Governance of the wildlife trade and the prevention of emerging zoonoses: a mixed methods network analysis of transnational organisations, silos, and power dynamics.

INTRODUCTION: The wildlife trade is an important arena for intervention in the prevention of emerging zoonoses, and leading organisations have advocated for more collaborative, multi-sectoral approaches to governance in this area. The aim of this study is to characterise the structure and function of the network of transnational organisations that interact around the governance of wildlife trade for the prevention of emerging zoonoses, and to assess these network characteristics in terms of how they might support or undermine progress on these issues. METHODS: This study used a mixed methods social network analysis of transnational organisations. Data were collected between May 2021 and September 2022. Participants were representatives of transnational organisations involved in the governance of wildlife trade and the prevention of emerging zoonoses. An initial seed sample of participants was purposively recruited through professional networks, and snowball sampling was used to identify additional participants. Quantitative data were collected through an online network survey. Measures of centrality (degree, closeness, and betweenness) were calculated and the network's largest clique was identified and characterised. To understand the extent to which organisations were connected across sectors, homophily by sector was assessed using exponential random graph modelling. Qualitative data were collected through semi-structured interviews. The findings from the quantitative analysis informed the focus of the qualitative analysis. Qualitative data were explored using thematic analysis. RESULTS: Thirty-seven participants completed the network survey and 17 key informants participated in semi-structured interviews. A total of 69 organisations were identified as belonging to this network. Organisations spanned the animal, human, and environmental health sectors, among others including trade, food and agriculture, and crime. Organisation types included inter-governmental organisations, non-governmental organisations, treaty secretariats, research institutions, and network organisations. Participants emphasised the highly inter-sectoral nature of this topic and the importance of inter-sectoral work, and connections were present across existing sectors. However, there were many barriers to effective interaction, particularly conflicting goals and agendas. Power dynamics also shaped relationships between actors, with the human health sector seen as better resourced and more influential, despite having historically lower engagement than the environmental and animal health sectors around the wildlife trade and its role in emerging zoonoses. CONCLUSION: The network of transnational organisations focused on the governance of wildlife trade and the prevention of emerging zoonoses is highly multi-sectoral, but despite progress catalysed by the COVID-19 pandemic, barriers still exist for inter-sectoral interaction and coordination. A One Health approach to governance at this level, which has gained traction throughout the COVID-19 pandemic, was shared as a promising mechanism to support a balancing of roles and agendas in this space. However, this must involve agreement around equity, priorities, and clear goal setting to support effective action.

Public awareness of One Health in China.

One Health is recognized as an increasingly important approach to global health. It has the potential to inform interventions and governance approaches to prevent future pandemics. Successfully implementing the One Health approach in policy will require active engagement from the public, which begs the question: how aware is the public of One Health? In this study, we examine the level and distribution of One Health awareness among the general public in China using a survey conducted in Beijing (n = 1820). We distinguish between awareness of the term of "One Health" versus awareness of the core set of ideas - the interconnection between the health of people, animals, and the environment. Our analysis shows that 40% of respondents reported that they have heard of the term, but more than double the number indicated that they recognize the core idea of interconnection between people, animals, and the environment. Specifically, about 83% of the respondents said that they believe people's health is closely connected to animal health and 86% believe people's health is closely connected to plant and environmental health. Multiple regression analysis indicates that women, younger people, and individuals with a higher level of education show higher levels of One Health awareness than their counterparts. Being aware of the term is associated with higher recognition of the core ideas. Policymakers and health practitioners should consider these findings when designing public awareness campaigns and educational initiatives to promote One Health principles.

COVID-19 - An Opportunity to Redesign Health Policy Thinking.

Coronavirus disease 2019 (COVID-19) dramatically unveiled the fragile state of the world's health and social systems - the lack of emergency health crisis preparedness (under-resourced, weak leadership, strategic plans without clear lines of authority), siloed policy frameworks (focus on individual diseases and the lack of integration of health into the whole of societal activity and its impact on individual as well as community well-being and prosperity), and unclear communication (misguided rationale of policies, inconsistent interpretation of data). The net result is fear - about the disease, about risks and survival, and about economic security. We discuss the interdependencies among these domains and their emergent dynamics and emphasise the need for a robust distributed health system and for transparent communication as the basis for trust in the system. We conclude that systems thinking and complexity sciences should inform the redesign of strong health systems urgently to respond to the current health crisis and over time to build healthy, resilient, and productive communities.

From "learning from the field" to jointly driving change.

The theme of the 8th edition of the Geneva Health Forum (GHF) was Improving access to health: learning from the field. While 'the field' often denotes people, patients, communities, and healthcare workers, we challenge the notion and its usage. A group of like-minded conference participants set up a working group to examine the term 'the field' and look at questions related to language, power, participation, and rights. By highlighting deficiencies of existing terms and jargon, we explain why language is a form of power that matters in public health. We describe global, regional, and national case studies that facilitate full participation to achieve more equitable health outcomes. By concluding with concrete recommendations, we hope to contribute to these shared goals: to correct power imbalances between health authorities and the people that they intend, and are expected, to serve. The authors are all members of the working group.

Reconceptualising Person-Centered Service Models as Social Ecology Networks in Supporting Integrated Care.

Efforts to address problems such as mental health, poverty, social exclusion, and chronic disease have often proven resistant to traditional policies or interventions. In this paper, we take up the challenge and present a pioneering new method of analysis in drawing on theoretical and methodological extensions of two prominent approaches, namely, social network analysis and developmental social ecology. Considered in combination, these two seemingly disparate approaches frame a powerful new way of thinking about person-centred care, as well as offer a methodologically more rigorous set of analytical tools. The conceptual model developed from this combination offers to bridge the apparent disconnect between service integration levels and patient needs in such a way as to direct optimal effort to interventions at the individual level and to provide a new innovative approach to the delivery of integrated care.

Conceptualizing type 2 diabetes and its management.

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.

Outcome mapping for health system integration.

Health systems around the world are implementing integrated care strategies to improve quality, reduce or maintain costs, and improve the patient experience. Yet few practical tools exist to aid leaders and managers in building the prerequisites to integrated care, namely a shared vision, clear roles and responsibilities, and a common understanding of how the vision will be realized. Outcome mapping may facilitate stakeholder alignment on the vision, roles, and processes of integrated care delivery via participative and focused dialogue among diverse stakeholders on desired outcomes and enabling actions. In this paper, we describe an outcome-mapping exercise we conducted at a Local Health Integration Network in Ontario, Canada, using consensus development conferences. Our preliminary findings suggest that outcome mapping may help stakeholders make sense of a complex system and foster collaborative capital, a resource that can support information sharing, trust, and coordinated change toward integration across organizational and professional boundaries. Drawing from the theoretical perspectives of complex adaptive systems and collaborative capital, we also outline recommendations for future outcome-mapping exercises. In particular, we emphasize the potential for outcome mapping to be used as a tool not only for identifying and linking strategic outcomes and actions, but also for studying the boundaries, gaps, and ties that characterize social networks across the continuum of care.

Reframing the challenges to integrated care: a complex-adaptive systems perspective.

INTRODUCTION: Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care. METHODS: In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses. RESULTS: Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity. DISCUSSION AND CONCLUSION: One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.

CAM in Canadian hospitals: the new frontier?

The provision in hospitals of traditional, complementary and alternative medicine (TCAM), as recognized by the World Health Organization, is now widespread in many of the world's healthcare systems. As a significant part of integrative medicine (IM) or healthcare (IHC), research has now begun to focus on the varied parameters of hospital-based TCAM, however, little research has been conducted on the topic in the Canadian context. Drawing on a multi-site case study of four Canadian hospitals, qualitative observation was conducted at hospital sites, and interviews were conducted with senior hospital leaders and biomedical and TCAM hospital practitioners. The main focus of inquiry was to obtain the views of hospital leaders on the topic of incorporating TCAM, and to examine the motivations for TCAM inclusion, economic dimensions and level of integration between TCAM and biomedicine. Hospital leaders were both highly critical of TCAM and cautiously supportive. Inclusion of TCAM was directly related to hospital leadership and institutional relationships, while TCAM practitioners remained marginalized due to economic, geographical, political and epistemological barriers. Although signs of integration were apparent, significant challenges remained that prevented TCAM practitioners from operating as fully-fledged hospital providers. An integrated change strategy is needed that engages the TCAM professions in mainstream interprofessional education and training opportunities, and that also addresses wider structural and political barriers.

Chronic disease management and the home-care alternative in Ontario, Canada.

The pressure on our health-care system to deliver efficient, quality and cost-effective care is increasing. The debate on its sustainability is also expanding. These challenges can be managed with revisions to our health-care policy frameworks governing how and what public health-care services are delivered. Chronic disease management and home care can together ease many of the present and future pressures facing the health-care system. However, the current level of investment and the present policy are not effectively supporting movement in this direction. Updating the Canada Health Act to reflect the realities of our health-care system, and developing policies to support the areas of interdisciplinary teamwork and system integration are needed to facilitate chronic disease management and home care in Canada. This article lays out the challenges, highlights the impending issues and suggests a framework for moving forward.

Chronic disease: shifting the focus of healthcare in Canada.

The pressure on the Canadian healthcare system to deliver quality and cost-effective care is escalating at a time of an increasing prevalence of chronic diseases. The healthcare system's traditional focus on acute care falls short of meeting the needs of those suffering from chronic diseases, which represent a sizeable portion of the population. This article highlights the impending issues and explores how shifting the focus of healthcare can have a profound impact on meeting the needs of those suffering from chronic diseases in the province of Ontario.

Using the balanced scorecard in the development of community partnerships.

The benefits of community partnerships have been well established in the health service literature. However, measuring these benefits and associated outcomes is relatively new. This paper presents an innovative initiative in the application of a balanced scorecard framework for measuring and monitoring partnership activity at the community level, while adopting principles of evidence-based practice to the partnership process. In addition, it serves as an excellent example of how organizations can apply scorecard methodology to move away from relationship-based partnerships and into new collaborations of which they can select - using a formal skill and competency assessment for partnership success.

Management of complex chronic disease: facing the challenges in the Canadian health-care system.

This paper discusses the challenges that those living with complex chronic disease present to the Canadian health-care system. The literature suggests home care and the management of complex chronic disease can together ease many of the present and future pressures facing the health-care system in dealing with this new health-care phenomenon. A review of current literature and dialogue with key informants reveals that the current level of investment and the present policy environment are not sustainable to support the health-care system. In this paper, changes to policy and resource allocation to the home care sector are suggested to help manage complex chronic disease and thus improve the effectiveness of the Canadian health-care system. A case is made for a reorganization and increased commitment to the home care sector for a more efficient and patient-centred health-care delivery system.

Organizational change through Lean Thinking.

In production and manufacturing plants, Lean Thinking has been used to improve processes by eliminating waste and thus enhancing efficiency. In health care, Lean Thinking has emerged as a comprehensive approach towards improving processes embedded in the diagnostic, treatment and care activities of health-care organizations with cost containment results. This paper provides a case study example where Lean Thinking is not only used to improve efficiency and cost containment, but also as an approach to effective organizational change.

Using the balanced scorecard to mobilize human resources in organizational transformation.

Traditionally, the balanced scorecard (BSC) has been an effective tool in linking measurement to strategy. However, what is least understood is how the BSC can be used to redefine organizational relationships, re-engineer fundamental processes and transform organizational culture, for superior performance in an organization with the same people, services and technology that previously delivered dismal performance. This paper highlights the process and uses York Central Hospital in Toronto, Ontario, Canada as an illustrative example.

Vulnerability and risk perception in the management of HIV/AIDS: Public priorities in a global pandemic.

Understanding the way perception of risk is shaped and constructed is crucial in understanding why it has been so difficult to mitigate the spread of HIV/AIDS. This paper uses the Pressure and Release (PAR) model, used to predict the onset of natural disasters as the conceptual framework. It substitutes vulnerability and risk perception as the trigger factors in the model, in making the case that HIV/AIDS can be characterized as a slow onset disaster. The implications are that vulnerability must be managed and reduced by addressing root causes, dynamic pressures, and unsafe conditions that contribute to the HIV/AIDS pandemic. HIV/AIDS programs must be culturally appropriate and work toward influencing risk perception, while addressing social norms and values that negatively impact vulnerable populations. By impacting cultural and social expectations, individuals will be able to more readily adopt safer sex behaviors. The development of policies and programs addressing the issues in context, as opposed to individual behaviors alone, allows for effective public health intervention. This may have implications for public health measures implemented for combating the spread of HIV/AIDS.

A critical review of financial measures as reported in the Ontario hospital balanced scorecard.

For Ontario hospitals in Canada, the Financial Performance and Condition measures in the Ontario hospital balanced scorecard are especially of interest since in the foreseeable future, they may be linked to provincial government funding decisions. However, we find that these measures lack valuable information on key attributes that affect organizational performance. We suggest changes that focus on key drivers of performance and reflect the operational realities of Ontario hospitals.