%point risk difference = 30; 95% CI = 26, 35) more likely to experience corrupt practices than residents in the eastern state. People seeking healthcare in urban (%point risk difference = 09; 95% CI = -05, 08) and semi-urban (%point risk difference = 12; 95% CI = 05, 19) locations were more likely to have bribed or made ‘unapproved’ payments to healthcare providers compared to rural residents. 

  Health sector corruption, in its various forms, is frequently reported in both northern and southern Nigeria. However, user experience of corruption varies according to socio-demographic characteristics, and this is often insufficiently acknowledged. To combat corrupt practices in both health sectors, anti-corruption initiatives must be tailored to particular groups and settings, addressing specific disadvantages at individual and community levels.

  Successive government public health strategies in England have described structural influences of dietrelated ill health, including obesity, while emphasising the solution of individual-level change in policy documents. This entrenchment of an individualistic policy paradigm, despite communicating a recognition of structural determinants of health on paper, has been termed “lifestyle drift.” The 2020 government strategy, Tackling Obesity, included policies to address structural determinants of health like the physical and digital food environments but ultimately failed to shift responsibility for diet-related ill health onto structural factors. This study uses the contestation of calorie labelling (CL) in the out-of-home (OOH) sector, one of the strategy’s only two implemented measures, in English newspapers to investigate how the policy is framed, and the potential role of media framing in facilitating lifestyle drift. 

We systematically searched the Factiva database for articles from 12 UK national newspapers that discussed CL between January 2017 and May 2022, and assessed them relative to inclusion criteria. We then used a combination of reflexive thematic analysis (RTA) and framing theory to qualitatively analyse the framing of policy problems and the solutions meant to address them. 

A total of 177 articles met our criteria. We found that media framing often reinforced individualism, personal responsibility, and moralisation of behaviour. It also emphasised perceived mixed and inconclusive evidence of CL’s effectiveness, unfairness to businesses, and unintended consequences, including negative impacts on the economy and people living with eating disorders. 

Despite an initial shift towards framing interventions to address obesity through a structural lens in Tackling Obesity, CL legislation and accompanying news coverage reflected a drift back towards individualism. To enact effective, structural change to address diet-related public health issues, policy discourses and approaches need to move away from individualising and moralising framing of both public health problems and potential solutions.

Energy policies have a major impact on the health and well-being of the population. However, Australia’s energy policies rarely consider health and well-being in their policies. In Australia and in many other countries, energy policies, while developed by governments, are heavily influenced by commercial entities within the fossil fuel industry. This means that Australia’s energy policy does not reflect what climate science tells us is necessary for a safe climate. Australia’s environmental laws are insufficient to protect both nature and the environment. Environment and climate advocates have been urging the Australian government to strengthen these laws while industry, particularly the mining industry have been pushing to weaken them. This clearly demonstrates the strong intersection between commercial and political determinants of health.

Operational effectiveness is about improving what is being done, reducing errors and harms, and improving efficiency, while strategy involves making decisions and choices. Implementing value-based healthcare (VBHC) also means matching previous strategies and performance literature to guide building sustainable organizations in healthcare businesses. This commentary paper explores answers for: What does it mean to have a high-performance, sustainable, and impactful health organization By describing frameworks about leadership and social capital, this piece argues that the healthcare system’s sustainability involves making choices that set as a strategy implementing VBHC principles, cause implications on regulatory, organizational, and individual levels, and result in structuring systems that contribute to achieving high performance on improving population health. The argumentation suggests that achieving a high-performance, sustainable, and impactful health organization can be translated into positively impacting population health with financial accountability, and systems internal processes may serve as roads to achieve that impact on society.

McKee et al make a powerful plea for placing trust-building at the core of public health initiatives. I endorse that call and propose one general principle along with four practical guidelines for building trust between the public and the authorities. The general principle is that trust is rooted in shared identity and that, therefore, the task of building trust is rooted in building a sense of shared identity both amongst the public and between the public and authorities. The four guidelines are (1) trust the people!; (2) recognise and respect difference; (3) engage with the public; and (4) understanding and support trump blame and punishment. Details and justifications for each of these guidelines is provided in Supplementary file 1.

Quality metrics for improving care are deeply embedded in healthcare systems. Patient-reported measures (PRMs) have now been implemented for many conditions and are a high priority for the Centers for Medicare and Medicaid Services (CMS).1 However, the development of PRMs specific to diagnostic quality remains largely exploratory. Early progress in acquiring and analyzing diagnostic PRMs reveals that patients offer a novel and valuable source of information about their diagnostic journeys. To fully understand and learn from patient experiences, work needs to include varied clinical settings, sites, and conditions. This work requires and deserves focused commitment and coordinated effort with a unifying strategic vision optimally facilitated by a national, or international, coordinating center.

Labonté offers important critical optimism around the idea of a well-being economy, which is gaining considerable international momentum and offers a much-needed alternative to the current political economic paradigm of neoliberal capitalism and its significant social and ecological consequences. Because of its focus on systems and structures that constitute “root causes” of poor health and health inequities at the population level, a well-being economy aligns strongly with stated tenets and value commitments of public health. It thus provides an important opportunity for public health communities to engage and mobilize as a collective around this important vision. For this to happen, however, public health communities must overcome a reluctance to engage with political economy and take seriously the field’s commitment to the public’s health. In this commentary I reflect on these opportunities and challenges in the Canadian public health context.

Impacts of integrated care interventions, particularly on utilisation and financial outcomes, can be mixed, sometimes quite disappointing when compared to expectations. Positive deviants come along occasionally, but it is extremely difficult to unpick exactly why one intervention might “work” where others have not. Choi and Yoo evaluated a programme in Korea, which appears to have increased time older patients discharged from hospital spend at home, reduced their odds of a subsequent emergency admission, and decreased total expenditure, although re-admissions increased. The programme stands out particularly in its breadth of non-traditional care activity, home-based primary care and long-term (social) care services, but also broader activities such as nutrition support (eg, meal delivery), movement assistance, lifestyle education, housekeeping, and even home repair. In this commentary, I discuss this broadening of interventions to capture more social determinants of health, ask where boundaries of each sector/ service should lie, and who should pay for what.

  Integrated care systems (ICSs) in England were formally established in July 2022 to coordinate the planning and delivery of health and care services. A key responsibility was to address the quality of these services. Our study aimed to examine how ICSs approach this responsibility and to identify opportunities and barriers experienced in their early establishment and development. 

  A sample of four ICSs were recruited to participate. Interviews and meeting observations were undertaken in two phases (before and after the inception of ICSs) around 12 months apart. A total of 112 interviews were carried out with senior figures in the four ICSs supplemented by observation of relevant meetings and analysis of relevant documents. 

  Regarding quality, ICSs demonstrated several new ways of working. They set-up new structures for quality governance and created whole-system strategies for quality centred on major responsibilities regarding population health and health inequalities. These strategies required new and relevant metrics to assess quality and outcomes and a greater focus upon co-production in the development of services. They aimed to strike a fine balance between longstanding requirements for quality assurance and new responsibilities for quality improvement (QI). New approaches were underpinned by new collaborations between system partners extending beyond healthcare to include Local Authorities (responsible for social care and public health) and local communities. 

  To address the many challenges of quality, ICSs have created new ways of working cultivating different kinds of collaborative relationships compared to established hierarchical, siloed and top-down ways of working prior to their formation. A focus on improving population health and reducing inequalities has required a shift from “here and now” urgent problem-solving to working with longer timelines. Such changes require patience in the context of political pressure to devote efforts to more salient problems such as waiting lists.

  Over 80 countries have now signed up to the COP26 Health Programme—a World Health Organization (WHO)-led initiative on climate change and health—of which 45 countries have committed to reaching net zero emissions before 2050. Efforts to reduce healthcare’s carbon footprint raise conceptual, ethical and practical challenges for efficient and fair resource allocation. This study investigates how civil servants leading the development and implementation of national net zero healthcare strategies conceptualise the responsibility of health systems to cut emissions and describe potential trade-offs along the way. 

  We undertook 11 online, semi-structured qualitative research interviews between September 2022 – May 2023 with civil servants leading national net zero healthcare strategies. The interview guide explored three main areas: responsibility for emissions, priority setting and international perspectives. Interviews were coded and analysed the data using Malterud’s systematic text condensation (STC). 

  Four main themes emerged: obligation to act, leadership, governance, and prioritization. Participants described that the healthcare system should take responsibility for its entire carbon footprint, including harms inflicted beyond national borders. We also found indications of synergistic, multi-scalar health leadership—clinical, civil service, and political—helping to accelerate the net zero healthcare agenda. Participants generally rejected the notion of direct “tradeoffs” between efforts to reduce emissions and patient care, emphasising ways net zero healthcare can leverage societal health improvements more broadly. These empirical findings inform the emerging literature exploring how health systems should account for their environmental impacts. 

  Our findings highlight the sincerity of ambitions to deliver net zero healthcare and uncertainties on how to get there. Further work characterising the types of constraints and trade-offs policy-makers face on the path to net zero healthcare systems, including examples of how these have been overcome, could help integrate climate concerns into healthcare decision-making and resource allocation processes.

  As public policies have the potential to change the entire system of physical activity (PA) promotion and to create conducive environments, they are particularly relevant to address the persistently low levels of PA across the world. Furthermore, World Health Organization’s (WHO’s) Global Action Plan on Physical Activity highlights the relevance of local governments as important partners for policy action. However, our knowledge on how local PA promotion policy compares across countries remains limited. 

  We conducted an exploratory study as part of the LoGoPAS project to compare the status quo of local PA policies across five municipalities in five different countries. Using purposive sampling, Jyväskylä (Finland), Nice (France), Erlangen (Germany), Fujisawa (Japan), and Cluj-Napoca (Romania) were selected. Data were collected and analysed via desk research and expert consultation using the CAPLA-Santé, a validated tool designed to assess relevant aspects of local PA promotion policies. 

  The analysis showed that the main responsibility for PA promotion varied between municipalities, resting either with the sport or the health sector. A total of 50 relevant PA policy documents were identified, focusing on multiple settings and target groups. Budgets for PA promotion differed across municipalities. Research on PA was reported to have informed policy development in some but not all cases. Across countries, political support was identified as a key driver of local PA promotion. 

   LoGoPAS is the first study to apply the CAPLA-Santé outside of France and the first to use it for an international comparative analysis. Results highlight the ability of the tool to provide insights into local PA policy development, contents, and implementation worldwide. While this study provided a cross-sectional in-depth analysis of the status quo in select municipalities, future research could also aim to assess policies at a large scale, ie, for multiple municipalities and/or on a regular basis.

  The participatory approach in policy construction is a historical debt to communities. An example of the above is the definition that Colombian Indigenous communities give to mental health or spiritual harmony. Spiritual harmonies are a collective good that implies being in harmony with the spirit and with thought, which is why it is related to the community context, with the territory, identity, autonomy, spirituality, worldview, diverse cultural uses, practices, and customs. The objective of this study was to analyze the process of building a mental health recovery path with multiple community representatives in a Colombian territory. 

  Through a co-production method based on Participatory Action Research, focus groups were developed with representatives of children, youth, indigenous peoples, migrant populations, as well as government sectors such as health, education, and decision-makers in the territory. This study was carried out in 2023 in the District of Riohacha, Colombia, in the last quarter of 2023, within the framework of the construction of a mental health route, led by the District Mayor’s Office. Fifty-nine people participated in the focus groups. 

  The necessity of living in safe and supportive environments was emphasized. The route built with the community was based on the definition of the necessary steps to generate a real approach to the context and their perceptions of well-being, mental health and spiritual harmonies. Three main themes were identified: (1) Mental health: a construct of well-being, care and identity, (2) Barriers to an integral approach and ideals of joint construction, and (3) The proposal for a comprehensive mental health route. 

  Co-productive methodologies strengthen community autonomy and empowerment, and make the implementation of mental health programs more feasible. In public policies, it is increasingly necessary to have communities that are strengthened in the production of knowledge and in the proposals for implementation.

  Smart health and senior care services have developed rapidly to cater to the aging society, but the corresponding regulations are not perfect. The platform and senior care service enterprises have chosen different strategies due to various factors, resulting in disorderly platform development and inefficient resource allocation. This research attempts to establish a regulatory mechanism to promote the active development of the platform.  

  In order to mitigate opportunistic behaviors in the smart health senior care service platform, drawing from evolutionary game theory, this study establishes a decision-making model involving the government, the platform, and senior care service enterprises, and scrutinizes the evolutionary behaviors and equilibrium strategies of these three parties. 

  There are five equilibrium points among the three parties in the game, and the strategy selection shows periodic changes. The cost and level of positive government regulation, the conversion rate of smart aging construction services provided by the platform, penalties for opportunistic behavior by the platform, as well as the benefits of positive cooperation and penalties for passive cooperation by senior care service enterprises, will significantly affect the strategies of all parties involved. 

  The research results indicate that establishing a regulatory mechanism for the smart health senior care service platform can promote effective cooperation between platform and senior care service enterprises. Active government regulation is the key to the smooth operation of the platform. Through quantitative analysis, the main strategic choices of participants in the smart health senior care service platform can be explained. This model can provide a reference for formulating policies related to smart senior care.

  Achieving universal health coverage for maternal health (MH) requires a health system that ensures the availability, accessibility, acceptability, and effective use of services. The study aimed to identify bottlenecks that hinder project outcomes of MH in the rural districts of Tanzania. 

  This study employed a convergent mixed-method approach to conduct the bottleneck analysis. Quantitative data were collected to identify indicators of MH utilization, with source including Tanzanian health statistics, health facilities and the women in reproductive age (WRA) survey. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with WRA, their families, community health workers (CHWs), and healthcare personnel (HP) to gain insight into factors influencing healthcare utilization from both a demand and an environmental perspective. Following the Tanahashi steps, the quantitative data were analyzed using descriptive statistics and the qualitative data were analyzed using a thematic approach. The findings from both were integrated to identify bottlenecks toward effective coverage and how bottlenecks affected the utilization of MH services. 

  Community awareness and acceptance were observed to be high, however only a limited number of individuals had received MH services. Utilization rates for antenatal care (ANC) and postnatal care (PNC) were 17.4% and 22.0%, respectively. This suggests that efforts to enhance awareness may be inadequate to change social norms and lead to health behaviors. Furthermore, even when women utilize the service, they may not do so in a timely or consistent manner due to low service quality or unsatisfactory experiences. 

  To strengthen the logic model, contextual factors such as provider attitudes, service quality, supportive family, and community climate need to be considered to ensure that WRAs are satisfied with and continue to access services. With building supply-side infrastructure, ongoing efforts to change stakeholders’ perceptions of MH services and utilization patterns will be needed to improve the coverage of MH services.

  Public health is a core governmental responsibility, with ministries or departments of health responsible for setting and ensuring adherence to standards, managing performance and instituting reforms as required. Although North Queensland (NQ), Australia has a well-developed health infrastructure, the COVID-19 pandemic exposed significant vulnerabilities in its public health surveillance and response system. Globally, research has highlighted how human and cultural elements (“system software”) influence the effectiveness of infrastructure, governance, and data systems (“system hardware”). This study examines the interaction between these elements to examine specific governance challenges and opportunities for strengthening communicable disease surveillance and response in NQ. 

Using an embedded case study design, we analysed four disease units—COVID-19, tuberculosis (TB), arboviruses, and sexually transmitted infections (STIs)—through interviews (n = 47), document review, and observations across NQ health services (October 2020–December 2021). Data were mapped against Sheikh and colleagues’ hardwaresoftware framework to examine the nature of governance bottlenecks in this region of northern Australia. 

Two key governance challenges emerged: (1) Accountability deficits—Hospital and Health Services (HHSs) lacked clear reporting or performance monitoring systems within Queensland’s devolved health service governance model, contributing to inconsistent prioritisation of resourcing for communicable disease functions by health service leadership. Within HHSs, public health units (PHUs) faced systemic underfunding, with prevention services accounting for as little as 0.1% of some health service budgets. (2) Data governance failures—Fragmented, siloed data systems, restrictive datasharing norms, and risk-averse culture hindered coordinated surveillance and response efforts. Weak interoperability and mistrust in data-sharing partnerships further compromised system effectiveness. 

This study highlights how political, normative, and structural factors shape public health performance alongside the more commonly assessed functional and technical dimensions. Findings suggest the need to improve performance monitoring systems, leadership, and data governance to build an effective, accountable, and data-driven surveillance and response system in NQ.

As global aging increases, health inequalities are becoming more prominent. The purpose of this study is to examine whether increasing the level of fund pooling of the New Rural Cooperative Medical Scheme (NRCMS) helps to improve health and health inequalities among older adults. 

Data from four periods of the China Longitudinal Healthy Longevity Survey (CLHLS) in 2008, 2011, 2014, and 2018 were used, the population for this paper was a sample of the older adults participating in the NRCMS. A sample of 955 treated participants and 13 477 control participants were included in the analysis after excluding samples with missing information. Time-varying difference-in-differences (DID) model was used to analyze the impact of the NRCMS Provincial Pooling Policy (NRCMS-PPP) on participants’ health and health inequalities. 

The results of the study showed that the NRCMS-PPP had a significant effect on the self-rated health (SH) (estimated coefficient = 0.149, P < .01) and health relative deprivation index (HRDI) (estimated coefficient = -0.018, P = .02). Further exploration of the heterogeneous effect of it revealed that implementation is more effective in improving the health and reducing health inequalities for older population with primary education or living in rural areas. The mediation mechanism suggests that NRCMS-PPP partially mediates through total out-of-pocket medical expenses (TOME) and catastrophic health expenditure (CHE). 

The NRCMS-PPP reduces the probability of the older adults experiencing CHE and reduces their burden of disease costs, thus improving their health and reducing their health inequality. Policy effects vary in terms of educational status and areas of residence.

Excess mortality provides a comprehensive measure to assess the true impact of the disease on mortality rates. This study aimed to quantify excess mortality attributable to COVID-19 in northeastern Iran during the pandemic period (2020–2022). 

This population-based cross-sectional study utilized population and mortality data extracted from electronic systems linked to Mashhad University of Medical Sciences (MUMS). Data analysis was conducted using R Version 4.3.3. A log-linear model was employed to predict expected deaths during the two-year pandemic period, incorporating predictor variables such as the year of interest, the presence of COVID-19, and the population size for each respective year. Excess deaths were calculated as the difference between the expected and observed mortality. Furthermore, by considering the confirmed deaths directly attributed to COVID-19 and the difference between these and the excess deaths, the number of indirect deaths during the pandemic was determined. 

The total count of recorded deaths from all causes exceeded the expected deaths by 31.15% (6750 cases) in the first year and 44.74% (10 078 cases) in the second year. The excess deaths were 1.48 and 1.79 times greater than the official reports of COVID-19 for the first and second years, respectively. It was also found that men experienced increased rates of excess deaths in each of the two years. Moreover, urban residents experienced higher rates of excess death in the same years. Based on cause-specific excess mortality, following infectious diseases, cardiovascular diseases (CVDs) accounted for the largest proportion of excess deaths in both years of the pandemic. 

The overall mortality burden during the COVID-19 pandemic exceeded the official reports, highlighting the undercounting of the number of direct effects and emphasizing the significance of indirect effects. These findings underscore the importance of preparedness and organization of healthcare systems prior to a pandemic.

Pharmacoeconomic evaluations are becoming more important in China, and their research quality directly impacts government decisions, deserving extra attention. To summarize the quality of pharmacoeconomic publications for China compared to internationally and to identify areas for improvement both from a China-specific and international perspective.

First, we conducted a systematic review of pharmacoeconomic publications for China, with subsequent reporting quality assessment based on the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Second, we conducted an umbrella review of pharmacoeconomic publications internationally which used a similar quality assessment. We extracted the CHEERS checklist scores for each study and converted them to percentages to facilitate comparison of results.

CHEERS 2022 instrument was used to evaluate the quality of 154 pharmacoeconomic publications by Chinese scholars. Across these articles, the average quality score was 61.0%, indicating a moderate level of quality on average. There were 27 (17.5%) high-quality articles, 85 moderate quality articles (55.2%) and 42 low-quality (27.3%) articles. Out of 28 scoring items, those included in the methods section such as: health economic analysis plan, characterizing heterogeneity, characterizing distributional effects, approach to engagement with patients and others affected by the study, got low scores. In addition to the generally lower scores of international articles on items 9 (Time horizon), 18 (Characterizing heterogeneity) and 24 (Effect of uncertainty), Chinese articles also scored lower than international articles on items included in the methods and other relevant information section, eg, health economic analysis plan, perspective, discount rate, analytics and assumptions, characterizing distributional effects, approach to engagement with patients and others affected by the study, source of funding, and conflicts of interest.

The quality of China’s pharmacoeconomic publications has been improving year by year since the establishment of the National Healthcare Security Administration (NHSA) in 2018, but there is still a quality gap with similar international publications which requires further focus and improvement in study conduct and reporting standards for the evidence-base to be sufficient for health technology assessment (HTA).

The National Volume-Based Procurement (NVBP), implemented in China in 2019, aims to reduce patients’ economic burden by lowering drug prices and promoting the use of NVBP drugs in public hospitals. We evaluated the impact of NVBP on medical expenditures among hypertensive patients, analyzing both the overall impact and variations in policy effects across individual hospitals. 

Using medical records from 1.17 million hypertensive patients across 82 hospitals in Tianjin (2017-2021), we conducted an interrupted time series analysis to assess expenditure changes among hypertensive patients for the treatment of hypertension, dyslipidaemia, type 2 diabetes, and chronic ischemic heart disease (IHD). Multilevel model was employed to estimate the overall impact and hospital-specific variations in policy effects. 

NVBP implementation significantly reduced per-visit outpatient expenditures among hypertensive patients for the treatment of hypertension (-15.61%), dyslipidaemia (-25.77%), and diabetes (-17.59%) by lowering drug expenditures. Although drug expenditures for chronic IHD decreased, non-drug expenditures increased, leading to no significant change in total expenditures for chronic IHD (-8.97%). For inpatient expenditures, no significant changes in total per-admission expenditures were observed for chronic IHD or diabetes hospitalizations. Drug expenditures for diabetes decreased significantly, but diagnostic expenditures increased, while no significant change was found in chronic IHD drug expenditures. At the individual hospital level, significant variations in policy effects were observed. Despite the overall decrease in outpatient expenditures for the treatment of hypertension, dyslipidaemia, and diabetes, only 45.6%, 67.2%, and 46.3% of hospitals, respectively, showed significant decreases, while the remainder exhibited either non-significant changes or increases. 

NVBP effectively reduced outpatient expenditures among hypertensive patients for the treatment of hypertension, dyslipidaemia, and diabetes, suggesting its potential to alleviate patients’ economic burdens. However, the increases in non-drug expenditures and substantial variations in policy effects across hospitals highlight a room for further improvement in policy implementation and overall effectiveness.

Blantyre city is among the jurisdictions in Malawi with the highest rates of people living with HIV and new HIV infections, driven by numerous structural factors. The Malawi National AIDS Commission hypothesized that local elected officials may be uniquely positioned to understand and address structural drivers of HIV infection in their communities. However, these leaders have been disengaged in HIV prevention efforts over time. This formative study aimed to explore city councillors’ understanding of the HIV landscape in Blantyre, including structural drivers of HIV, and to identify opportunities for engaging elected city councillors to address these drivers. 

 Between November-December 2021, we conducted a descriptive qualitative study in Blantyre city, involving 59 purposively sampled participants: 23 city councillors, 14 technical experts, 7 implementing partners, and 15 community leaders. Data were collected through in-depth interviews and analysed thematically using MAXQDA software.  

HIV technical experts and implementing partners were generally knowledgeable about the current HIV epidemic in Blantyre while most councillors and community leaders were not. Nearly all participants referenced structural drivers of HIV transmission in the city, including migration between districts, poverty, substance abuse, and transactional sex. Councillors noted their successes in mobilizing people and identifying resources for projects. However, they reported limited knowledge and training in HIV, no involvement in related programmes in their wards, and had minimal access to HIV data. They suggested access to trainings and data would equip them to better engage with HIV programs.  

Elected leaders in Blantyre have limited access to HIV data and training. However, they demonstrate well-established relationships with ward residents and possess motivation and interest in enhancing their knowledge and capacity to address structural and other drivers of HIV infection—key factors for designing interventions for local leaders.

The study aims to determine adults’ interest in weight loss methods and their predictors such as anthropometric parameters, physical activity, and sociodemographic factors. 

A two-step procedure was adopted. First, anthropometric parameters of 1130 Polish adults were taken, and the body mass index (BMI), the waist-to-hip ratio (WHR), and the body fat (BF) percentage were calculated. Next, the participants completed a questionnaire consisting of questions about their interest in different weight loss methods, questions about physical activity, and metric questions. Interest in six arbitrarily selected weight loss methods was measured using a five-point Likert scale. For analysis ordinal logistic regression and omnibus likelihood ratio tests were used. 

The results proved different predictors of adults’ interest in weight loss methods (measured on an ordinal scale). More interest in physical activity and diets as methods of weight loss is observed in underweight individuals (compared to normal body weight status), older, with better economic situation, and higher level of physical activity individuals. In the case of bariatric surgery and liposuction, more interest in this weight loss methods are observed in overweight (compared to normal body weight status), economically well-off participants, and in women (compared to men). More interest of liposuction as a weight loss method is observed in overweight. Interest in dietary supplements to support weight loss (DSSWL) is more in women (compared to men), higher WHR, better economic situation, higher level of education and older individuals. More interest in weight loss drugs is observed in women (compared to men) and economically well-off people. 

The key predictors of interest in weight loss methods are body weight status, gender, and economic situation. These vary in importance depending on the type of weight loss method. Healthcare providers should recommend various weight-management strategies, having regard for the level of interest in weight loss methods and their predictors.

Value-based procurement (VBP) is gaining traction in healthcare. This approach to procurement prioritizes obtaining the best health outcomes for patients while considering overall healthcare costs. Despite its recognized potential, VBP remains underutilized in hospitals. Little is known about the barriers and enablers of VBP in hospitals. This study aims to identify barriers and enablers specific to VBP in hospital procurement, utilizing the Theoretical Domains Framework (TDF). 

This qualitative study comprises semi-structured interviews with 20 Dutch purchasers working at hospitals. The interviews aim to capture diverse perspectives on VBP, with the data undergoing an extensive coding and analysis process. Using redefined domains of the TDF, themes for barriers and enablers are identified. 

We explored the significance of broader barriers and enablers while also pinpointing new and distinctive ones specific to VBP in a hospital context. The newly identified barriers encompass challenges in procurement skills, low strategic priority, environmental context and resources, stakeholder influences, and outcome expectations. Noteworthy barriers include a cost saving focus, resistance to change, influence of the health insurer, and supplier preferences by end-users. Enablers involve stakeholder commitment, positive buyer-supplier relationships, effective storytelling, and demonstrated effectiveness of VBP. Stakeholder influence emerges as an important enabler, emphasizing the importance of the early involvement of medical specialists and other key stakeholders, overcoming resistance and fostering collaboration during VBP adoption in hospitals. 

VBP in healthcare prioritizes optimal patient outcomes and value over costs. Although this is a promising concept, we identified several barriers and enablers for implementing VBP. While facing barriers related to procurement skills and environmental context, successful implementation relies on, among other things, training and stakeholder involvement, including early involvement of key stakeholders such as medical specialists and healthcare insurers, ambassadorship, trust-building, and effective storytelling.

The increasing utilization of high-cost drugs with multiple indications poses significant financial challenges to healthcare systems worldwide. This study evaluates the financial impact of expanding drug indications in Korea, focusing on pharmaceutical expenditure trend. 

This study analyzed claims data from the National Health Insurance Service (NHIS) to examine drug characteristics and annual expenditure. Interrupted time-series analysis assessed monthly expenditure changes following indication expansions. 

We analyzed 57 drugs that expanded their indications between 2012 and 2023. From 2012 to 2022, drug expenditures increased 15-fold (compound annual growth rate [CAGR] 30.8%), a significantly larger rise compared to the 1.9-fold rise (CAGR 6.5%) in total pharmaceutical expenditures covered by the NHIS. Notably, expenditures increased 35-fold for 35 drugs classified under anatomical therapeutic chemical (ATC) code L (antineoplastic and immunomodulating agents) and 375-fold for 26 drugs with risk-sharing agreements (RSAs). Interrupted time-series analysis (n = 27) demonstrated significant monthly expenditure increases before expansion (US$ 0.33 million per month, P = .000). There were significant increases in expenditure between the pre- and post-expansion period (US$ 4.99–5.64 million, P = .000). Moreover, post-expansion trends showed significant additional increases in expenditure: US$ 0.13 million per month (P = .003) at +24 months and US$ 0.07 million per month (P = .037) at +36 months.  

Despite price reduction strategies for multi-indication drugs, expenditure accelerated increase in expenditure post-expansion of indication. This highlights the need for robust post-pricing management for listed drugs. In the long term, a total budget system could ensure predictable and sustainable financing by providing clear financial boundaries within the health insurance budget.

Child restraint systems (CRS) can lead to a 60% reduction in child deaths, yet few low- and middle-income countries (LMICs) have comprehensive policies to enforce best practice standards. In 2019, the Philippines established such a policy: the Child Safety in Motor Vehicles (CSMV) Act. 

Drawing on framing theory, this study aims to understand the social dimensions of policy change to identify the Act’s origins, design, and implementation. Three sources of data – 25 articles, 27 key-informant interviews, and field notes – were collected and thematically analysed. 

We present the findings according to two features of the framing process: storytelling and naming. The policy process can be sharply distinguished into two sections: the Act’s passage into law (which was swift and successful) and its implementation (which to date has not been). The Act’s implementation was stymied by three overarching frames – that it is “anti-poor,” “unnecessary,” and a “strategic political distraction.” A media backlash at the time of implementation solidified these frames, leading President Duterte to indefinitely defer enforcement of the Act. 

The CSMV Act emphasises that passing a law is insufficient. The trajectory of the act highlights the combined importance of (a) the framing of policy, (b) framing processes operate throughout a policy’s lifecycle, and (c) the media in creating a narrative. Our findings offer valuable insights for other LMICs implementing evidence-based road safety measures, suggesting that successful implementation requires not only strong legislation but also strategic communication and frame management throughout the policy process. Understanding framing dynamics can help policy-makers anticipate and address potential resistance to life-saving public health interventions.

This study aimed to develop an analytical framework to investigate the key motivators influencing family physician team members (FPTMs) in delivering integrated care at the primary healthcare (PHC) level within urban China. The objective was to identify critical factors based on cause and effect relationships, with the ultimate aim of enhancing the integration of primary care and public health services.  

A mixed-methods design was implemented, integrating thematic analysis and the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method. Data were gathered from semi-structured interviews with 24 participants, comprising FPTMs and administrators from Wuhan, Shenzhen, and Shanghai, collected between January and July 2022. The thematic analysis facilitated the construction of an initial framework of motivators, while the DEMATEL method was employed to examine and map the interdependent relationships among these motivators. 

The analysis distilled 64 first-order concepts into 15 second-order themes, which were then categorized into four broader dimensions: Government agencies, PHC institutions, family physician teams (FPTs), and residents. Motivators at the government level, such as resource allocation and the development of information technology (IT) infrastructure, were identified as proactive forces driving change. In contrast, resident-level factors, including trust and adherence, were more reactive, shaped by external conditions and responsive rather than initiators of change. 

The findings emphasize the pivotal role of government leadership in fostering the adoption of integrated care. Key strategies include enhancing interdisciplinary team collaboration, optimizing performance evaluations, and refining incentive structures to boost FPTMs’ motivation. Equally important is the need to encourage residents to engage in proactive health management, promoting a collaborative care model that integrates both FPTMs and the communities they serve.

Current economic evaluations (EEs) of precision medicine (PM) often adhere to generic reference cases (RCs) which overlook the unique healthcare paradigms of PM. This study aimed to develop an RC to standardize the conduct and reporting of EEs of PM. 

A working group comprising 5 core health economists, 22 PM experts, and research staff from Singapore, Thailand, the Netherlands, UK, and Australia who were actively engaged in EE and clinical PM implementation. The RC development comprised four stages: (1) Expert consultation shaping the RC’s scope and structure across nine domains: Population, Intervention, Comparator, Cost, Outcome, Time, Equity and ethics, Adaptability, and Modelling (ie, “PICCOTEAM” framework); (2) A comprehensive literature review on current PM EE approaches and challenges; (3) Obtaining expert consensus and drafting recommendations; (4) A workshop for RC refinement based on stakeholder feedback on relevance and feasibility. Following an experts’ workshop, consensus was reached to tailor PM recommendations for screening, diagnosis, and pharmacogenomics, market-access, and early EEs. 

The PICCOTEAM RC offers 46 recommendations for conventional EEs to guide PM reimbursement, emphasizing expert engagement, iterative study processes, disease-specific outcomes, decision uncertainty analyses, and equity considerations. Additionally, 30 recommendations are provided for early-stage evaluation to enhance PM’s positioning and value proposition, mitigating uncertainty, equity, and ethical issues. 

The PICCOTEAM RC offers a standardized process to conduct and report diverse PM EEs. This will serve as guidance for health departments, researchers, clinicians, editors, and reviewers. Pilot testing and continuous updates are recommended for ongoing relevance and applicability of this RC.

Government budget allocation (GBA) and social health insurance (SHI) constitute the primary revenue sources for public hospitals in China, with GBA accounting for a substantially smaller proportion compared to SHI. Starting in 2015, a megacity in southern China gradually introduced payment reforms. GBA, previously based on government approved number of staff (input-based), was replaced with an output-based model. Subsequently, SHI payment method was changed from fee-for-service (FFS) to case-based payment.  

The study adopted a staggered difference-in-differences (DiD) model to assess the effects of reforms on service volume and capacity, as well as hospital efficiency. We used hospital-level panel data of 29 hospitals in the city from 2009 to 2022.  

The GBA reform increased annual outpatient visits by 301 374 per hospital (P < .01) and promoted efficiency (score increase of 0.02, P < .05). In contrast, the SHI reform increased annual inpatient discharges by 2417 per hospital (P < .05) but had no significant effect on efficiency (-0.15, P > .1).  

The output-based GBA reform increased outpatient service volume and the number of healthcare professionals, while the case-based SHI reform raised inpatient discharges. Only GBA was associated with a modest efficiency gain given the distinct incentives of GBA and SHI. Future research should explore strategies for better alignment of multiple funding streams, such as unified purchasing with blended payment models or clearer functional differentiation.

The vision to create “Healthy Societies” is a reiteration of “Health for All” first made in the Declaration of Alma-Ata almost half a century ago. We contend that this long journey is due to “Socio-Political Inertia” that has prevented societies from transforming even in the presence of enabling policies. The analysis of policy documents by Nambiar et al could help set the stage for understanding how best to advance healthy societies, but the aspirations expressed in documents require active engagement and implementation to enable societal change. We first draw inspiration from the convergence of multiple streams in Kingdon’s model in exploring how to chart the journey toward healthy societies. We then argue that the vision of healthy societies should be articulated in ways that speak to the different societies that will own it and build coalitions to turn this vision into reality.

The pursuit of healthy societies has long been a global aspiration, yet the pathways to achieving them remain fraught with challenges. The paper “How to Build Healthy Societies: A Thematic Analysis of Relevant Conceptual Frameworks” provides an insightful thematic analysis, identifying key policy levers and enablers necessary for transformative change. This commentary critically examines the paper’s approach, highlighting the need for a more profound engagement with political and economic structures. Additionally, the commentary highlights the role of civic engagement and evidence-based policy-making in overcoming systemic inertia. Ultimately, achieving healthy societies requires a paradigm shift—one that moves beyond technical solutions towards an equity-driven and justiceoriented framework.

Even in situations where there exists robust evidence on what works and what needs to change to tackle deep-seated and persistent public health challenges, the lack of sustained progress across polities globally remains a cause for concern. Adopting a political economy perspective to better understand why the adoption and implementation of policies to tackle non-communicable diseases (NCDs) continues to be deficient, Loffreda and colleagues’ systematic review of facilitating and inhibiting factors sheds valuable light on the subject. The adoption of a political economy approach is long overdue since it gets to the nub of identifying enablers and barriers to change and how to tackle the latter while strengthening the former. However, whether such an approach will be welcomed by policy-makers or be rejected merits further exploration if research is going to stand any chance of being heeded and acted upon.

Nambiar and colleagues in this journal identify the main conceptual frameworks offered by public health on how to build healthy societies, drawn from key documents published over a span of 50 years. In their analysis they point to strengths and limitations of these frameworks and offer suggestions for their improvement. In this commentary, I argue that both the frameworks on offer and Nambiar and colleagues’ critique are missing important perspectives on well-being itself, on the role of the democratic State, and on the “community arena” and the “policy arena” as two related but distinct arenas for political and social change toward healthy societies.

Taxonomies are essential tools for structuring evidence in public health, particularly in rapidly evolving fields like the Commercial Determinants of Health (CDoH). Ulucanlar et al addressed an important gap by proposing taxonomies to systematically document and classify corporate political activity (CPA) across unhealthy commodity industries. In this commentary we reflect on the broader relevance of these frameworks for CDoH research and discuss their real-world applicability through a case study of the Portuguese alcohol industry. Drawing from our empirical findings, we highlight both the practical strengths and challenges we encountered, and propose an additional use: employing CPA taxonomies as communication tools to translate complex corporate strategies into accessible narratives for broader public health audiences. Finally, we identify opportunities for refinement, including developing complementary quantitative metrics and the integration of CPA surveillance into routine public health systems.

Over a decade has passed since the World Health Organization (WHO) proposed a set of “best buys” for the prevention of non-communicable diseases (NCDs). Loffreda and colleagues’ review describes how, despite the costeffectiveness of these interventions, their adoption is often complex and governments face many challenges in both implementing and maintaining NCD prevention policies. Industry opposition and the commercial determinants of health (CDoH) remain significant challenges to an effective NCD response. In addition, the best buys may operate inequitably and are often unable to respond to the interrelated challenges posed by the global syndemic of obesity. We suggest that the next revision of the best buys adopts a more integrated approach that prioritize structural interventions, equity-focused strategies, and mechanisms to counteract industry interference.

Green practices have become the responsibility of healthcare system in the current warming planet. The article by Soares and colleagues reviews the literature on circular economy implementation in the European Union (EU) and its application in healthcare system. In this commentary, we complement the findings by discussing ways to build a greener healthcare system and introducing life cycle assessment (LCA), a method to quantify the environmental impacts of products and services in healthcare. LCA is useful to compare the environmental impacts of different clinical products and pathways. Within the healthcare system, avoiding overdiagnosis and overprescribing, improving building energy efficiency, and fleet electrification are important green practices. In addition, we cannot ignore the differences in regional energy system when comparing the carbon footprint of different healthcare systems.

Health system resilience in the context of economic sanctions (ES) is an underexplored area. We used data from recent studies on the impact of ES on the health systems to cross-reference and assess the applicability of the conceptual framework of health system resilience (CFHSR). Reviewing the interventions implemented under ES and aligning them with the CFHSR and COVID-19 responses, we found that the CFHSR domains encompass most strategies from the ES and COVID-19 studies. However, CFHSR does not cover several strategies related to equity and teamwork. Additionally, monitoring the consequences is missing from the experiences of COVID-19 and ES. The CFHSR appears to be reasonably effective in categorizing strategies for both COVID-19 and ES. Nonetheless, its domains can be further refined. Specifically, incorporating an intersectional equity lens could enhance this conceptual framework. The next step is to develop a practical guide to apply CFHSR to strengthen health system resilience.

The World Health Organization’s (WHO’s) non-communicable disease (NCD) Best Buys provides a comprehensive package of technically sound policy advice in response to the growing global burden of NCDs. However, despite these policy mechanisms being touted as beneficial to countries’ health and economic bottom lines, uptake has remained slow and globally disparate. Loffreda and colleagues’ analysis draws attention to the importance of political economy forces in shaping governments’ responses to NCDs and, in particular, their uptake of the NCD Best Buys. In building on this work, we examine the history and instances of contemporary application of the NCD Best Buys to consider the limitations of these technocratically framed policy recommendations. In doing so, we highlight the risks present in focusing on the technical – while negating the contextually nuanced political – dimension of policy adoption. We thus advocate for greater political engagement in policy design and implementation as well as a revitalised “doubleloop” approach to NCD policy learning, where policy and system feedback is not solely used to reify policy advice but rather interrogate the assumptions underpinning such.

Patients often experience long journeys within the healthcare system before obtaining a diagnosis. Though progress has been made in measuring the quality of diagnosis, existing measures largely fail to capture the diagnostic process from the patient’s perspective. McDonald and colleagues’ paper presents 7 overarching goals for the use of patientreported measures (PRMs) in diagnostic excellence and presents visual roadmaps to guide the development, implementation, and evaluation of these measures. To accelerate the real-world use of PRMs, organizations should initially prioritize the use of patient-reported metrics that are already in development, such as patient-reported experience measures. Pairing PRMs with artificial intelligence (AI) techniques, such as “diagnostic wayfinding” (a dynamic diagnostic refinement process that also includes analysis of electronic health record data and metadata to characterize the diagnostic journey), should also improve diagnostic performance. Ultimately, combining PRMs with technological advancements holds the potential to achieve true co-production of diagnostic excellence.

There is a growing interest in complexity research. A recent systematic review by Loffreda et al attempted to study the barriers and opportunities for the adoption and implementation of the “best buys” for non-communicable diseases (NCDs) from a political economy perspective. In this commentary we take forward the discussion on the NCD best-buys by comparing the findings of the article with one of the risk factors of tobacco use and its control in India. We reflect on the challenges in actualizing the promise of research methods and approaches while studying such complex interventions like the NCD best buys. The balance of studying complexity while still keeping the findings translatable at country levels. Future research could potentially use a comparative lens focusing on either industry/ government or actor behaviour across the different risk factors to facilitate cross learning, anticipate and pre-empt adverse policy decisions and implementation outcomes.

Determining the effects of devolution policies through health system financing is pivotal in understanding their impact. Few existing studies have considered total health and care system expenditure, overlooking the transfer of resources through spending in different services locally. We evaluated the impact of devolution in Greater Manchester (GM), an area in England which received devolved health and social care powers from 2016, on the whole system of local public expenditures on health and care. 

Using data on public health and care spending for 149 local health systems between 2013 and 2020, we estimated synthetic difference-in-differences (DiD). We compared expenditure in total and by services for ten GM localities relative to a weighted combination of localities from the rest of England (excluding London) for four years post-devolution. We analysed expenditures in per capita terms and as a share of total expenditure. We investigated dynamic effects with an event study specification. 

Compared with the synthetic control (SC) group, total annual expenditure on health and care increased in GM post-devolution by an average of £66.58 per-capita (95% CI: 11.85 to 121.30). Total expenditure on public health and social care, managed by Local Authorities, increased by £36.39 (95% CI: 6.99 to 65.80) and expenditure on social care specifically increased in the third and fourth years after devolution. We detected some short-term changes in expenditure managed by the National Health Service (NHS) Clinical Commissioning Groups (CCGs), including reduced expenditure on Continuing Healthcare and increased expenditure on acute healthcare and “other” miscellaneous expenditure. We did not detect a statistically significant effect for public health, primary care, community or mental healthcare. 

Results suggest that additional resources were used to respond to existing pressures on the health system, and that to redirect expenditure substantial increase in resources or re-organisation of services may be required alongside devolution of sufficient powers.

To support policy development, a number of tools are available to inform policy-makers about the current status of physical activity (PA) promotion in a specific country. However, a recent exchange between policy-makers and researchers in Germany revealed two major gaps: First, examples of successful good practice projects are often not selected in an objective and systematic process. Second, there is usually no systematic assessment of “routine practice,” ie, PA promotion activities already taking place on large scale and regular basis. These issues are addressed by the newly developed TARGET:PA tool. 

The TARGET:PA tool was developed in a co-production process involving researchers from the World Health Organization Collaborating Centre for Physical Activity and Public Health (WHO CC) at FAU Erlangen-Nürnberg and the policy unit in charge of cardiovascular diseases, diabetes and non-communicable diseases at the German Ministry of Health. We documented the development process, details on the structure of the tool itself, and the outputs produced using the tool. 

The development process involved a negotiation process between researchers and policy-makers and the need to adapt to extended decision-making timelines within the ministry. With regard to PA behavior at the individual level, the TARGET:PA tool includes an overview about (1) PA recommendations and (2) national PA prevalence rates. At the organizational/policy level, it contains information on (3) recommendations for PA promotion, (4) routine practice, (5) good practice projects, and (6) policies. Key outputs of the tool are policy briefs as well as scientific background documents. 

The TARGET:PA tool provides added value as it can support the integration of “good” and “routine” practices into the monitoring of PA promotion. While the tool has been developed and tested in Germany, it has the potential to be adapted to other countries, either by directly utilizing the tool or by emulating the collaborative development process to design new instruments adapted to specific contexts.

Improving nutrition is a global priority for food systems transformation. The introduction of policy measures across multiple sectors relevant to food systems is critical to this transformation. However, integrating measures to improve nutrition into food system policies across multiple government sectors has proved challenging. 

A theory-informed qualitative policy analysis was conducted to identify enablers and barriers of “cross-sectoral” policy action for nutrition in government sectors related to the food system. The analysis drew on interview data (n = 43) with policy-makers at global, regional, and national level, in diverse policy sectors, who had experience of engaging successfully across food system policy sectors to improve nutrition. 

Success in cross-sectoral policy related to the achievement of nutrition objectives in a way that also enabled achievement of other sectoral objectives, and involved strategic and constructive policy engagement across sectors. Challenges included the need to overcome diverse sectoral mandates and norms, siloed structures of governance, and fluctuations in political interest to engage effectively across sectors for policy change. Key enablers of cross-sectoral policy for nutrition included: supportive institutional structures, such as platforms for engagement, mandates and incentives; ideas that facilitated constructive engagement between policy sectors, including a shared vision, a long-term approach and effective framing; discursive approaches to engagement that balanced multiple interests across policy sectors; and ongoing learning. 

This analysis provides new insights to strengthen policy engagement and design more effective capacity building for nutrition policy-makers. This includes “soft skills” that enable effective engagement across sectors and strategic approaches to managing diverse interests influencing policy.

In their study, Shikako et al analyzed how national policies during the COVID-19 pandemic either supported or neglected the rights of persons with disabilities, aiming to inform the development of inclusive policies that align with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). They concluded that the differences in policies across countries during the COVID-19 pandemic indicate a need for greater alignment and standardization of policy responses for individuals with disabilities. While the study revealed disparities across countries and underscored the importance of disability-inclusive policy, this commentary provides actionable insights to guide governments in creating equitable policies that uphold the rights of persons with disabilities during crises and beyond. Specific recommendations in accordance with the UNCRPD include the establishment of permanent consultative committees, adopting a shared understanding of disability, addressing intersectionality and structural barriers, and utilizing non-ableist participation methods so that a diverse range of perspectives are incorporated and lived experiences shape the policies that impact them.

This commentary piece on the editorial piece by Eivind Engebretsen and Mona Baker entitled “The Rhetoric of Decolonizing Global Health Fails to Address the Reality of Settler Colonialism: Gaza as a Case in Point” explores the interconnected contexts of settler colonialism affecting health in occupied Turtle Island (also known as Canada) to Palestine. Addressing true and authentic health equity work means sharpening our politics and rhetoric beyond decolonizing “global health” as epistemically colonial and towards meaningful solidarity work and framings of liberatory or revolutionary health. There is a moral obligation to contextualize and historicize, rather than depoliticize. This ultimately means supporting through unwavering solidarity for collective liberation through the Indigenous resistance and resurgence movements in Turtle Island to Palestine if we are serious about decolonizing global health. Moving towards rhetoric and actions for collective liberation must be the focused goal of all who care deeply about true and authentic health equity work towards just and life-affirming systems for health for all.

Coproduction is not a new idea in implementation research, health research, or research in general. There is substantial scholarship that establishes its importance and provides guidance and examples for adoption. Given this, why do editorials like Rycroft-Malone and colleagues’ recent paper, “Research Coproduction: An Underused Pathway to Impact,” continue to be published, and also, necessary In this commentary, we discuss the importance of equity—not equality—as the underlying paradigm of coproduction research. We argue that it is the incomplete understanding and adoption of this equity paradigm by researchers and their institutions that inhibit coproduction from being fully realized and thus, impactful. We offer examples of what such a paradigm shift might look like, including futures thinking that yields difficult questions that must be addressed to dismantle systemic barriers to power redistribution.

In his recent editorial, Professor Labonté1 surveyed international initiatives calling for a well-being global economy. Most of these initiatives offer glowing visions but implausible theories of change. The 1974 United Nations call for a New International Economic Order (NIEO) provides a case study of an earlier instance of well-being economics (although not labelled as such). The NIEO included specific institutional and regulatory initiatives directed to achieving a fairer and more liveable world. However, it was defeated through the rise of neoliberalism from the 1980s as well as internal contradictions within the movement for a NIEO. The history of the NIEO provides useful lessons regarding the political dynamics of global transformation. Any policy initiatives, directed towards reforming the global economy for the well-being of people and planet, need to be based on a robust theory of change.

In this commentary I aim to contribute to Ronald Labonté’s recent editorial “Can a Well-Being Economy Save Us” on the role of well-being economies in providing for everyone’s needs within the limits of our planet. In particular, I add a couple of lessons from the COVID-19 pandemic that can provide the required inspiration to plot a path beyond capitalism – one that is based on hope that change is possible, one where our understanding of well-being is detached from economic growth, one where demand and excess are challenged and one where we go beyond the market to meet our needs.

Shikako et al analysis highlights that needs of persons with disability (PwD) were often overlooked, with policies primarily focused on general population health measures rather than specific accommodations for PwD. This commentary suggests adopting universal design principles in policy development to ensure inclusivity and advocate for maintaining services essential for PwD even during crises. It emphasizes the importance of involving PwD in policy-making processes and enhancing data collection for better policy analysis and concludes with recommendations for creating more inclusive policies, stressing the need for international collaboration and the integration of PwD needs into all policy levels.

Rycroft-Malone et al.’s editorial on research co-production highlights the potential of a coproduction mode of research to narrow the gap between knowledge production and use. This commentary critiques implicit assumptions within the argument and challenges the view that traditional (Mode 1) science bears the primary responsibility for delayed implementation and questions the inherent superiority of co-production. It also highlights the importance of political and policy considerations in considering research uptake. ‘Mode 3’ knowledge production (integrating Modes 1 and 2 discovery) offers a potentially more advanced framework that recognizes systems and organizational perspectives. A deeper, multi-layered exploration of the influence of socio-political and policy contexts is needed to understand the full potential of co-production on knowledge utilization.

McDonald and colleagues’ paper on “Achieving Diagnostic Excellence: Roadmaps to Develop and Use Patient-Reported Measures With an Equity Lens” describes seven goals for using patient-reported measures (PRMs) to promote diagnostic excellence and describes roadmaps to plan the development and implementation of PRMs. Incorporating more patient voices into diagnostic measurement and measure development can improve the patient-centricity of processes and outcomes. Additionally, organizations beginning their measure development journeys may find road-mapping tools helpful, especially the focus on setting goals and engaging stakeholders. However, the authors do not offer suggestions for prioritizing measure concepts for development, and the long timeframes of the examples may dissuade some organizations from engaging in measurement to begin with. Real-world examples of measure development processes and potential applications of emerging technologies are important complements to aspirational roadmap goals and processes.

This commentary elaborates on the model proposed by Miranda et al for implementing remote patient monitoring (RPM) from an integrated care perspective. It stresses the complexity of RPM deployment as a digital health technology (DHT) and discusses essential features that developers and procurement managers should take into consideration in RPM systems to facilitate the implementation of integrated care practices. Furthermore, three major challenges for DHT implementation that align with the proposed RPM-based integrated care model are discussed: (1) the success of DHT in implementing a healthcare strategy requires elements of service innovation that align to the context of care delivery; (2) evidence generation methods influence the adoption of DHT and need an evolutive and multi-stakeholder perspective; (3) governance and policy strategies are crucial since they profoundly influence digital health priorities, investments, and resource allocation within organizations and healthcare systems.

This commentary is in response to the paper titled “A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development” by Schneider et al. This well-done policy content analysis identifies key themes and transferable principles to guide policy development for musculoskeletal health. In this commentary, I argue that the findings of this policy analysis should be used to develop global policies within the current framing of non-communicable diseases (NCDs), especially considering the growing burden of multimorbidity. The second point concerns the application of the building blocks framework and limitations in the use of the framework. Lastly, in this paper, I miss the needed emphasis for a global health policy that specifies primary healthcare and universal health coverage for a life course approach and an equitable response.

This article builds on Engebretsen and Baker’s editorial to explore recent developments in medical neutrality, the depoliticization of healthcare, and political intervention in the context of the war in Gaza. We examine how international health organizations have increasingly, though insufficiently, taken a political stance, criticizing the detrimental structural forces affecting Palestinians’ life and health. Concomitantly, many Israeli healthcare professionals and organizations have shifted from a declared neutral stance to endorsing the state’s official narrative. Additionally, we analyze the connections between settler colonialism, Israeli and US policies, medicine, and international health organizations. While the discourse of decolonization provides valuable historical context for understanding the ongoing oppression of Palestinians, it often obscures critical issues, particularly the atrocity of the October 7 attack. We conclude by discussing the shift from literal denial to interpretive and implicatory denial, emphasizing the role of international health professionals and organizations in confronting these pervasive forms of denial.

This commentary commends Milsom et al for their critical and rigorous application of qualitative system dynamics to unpack corporate power in food policy-making. Their use of Critical Realism, best practice qualitative methods, and feedback loops exemplifies the maturation of system dynamics applications in public health research. We reflect on how their work aligns with broader debates about power and social theory in system dynamics and how it offers a blueprint for trustworthiness and reflexivity in qualitative modelling. Drawing on our team’s work with Aboriginal communities in Australia, we highlight the value of culturally grounded, participatory modelling in amplifying the voices of communities experiencing historical and ongoing oppression. We support the authors’ call to advance toward simulation modelling and stress the importance of engaging with both system dynamics and communitybased knowledge to realise the transformative potential of systems-informed, community-led research in reshaping food policy and practice.

Value-based healthcare (VBHC) has emerged as a widely embraced strategy to address pressing healthcare challenges, including workforce shortages, rising healthcare costs, and inconsistent care quality. A scoping review by van Elten et al shows that despite their expected importance of integrating VBHC with performance management systems, very few articles provide concrete examples of this integration. Drawing on existing performance management literature, the authors explore possible reasons for why VBHC practitioners and researchers have largely overlooked this topic. This commentary critically engages with their review by examining their conceptual definitions, offering alternative explanations for the apparent lack of performance management in VBHC, and suggesting directions for future interdisciplinary research.

McDonald and colleagues’ work “Achieving Diagnostic Excellence: Roadmaps to Develop and Use Patient-Reported Measures With an Equity Lens” emphasizes the critical role of patient-reported measures (PRMs) in achieving diagnostic excellence, with a focus on equity. PRMs capture patients’ experiences, symptoms, and concerns throughout the diagnostic process, enhancing accuracy and addressing uncertainties. In contexts like maternity care, PRMs have been applied to reveal and reduce communication gaps and alleviate anxiety, offering crucial support for improving diagnostic experiences and outcomes. This commentary explores the application of McDonald and colleagues’ visions and roadmaps to prenatal diagnosis, specifically focusing “prenatal screening and testing” (PreST), a complex process where diverse patient populations face challenges in understanding and responding to sequential test results. Tailored diagnosis-related PRMs can provide healthcare providers with tools to enhance shared decision-making, equitable communication, and patient satisfaction, leading to more inclusive and personalized diagnostic pathways.

In their study on which we provide commentary, the authors applied a qualitative systems dynamics methodology to explore how transnational corporate power has led to policy inertia in the prevention of diet-related noncommunicable disease (RD-NCD) in South Africa. This commentary explores the potential of systems thinking and causal loop diagrams to deepen understandings of – and responses to – the commercial determinants of health (CDOH). We reflect on the application of causal loop diagrams in policy processes and provide reflections that proposed strategies for change will need to take into account recent shifts in global discourse, funding streams and the balance of global power.

This article comments on the paper by Stadhouders et al titled “Measuring Active Purchasing in Healthcare: Analysing Reallocations of Funds Between Providers to Evaluate Purchasing Systems Performance in the Netherlands.” Its main aim is to respond to the fact that the paper, without discussion, assumes that competitive reform stimulates the efficient allocation of funds. To achieve this goal, this article discusses existing knowledge related to the author’s assumption, highlighting that there is no uniform theory regarding the capacity of market forces to regulate healthcare markets. It also argues that market-based healthcare reforms may be very risky in countries with limited state regulatory capacity and widespread corruption.

Stadhouders et al critically examines the assumptions behind managed competition, revealing that competitive systems alone may not drive efficiency gains through fund reallocation. Their findings from the Dutch hospital sector suggest limited or low reallocation of funds between providers and highlight the need for monitoring resource allocation progress, understanding barriers and adjusting incentives for better functioning healthcare markets. For low- and middle-income countries (LMICs) undergoing health reforms, the Dutch experience underscores the importance of tailoring purchasing models to local contexts. LMICs should enhance data use for more strategic decision-making as well as building regulatory framework and institutional capacity for stronger implementation. Future research should explore how purchasing models interact with diverse health system characteristics to inform system-specific reforms.

Stadhouders and colleagues’ new measure answers an important question: Do strategic purchasing and managed competition redirect healthcare resources, and, if so, when, how, and to what Applying it to the Netherlands, they find that they do not. This commentary first examines logical problems in arguments for strategic purchasing and managed competition, and then briefly reviews other evidence of their very limited success from, in particular, the Netherlands and England. It then raises the question of why strategic purchasing and managed competition continue to be advocated despite the poor logic of the arguments behind them and substantial evidence that they do not work.

The healthcare sector is both a guardian of health and a significant contributor to global carbon emissions and environmental degradation. In their scoping review, Soares et al explore the applicability of circular economy (CE) principles within healthcare facilities, identifying eight areas for intervention. While their work provides a valuable synthesis, this commentary highlights future points of interest such as vulnerable populations, a call to broaden governance frameworks, and to move from an overly Eurocentric to a more global scope. Low- and middle-income countries (LMICs) face major barriers to implementing CE models in healthcare, including weak policy frameworks, a lack of holistic recycling chains, awareness and training, as well as limited incentives. Stronger government leadership is needed to develop CE policies, foster multi-sector collaboration among private investors, governments, academia, non-governmental organisations, and international partners. Drawing on public health and child health perspectives, and informed by work in net-zero hospital initiatives, this commentary argues for a more transformative, equitable, and globally inclusive vision of circular healthcare. Organisations like Health Care Without Harm (HCWH) can support implementation through technical expertise, advocacy, and capacity-building.

The analytical model proposal by Ulucanlar et al for the analysis of corporate political activity (CPA) establishes that corporate actors are aware of the high incidence of non-communicable diseases (NCDs) associated with their products and protect themselves against the consequences. This model helps to identify the strategies used by various corporate entities to influence public policies and protect their interests. The CPA analytical model applies a critical approach to commercial determinants of health that allows us to understand how corporate actors take advantage of their systems-based management of power. Due to its inherent complexity, this analysis presents several unanswered questions requiring along with theoretical and empirical challenges. The situation described in this commentary points to the importance of monitoring the CPA at a global and local level, identifying opportunities that favor the regulation of political influence, to reduce the influence of the commercial determinants of health on the NCDs.

The intersection of healthcare sustainability and clinical practice presents complex challenges in implementing circular economy (CE) principles. This commentary examines Soares and colleagues review of green practices in healthcare facilities while identifying significant gaps in the current discourse. While healthcare facilities are adopting sustainability measures like renewable energy and efficiency improvements, the implementation faces significant operational challenges, particularly in embedding environmental considerations in the clinical decision-making and care delivery process. The analysis discusses that overdiagnosis and low-value care contribute substantially to healthcare’s environmental footprint, exemplified through screening cases that demonstrate the delicate balance between clinical necessity and resource utilisation. We emphasize the need for context-specific approaches that acknowledge operational realities and stakeholder diversity within healthcare governance. We advocate for an integrated approach that places health outcomes at the center of climate initiatives, recognising that public health interventions must equally consider environmental impacts. Ultimately, we call for a paradigm shift that moves beyond siloed environmental initiatives toward systemic integration that complements rather than competes with clinical responsibilities.

Unhealthy commodities industry actors use different practices, including political practices, to influence policy-making in industry-friendly ways that may result in increased ill health and health inequalities. Ulucanlar and colleagues formulated a comprehensive evidenced-based model and taxonomies to study the corporate political activities of unhealthy commodity industries. This commentary reflects on the process of applying these taxonomies to the study of lobbying of ultra-processed sugary food and drink industries in Chile, a country from the global south that faced strong opposition during the discussion and implementation of legislation to create healthier food environments. The taxonomies were a useful tool to identify and classify the different claims and actions used by ultra-processed sugary food and drink industries when lobbying Chilean authorities. However, there were some challenges in their use that need to be considered when using these taxonomies in similar settings.

The article by Nambiar et al reviews the literature on the influence of policies from outside the health sector, proposing Policy Levers and Enablers to enhance their positive contribution. The regulatory and fiscal lever has a central role, but it should be better articulated with the set of vectors of good governance. Intersectoral action is a complex but necessary axis of work. And it is necessary to change the way of measuring progress and social well-being, but the purpose exceeds the scope and legitimacy of the health sector. In a hostile political environment, it would be advisable to draw up more defensive strategies to defend achievements and avoid setbacks.

This commentary discusses the study by Stadhouders et al, which analyzes budget reallocations among Dutch healthcare providers as a result of one form of active purchasing. The study assumes that healthcare purchasers aim to shift substantial funds from inefficient to efficient providers, yet finds little evidence of such shifts. This commentary explains more explicitly why substantial volume shifts are not and should not be a major factor in the Dutch context, citing factors such as the scarcity of underperforming providers, strong regional dependencies, data quality limitations, and patient reluctance to change provider. More promising avenues for active purchasing include fostering active collaboration and improving contractual arrangements.

This commentary discusses the study by Remers et al. The authors analysed the impact of the Dutch DementiaNet programme on hospital admissions and healthcare costs for individuals with dementia. Using detailed claims data of over 38 000 insured individuals, the study found that participation in DementiaNet networks was associated with fewer hospital admissions and care days, as well as reduced hospital costs. Furthermore, participation in DementiaNet was linked to increased outpatient healthcare expenditure, while overall healthcare costs remained stable. This commentary seeks to place the findings within health economic theory. It posits that DementiaNet could reduce information asymmetries, transaction costs and disincentives in dementia care. Through its network- and primary care–based approach, DementiaNet plausibly improves care coordination, which might enable earlier interventions. This could account for the shift in costs from inpatient to outpatient care. Additionally, the commentary addresses methodological considerations, limitations, and directions for future research.

Corporate political activities of unhealthy commodity industries have been identified and categorised in terms of framing and action strategies. This commentary discusses the relevance of systematically and comprehensively applying these taxonomy models to other commercial determinants of health, with special attention to their joint activities and health implications. The social media industry is an especially relevant case to be analysed due to its direct and indirect health effects, namely those associated with digital marketing of unhealthy commodities, mis and disinformation, and social polarisation. Interferences in research, lobbying, and corporate social responsibility actions are examples of the strategies used by this industry to prevent and obstruct regulators’ efforts, limiting the control of the marketing of unhealthy products, the spread of mis/disinformation, and the promotion of violent speech and attitudes.

This paper situates Choi and Yoo’s study within broader sets of policy challenges related to rapid increases in numbers of older people in need of long-term care (LTC). These challenges include a need to fundamentally transform health services and to develop fully integrated systems of health and LTC for older people. The paper argues that Korea’s Integrated Pilot Project (IPP) is a key step in this direction, along with similar interventions in Thailand and Brazil. Choi and Yoo’s study adds to a wider body of evidence that these interventions enhance health system efficiency at the same time as improving the lives of older people and their family caregivers.