The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018-2023.

BACKGROUND: Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation. METHODS: This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis. RESULTS: The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes. CONCLUSIONS: Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.

The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis.

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

Exploring evidence use and capacity for health services management and planning in Swiss health administrations: A mixed-method interview study.

BACKGROUND: Health administrations require evidence, meaning robust information, data, and research, on health services and systems. Little is known about the resources and processes available within administrations to support evidence-informed policymaking. This study assessed Swiss health administrations' capacity for evidence use and investigated civil servants' needs and perspectives regarding the role and use of evidence in health services management and planning. METHODS: In this mixed-method study, we interviewed civil servants from Swiss German-speaking cantonal health administrations. We quantitatively assessed administrations' organization-level capacity by applying six structured interviews using an existing measurement tool (ORACLe). Individual-level needs and perspectives regarding evidence use and capacity were qualitatively explored with twelve in-depth interviews that were analyzed using the framework method. FINDINGS: Respondents indicated moderate evidence-use capacity in all administrations. Administrations displayed a similar pattern of high and low capacity in specific capacity areas, generally with considerable variation within administrations. Most administrations indicated high capacity for producing or commissioning evidence and close relationships with research. They showed limited capacity in the documentation of processes and availability of tools, programs, or training opportunities. Administrations place the responsibility for engagement with evidence at the level of individual civil servants rather than at the organizational level. Although administrations highly value evidence-informed policymaking and consider it vital to effective health services management and planning, they face significant constraints in accessing evidence-specific resources and receive little organizational support. Administrations rely on external capacity to compensate for these limitations and engage with evidence pragmatically. CONCLUSION: Our findings indicate moderate and improvable capacity for evidence use in Swiss health administrations that place limited value on organizational support. Besides strengthening organizational support, leadership buy-in, particular staff needs, and balancing the implementation of specific measures with the provision of more general resources should be considered to unlock the potential of strengthened engagement with evidence.

Environmental Modifications for People With Intellectual and Developmental Disabilities: A Policy Analysis of Medicaid Home- and Community-Based Services.

IMPORTANCE: Environmental modifications are targets for occupational therapy intervention because they support activities of daily living, self-efficacy, personal control, independence, and community living for people with intellectual and developmental disabilities (IDDs). OBJECTIVE: To examine how environmental modifications were provided to people with IDDs through Medicaid home- and community-based services (HCBS) waivers across the United States in fiscal year (FY) 2021. DESIGN: Using a mixed-methods policy analysis, we examined FY 2021 Medicaid HCBS 1915(c) waivers from across the United States to examine whether, and how, states provided environmental modifications to people with IDDs. RESULTS: In FY 2021, 35 states projected spending $68.8 million on environmental modifications for 12,671 people with IDDs. The purpose of environmental modifications was most often to promote the health, welfare, and safety of people with IDDs (82.68%), and to promote their independence (69.29%). The most common examples of environmental modifications included ramps and/or lifts (70.08%), widening doorways and/or hallways (61.42%), bathroom modifications (58.27%), specialized electrical and/or plumbing for medical equipment (54.33%), and grab bars and/or handrails (53.54%). CONCLUSIONS AND RELEVANCE: HCBS waiver data on environmental modifications for people with IDDs enhances an understanding of this funding source and provides a foundation of advocacy for occupational therapy practitioners to support people with IDDs with living, as well as aging, in the community rather than in institutions. An expansion of environmental modifications in HCBS for people with IDDs aligns with the aim of Medicaid HCBS waivers to promote community integration, self-determination, and independence, which are all benefits of environmental modifications. Plain-Language Summary: This study can help occupational therapy practitioners determine what funding sources are available in their state to help their clients with intellectual and developmental disabilities access environmental modifications. The findings can also help guide advocacy and lobbying efforts to expand access to environmental modifications.

Road To Deceased Donor Transplantation in Egypt.

In Egypt, there is presently a growing need to have a deceased donor transplant program. Egypt conducted its first kidney transplant from a living donor in 1976 and a first partial liver transplant in 2001. Since 2009, the Egyptian Health Authorities Combat Transplant Tourism in concordance with ethics codes and the Declaration of Istanbul Custodian Group has been in place. The Egyptian Transplantation Law of 2011 mentions that organs could be procured from deceased donors based on a will and on family consent. This law has had many critics, including religious authorities who have stressed that organs cannot be taken from a person with brain death because, in their view, life ends with death of all organs. Many intensivists disagree over the definition of death. In addition, the media has communicated contradicting and sometimes misleading health care information. Mummification is rooted in pharos practice and linked to religious beliefs. The ancient Egyptians believed that, by burying the deceased with their organs, they may rejoin with them in the afterlife. Since 2019, the transplant community in Egypt has started collaborations with international transplant organizations and campaigns with doctors and celebrities to donate their organs after death, which have stressed that a deceased donor program could help against end-stage organ mortality. In November 2022, after communications with politicians, President Abdelfattah El Sisi directed the government to establish a regional center for organ transplantation, which aimed to be the biggest in the Middle East and North Africa region. The new center will be part of a new medical city that would replace Nasser Medical Institution in Cairo, Egypt. The Ministry of Health issued an official form to be signed by a person before his death, accepting use of organs, to give hope and support to other patients in need.

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences.

BACKGROUND: A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners. METHOD: An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these - allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately. RESULTS: Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners. CONCLUSION: For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

An Anticipatory Approach to Ethico-Legal Implications of Future Neurotechnology.

This paper provides a justificatory rationale for recommending the inclusion of imagined future use cases in neurotechnology development processes, specifically for legal and policy ends. Including detailed imaginative engagement with future applications of neurotechnology can serve to connect ethical, legal, and policy issues potentially arising from the translation of brain stimulation research to the public consumer domain. Futurist scholars have for some time recommended approaches that merge creative arts with scientific development in order to theorise possible futures toward which current trends in technology development might be steered. Taking a creative, imaginative approach like this in the neurotechnology context can help move development processes beyond considerations of device functioning, safety, and compliance with existing regulation, and into an active engagement with potential future dynamics brought about by the emergence of the neurotechnology itself. Imagined scenarios can engage with potential consumer uses of devices that might come to challenge legal or policy contexts. An anticipatory, creative approach can imagine what such uses might consist in, and what they might imply. Justifying this approach also prompts a co-responsibility perspective for policymaking in technology contexts. Overall, this furnishes a mode of neurotechnology's emergence that can avoid crises of confidence in terms of ethico-legal issues, and promote policy responses balanced between knowledge, values, protected innovation potential, and regulatory safeguards.

Challenges of determining the relative contribution of determinants of health on population health: a Canadian perspective.

This article investigates the source of frequently cited data regarding the relative contribution of determinants of health to population health in Canada. It critically discusses the imperative for such national or regional data in policymaking, and the challenges and limitations of this approach.

Tackling the non-communicable disease epidemic: a framework for policy action in low- and middle-income countries.

Health policy frameworks for the prevention and control of non-communicable diseases have largely been developed for application in high-income countries. Limited attention has been given to the policy exigencies in lower- and middle-income countries where the impacts of these conditions have been most severe, and further clarification of the policy requirements for effective prevention is needed. This paper presents a policy approach to prevention that, although relevant to high-income countries, recognizes the peculiar situation of low-and middle-income countries. Rather than a narrow emphasis on the implementation of piecemeal interventions, this paper encourages policymakers to utilize a framework of four embedded policy levels, namely health services, risk factors, environmental, and global policies. For a better understanding of the non-communicable disease challenge from a policy standpoint, it is proposed that a policy framework that recognizes responsible health services, addresses key risk factors, tackles underlying health determinants, and implements global non-communicable disease conventions, offers the best leverage for prevention.

Politics-evidence conflict in national health policy making in Africa: a scoping review.

BACKGROUND: Generally, public health policy-making is hardly a linear process and is characterized by interactions among politicians, institutions, researchers, technocrats and practitioners from diverse fields, as well as brokers, interest groups, financiers and a gamut of other actors. Meanwhile, most public health policies and systems in Africa appear to be built loosely on technical and scientific evidence, but with high political systems and ideologies. While studies on national health policies in Africa are growing, there seems to be inadequate evidence mapping on common themes and concepts across existing literature. PURPOSE: The study seeks to explore the extent and type of evidence that exist on the conflict between politics and scientific evidence in the national health policy-making processes in Africa. METHODS: A thorough literature search was done in PubMed, Cochrane Library, ScienceDirect, Dimensions, Taylor and Francis, Chicago Journals, Emerald Insight, JSTOR and Google Scholar. In total, 43 peer-reviewed articles were eligible and used for this review. RESULT: We found that the conflicts to evidence usage in policy-making include competing interests and lack of commitment; global policy goals, interest/influence, power imbalance and funding, morals; and evidence-based approaches, self-sufficiency, collaboration among actors, policy priorities and existing structures. Barriers to the health policy process include fragmentation among actors, poor advocacy, lack of clarity on the agenda, inadequate evidence, inadequate consultation and corruption. The impact of the politics-evidence conflict includes policy agenda abrogation, suboptimal policy development success and policy implementation inadequacies. CONCLUSIONS: We report that political interests in most cases influence policy-makers and other stakeholders to prioritize financial gains over the use of research evidence to policy goals and targets. This situation has the tendency for inadequate health policies with poor implementation gaps. Addressing these issues requires incorporating relevant evidence into health policies, making strong leadership, effective governance and a commitment to public health.

Towards a social harm approach in drug policy.

In this paper, we explore how the social harm approach can be adapted within drug policy scholarship. Since the mid-2000s, a group of critical criminologists have moved beyond the concept of crime and criminology, towards the study of social harm. This turn proceeds decades of research that highlights the inequities within the criminal legal system, the formation of laws that protect the privileged and punish the disadvantaged, and the systemic challenge of the effectiveness of retribution and punishment at addressing harm in the community. The purpose of this paper is to first identify parallels between the social harm approach and critical drug scholarship, and second to advocate for the adoption of a social harm lens in drug policy scholarship. In the paper, we draw out the similarities between social harm and drug policy literatures, as well as outline what the study of social harm can bring to an analysis of drug policy. This includes a discussion on the ontology of drug crime, the myth of drug crime and the ineffective use of the crime control system in response to drug use. The paper then discusses how these conversations in critical criminology and critical drugs scholarship can be brought together to inform future drug policy research. This reflection details the link between social harm and the impingement of human flourishing, explores the role of decolonizing drug policy, advocates for the centralization of lived experience within the research process and outlines how this might align with harm reduction approaches. We conclude by arguing that the social harm approach challenges the idea that neutrality is the goal in drug policy and explicitly seeks to expand new avenues in activist research and social justice approaches to policymaking.

What is context in knowledge translation? Results of a systematic scoping review.

Knowledge Translation (KT) aims to convey novel ideas to relevant stakeholders, motivating their response or action to improve people's health. Initially, the KT literature focused on evidence-based medicine, applying findings from laboratory and clinical research to disease diagnosis and treatment. Since the early 2000s, the scope of KT has expanded to include decision-making with health policy implications.This systematic scoping review aims to assess the evolving knowledge-to-policy concepts, that is, macro-level KT theories, models and frameworks (KT TMFs). While significant attention has been devoted to transferring knowledge to healthcare settings (i.e. implementing health policies, programmes or measures at the meso-level), the definition of 'context' in the realm of health policymaking at the macro-level remains underexplored in the KT literature. This study aims to close the gap.A total of 32 macro-level KT TMFs were identified, with only a limited subset of them offering detailed insights into contextual factors that matter in health policymaking. Notably, the majority of these studies prompt policy changes in low- and middle-income countries and received support from international organisations, the European Union, development agencies or philanthropic entities.

Faculty members as academic knowledge brokers in Iran's health sector: a social network analysis study.

BACKGROUND: Interaction between researchers and policymakers is an essential factor to facilitate the evidence-informed policymaking. One of the effective ways to establish this relationship and promote evidence-informed policymaking is to employ people or organizations that can play the role of knowledge brokers. This study aims to analyze the communication network and interactions between researchers and policymakers in Iran's health sector and identify key people serving as academic knowledge brokers. METHODS: This study was a survey research. Using a census approach, we administered a sociometric survey to faculty members in the health field in top ten Iranian medical universities to construct academic-policymaker network using social network analysis method. Network maps were generated using UCINET and NetDraw software. We used Indegree Centrality, Outdegree Centrality, and Betweenness Centrality indicators to determine knowledge brokers in the network. RESULTS: The drawn network had a total of 188 nodes consisting of 94 university faculty members and 94 policymakers at three national, provincial, and university levels. The network comprised a total of 177 links, with 125 connecting to policymakers and 52 to peers. Of 56 faculty members, we identified four knowledge brokers. Six policymakers were identified as key policymakers in the network, too. CONCLUSIONS: It seems that the flow of knowledge produced by research in the health field in Iran is not accomplished well from the producers of research evidence to the users of knowledge. Therefore, it seems necessary to consider incentive and support mechanisms to strengthen the interaction between researchers and policymakers in Iran's health sector.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

National strategies for knowledge translation in health policy-making: A scoping review of grey literature.

BACKGROUND AND OBJECTIVES: Without strategic actions in its support, the translation of scientific research evidence into health policy is often absent or delayed. This review systematically maps and assesses national-level strategic documents in the field of knowledge translation (KT) for health policy, and develops a practical template that can support Evidence-informed Policy Network (EVIPNet) Europe countries in producing national strategies for evidence-informed policy-making. METHODS: Websites of organizations with strategic responsibilities in KT were electronically searched, on the basis of pre-defined criteria, in July-August 2017, and an updated search was carried out in April-June 2021. We included national strategies or elements of national strategies that dealt with KT activities, as well as similar strategies of individual institutions with a national policy focus. Two reviewers screened the strategies for inclusion. Data were analysed using qualitative content analysis. RESULTS: A total of 65 unique documents were identified, of which 17 were eligible and analysed for their structure and content. Of the 17, 1 document was a national health KT action plan and 6 documents were institution-level KT strategies. The remaining 10 strategies, which were also included were 2 national health strategies, 5 national health research strategies and 3 national KT strategies (not specific to the field of health alone). In all, 13 structural elements and 7 major themes of health policy KT strategies were identified from the included documents. CONCLUSION: KT in health policy, as emerged from the national strategies that our mapping identified, is based on the production and accessibility of policy-relevant research, its packaging for policy-making and the activities related to knowledge exchange. KT strategies may play different roles in the complex and context-specific process of policy-making. Our findings show that the main ideas of health-specific evidence-informed policy literature appear in these strategies, but their effectiveness depends on the way stakeholders use them. Specific knowledge-brokering institutions and organizational capacity, advocacy about the use of evidence, and close collaboration and co-decision-making with key stakeholders are essential in furthering the policy uptake of research results.

An analysis of Nepal's Draft Mental Health Acts 2006-2017: competing values and power.

This qualitative study maps the process of drafting and consulting on Nepal's mental health legislation from 2006 to 2017. A total of 14 people were interviewed and interviews were analysed thematically. These themes were subsequently interpreted in light of Shiffman and Smith's policy analysis framework, as the process was found to be at the agenda-setting stage. Two groups of actors were identified with different views on appropriate policy content and how the policy process should be conducted. The first group included psychiatrists who initiated and controlled the drafting process and who did not consider people with psychosocial disabilities to be equal partners. The psychiatrists viewed forced detention and treatment as upholding people's right to health and lobbied the Ministry of Health and Population (MoHP) to pass the draft acts to parliament. The second included the rights-based civil society actors and lawyers who saw the right to equality before the law as of utmost priority, opposed forced detention and treatment, and actively blocked the draft acts at the MoHP. There is no clear legal definition of mental health and illness in Nepal, legal and mental capacity are not differentiated, and people with mental and behavioural conditions are assumed to lack capacity. The analysis indicates that there were few favourable conditions to support the progression of this policy into law. It is unclear whether the drafters or blockers will prevail in the future, but we predict that professionals will continue to have more input into content than service users due to national policy dynamics.

Beyond the average effect of the innovation subsidies: Using case selection via matching to break impasse in delivering useful advice to policy makers.

Experts and stakeholders promote the combined use of counterfactual and theory-based approaches in program evaluation. We illustrated combined application of these two approaches in a single evaluation study of innovation subsidies, using "case selection via matching" and follow-up in-depth interviews. We conducted interviews in contrasting pairs of companies-one successful and one unsuccessful-which were otherwise similar on a defined set of covariates. Our procedure helped to reveal factors, which might be overlooked or simply not available in data at hand and hence not accounted for in analyses of the intervention effects. As such it extends beyond the average effect estimate to highlight causes of an intervention success or failure.

Misrepresenting Pragmatism: Response to Greenhalgh and Engebretsen.

The Covid-19 pandemic has engendered intense public debate about the nature and place of a "science-driven" approach to decision making in such contexts, with contributions by a range of scientific authors critical of actual policy decisions. In a recent article in this journal, Greenhalgh and Engebretsen (TGEE) propose that science-driven policymaking should be abandoned in favour of a "Pragmatist turn". We critically analyze their portrayal of Pragmatism and demonstrate that their characterization is historically inaccurate, particularly focusing on the neglect of its strong commitment to scientific method and related evidential requirements. We conclude that Pragmatism's caution and respect for standards of evidence are a valuable corrective to the pandemics of fear and action that bias responses to any pandemic infection.