Changing roles of universities in the era of SDGs: rising up to the global challenge through institutionalising partnerships with governments and communities.

The 2030 Agenda for Sustainable Development covers a wide range of interrelated goals, including poverty eradication and economic growth, social inclusion, environmental sustainability and peace for all people by 2030. Policy decisions to meet the Sustainable Development Goals (SDGs) need to be informed by policy-relevant evidence co-designed and co-produced with the pertinent stakeholders, taking into consideration local and political contexts. Universities are uniquely placed to lead the cross-sectoral implementation of the SDGs and advance the 2030 agenda. This commentary provides the case for building, strengthening and institutionalising university partnerships with governments and communities to achieve the SDGs. The authors call for a change in mindsets and culture in both academia and government, and invite both parties to start the dialogue if we are to rise up to the global challenge.

Contractual health services performance agreements for responsive health systems: from conception to implementation in the case of Qatar.

OBJECTIVE: Despite their use worldwide, strategy-based performance management is limited in the Eastern Mediterranean Region. This article explores Qatar's experience, the first from the Region, in implementing contractual agreements between healthcare providers and the regulator-Ministry of Public Health-to align strategy, performance and accountabilities. DESIGN: mixed-methods including tools development and pilot-testing, guided by performance management cycle with a focus on knowledge translation and key principles: feasibility; mandatory participation; participatory approach through Steering Committee. SETTING: All public, private and semi-governmental hospitals and primary healthcare centers. INTERVENTION(S): (i) semi-structured interviews; (ii) review of 4982 indicators; (iii) Delphi technique for selecting indicators with > 80% agreement on importance and > 60% agreement on feasibility; (iv) capacity-building of providers and Ministry staff and 2-month pilot assessed by questionnaire with indicators scoring > 3 considered valid, reliable and feasible; and (v) 1-year grace period assessed by questionnaire. MAIN OUTCOME MEASURE(S): Approach strengths and challenges; Data collection and healthcare quality improvements. RESULTS: Contracts mandate reporting 25 hospital and 15 primary healthcare indicators to the regulator, which delivers confidential benchmarking reports to providers. Scorecards were discussed with the regulator for evidence-informed policymaking. The approach uncovered system-related challenges and learning for public and private sectors: providers commended the participatory approach (82%) and indicated that contracts enabled collecting valid and timely data (64%) and improved healthcare quality (55%). CONCLUSION: This experience provides insights for countries implementing performance management, responsive regulation and public-private partnerships. It suggests that contractual agreements can be useful, despite their mandatory nature, if clear principles are applied early on.

Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries.

BACKGROUND: Systems Thinking (ST) has recently been promoted as an important approach to health systems strengthening. However, ST is not common practice, particularly in Low- and Middle-Income Countries (LMICs). This paper seeks to explore the barriers that may hinder its application in the Eastern Mediterranean Region (EMR) and possible strategies to mitigate them. METHODS: A survey consisting of open-ended questions was conducted with a purposive sample of health policy-makers such as senior officials from the Ministry of Health (MoH), researchers, and other stakeholders such as civil society groups and professional associations from ten countries in the region. A total of 62 respondents participated in the study. Thematic analysis was conducted. RESULTS: There was strong recognition of the relevance and usefulness of ST to health systems policy-making and research, although misconceptions about what ST means were also identified. Experience with applying ST was very limited. Approaches to designing health policies in the EMR were perceived as reactive and fragmented (66%). Commonly perceived constraints to application of ST were: a perceived notion of its costliness combined with lack of the necessary funding to operationalize it (53%), competing political interests and lack of government accountability (50%), lack of awareness about relevance and value (47%), limited capacity to apply it (45%), and difficulty in coordinating and managing stakeholders (39%). CONCLUSION: While several strategies have been proposed to mitigate most of these constraints, they emphasized the importance of political endorsement and adoption of ST at the leadership level, together with building the necessary capacity to apply it and apply the learning in research and practice.

A retrospective health policy analysis of the development and implementation of the voluntary health insurance system in Lebanon: learning from failure.

Public policymaking is complex and suffers from limited uptake of research evidence, particularly in the Eastern Mediterranean Region (EMR). In-depth case studies examining health policymaking in the EMR are lacking. This retrospective policy analysis aims at generating insights about how policies are being made, identifying factors influencing policymaking and assessing to what extent evidence is used in this process by using the Lebanese Voluntary Health Insurance policy as a case study. The study examined the policymaking process through a policy tracing technique that covered a period of 12 years. The study employed a qualitative research design using a case study approach and was conducted in two phases over the course of two years. Data was collected using multiple sources including: 1) a comprehensive and chronological media review; 2) twenty-two key informant interviews with policymakers, stakeholders, and journalists; and 3) a document review of legislations, minutes of meetings, actuarial studies, and official documents. Data was analyzed and validated using thematic analysis. Findings showed that the voluntary health insurance policy was a political decision taken by the government to tackle an urgent political problem. Evidence was not used to guide policy development and implementation and policy implementers and other stakeholders were not involved in policy development. Factors influencing policymaking were political interests, sectarianism, urgency, and values of policymakers. Barriers to the use of evidence were lack of policy-relevant research evidence, political context, personal interests, and resource constraints. Findings suggest that policymakers should be made more aware of the important role of evidence in informing public policymaking and the need for building capacity to develop, implement and evaluate policies. Study findings are likely to matter in light of the changes that are unfolding in some Arab countries and the looming opportunities for policy reforms.

The impact of accreditation of primary healthcare centers: successes, challenges and policy implications as perceived by healthcare providers and directors in Lebanon.

BACKGROUND: In 2009, the Lebanese Ministry of Public Health (MOPH) launched the Primary Healthcare (PHC) accreditation program to improve quality across the continuum of care. The MOPH, with the support of Accreditation Canada, conducted the accreditation survey in 25 PHC centers in 2012. This paper aims to gain a better understanding of the impact of accreditation on quality of care as perceived by PHC staff members and directors; how accreditation affected staff and patient satisfaction; key enablers, challenges and strategies to improve implementation of accreditation in PHC. METHODS: The study was conducted in 25 PHC centers using a cross-sectional mixed methods approach; all staff members were surveyed using a self-administered questionnaire whereas semi-structured interviews were conducted with directors. RESULTS: The scales measuring Management and Leadership had the highest mean score followed by Accreditation Impact, Human Resource Utilization, and Customer Satisfaction. Regression analysis showed that Strategic Quality Planning, Customer Satisfaction and Staff Involvement were associated with a perception of higher Quality Results. Directors emphasized the benefits of accreditation with regards to documentation, reinforcement of quality standards, strengthened relationships between PHC centers and multiple stakeholders and improved staff and patient satisfaction. Challenges encountered included limited financial resources, poor infrastructure, and staff shortages. CONCLUSIONS: To better respond to population health needs, accreditation is an important first step towards improving the quality of PHC delivery arrangement system. While there is a need to expand the implementation of accreditation to cover all PHC centers in Lebanon, considerations should be given to strengthening their financial arrangements as well.

Capturing lessons learned from evidence-to-policy initiatives through structured reflection.

BACKGROUND: Knowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This study aims to gain a better understanding of the i) activities conducted by KTPs, ii) the way in which KTP leaders, policymakers, and stakeholders perceive these activities and their outputs, iii) facilitators that support KTP work and challenges, and the lessons learned for overcoming such challenges, and iv) factors that can help to ensure the sustainability of KTPs. METHODS: This paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Purposive sampling was used and data were analyzed using thematic analysis. RESULTS: Deliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests. CONCLUSIONS: The establishment of KTPs is a promising development in supporting EIHP. Real-time lesson drawing from the experiences of KTPs can support improvements in the functioning of KTPs in the short term, while making the case for sustaining their work in the long term. Lessons learned can help to promote similar EIHP initiatives in other countries.

Epilepsy surgery in a developing country (Lebanon): ten years experience and predictors of outcome.

We present our 10-year experience and preoperative predictors of outcome in 93 adults and children who underwent epilepsy surgery at the American University of Beirut. Presurgical evaluation included video-EEG monitoring, MRI, neuropsychological assessment with invasive monitoring, and other tests (PET, SPECT, Wada). Surgeries included temporal (54%), extratemporal (22%), and multilobar resections (13%), hemispherectomy (4%), vagal nerve stimulation (6%), and corpus callosotomy (1%). Mesial temporal sclerosis was the most common aetiology (37%). After resective surgery, 70% had Engel class I, 9% class II, 14% class III, and 7% class IV. The number of antiepileptic drugs before surgery was the only preoperative factor associated with Engel class I (p=0.005). Despite the presence of financial and philanthropic aid, many patients could not be operated on for financial reasons. We conclude that advanced epilepsy presurgical workups, surgical procedures, and favourable outcomes, comparable to those of developed countries, are achievable in developing countries, but that issues of financial coverage remain to be addressed.

Use of health systems evidence by policymakers in eastern Mediterranean countries: views, practices, and contextual influences.

BACKGROUND: Health systems evidence can enhance policymaking and strengthen national health systems. In the Middle East, limited research exists on the use of evidence in the policymaking process. This multi-country study explored policymakers' views and practices regarding the use of health systems evidence in health policymaking in 10 eastern Mediterranean countries, including factors that influence health policymaking and barriers and facilitators to the use of evidence. METHODS: This study utilized a survey adapted and customized from a similar tool developed in Canada. Health policymakers from 10 countries (Algeria, Bahrain, Jordan, Lebanon Oman, Pakistan, Palestine, Sudan, Tunisia, and Yemen) were surveyed. Descriptive and bi-variate analyses were performed for quantitative questions and thematic analysis was done for qualitative questions. RESULTS: A total of 237 policymakers completed the survey (56.3% response rate). Governing parties, limited funding for the health sector and donor organizations exerted a strong influence on policymaking processes. Most (88.5%) policymakers reported requesting evidence and 43.1% reported collaborating with researchers. Overall, 40.1% reported that research evidence is not delivered at the right time. Lack of an explicit budget for evidence-informed health policymaking (55.3%), lack of an administrative structure for supporting evidence-informed health policymaking processes (52.6%), and limited value given to research (35.9%) all limited the use of research evidence. Barriers to the use of evidence included lack of research targeting health policy, lack of funding and investments, and political forces. Facilitators included availability of health research and research institutions, qualified researchers, research funding, and easy access to information. CONCLUSIONS: Health policymakers in several countries recognize the importance of using health systems evidence. Study findings are important in light of changes unfolding in some Arab countries and can help undertake an analysis of underlying transformations and their respective health policy implications including the way evidence will be used in policy decisions.

A multi-faceted approach to promote knowledge translation platforms in eastern Mediterranean countries: climate for evidence-informed policy.

OBJECTIVES: Limited work has been done to promote knowledge translation (KT) in the Eastern Mediterranean Region (EMR). The objectives of this study are to: 1.assess the climate for evidence use in policy; 2.explore views and practices about current processes and weaknesses of health policymaking; 3.identify priorities including short-term requirements for policy briefs; and 4.identify country-specific requirements for establishing KT platforms. METHODS: Senior policymakers, stakeholders and researchers from Algeria, Bahrain, Egypt, Iran, Jordan, Lebanon, Oman, Sudan, Syria, Tunisia, and Yemen participated in this study. Questionnaires were used to assess the climate for use of evidence and identify windows of opportunity and requirements for policy briefs and for establishing KT platforms. Current processes and weaknesses of policymaking were appraised using case study scenarios. Closed-ended questions were analyzed descriptively. Qualitative data was analyzed using thematic analysis. RESULTS: KT activities were not frequently undertaken by policymakers and researchers in EMR countries, research evidence about high priority policy issues was rarely made available, and interaction between policymakers and researchers was limited, and policymakers rarely identified or created places for utilizing research evidence in decision-making processes. Findings emphasized the complexity of policymaking. Donors, political regimes, economic goals and outdated laws were identified as key drivers. Lack of policymakers' abilities to think strategically, constant need to make quick decisions, limited financial resources, and lack of competent and trained human resources were suggested as main weaknesses. CONCLUSION: Despite the complexity of policymaking processes in countries from this region, the absence of a structured process for decision making, and the limited engagement of policymakers and researchers in KT activities, there are windows of opportunity for moving towards more evidence informed policymaking.

Use of health systems and policy research evidence in the health policymaking in eastern Mediterranean countries: views and practices of researchers.

BACKGROUND: Limited research exists on researchers' knowledge transfer and exchange (KTE) in the eastern Mediterranean region (EMR). This multi-country study explores researchers' views and experiences regarding the role of health systems and policy research evidence in health policymaking in the EMR, including the factors that influence health policymaking, barriers and facilitators to the use of evidence, and the factors that increase researchers' engagement in KTE. METHODS: Researchers who published health systems and policy relevant research in 12 countries in the EMR (Bahrain, Egypt, Iran, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Sudan, Syria, and Yemen) were surveyed. Descriptive analysis and Linear Mixed Regression Models were performed for quantitative sections and the simple thematic analysis approach was used for open-ended questions. RESULTS: A total of 238 researchers were asked to complete the survey (response rate 56%). Researchers indicated transferring results to other researchers (67.2%) and policymakers in the government (40.5%). Less than one-quarter stated that they produced policy briefs (14.5%), disseminated messages that specified possible actions (24.4%), interacted with policymakers and stakeholders in priority-setting (16%), and involved them in their research (19.8%). Insufficient policy dialogue opportunities and collaboration between researchers and policymakers and stakeholders (67.9%), practical constraints to implementation (66%), non-receptive policy environment (61.3%), and politically sensitive findings (57.7%) hindered the use of evidence. Factors that increase researchers' engagement in KTE activities in the region were associated with involving policymakers and stakeholders at various stages such as priority-setting exercises and provision of technical assistance. CONCLUSIONS: Researchers in the EMR recognize the importance of using health systems evidence in health policymaking. Potential strategies to improve the use of research evidence emphasize two-way communication between researchers and policymakers. Findings are critical for the upcoming World Health Report 2012, which will emphasize the significance of conducting and translating health research to inform health policies.

Health Policy and Systems Research in Twelve Eastern Mediterranean Countries: a stocktaking of production and gaps (2000-2008).

BACKGROUND: The objectives of this study are to: (1) profile the production of Health Policy and Systems Research (HPSR) published between 2000 and 2008 in 12 countries in the Eastern Mediterranean Region (EMR): Bahrain, Egypt, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Sudan, Syria, Tunisia, and Yemen; (2) identify gaps; and (3) assess the extent to which existing HPSR produced in the region addresses regional priorities pertaining to Health Financing, Human Resources for Health and the Role of the Non-State Sector. This is the first stocktaking paper of HPSR production and gaps in the EMR. METHODS: Articles indexed on Medline between years 2000 and 2008 for the 12 study countries were selected. A MeSH term based search was conducted using country names. Articles were assessed using a coding sheet adapted for the region which included themes on: Governance Arrangements, Financial Arrangements, Delivery Arrangements, and Implementation Strategies. Identified articles were matched against regional research priorities to assess the extent to which research production aligns with priorities. RESULTS: A total of 1,487 articles (11.94%) fit the criteria in the coding sheet. Results showed an increase in HPSR production which peaked after 2005. Most identified articles focused on Delivery Arrangements (68.1%), and Implementation Strategies (24.4%). Most HPSR addressed priorities in Human Resources for Health (39%), and some articles focused on Health Financing (12%) and Role of the Non-State Sector (6.1%). CONCLUSIONS: Despite global calls for producing and translating HPSR into policy, there are still significant gaps in the EMR. More efforts are needed to produce HPSR and align production and translation with the demand for evidence by policymakers. Findings can help inform and direct future plans and activities for the Evidence Informed Policy Network- EMR, World Health Organization- EMR, and the Middle East and North Africa Health Policy Forum, in addition to being useful for countries that host or are planning to host KT platforms in the region.

Design, implementation and scaling up of the balanced scorecard for hospitals in Lebanon: policy coherence and application lessons for low and middle income countries.

OBJECTIVES: This paper describes the development and implementation of the first national hospital performance indicators in Lebanon including its institutionalization within existing policy framework and the initiation of independent governance structure for sustainability. METHODS: Guided by the Ontario Acute Care Balanced Scorecard framework, a step-wise approach was used. Guiding principles were non-punitive reporting, anonymity, voluntary participation, stakeholder involvement, consensus and feasibility. Modified Delphi technique was used, readiness assessment surveys in 52 hospitals were conducted, pilot testing and evaluation were completed in 14 hospitals. RESULTS: Initial balanced set of 21 indicators were selected. Findings showed wide variations in indicators' measurement in hospitals including formulas and tools. Barriers to measurement included lack of quality culture, physician resistance and resources. A gradual implementation strategy was developed and selected indicators were divided into two levels. Most piloted indicators proved to be valid, feasible and reliable. The initiative was linked to the national hospital accreditation system resulting in a balanced set of 40 indicators. An independent, not-for-profit, arm's-length organization was established. CONCLUSIONS: This is among the first attempts made in the East Mediterranean Region to adapt the BSC approach and translate the experience of its development to addresses local needs and contextual reality.

The effect of vagus nerve stimulation therapy on body mass index in children.

The effects of vagus nerve stimulation on weight in individuals with epilepsy are not fully characterized. A retrospective review was performed of all pediatric patients who underwent placement of a vagus nerve stimulator at Duke University Medical Center. Baseline body mass index (BMI) percentile was compared with percentile on follow-up visits. We studied 23 patients who had undergone VNS placement during the period 2001-2009. Baseline BMI percentile was 61.7 ± 34.3. We had a power of 81% to detect a difference of 20 in BMI percentile from baseline to last follow-up. At the 1-year follow-up (mean=345 ± 112 days) and last follow-up (mean 4.2 ± 2.4 years) the average BMI percentile was 61.6 ± 31.88 and 56.09 ± 30.83, respectively. There was no significant difference in BMI percentile as compared with baseline at the 1-year and last follow-up visits (P=0.992 and 0.681, respectively). Long-term pediatric VNS therapy did not have a major clinically significant effect on BMI percentile during an average follow-up of more than 4 years.

Quality of life after surgery for intractable partial epilepsy in children: a cohort study with controls.

PURPOSE: Investigate if quality of life (QOL) normalizes on long-term follow-up after surgery for partial epilepsy in children. METHODS: This is a cohort study with controls in which a consecutive cohort of nineteen 2-14-year-old children who underwent focal resections for intractable partial seizures between 1996 and 2006, were matched with 19 non-surgery intractable partial epilepsy patients, and with 19 healthy subjects. The two epilepsy groups were matched for age, sex, socio-economic status (SES), cognitive level, seizure type, and seizure frequency. The healthy group was matched with the two epilepsy groups for age, sex, SES, and cognitive level. QOL was assessed using the QOLCE (Quality of Life in Childhood Epilepsy Questionnaire). RESULTS: In the surgery group (follow-up 3.84+/-2.26 years), 78.9% had Engel class-I versus 21.1% in non-surgery (p=0.01) (follow-up 3.44+/-2.95 years). Surgery patients were similar to healthy subjects in the social, emotional, cognitive, behavioral, and overall QOL (p>0.05) but had lower scores in the total QOL, physical, and health domains (p<0.05). Surgery patients scored better than non-surgery in the behavioral domain and the HASES (Hague Side Effects Scale) score (p<0.05). Non-surgery patients scored worse than healthy in total QOL, physical, behavioral, health, and overall QOL (p<0.05). IQ, HASS (Hague Seizure Severity Scale), and HASES scores were positively associated with total QOL score (p<0.05). Subgroup analysis on seizure-free surgery patients showed that they did not differ from healthy subjects in any of QOL domains (p>0.05, power>0.8). CONCLUSION: Our data indicate that epilepsy surgery for partial seizures in children is associated with better QOL as compared to children with intractable epilepsy who are not operated on, and suggest that in those who achieve seizure freedom normal QOL may at least potentially be possible.

Quality of life after vagal nerve stimulator insertion.

AIM: Assess quality-of-life after vagal nerve stimulation and determine patient characteristics associated with improvement in quality-of-life. METHODS: Sixteen patients (11 children, 5 adults) who had vagal nerve stimulation at our center were studied. Quality-of-life was assessed pre- and post-vagal nerve stimulation using the Quality-of-Life in Childhood Epilepsy questionnaire for children and the Epilepsy Surgery Inventory-55 for adults. RESULTS: Sixteen patients who did not qualify for resective surgery were included; seven (43.75%) were males and 9 (56.25%) were females. Mean age at onset of seizures was 3.96 +/- 4.00 years and at surgery was 15.78 +/- 10.78. Follow-up time was 1.26 +/- 0.92 years. Fourteen patients (87.5%) were mentally retarded. Ten (62.5%) had cryptogenic etiology and 6 patients (37.5%) symptomatic etiology. Fifty percent had localization-related epilepsy. Six of 7 patients with generalized cryptogenic etiology (85.71%) had Lennox-Gastaut syndrome. Seizures dropped from 122.31 +/- 159.49 to 67.84 +/- 88.22 seizures/month. Seizure reduction (> 50%) correlated with improvement in total quality-of-life (p = 0.034). Post-vagal nerve stimulation, the total group scored significantly higher in the social domain (p = 0.039). In patients with localization-related epilepsy, significant improvements were detected in the social domain (p = 0.049) and in total quality-of-life (p = 0.042). CONCLUSION: Despite a diverse and small population size, we observed significant improvements in the social domain 1.26 years post-vagal nerve stimulation. In addition, there was an improvement in total quality-of-life amongst patients with partial seizures. Finally, seizure reduction was associated with quality-of-life improvement. Our results support previous studies from the West reporting improvement in quality-of-life following vagal nerve stimulation, contradict those studies that did not show such differences, and are the first coming from a developing country.