Building Health Policy and Systems Research (HPSR) capacity in India: Reflections from the India HPSR fellowship program (2020-2023).

Building capacity for Health Policy and Systems Research (HPSR) is critical for advancing the field in lower- and middle-income countries (LMICs). The India HPSR fellowship program is a home-grown capacity-building initiative, anchored at the Health Systems Transformation Platform (HSTP), New Delhi, and developed in collaboration with a network of institutes in India and abroad. In this practice-oriented commentary, we provide an overview of the fellowship program and critically reflect upon the learnings from working with three cohorts of fellows between 2020 and 2023. This commentary draws on routine program documentation (guidelines, faculty meeting reports, minutes of meetings of curricula and course development) as well as the perspectives of faculty and program managers associated with the fellowship. We have had several important learnings in the initial years of program implementation. One, it is important to iteratively modify globally available curricula and pedagogies on HPSR to suit country-specific requirements and include a strong component of 'unlearning' in such fellowships. Secondly, the goals of such fellowship programs need to be designed with country-specific contextual realities in mind. For instance, should publication of fellows' work be an intended goal, then contextual deterrents to publication such as article processing fees, language barriers and work-related obligations of faculty and participants need to be addressed. Furthermore, to improve the policy translation of fellows' work, such programs need to make broader efforts to strengthen research-policy-practice interfaces. Lastly, fellowship programs are cost-intensive, and outputs from them, such as papers or policy translation, are less immediate and less visible to donors. In the absence of these outputs, consistent funding can be a roadblock to sustaining these fellowships in LMICs. The experience of our fellowship program suggests that LMIC-led capacity-building initiatives on HPSR have the potential to influence changes in health systems and build the capacity of researchers to generate evidence for policy-making. The sharing of resources and teaching material through the fellowship can enable learning for all institutions involved. Furthermore, such initiatives can serve as a launchpad for the creation of regional and international HPSR communities of practice, with a focus on LMICs, thereby challenging epistemic injustice in teaching and learning HPSR.

'A void in our community': exploring the complexities of delivering and implementing primary care services for transgender individuals in Northern Ontario.

AIM: To understand how the implementation of primary care services for transgender individuals is undertaken and delivered by practitioners in Northern Ontario. BACKGROUND: Northern Ontario, Canada, has a shortage of primary care health practitioners, and of these, there are a limited number providing transgender primary care. Transgender people in Northern Ontario must also negotiate a lack of allied and specialty services related to transgender health and travel over long distances to access those services that do exist. METHODS: A convergent mixed methods design was guided by normalization process theory (NPT) to explore transgender primary care delivery and implementation by nurses, nurse practitioners, physicians, social workers, and psychotherapists. A survey measuring implementation processes was elaborated through qualitative interviews with participants. Analysis of key themes emerging using the NPT framework informed understanding of primary care successes, barriers, and gaps in Northern Ontario. FINDINGS: Key themes included the need for more education on transgender primary care practice, increased need for training and awareness on transgender resources, identification of unique gaps and barriers to access in Northern Ontario transgender care, and the benefits of embedding and normalizing transgender care in clinical practice to practitioners and transgender patients. These findings are key to understanding and improving access and eliminating healthcare barriers for transgender people in Northern Ontario.

Integrating meta-heuristic with named data networking for secure edge computing in IoT enabled healthcare monitoring system.

The advancement in technology, with the "Internet of Things (IoT) is continuing a crucial task to accomplish distance medical care observation, where the effective and secure healthcare information retrieval is complex. However, the IoT systems have restricted resources hence it is complex to attain effective and secure healthcare information acquisition. The idea of smart healthcare has developed in diverse regions, where small-scale implementations of medical facilities are evaluated. In the IoT-aided medical devices, the security of the IoT systems and related information is highly essential on the other hand, the edge computing is a significant framework that rectifies their processing and computational issues. The edge computing is inexpensive, and it is a powerful framework to offer low latency information assistance by enhancing the computation and the transmission speed of the IoT systems in the medical sectors. The main intention of this work is to design a secure framework for Edge computing in IoT-enabled healthcare systems using heuristic-based authentication and "Named Data Networking (NDN)". There are three layers in the proposed model. In the first layer, many IoT devices are connected together, and using the cluster head formation, the patients are transmitting their data to the edge cloud layer. The edge cloud layer is responsible for storage and computing resources for rapidly caching and providing medical data. Hence, the patient layer is a new heuristic-based sanitization algorithm called Revised Position of Cat Swarm Optimization (RPCSO) with NDN for hiding the sensitive data that should not be leaked to unauthorized users. This authentication procedure is adopted as a multi-objective function key generation procedure considering constraints like hiding failure rate, information preservation rate, and degree of modification. Further, the data from the edge cloud layer is transferred to the user layer, where the optimal key generation with NDN-based restoration is adopted, thus achieving efficient and secure medical data retrieval. The framework is evaluated quantitatively on diverse healthcare datasets from University of California (UCI) and Kaggle repository and experimental analysis shows the superior performance of the proposed model in terms of latency and cost when compared to existing solutions. The proposed model performs the comparative analysis of the existing algorithms such as Cat Swarm Optimization (CSO), Osprey Optimization Algorithm (OOA), Mexican Axolotl Optimization (MAO), Single candidate optimizer (SCO). Similarly, the cryptography tasks like "Rivest-Shamir-Adleman (RSA), Advanced Encryption Standard (AES), Elliptic Curve Cryptography (ECC), and Data sanitization and Restoration (DSR) are applied and compared with the RPCSO in the proposed work. The results of the proposed model is compared on the basis of the best, worst, mean, median and standard deviation. The proposed RPCSO outperforms all other models with values of 0.018069361, 0.50564046, 0.112643119, 0.018069361, 0.156968355 and 0.283597992, 0.467442652, 0.32920734, 0.328581887, 0.063687386 for both dataset 1 and dataset 2 respectively.

A Vision For the Future of Cardiovascular Medicine Practise in Ghana: Inspiration From the Yale-New Haven Health System.

The Ghana Physicians and Surgeons Foundation (GPSF) of North America sponsors Ghanaian clinical fellows to undertake an eight-weeklong clinical observation with the Yale University School of Medicine and Yale-New Haven Health (YNHH) annually, through the Residents in Training Educational Stipend (RITES) programme. This offers the opportunity to appreciate new perspectives in clinical care to improve Ghana's healthcare standard. The cardiovascular medicine workforce at the YNHH is heterogenous, with significant reliance on non-doctor cadres of health workers who demonstrate competence. This is contrasted from the Ghanaian system which despite having a poorer physician-patient ratio, is heavily dependent on doctors. Technological advancements are minimal in Ghana, posing diagnostic and therapeutic challenges which are otherwise minimised at the YNHH. A strong patient-centred culture, coupled with a coordinated emergency response system that ensures appropriate timely transfers, culminate in good care and outcomes. Ideas on how the experience can be translated to Ghanaian clinical practise in cardiovascular medicine, after participating in the RITES programme, are shared in this paper with an emphasis on task sharing, strengthening emergency response systems and improving technological sophistication through capacity building, mentorship and improved health financing.

The intersection of social and Indigenous determinants of health for health system strengthening: a scoping review.

The COVID-19 pandemic exposed long-standing gaps in health service systems and realities of environmental changes impacting Native nations and Indigenous communities in the US and circumpolar regions. Despite increased awareness and funding, there is limited research and few practical resources available for the work. This is a scoping review of the current literature on social determinants of health (SDOH) impacting Indigenous peoples, villages, and communities in the US and circumpolar region. The review used the York methodology to identify research questions, chart, and synthesize findings. Thirty-two articles were selected for full review and analysis. The articles were scoping reviews, evaluations, and studies. The methods used were 44% mixed (n = 14), 31% quantitative (n = 10) and 25% qualitative (n = 8). The synthesis identified four areas for discussion: 1) systemic and structural determinant study designs, 2) strengthening Indigenous health systems, 3) mapping the relationship of co-occurring health conditions and SDOH, and 4) emergent areas of inquiry. While the scoping review has limitations, it provides a snapshot of broad SDOH and shared Indigenous social determinants of health (ISDOH) to create tailored frameworks for use by tribal and urban Indigenous health organisations, with their partners, in public health and system strengthening.

Possibility of the optimum monitoring and evaluation (M&E) production frontier for risk-informed health governance in disaster-prone districts of West Bengal, India.

An efficient M&E system in public healthcare is crucial for achieving universal health coverage in low- and middle-income countries, especially when the need for service remains unmet due to the exposure of the population to disaster risks and uncertainties. Current research has conducted exploratory and predictive analyses to estimate the determinants of sustainable M&E solutions for ensuring uninterrupted access during and after disasters. The aim was to estimate the efficiency of reaching a higher M&E production frontier via the Cobb‒Douglas model and stochastic frontier model as the basic theoretical and empirical frameworks. The research followed a deductive approach and used a stratified purposive sampling method to collect data from different layers of health and disaster governance in a flood-prone rural setting in the Malda, South 24 Parganas and Purulia districts in West Bengal, India. The present mixed-method study revealed multiple challenges in healthcare seeking during disasters and how a well-structured M&E system can increase system readiness to combat these challenges. The stochastic frontier model estimated the highest M&E frontier producing the most attainable M&E effectiveness through horizontal convergence between departments, enhanced coordination, the availability of frontline health workers at health centers, the adoption of learned innovation and the outsourcing of the evaluation component to external evaluators to improve M&E process quality. Although the study has several limitations, it shows the potential to increase technical and allocative efficiency through building skills in innovative techniques and applying them in process implementation. In the future, research on strategy improvement followed by real-world evidence-based policy advocacy is needed to increase the impact of M&E on access to healthcare services.

Effective clinical decision support implementation using a multi filter and wrapper optimisation model for Internet of Things based healthcare data.

Feature Selection (FS) is essential in the Internet of Things (IoT)-based Clinical Decision Support Systems (CDSS) to improve the accuracy and efficiency of the system. With the increasing number of sensors and devices used in healthcare, the volume of data generated is vast and complex. Relevant FS from this data is crucial in reducing computational overhead, improving the system's interpretability, and enhancing the Decision-Making System (DMS) quality. FS also aids in addressing the problems of data redundancy and noise, which can negatively impact the system's performance. FS is critical to developing practical and dependable CDSS in IoT-based healthcare sectors. This research proposes a two-phase FS model. Phase-I employs an ensemble of five Filter Methods (FM), followed by a Pearson Correlation Method (PCM). Phase-II uses the Binary Optimized Genetic Grey Wolf Optimization Algorithm (BOGGWOA) as a Wrapper Method (WM). This recommended model integrates the most valuable features of each filter. Then, it uses the Pearson Correlation Coefficient (PCC) to get rid of features that aren't needed, a Support Vector Machine (SVM) to guess how accurate their classification will be, and BOGGWOA as the Wrapper Method (WM) to pick the most essential features with the best CA.

Digital economy and the medical and health service supply in China.

The impact of the digital economy on the healthcare sector is becoming increasingly profound. This article focuses on the relationship between the development of China's digital economy and medical and health services supply. Based on panel data from 30 provinces in China from 2012 to 2021, the CRITIC weight method was applied to measure the supply capacity of medical and health services and the level of digital economy development, and the kernel density estimation method and Dagum Gini coefficient method was used to characterize the evolutionary trends and regional differences. Additionally, a two-way fixed-effects model is adopted to investigate the impact of digital economy development on medical and health services supply. The results show that both the supply capacity of healthcare services and the level of digital economy development have been increasing continuously in terms of evolutionary trends. From the perspective of regional differences, compared to the supply level of healthcare services, the regional differences in digital economy development are more significant. The intra-regional differences in medical and health services supply are greater than the inter-regional differences, while the development of the digital economy exhibits the opposite trend. The findings of this paper provide supports for China to enhance the development level of digital economy and improve supply of medical and health service.

Strengthening facility-based integrated emergency care services for time sensitive emergencies at all levels of healthcare in India: An implementation research study protocol.

BACKGROUND: The healthcare system in India is tiered and has primary, secondary and tertiary levels of facilities depending on the complexity and severity of health challenges at these facilities. Evidence suggests that emergency services in the country is fragmented. This study aims to identify the barriers and facilitators of emergency care delivery for patients with time-sensitive conditions, and develop and implement a contextually relevant model, and measure its impact using implementation research outcomes. METHODS: We will study 85 healthcare facilities across five zones of the country and focus on emergency care delivery for 11 time-sensitive conditions. This implementation research will include seven phases: the preparatory phase, formative assessment, co-design of Model "Zero", co-implementation, model optimization, end-line evaluation and consolidation phase. The "preparatory phase" will involve stakeholder meetings, approval from health authorities and the establishment of a research ecosystem. The "formative assessment" will include quantitative and qualitative evaluations of the existing healthcare facilities and personnel to identify gaps, barriers and facilitators of emergency care services for time-sensitive conditions. On the basis of the results of the formative assessment, context-specific implementation strategies will be developed through meetings with stakeholders, providers and experts. The "co-design of Model 'Zero'" phase will help develop the initial Model "Zero", which will be pilot tested on a small scale (co-implementation). In the "model optimization" phase, iterative feedback loops of meetings and testing various strategies will help develop and implement the final context-specific model. End-line evaluation will assess implementation research outcomes such as acceptability, adoption, fidelity and penetration. The consolidation phase will include planning for the sustenance of the interventions. DISCUSSION: In a country such as India, where resources are scarce, this study will identify the barriers and facilitators to delivering emergency care services for time-sensitive conditions across five varied zones of the country. Stakeholder and provider participation in developing consensus-based implementation strategies, along with iterative cycles of meetings and testing, will help adapt these strategies to local needs. This approach will ensure that the developed models are practical, feasible and tailored to the specific challenges and requirements of each region.

Clinician voices on ethics of LLM integration in healthcare: a thematic analysis of ethical concerns and implications.

OBJECTIVES: This study aimed to explain and categorize key ethical concerns about integrating large language models (LLMs) in healthcare, drawing particularly from the perspectives of clinicians in online discussions. MATERIALS AND METHODS: We analyzed 3049 posts and comments extracted from a self-identified clinician subreddit using unsupervised machine learning via Latent Dirichlet Allocation and a structured qualitative analysis methodology. RESULTS: Analysis uncovered 14 salient themes of ethical implications, which we further consolidated into 4 overarching domains reflecting ethical issues around various clinical applications of LLM in healthcare, LLM coding, algorithm, and data governance, LLM's role in health equity and the distribution of public health services, and the relationship between users (human) and LLM systems (machine). DISCUSSION: Mapping themes to ethical frameworks in literature illustrated multifaceted issues covering transparent LLM decisions, fairness, privacy, access disparities, user experiences, and reliability. CONCLUSION: This study emphasizes the need for ongoing ethical review from stakeholders to ensure responsible innovation and advocates for tailored governance to enhance LLM use in healthcare, aiming to improve clinical outcomes ethically and effectively.

The Effects of COVID-19 Pandemic on HIV Service Provision in Ukraine.

Ukraine faced significant fluctuations in COVID-19 morbidity and mortality, alongside an escalating HIV epidemic. This mixed-methods study, conducted between February and August 2022, employed a sequential explanatory design combining a quantitative analysis of national data and qualitative interviews to investigate the pandemic's effects on HIV services in Ukraine. The observed trends confirmed that the pandemic significantly disrupted facility-based HIV testing due to logistical challenges, an increased burden on healthcare workers, and supply shortages. Meanwhile, community-based testing showed resilience, largely attributed to programmatic adjustments rather than the pandemic itself. The initiation of antiretroviral therapy declined, especially during initial lockdowns, reflecting diminished treatment capacities. Despite these challenges, telemedicine and home medication delivery innovations supported antiretroviral therapy adherence. Furthermore, improvements in viral load testing and suppression rates showed healthcare resilience. The study highlights the critical need for adaptable, sustainable healthcare strategies in crises, emphasized during the war with Russia.

How COVID-19 Changed HIV Care in Ukraine: Challenges, Adaptations, and Innovations In recent times, Ukraine, like many other countries, has been dealing with two big health problems: the COVID-19 pandemic and the ongoing HIV epidemic. With over 104 million cases of COVID-19 reported in Europe by early 2022, Ukraine faced the coronavirus as well as an increasing HIV crisis, especially among older adults and through various ways of spreading. This study, done between February and August 2022, aimed to understand how the COVID-19 pandemic affected the HIV services in Ukraine. By using numbers and in-depth interviews with health officials, service providers, and community members, we looked into the state of HIV care during this challenging period. Our findings show that the effects of the pandemic on HIV services were mixed. While HIV testing done in the community managed to adjust and keep going despite the changes, services in healthcare facilities ran into many problems. Lockdowns and restrictions made it hard for people to get to these places, leading to a big drop in HIV testing and the start of antiretroviral therapy, a key treatment for managing HIV. Despite these challenges, there were important changes and new ideas. Services such as telemedicine and delivering medication were started to make sure patients could continue their antiretroviral therapy without any breaks. The testing for viral load, which is important for checking how well HIV treatment is working, slowly went up, showing a system that could adapt to the pressures of the pandemic. The ability to adjust and keep going shown by some HIV services in Ukraine during the COVID-19 pandemic highlights the need for healthcare delivery methods that can change as needed and last over time. This study points out the importance of ongoing efforts to support people living with HIV, especially when facing big challenges, and gives valuable lessons for managing healthcare services during difficult times like the conflict with Russia.

Spending on Healthcare: What Is the Right Number?

Healthcare is canada's favourite punching bag. Admittedly, Canadian healthcare has many problems and, sometimes, it feels as though the system cannot get anything right. But is all the criticism fair?

The state of decentralization of the healthcare system and nutrition programs in the Lao People's Democratic Republic: an organizational study.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle income country, has a higher malnutrition rate than other Southeast Asian countries. The decentralization of healthcare is a determinant of the effectiveness of programs to reduce malnutrition, but no study has focused on this factor in this country. This organizational study explores the state of decentralization of the healthcare system in Lao PDR that underlies the nutrition programs in the country. METHODS: A qualitative study, which is based on a neo-institutional theory conceptual framework, explored factors related to dominant structure (laws, regulations, resources) and interpretative schemes (dominant ideas and beliefs) that characterize the nutrition services provided in the Lao healthcare system. Twenty-four semistructured interviews were performed with representatives of healthcare institutions involved in nutrition programs at different government levels, external donors and civil society organizations. The interviews were completed with relevant documents. The analysis focused on the convergence of interpretative schemes of the organizations concerned and the coherence between the structure underpinning the nutrition programs and the interpretative schemes. RESULTS: Services deployed to reduce malnutrition in the Lao PDR remain largely centralized, despite factors specific to the country that led it to promote decentralization of its services. The convergence of interpretive schemes and the coherence between the observed structure and the interpretative schemes of actors at all governance levels ensure the stability of this state of decentralization, which has persisted for almost 50 years. CONCLUSION: Nutrition programs in the Laos PDR are largely under the responsibility of the central government. The transformations in the healthcare system, notably with the use of new information technologies and the fact that the provinces are populated by a growing number of professionals trained in nutrition in addition to factors that push the system to be decentralized, such as ethnic diversity, the increasing availability of human resources in provinces, and the use of communication technologies, are not strong enough to change the balance of power between governance levels. The deconcentration that characterizes decentralization is therefore likely to continue for the foreseeable future.

Examining attitudes to uptake and sustainment of technology among care aides in the delivery of care: a scoping review protocol.

INTRODUCTION: Care aides are health workers who deliver hands-on care to patients across the healthcare continuum. The use of technology in healthcare delivery is increasing, and evidence regarding how care aides' attitudes may either facilitate or hinder the adoption of healthcare technologies is lacking.The aim of the proposed scoping review is to examine available evidence regarding care aides' attitudes towards the adoption of innovation and factors that may influence the sustainable use of technology in healthcare delivery. Published studies, grey literature and review articles that identify a method for the review, conference abstracts and website publications regarding the attitude, uptake and sustainable use of technology in care delivery by care aides will be included. For abstracts that have resulted in publications, the full publications will be included. The search for evidence commenced in June 2023 and will end in March 2024. METHODS AND ANALYSIS: The Joanna Briggs Institute (JBI) method will be used to conduct the review. The CINAHL, Cochrane Library, EMBASE, MEDLINE, ProQuest, PubMed, SCOPUS, PROSPERO, Web of Science and JBI Evidence Synthesis databases will be searched using keywords for publications within the last 20 years to examine trends in health technology and attitudes of care aides towards innovation over the last two decades. A search of grey literature and websites will be conducted. The reference list of the retrieved articles will be used to identify additional literature. The search results will be exported into a literature management tool for screening and analysis. Article screening will be performed by two authors and if a third is needed to resolve any differences. Data analysis will be guided by two theoretical frameworks. ETHICS AND DISSEMINATION: No ethics approval is required. The findings will be disseminated in a peer-reviewed journal and presented in conferences. REGISTRATION DETAILS: https://doi.org/10.17605/OSF.IO/CZQUP.

Cocreative Development of Robotic Interaction Systems for Health Care: Scoping Review.

Background: Robotic technologies present challenges to health care professionals and are therefore rarely used. Barriers such as lack of controllability and adaptability and complex control functions affect the human-robot relationship. In addition to educational opportunities, the possibility of individual adaptation can improve the usability and practical implementation of robotics. Previous work has focused on developments from a technology-centered perspective and has included user interests too late in the process. Objective: This study addresses the following research question: What cocreative research approaches are used in the field of nursing robotics to improve the usability, intended use, and goal-directed application of robotic developments for nurses and to support the nursing process? Methods: This scoping review provides an overview of the topic and the research activities taking place within it. Five databases and the reference lists of the identified publications were searched for studies without further restrictions. Studies were included if they developed and evaluated interaction and control platforms for robotic systems in health care in a cocreative way with end users. Results: The search resulted in 419 hits, of which 3 publications were included. All publications were feasibility or user studies that were mainly carried out in the European Union. The 3 interaction and control platforms presented were all prototypes and not commercially available. In addition to those in need of care, all studies also included family carers and health care professionals. Conclusions: Robotic interaction and control platforms in health care are rarely, if ever, developed and evaluated with feasibility or user studies that include prototypes and end users. While the involvement of end users is crucial, this review emphasizes that all stakeholders, including health care professionals, should participate in the development process to ensure a holistic understanding of application needs and a focus on user experiences and practical health care needs. It is emphasized that the active involvement of end users in the development process is critical to effectively meeting the needs of the target group.

Short-term health system responses to epidemics across hard to reach areas in sub-Saharan Africa: A scoping review protocol.

Epidemics and Pandemics (disease outbreaks) are the occurrence of cases of disease in excess of what would be normally expected. Epidemic-prone diseases, including emerging and re-emerging diseases, constitute the greatest threat to public health security and disruption of social and economic development. When outbreaks are diagnosed in specific areas, an outbreak response is triggered to stop the spread rapidly. In the past 20 years, the sub-Saharan region has witnessed a marked increase in the number of outbreaks in pandemics, such as cholera, dengue, A/H5N 1 influenza among others. While efforts toward containment have been individually studied, we have no recent studies that examine them collectively in order to draw appropriate comparisons, no recent studies that have especially focused on hard-to-reach areas, and none that have applied a health systems lens. This study thus details a scoping review of short-term health system responses to epidemics across hard-to-reach areas in sub-Saharan Africa. The scoping review will be undertaken following PRISMA guidelines. A modified Donabedian framework will be used to understand the different approaches used while responding to epidemics. The review will focus on published and unpublished studies that report short-term health systems responses to epidemics in hard to reach areas. These will be gleaned from PubMed, google scholar and Cochrane, supplemented by a Google advanced search. In addition, manual searches will be carried out through related articles and websites. Data will be charted, coded, and narratively synthesized. our exclusion criteria will include; protocols, book chapters and countries not identified as hard to reach areas in SSA. We anticipate developing a document that will show the different approaches health systems in different countries used when responding to epidemics. The information generated will contribute to strengthening future epidemic responses by identifying best practices and innovative ideas as well as highlighting knowledge gaps.

Rethinking Health Systems Responsiveness in Low- and Middle-Income Countries: Validation Study.

BACKGROUND: Health systems responsiveness (HSR) is the ability of systems to respond to legitimate non-health expectations of the population. The concept of HSR by the World Health Organization (WHO) includes respect for dignity, individual autonomy, confidentiality, prompt attention to care, availability of basic amenities, choice of provider, access to social support networks, and clarity of communication. The WHO tool is applied globally to assess HSR in low, middle, and high-income countries. OBJECTIVE: We have revised the conceptual framework of HSR following a rigorous systematic review and made it specific for low- and middle-income countries (L&MICs). This study is designed to (1) run the Delphi technique to validate the upgraded conceptual framework of HSR, (2) modify and upgrade the WHO measurement tool for assessing HSR in the context of L&MICs, and (3) determine the validity of the upgraded HSR measurement tool by pilot testing it in Pakistan. METHODS: The Delphi technique will be run by inviting global public health experts to provide suggestions on the domains and subdomains of HSR specific to L&MICs. Cronbach ɑ will be calculated to determine internal consistency among the participants. The upgraded HSR conceptual framework will serve as a beacon to modify the measurement tool by the research team, which will be reviewed by subject experts for refinement. The modified tool will be pilot-tested by administering it to 1128 participants from primary, secondary, and tertiary care hospitals in Rawalpindi district, Pakistan. Additionally, an "observation checklist" of HSR domains and subdomains will be completed to objectively measure the state of HSR across health care facilities. HSR assessment will be further strengthened by incorporating the perspective of hospital managers, service providers, and policy makers (ie, the supply side) as well as community leaders and representatives (ie, the demand side) through qualitative interviews. RESULTS: The study was started in January 2024 and will continue until February 2025. A multidimensional approach will yield significant quantifiable information on HSR from the demand and supply sides of L&MICs. CONCLUSIONS: This study will provide a conceptual understanding of HSR and a corresponding measurement tool specific to L&MICs. It will contribute to global public health literature and provide a snapshot of HSR in Rawalpindi district, Pakistan, with concrete action points for policy makers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59836.

Measuring environmentally sustainable health care: a scoping review.

Work to reduce environmental pollution from the health system is hampered by an absence of consensus on the definition of environmentally sustainable health care and the relevant measurement needed. This scoping review aims to encourage standardisation across sustainability efforts by examining how environmentally sustainable health care is defined and measured in current literature. We conducted a scoping review to identify candidate publications that included either a definition or description of environmentally sustainable health care or a measurement of the impact of health care on the environment. 328 publications were included in the final analysis. 52 publications included definitions or descriptions of environmentally sustainable health care. Results of the study highlight the heterogeneity in the current definition, measurement, and measurement calculation methods of environmentally sustainable health care in published literature. Work is needed to create more harmonised definitions and measurement to support progress and reduce environmental pollution from health care.

Confronting the Medical Leviathan: Reading a Report from the Front Lines.

This essay discusses how two physicians in Britain's National Health Service describe and analyze the conditions of their work: how algorithms and protocols structure the care they can provide and create the dilemmas they and their patients face. In these issues, the NHS is a canary in the mineshaft of contemporary Western health care. NHS practices are understood as how states and state-like entities, Leviathans, seek to render their subjects legible; in this instance, to make both physicians and patients transparently visible to surveillance and administration by standardizing medical work and patient need. Physicians respond by engaging in workarounds, finding ways to provide care despite systemic restrictions.