Use of mobile hospitals to improve access to health services and promote primary health care: lessons from Zambia (2011-2018).

Background: Mobile hospitals play a critical role in serving difficult to access populations. In 2011, they were introduced by the Zambian government to improve access to health care. However, little is known about and/or documented about their use in Zambia, and other similar settings where people rely on them to access critical health care, or have to travel long distances to the nearest health centre. Objective: To understand the use of mobile hospitals in Zambia and share lessons on their implementation that may be useful for similar settings. It describes their design, implementation, and challenges. Methods: The qualitative research employed document review, key informant interviews with 15 respondents, and observation of the operations of the mobile hospitals in the field. Results: The research finds that while they help to reduce inequities associated with accessing health services, there needs to be careful resource planning and addressing of the major issues in health care such as human resources, infrastructure, and disease prevention before long term use. Conclusion: The research not only highlights conditions that must be considered for the effective implementation of mobile hospitals, but also the need for engagement of various key stakeholders during agenda setting in order to build trust and buy in, which contribute to smoother implementation.

Facilitators and Barriers to Implementing a Comprehensive Sexual Health Education Policy in Chicago Public Schools.

BACKGROUND: In 2013, the Chicago Public Schools (CPS) district passed a policy requiring schools to deliver comprehensive sexual health education (SHE) to all K-12th grade students. A performance improvement case study was conducted in the 2019-2020 school year to evaluate the implementation of the policy and identify lessons learned to support implementation in schools. METHODS: Key informant interviews were conducted with 11 school principals and 29 teachers to discuss SHE implementation at their school. Interviews were recorded, transcribed, and analyzed to assess school and classroom factors that affect implementation. Themes that cut across these factors were then identified and summarized by 2 evaluators. RESULTS: The following themes were identified across key informant interviews: (a) principal prioritization of SHE helps ensure SHE is implemented, (b) the expansion of school and teacher capacity facilitates SHE implementation, and (c) the creation of accountability mechanisms in classrooms and schools fosters adherence to SHE policy. CONCLUSIONS: Principals play a crucial role in building capacity to deliver SHE and ensuring SHE accountability mechanisms are implemented in their school. CPS is using these findings to adjust technical assistance and resources provided to principals and SHE instructors.

Strengthening accountability for tuberculosis policy implementation in South Africa: perspectives from policymakers, civil society, and communities.

Background: Translating health policy into effective implementation is a core priority for responding effectively to the tuberculosis (TB) crisis. The national TB Recovery Plan was developed in response to the negative impact that the COVID-19 pandemic had on TB care in South Africa. We aimed to explore the implementation of the TB Recovery Plan and develop recommendations for strengthening accountability for policy implementation for this and future TB policies. Methods: We interviewed 24 participants working on or impacted by TB policy implementation in South Africa. This included perspectives from national, provincial, and local health department representatives, civil society, and community representatives. In-depth interviews were conducted in English and isiXhosa and we drew on reflexive thematic methods for analysis. Results: Participants felt that there was potential for COVID-19 innovations and urgency to influence TB policy development and implementation, including the use of data dashboards. Implementation of the TB Recovery Plan predominantly used a top-down approach to implementation (cascading from national policy to local implementers) but experienced bottlenecks at provincial level. Recommendations for closing the TB policy-implementation gap included using phased implementation and enhancing provincial-level accountability. Civil society organisations were concerned about the lack of provincial implementation data which impeded advocacy for improved accountability and inadequate resourcing for implementation. Community health workers were viewed as key to implementation but were not engaged in the policy development process and were often not aware of new TB policies. At local level, there were also opportunities to strengthen community engagement in policy implementation including through community-led monitoring. Participants recommended broader multi-stakeholder engagement that includes community and community health worker representatives in the development and implementation phases of new TB policies. Conclusions: Communities affected by TB, with the support of civil society organisations, could play a bigger role in monitoring policy implementation at local level and need to be capacitated to do this. This bottom-up approach could complement existing top-down strategies and contribute to greater accountability for TB policy implementation. Supplementary Information: The online version contains supplementary material available at 10.1186/s44263-024-00077-y.

From political priority to service delivery: Complexities to real-life priority of abortion services in Ethiopia.

Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data was collected from February to April 2022. Health bureaucrats from nine of the twelve regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment, and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programs and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.

Navigating intersectoral collaboration in nutrition programming: implementors' perspectives from Assam, India.

BACKGROUND: There is a growing interest in the use of intersectoral collaborative (ISC) approaches to address complex health-related issues. However, relatively little empirical research exists on the challenges of implementing, fostering and sustaining these approaches. Our study explores the perceptions and experiences of programme implementers regarding the implementation of an ISC approach, focusing on a case study of nutrition programming in Assam, India. METHODS: We conducted qualitative semi-structured face-to-face in-depth interviews with eleven programme implementers from two selected districts of Assam, India. These participants were purposefully sampled to provide a comprehensive understanding of the experiences of implementing intersectoral collaboration. Following the interviews, an inductive thematic analysis was performed on the collected data. RESULTS: The study identified three main themes: operationalisation of ISC in daily practice, facilitators of ISC, and barriers to effective ISC. These were further broken down into six subthemes: defined sectoral mandates, leadership dynamics, interpersonal relationships and engagement, collective vision and oversight, resource allocation, and power dynamics. These findings highlight the complexity of ISC, focusing on the important structural and relational aspects at the macro, meso, and micro levels. Interpersonal relationships and power dynamics among stakeholders substantially influenced ISC formation in both the districts. CONCLUSION: Despite challenges, there is ongoing interest in establishing ISC in nutrition programming, supported by political development agendas. Success relies on clarifying sectoral roles, addressing power dynamics, and engaging stakeholders systematically. Actionable plans with measurable targets are crucial for promoting and sustaining ISC, ensuring positive programme outcomes. The insights from our study provide valuable guidance for global health practitioners and policymakers dealing with similar challenges, emphasising the urgent need for comprehensive research given the lack of universally recognised policies in the realm of ISC in global health practice.

Small Steps, Big Vision: using multi-stage qualitative research to develop a grab-and-go guide to support utilisation of the Ambitions for Palliative and End of Life Care framework.

BACKGROUND: The Ambitions for Palliative and End of Life Care is a national framework for local action in England co-produced by over 30 partners; little research has been conducted on how the Framework is received and used. This study sought to examine and support how people understand, interpret, and implement the Framework. METHODS: A multi-stage qualitative methodology involving four stages of data collection: (1) case study interviews, (2) focus groups, (3) interactive workshops, and (4) Evidence Cafés. From initial interviews, ongoing thematic data analysis informed the design and focus of subsequent stages as part of a process of knowledge transfer. RESULTS: A practical resource to support service provision and development was produced; a grab-and-go guide called "Small Steps, Big Visions". It focuses on the eight foundations in the Ambitions Framework, with additional guidance on collaboration and partnership working, and sharing learning. Each foundation is presented with a 'what' (definition), 'ask' (prompt questions), and 'examples in action' (drawn from case studies). CONCLUSIONS: Research can contribute to policy implementation to advance palliative and end of life care. The engagement and input of those responsible for implementation is key.

Implementing Primary Care Reform in France: Bargaining, Policy Adaptation, and the Maisons de Santé Pluriprofessionnelles.

CONTEXT: The organization of primary care in France has long remained a secondary issue on the political agenda. The government began to address the difficulties of care access and coordination in the 2000s, when a seemingly viable solution emerged from the field: the Maisons de Santé Pluriprofessionnelles (MSPs). In a corporatist system and a predominantly private sector, the government chose an incentive-based, contractual policy to encourage providers to join these structures. This article analyzes the implementation of this policy which depends on private providers' commitment. METHODS: The article offers a comparative case study of six MSPs. Data were collected through semi-structured interviews, observation sessions, and document analysis. FINDINGS: First, the article shows that the emergence of MSPs has only been possible thanks to an unprecedented alliance between GPs, the state, and the health insurance fund. Second, it argues that MSP policy's implementation relies on a complex bargaining process between private providers and public authorities that enables the former to shape it to their local needs. CONCLUSIONS: MSP implementation experiences raise questions both about the understanding of medical corporatism in France and the assimilation of policy changes and local variation through implementation.

Prescribing antibiotics prudently-A survey of policy implementation drivers among physicians and veterinarians.

Background: As the antimicrobial resistance (AMR) problem accelerates, humans and animals are suffering from the consequences of infections with diminishing antimicrobial treatment options. Within the One Medicine and One Health mandate, which denotes a collaborative, multisectoral, and transdisciplinary approach to improve medicine and health across human and animal sectors, we investigate how human and veterinary medical practitioners apply their medical and policy knowledge in prescribing antimicrobials. Different regions and locations establish different intermediary policies and programs to support clinicians in that pursuit. In Hong Kong, there are locally adapted programs at governance and clinical levels in the human medical field. However, there is no locally adapted veterinary antibiotic prescription guideline or stewardship program, and veterinarians adopt overseas or international professions' antimicrobial use guidelines. Such a policy environment creates a natural experiment to compare local policy implementation conditions and clinicians' knowledge, perception, and practice. Method: We construct the investigative survey tool by adaptation of Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, and Motivation-Behavior (COM-B) models. We identify, compare and contrast factors that influence clinicians' antimicrobial prescription behavior. The factors are considered both intrinsically, such as personal attributes, and extrinsically, such as societal and professional norms. Findings: The absence of locally adopted antimicrobial guidelines influences AMR stewardship program implementation in local Hong Kong veterinary community. As medical allies, physicians and veterinarians share similar demographic influence, organization considerations and perception of public awareness. Both cohorts prescribe more prudently with more years-in-practice, time available to communicate with patients or caretakers, and public awareness and support.

Who shouts the loudest? A qualitative study exploring barriers and enablers to implementing a low emission zone in a Northern UK city.

Pollution is a major cause of ill health globally. Low emission zones (LEZ) have been identified as effective in reducing pollution and are increasing in popularity but remain divisive. Understanding what factors help or hinder implementation is important. In the UK, Clean Air Zones (CAZ, a type of LEZ) are being implemented in several cities. We aimed to identify key barriers and enablers to the implementation of a CAZ in real time, as policy was being developed and implemented in a large Northern city in England, UK. Twenty-five semi-structured interviews were conducted with city stakeholders and implementors approximately 6 months before a CAZ charging non-compliant taxis, buses, heavy goods vehicles and vans was launched. Thematic analysis was used to analyse data. Implementers were required to operate within a tight policy framework. Key enablers included: freedom to adapt the framework to local context, financial support, and cross-sector working. A focus on health was felt to be useful in justifying the policy to the public. Key barriers included conflict and opposition from local industry, politicians, and communities. Implementation of air quality policy which involves traffic restrictions remains controversial. The voices which 'shout the loudest' are often those with negative views, and these can create divisive discourse which shape public opinion and damage confidence of implementers. A systems perspective is needed to understand socio-political contexts which can influence implementation success. We provide recommendations to other areas considering implementing a LEZ.

Study on the policy implementation effect of serious Illness medical insurance in the ethnic minority autonomous area of Western China

Objective: To evaluate the implementation effect of serious illness medical insurance in Guang Xi Zhuang Autonomous Region of western China. Study design: Through the collection of 2017-2021 Guang Xi serious illness medical insurance specific policy making such as fund usage, serious illness compensation, medical expenses data, and data analysis of a serious illness medical insurance effect. Method: Literature research, Policy text analysis, quantitative data collection method, using Excel and SPSS 19.0 data descriptive statistical analysis and comparative analysis. Results: Serious illness medical insurance has had some effect, e.g., from 2017 to 2021, the utilization rate of serious illness medical insurance fund in Guang Xi was 109.49% and 103.87% respectively, the fund balance rate was -9.45% and -8.54% respectively, and the accumulated balance was -2.3871 million CNY and -70.7955 million CNY. Conclusion: The serious illness medical insurance has reduced the burden of large medical expenses of patients to a certain extent, but the fund is under too much pressure, and there is a payment deficit. The coverage and security of serious illness medical insurance need to be expanded and strengthened, and the cooperation mechanism with commercial insurance institutions should be gradually explored to improve the serious illness medical insurance.

Objetivo: evaluar el efecto de la implementación de seguros médicos para enfermedades graves en la Región Autónoma Guang Xi Zhuang, al oeste de China. Diseño del estudio: a través de la recopilación de pólizas de seguro médico específicas para enfermedades graves de la región de Guang Xi entre 2017-2021, como por ejemplo: uso de fondos, compensación por enfermedades graves, datos de gastos médicos y análisis de datos del efecto de seguros médicos para enfermedades graves. Método: investigación de literatura, análisis de textos de políticas públicas, metodología de recolección de datos cuantitativos utilizando Excel y SPSS 19.0, análisis estadístico descriptivo de datos y análisis comparativo. Resultados: el seguro médico para enfermedades graves ha demostrado tener efectos, tales como: entre 2017 y 2021, la tasa de utilización de fondos de seguros médicos para enfermedades graves en Guang Xi fue de 109,49 % y 103,87 % respectivamente, las tasas de saldo del fondo fue de -9,45 % y -8,54 % respectivamente y el saldo acumulado fue de -2,3871 millones de CNY y -70,7955 millones de CNY. Conclusión: El seguro médico para enfermedades graves ha reducido en cierta medida la carga de los grandes gastos médicos de los pacientes, pero al existir un déficit de pagos está bajo demasiada presión. Por ello, es necesario ampliar y fortalecer la cobertura y seguridad del seguro médico para enfermedades graves, y explorar gradualmente mecanismos de cooperación con instituciones de seguros comerciales.

Objetivo: Avaliar o efeito da implementação de seguro médico para doenças graves na Região Autônoma de Guang Xi Zhuang da China Ocidental. Desenho do Estudo: Através da coleta de políticas específicas de seguro médico para doenças graves de Guang Xi 2017-2021, uso de fundos, compensação por doenças graves, dados de despesas médicas e análise de dados de um efeito de seguro médico para doenças graves. Método: Pesquisa na literatura, análise do texto da política, método de coleta de dados quantitativos usando Excel e SPSS 19.0, análise estatística descritiva de dados e análise comparativa. Resultados: Seguro médico de doenças graves teve um certo efeito. Em 2017 e 2021, a taxa de utilização do fundo de seguro médico para doenças graves em Guang Xi foi 109,49% e 103,87% respectivamente, a taxa de saldo do fundo foi -9,45% e -8,54% respectivamente e o saldo acumulado foi -2,3871 milhões de yuans e -70,7955 milhões de yuans. Conclusão: O seguro médico para doenças graves reduziu o ônus de grandes despesas médicas dos pacientes até certo ponto mas o fundo está sob demasiada pressão e há um déficit de pagamentos. A cobertura e segurança do seguro médico de doenças graves necessitam ser expandidas e fortalecidas, e o mecanismo de cooperação com instituições de seguros comerciais deve ser gradualmente explorado para melhorar o seguro médico para doenças graves.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

Integrating family caregivers in older adults' hospital stays: a needed cultural shift.

OBJECTIVES: This study aimed to examine perceived barriers and facilitators to caregiver inclusion in the hospital care of older adult family members or friends through the perspectives of (1) hospitalized older adults, (2) caregivers of a hospitalized older adult, (3) healthcare clinicians, and (4) policymakers. METHODS: This qualitative descriptive exploratory study utilized semi-structured interviews with N = 24 participants and was analyzed using a framework method. RESULTS: Eight codes arose that were categorized into four domains guided by the Social Ecological Model. Individual-level factors were determined both for the caregiver and for the clinician. Relationship-level factors were revealed pertaining to communication style and method. Hospital-level factors included hospital environment and resources. Societal-level factors included healthcare climate and policies. DISCUSSION: Findings indicated that hospital workflows and policies inadequately support family caregivers. This study highlights potential solutions to caregivers' integration into hospital workflows.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Implementation of National Nutrition Policies and Strategies to Reduce Unhealthy Diets: An Ecological Analysis of 194 Countries from 2017 to 2021.

This study investigates the implementation of national policies and strategies to control unhealthy diets, which are pivotal in the global surge of non-communicable diseases. Leveraging data from the World Health Organization's Non-Communicable Diseases Progress Monitors and Country Capacity Surveys, we calculated aggregate implementation scores for 13 diet-related policies across 194 countries from 2017 to 2021. We used descriptive statistics and linear regression to investigate the implementation trends and associations between key national-level factors and implementation scores. The mean score in 2021 was 52% (SD = 24), with no statistical differences in the 5-year period. Stark disparities in implementation efficacy were noted, ranging from comprehensive adoption in some nations to minimal application in others. Our analysis also highlights a shifting focus in policy adoption: notably, an increased commitment to taxing sugar-sweetened beverages juxtaposed with a decline in dietary awareness initiatives. Significant predictors of policy implementation include the Human Development Index, the cost of a healthy diet, and health service coverage. These findings suggest a complex interdependence of socioeconomic factors influencing policy implementation. Our research underscores the need for multifaceted, globally collaborative strategies to effectively combat diet-related diseases, emphasizing the importance of comprehensive policy frameworks in public health interventions.

The Fragmented Picture of Antimicrobial Resistance in Kenya: A Situational Analysis of Antimicrobial Consumption and the Imperative for Antimicrobial Stewardship.

Antimicrobial resistance (AMR) jeopardizes the effectiveness of essential antimicrobial agents in treating infectious diseases. Accelerated by human activities, AMR is prevalent in Sub-Saharan Africa, including Kenya, due to indiscriminate antibiotic use and limited diagnostics. This study aimed to assess Kenya's AMR efforts through a situational analysis of policy efficacy, interventions, and implementation, culminating in recommendations for strengthening mitigation. Employing two methodologies, this study evaluated Kenya's AMR endeavors. A systematic scoping review summarized AMR dynamic, and an expert validated the findings, providing an on-the-ground perspective. Antibiotic resistance is driven by factors including widespread misuse in human medicine due to irrational practices, consumer demand, and substandard antibiotics. Heavy antibiotic use in the agricultural sector leads to contamination of the food chain. The National Action Plan (NAP) reflects a One Health approach, yet decentralized healthcare and funding gaps hinder its execution. Although AMR surveillance includes multiple facets, diagnostic deficiencies persist. Expert insights recognize proactive NAP but underscore implementation obstacles. Kenya grapples with escalating resistance, but commendable policy efforts exist. However, fragmented implementations and complexities persist. Addressing this global threat demands investment in healthcare infrastructure, diagnostics, international partnerships, and sustainable strategies.

Mending the gap: Measurement needs to address policy implementation through a health equity lens.

Policies represent a key opportunity to improve the health outcomes of populations, and if implemented well, can reduce disparities affecting marginalized populations. Many policies are only evaluated on whether they elicit their intended health outcome. However, a lack of understanding regarding if and how they are implemented may hinder the intended impact overall and on addressing health disparities. Implementation science offers an array of frameworks and methodological approaches for assessing policy delivery, yet few examples exist that meaningfully include health equity as a core focus. This commentary describes the importance of equity-informed implementation measurement by providing case examples and implications for assessment. In addition, we highlight examples of emerging work in policy implementation grounded in health equity with suggested steps for moving the field forward. The ultimate goal is to move toward open-access measurement approaches that can be adapted to study implementation of a variety of policies at different stages of implementation, driven by input from marginalized populations and implementation practitioners, to move the needle on addressing health disparities.

This article talks about the need to include health equity as a major focus when understanding if and how policies are being implemented. We talk about gaps in the implementation science field and how equity-informed measurement tools can help to bridge this gap. Finally, we give some examples of efforts in place and where others can add to the growing resources to improve policy delivery.

The workforce crisis in healthcare: Moving the debate to bridge evidence and policy.

This Special Issue aims to advance the healthcare workforce (HCWF) debate by directing its attention to the implementation of policy recommendations and identifying weaknesses. The selection of articles highlights a wide range of HCWF policies and interventions across various countries. The challenges faced often stem from policy failures and governance gaps at the macro-, meso- and micro-levels of health systems. Recommendations to mitigate the HCWF crisis include interconnected strategies, multi-/transsectoral policies, solidarity-based efforts, collaboration, skill-mix reforms, equity measures, global approaches, and crucially, strong political will. In addition, specific policy solutions are explored, such as community-centred action and employment of community health workers, mental health support initiatives, inclusion of refugees and displaced healthcare workers into the labour market, and preparing the HCWF for the impact of climate change. This Special Issue calls for transformative HCWF policies and multi-level transsectoral governance as essential components needed to effectively address the crisis. This will only be possible, if HCWF policy moves higher up in the public policy arena leading, among other things, to the establishment of HCWF research as a distinct academic field.

Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19.

Introduction: This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona. Methods: A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time. Results: Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey). Conclusions: Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

Evaluating Policies of Expanding Versus Restricting First-Line Treatment Choices: A Cost-Effectiveness Analysis Framework.

OBJECTIVES: Healthcare payers often implement coverage policies that restrict the utilization of costly new first-line treatments. Cost-effectiveness analysis can be conducted to inform these decisions by comparing the new treatment with an existing one. However, this approach may overlook important factors such as treatment effect heterogeneity and endogenous treatment selection, policy implementation costs, and diverse patient preferences across multiple treatment options. We aimed to develop a cost-effectiveness analysis framework that considers these real-world factors, facilitating the evaluation of alternative policies related to expanding or restricting first-line treatment choices. METHODS: We introduced a metric of incremental cost-effectiveness ratio (ICER) that compares an expanded choice set (CS) including the new first-line treatment with a restricted CS excluding the new treatment. ICER(CS) accounts for treatment selection influenced by heterogeneous treatment effects and policy implementation costs. We examined a basic scenario with 2 standard first-line treatment choices and a more realistic scenario involving diverse preferences toward multiple choices. To illustrate the framework, we conducted a retrospective evaluation of including versus excluding abiraterone acetate plus prednisone (AAP) (androgen deprivation therapy [ADT] + AAP) as a first-line treatment for metastatic hormone-sensitive prostate cancer. RESULTS: The traditional ICERs for ADT + AAP versus ADT alone and ADT+ docetaxel were $104 269 and $206 324/quality-adjusted life-year, respectively. The ICER(CS) for comparing an expanded CS with ADT + AAP with a restricted CS without ADT + AAP was $123 179/quality-adjusted life-year. CONCLUSIONS: The proposed framework provides decision makers with policy-relevant tools, enabling them to assess the cost-effectiveness of alternative policies of expanding versus restricting patients' and physicians' first-line treatment choices.

An evaluation of the impact of China's green credit policy on different pathways using a CGE model.

The objective of the study was to quantitatively analyze the heterogeneous effects of different green credit implementation methods on energy, environmental, and economic systems by developing a computable general equilibrium model. The specific green credit implementation methods are divided into interest-penalty policy for energy-intensive industries and interest preferential policy for green industries. Various approaches to implementing green credit can lead to distinct impacts on energy consumption, environmental outcomes, and economic performance. Green credit policy experiments are carried out utilizing short-, medium-, and long-term scenarios to investigate how the consequences of green credit policies evolve. The findings demonstrate that (1) implementing a penalty interest policy for energy-intensive industries can have substantial short-term environmental effects, cutting total demand for fossil energy and lowering carbon dioxide emissions significantly. As the cycle progresses, this effect will progressively fade and have a negative economic impact. (2) The interest preferential policy for the green industry has a significant promoting effect on green technology, and its energy and environmental effects will be reflected in the long term, and the effect will continue to increase, which has a positive promoting effect on the economy. (3) There are significant differences in the policy effects brought about by the different implementation methods of green credit policies. Both policies can positively affect social energy and the environment, but the effect cycles are different. When two types of interest policies are implemented in the economy, the negative economic effect of the penalty interest policy is greater than the positive effect of the preferential interest policy, which harms the macroeconomy. These conclusions will provide theoretical and practical references for the government and banks to choose a better green credit implementation path.