Showing papers in "International journal of health policy and management in 2021"

Understanding the Prevalence and Associated Factors of Behavioral Intention of COVID-19 Vaccination Under Specific Scenarios Combining Effectiveness, Safety, and Cost in the Hong Kong Chinese General Population.

Abstract: Background The prevalence of coronavirus disease 2019 (COVID-19) vaccination is very critical in controlling COVID-19. This study mainly aimed to (1) investigate behavioral intentions of COVID-19 vaccination under various specific scenarios, and (2) associated factors of the afore-mentioned vaccination intentions. Methods A random anonymous telephone survey interviewed 450 Chinese adults from September 16-30, 2020 in Hong Kong, China. Nine scenarios of behavioral intentions of COVID-19 vaccinations were measured combining effectiveness (80% versus 50%), safety (rare versus common mild side effect), and cost (free versus HK$ 500). Results The prevalence of behavioral intentions of COVID-19 vaccination under the 9 specific scenarios was very low and varied greatly (4.2% to 38.0%). The prospective countries of manufacture also influenced vaccination intention (eg, Japan: 55.8% vs China: 31.1%). Only 13.1% intended to take up COVID-19 vaccination at the soonest upon its availability. The attributes of effectiveness and side effect influenced vaccination intention most. Positively associated factors of behavioral intentions of COVID-19 vaccination included trust/satisfaction toward the government, exposure to positive social media information about COVID-19 vaccines, descriptive norms, perceived impact on the pandemic, perceived duration of protectiveness, and life satisfaction. Conclusion Intention of COVID-19 vaccination was low in the Hong Kong general population, especially among younger people, females, and single people. Health promotion is warranted to enhance the intention. The significant factors identified in this study may be considered when designing such health promotion. Future research is required to confirm the findings in other countries. Such studies should pay attention to the specific context of cost, safety, and effectiveness, which would lead to different responses in the level of behavioral intention of COVID-19 vaccination (BICV).

Methods for the Economic Evaluation of Health Care Interventions for Priority Setting in the Health System: An Update From WHO CHOICE.

Abstract: The World Health Organization's (WHO's) Choosing Interventions that are Cost-Effective (CHOICE) programme has been a global leader in the field of economic evaluation, specifically cost-effectiveness analysis for almost 20 years. WHO-CHOICE takes a "generalized" approach to cost-effectiveness analysis that can be seen as a quantitative assessment of current and future efficiency within a health system. This supports priority setting processes, ensuring that health stewards know how to spend resources in order to achieve the highest health gain as one consideration in strategic planning. This approach is unique in the global health landscape. This paper provides an overview of the methodological approach, updates to analytic framework over the past 10 years, and the added value of the WHO-CHOICE approach in supporting decision makers as they aim to use limited health resources to achieve the Sustainable Development Goals (SDGs) by 2030.

Ultra-Processed Profits: The Political Economy of Countering the Global Spread of Ultra-Processed Foods - A Synthesis Review on the Market and Political Practices of Transnational Food Corporations and Strategic Public Health Responses.

Abstract: Background Ultra-processed food (UPF) and Ultra-processed beverage (UPB) consumption is associated with higher risks of numerous non-communicable diseases (NCDs). Yet global consumption of these products is rising due to profound changes in production, processing, manufacturing, marketing, retail, and consumption practices, alongside the growth of the resources and political influence of Big Food. Whilst the sales of UPFs and UPBs in high-income countries (HICs) are stagnating, sales are rapidly expanding in more populous middle-income countries (MICs). In this paper, we adopt a political economy of food systems approach to understand how growth of Big Food in MICs drives the NCD pandemic. Methods We conducted a mixed methods synthesis review. This involved quantitative data collection and development of descriptive statistics; a search for academic, market and grey literature on the expansion of UPF in MICs; and the development of themes, three illustrative case examples (South Africa, Colombia, and Indonesia), and synthesis of the enablers of successful campaigns in MICs into recommendations for public health campaigns. Results We project that the combined sales volume of UPFs in MICs will reach equivalency with HICs by 2024, and the total sales volume of UPBs in MICs is already significantly higher than in HICs. Similarly, annual growth in UPF sales is higher in MICs compared to HICs. We also show how Big Food has entrenched its presence within MICs through establishing global production and hyper-local distribution networks, scaling up its marketing, challenging government policies and scientific expertise, and co-opting civil society. We argue that public health can counter the influence of Big Food by developing an expanded global network of driven and passionate people with diverse skillsets, and advocating for increased government leadership. Conclusion The projected increase in sales of UPFs and UPBs in MICs raises major concerns about the global capacity to prevent and treat NCDs.

Prosociality and Social Responsibility Were Associated With Intention of COVID-19 Vaccination Among University Students in China.

Abstract: Background Coronavirus disease 2019 (COVID-19) vaccination is expected to end the pandemic; a high coverage rate is required to meet this end. This study aimed to investigate the prevalence of behavioral intention of free/self-paid COVID-19 vaccination and its associations with prosociality and social responsibility among university students in China. Methods An anonymous online cross-sectional survey was conducted among 6922 university students in five provinces in China during November 1-28, 2020. With informed consent, participants filled out an online survey link distributed to them via WeChat study groups. The response rate was 72.3%. Results The prevalence of behavioral intentions of free COVID-19 vaccination was 78.1%, but it dropped to 57.7% if the COVID-19 vaccination involved self-payment (400 RMB; around 42 USD). After adjusting for background factors, prosociality (free vaccination: adjusted odds ratio [ORa] = 1.10, 95% CI: 1.09-1.12; self-paid vaccination: ORa = 1.08, 95% CI: 1.07-1.09) and social responsibility (free vaccination: ORa = 1.17, 95% CI: 1.14-1.19; self-paid vaccination: ORa = 1.13, 95% CI: 1.11-1.14) were positively associated with the two variables of COVID-19 vaccination intention. Conclusion The present study demonstrated the positive effects of prosociality and social responsibility on the intention of COVID-19 vaccination. Accordingly, modification of prosociality and social responsibility can potentially improve COVID-19 vaccination. Future longitudinal and intervention studies are warranted to confirm such associations across populations and countries.

"Part of the Solution:" Food Corporation Strategies for Regulatory Capture and Legitimacy.

Abstract: Background For decades, the food industry has sought to deflect criticisms of its products and block public health legislation through a range of offensive and defensive strategies. More recently, food corporations have moved on to present themselves as “part of the solution” to the health problems their products cause. This strategic approach is characterised by appeasement, co-option and partnership, and involves incremental concessions and attempts to partner with health actors. This paper details how corporate practices have evolved and changed over the past two decades and gives some definition to what this new political economy signifies for the wider behaviours of corporations producing and selling harmful commodities. Methods This paper draws on public health and political science literature to classify the food industry’s “part of the solution” strategy into three broad components: regulatory responses and capture; relationship building; and market strategies. We detail the key characteristics and consequences of each component. Results The three components of the food industry’s “part of the solution” strategy all involve elements of appeasement and co- option. They also improve the political environment and resources of the food industry. Regulatory responses offer incremental concessions that seek to maintain corporate influence over governance processes and minimise the threat of regulations; relationship building fosters access to health and government stakeholders, and opportunities to acquire and maintain channels of direct influence; and market strategies to make products and portfolios healthier bolster the market share and revenue of food corporations while improving their public image. Conclusion Rather being a signal of lost position and power, the food industry’s repositioning as “part of the solution” has created a highly profitable political economy of ‘healthy’ food production, alongside continued production of unhealthy commodities, a strategy in which it is also less burdensome and conflictual for corporations to exercise political power and influence.

Seeking Healthcare During Lockdown: Challenges, Opportunities and Lessons for the Future.

Abstract: Background In Aotearoa/New Zealand, the first nation-wide coronavirus disease 2019 (COVID-19) lockdown occurred from March 23, 2020 to May 13, 2020, requiring most people to stay at home. Health services had to suddenly change how they delivered healthcare and some services were limited or postponed. This study investigated access to healthcare during this lockdown period, whether patients delayed seeking healthcare and reasons for these delays, focusing on the accessibility of primary care services. Methods Adults (aged 18 years or older) who had contact with primary care services were invited through social media and email lists to participate in an online survey (n = 1010) and 38 people were recruited for in-depth interviews. We thematically analysed qualitative data from the survey and interviews, reported alongside relevant descriptive survey results. Results More than half (55%) of survey respondents delayed seeking healthcare during lockdown. Factors at a national or health system-level that could influence delay were changing public service messages, an excessive focus on COVID-19 and urgent issues, and poor service integration. Influential factors at a primary care-level were communication and outreach, use of technology, gatekeeping, staff manner and the safety of the clinical practice environment. Factors that influenced patients’ individual decisions to seek healthcare were the ability to self-manage and self-triage, consciousness of perceived pressure on health services and fear of infection. Conclusion In future pandemic lockdowns or crises, appropriate access to primary care services can be improved by unambiguous national messages and better integration of services. Primary care practices should adopt rapid proactive outreach to patients, fostering a calm but safe clinical practice environment. More support for patients to self-manage and self-triage appropriately could benefit over-burdened health systems during lockdowns and as part of business as usual in less extraordinary times.

Inpatient Care Costs of COVID-19 in South Africa's Public Healthcare System.

Abstract: BACKGROUND: Coronavirus disease 2019 (COVID-19) has had a devastating impact globally, with severe health and economic consequences. To prepare health systems to deal with the pandemic, epidemiological and cost projection models are required to inform budgets and efficient allocation of resources. This study estimates daily inpatient care costs of COVID-19 in South Africa, an important input into cost projection and economic evaluation models. METHODS: We adopted a micro-costing approach, which involved the identification, measurement and valuation of resources used in the clinical management of COVID-19. We considered only direct medical costs for an episode of hospitalisation from the South African public health system perspective. Resource quantities and unit costs were obtained from various sources. Inpatient costs per patient day was estimated for consumables, capital equipment and human resources for three levels of inpatient care - general wards, high care wards and intensive care units (ICUs). RESULTS: Average daily costs per patient increased with the level of care. The highest average daily cost was estimated for ICU admissions - 271 USD to 306 USD (financial costs) and ~800 USD to 830 USD (economic costs, excluding facility fee) depending on the need for invasive vs. non-invasive ventilation (NIV). Conversely, the lowest cost was estimated for general ward-based care - 62 USD to 79 USD (financial costs) and 119 USD to 278 USD (economic costs, excluding facility fees) depending on the need for supplemental oxygen. In high care wards, total cost was estimated at 156 USD, financial costs and 277 USD, economic costs (excluding facility fees). Probabilistic sensitivity analyses suggest our costs estimates are robust to uncertainty in cost inputs. CONCLUSION: Our estimates of inpatient costs are useful for informing budgeting and planning processes and cost-effectiveness analysis in the South African context. However, these estimates can be adapted to inform policy decisions in other context.

Equitable and Effective Distribution of the COVID-19 Vaccines - A Scientific and Moral Obligation.

Abstract: The rapid development of coronavirus disease 2019 (COVID-19) vaccines has not been met with the assurance of an effective and equitable global distribution mechanism. Low-income countries are especially at-risk, with the price of the vaccines and supply shortages limiting their ability to procure and distribute the vaccines. While the COVAX initiative is one of the solutions to these challenges, vaccine nationalism has resulted in the hoarding of vaccines and the signing of parallel bilateral deals, undermining this formerly promising initiative. Moreover, inequity in local distribution also remains a problem, with clear discrimination of minorities and lack of logistical preparation in some countries. As we continue to distribute the COVID-19 vaccines, pharmaceutical companies should share their technology to increase supply and reduce prices, governments should prioritize equitable distribution to the most at-risk in all nations and low-income countries should bolster their logistical capacity in preparation for mass vaccination campaigns.

Motivations and Limits for COVID-19 Policy Compliance in Germany and Switzerland.

Abstract: Background In contrast to neighboring countries, German and Swiss authorities refrained from general curfews during the first pandemic wave in spring 2020, calling for solidarity and personal responsibility instead. Using a qualitative methodology, this study aims to explore why people in Germany and Switzerland were motivated to comply with policy measures during the first wave of the coronavirus disease 2019 (COVID-19) pandemic, and what factors hindered or limited their motivation. While quantitative surveys can measure the level of compliance, or broadly ask what motives people had for compliance, we here strive to explain why and how these motives lead to compliance. Methods This publication has been made possible by the joint work of the members of the “Solidarity in times of pandemics” (SolPan) research commons. Seventy-seven semi- structured qualitative interviews were conducted with members of the general public in Germany (n = 46) and the German-speaking part of Switzerland (n = 31) in April 2020. Interviews were transcribed and analyzed following a grounded theory approach. Results Three themes were identified that summarize factors contributing to compliant or noncompliant behavior. (1) Social cohesion was, on the one hand, an important motivator for compliance, but at the same time related to conflicting needs, illustrating the limits of compliance. (2) Consequences were considered on both the individual level (eg, consequences of individual infection) and societal level (eg, the societal and economic consequences of restrictions). (3) While for some participants following the rules was perceived as a matter of principle, others stressed the importance of making their own risk assessment, which was often associated with with a need for evidence on the effectiveness and reasons behind measures. Conclusion A variety of motives contribute to COVID-19 related compliance. Authorities should seek to address these multi-faceted aspects to support motivation for compliance in a large proportion of the population.

Conceptualising the Commercial Determinants of Health Using a Power Lens: A Review and Synthesis of Existing Frameworks.

Abstract: Background There is increasing recognition that power imbalances that favour corporations, especially those active in unhealthy commodity industries, over other actors are central to the ways in which corporations influence population health. However, existing frameworks for analysing corporate strategies and practices that impact on health do not incorporate concepts of power in consistent ways. This paper aimed to review the ways in which corporate power has been incorporated into such frameworks, and to propose a revised framing of the commercial determinants of health(CDoH) that makes concepts of power explicit. Methods We conducted a narrative review of frameworks that identify corporate strategies and practices and explain how these influence population health. Content analysis was conducted to identify explicit references to different qualities of power – its origins, nature, and manifestations. Results Twenty-two frameworks were identified, five of which used theories of power. A wide range of contexts that shape, and are shaped by corporate power were discussed, as were a diversity of corporate, social and ecological outcomes. A variety of material and ideational sources of power was also covered. We proposed an integrated ‘Corporate Power and Health’ framework to inform analysis of the CDoH, organised around key questions on power set out by Foucault. The proposed framework draws from a number of well-established corporate power theories and synthesises key features of existing CDoH frameworks. Conclusion Public health advocates, researchers and policy-makers would likely be better placed to understand and address the CDoH by engaging with theories of power to a greater extent, and by explicitly incorporating concepts of corporate power in analyses of how the deployment of corporate strategies and practices influence population health.

Emerging and Re-emerging Infectious Diseases in the WHO Eastern Mediterranean Region, 2001-2018.

Abstract: Background Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018. Methods To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect. Results Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia. Conclusion EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.

Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis.

Abstract: BACKGROUND: Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare. METHODS: A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role. RESULTS: A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes). CONCLUSION: The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.

The Political Economy of Healthy and Sustainable Food Systems: An Introduction to a Special Issue.

Abstract: Today’s food systems are contributing to multiple intersecting health and ecological crises. Many are now calling for transformative, or even radical, food systems change. Our starting assumption in this Special Issue is the broad claim that the transformative changes being called for in a global food system in crisis cannot – and ultimately will not – be achieved without intense scrutiny of and changes in the underlying political economies that drive today’s food systems. The aim is to draw from diverse disciplinary perspectives to critically evaluate the political economy of food systems, understand key challenges, and inform new thinking and action. We received 19 contributions covering a diversity of country contexts and perspectives, and revealing inter-connected challenges and opportunities for realising the transformation agenda. We find that a number of important changes in food governance and power relations have occurred in recent decades, with a displacement of power in four directions. First, upwards as globalization has given rise to more complex and globally integrated food systems governed increasingly by transnational food corporations (TFCs) and international financial actors. Second, downwards as urbanization and decentralization of authority in many countries gives cities and sub-national actors more prominence in food governance. Third, outwards with a greater role for corporate and civil society actors facilitated by an expansion of food industry power, and increasing preferences for market-orientated and multi-stakeholder forms of governance. Finally, power has also shifted inwards as markets have become increasingly concentrated through corporate strategies to gain market power within and across food supply chain segments. The transformation of food systems will ultimately require greater scrutiny of these challenges. Technical ‘problem-solving’ and overly-circumscribed policy approaches that depoliticise food systems challenges, are insufficient to generate the change we need, within the narrow time-frame we have. While there will be many paths to transformation, rights-based and commoning approaches hold great promise, based on principles of participation, accountability and non-discrimination, alongside coalition building and social mobilization, including social movements grounded in food sovereignty and agroecology.

A Complexity Lens on the COVID-19 Pandemic.

Abstract: The most striking feature of the coronavirus disease 2019 (COVID-19) pandemic and associated responses is its social and ecological complexity. Applying a complexity lens can improve our understanding of the current COVID-19 pandemic but how can this best be done? Complexity science is not a unified theory but rather a collection of concepts, theories, and methods that are increasingly influencing a range of scholarly disciplines. Complex systems can be simply defined as “co-evolving multilayer networks.”1 This definition stresses the dynamic nature of causality as well as the emergent and difficult to predict behaviour in networks that can adapt to a changing environment. Based on this definition, we describe key features of the COVID-19 pandemic, draw insights from complexity science about the nature of these features, and understand the implications for effective response and governance. This framework offers a relevant approach for shaping future research on the social ecological impact of the pandemic including comparative measures of resilience of different health systems to future events.

Recovered but Constrained: Narratives of Ghanaian COVID-19 Survivors Experiences and Coping Pathways of Stigma, Discrimination, Social Exclusion and Their Sequels.

Abstract: BACKGROUND: Research about the coronavirus disease 2019 (COVID-19), its epidemiology and socio-economic impact on populations worldwide has gained attention. However, there is dearth of empirical knowledge in low- and middle-income settings about the pandemic's impact on survivors, particularly the tension of their everyday life arising from the experiences and consequences of stigma, discrimination and social exclusion, and how they cope with these behavioral adversities. METHODS: Realist qualitative approach drawing data from people clinically diagnosed positive of COVID-19, admitted into therapy in a designated treatment facility, and subsequently recovered and discharged for or without follow-up domiciliary care. In-depth interviews were conducted by maintaining a code book for identifying and documenting thematic categories in a progression leading to thematic saturation with 45 participants. Data were transcribed and coded deductively for broad themes at the start before systematically nesting emerging themes into the broad ones with the aid of NVivo 12 software. RESULTS: Everyday lived experiences of the participants were disrupted with acts of indirect stigmatization (against relatives and family members), direct stigmatization (labeling, prejudices and stereotyping), barriers to realizing full social life and discriminatory behaviors across socio-ecological structures (workplace, community, family, and social institutions). These behavioral adversities were associated with self-reported poor health, anxiety and psychological disorders, and frustrations among others. Consequently, supplicatory prayers, societal and organizational withdrawal, aggressive behaviors, supportive counseling, and self-assertive behaviors were adopted to cope and modify the adverse behaviors driven by misinformation and fearful perceptions of the COVID-19 and its contagious proportions. CONCLUSION: In the face of the analysis, social campaigns and dissemination of toolkits that can trigger behavior change and responsible behaviors toward COVID-19 survivors are proposed to be implemented by health stakeholders, policy and decision makers in partnership with social influencers, the media, and telecoms.

A Report on Statistics of an Online Self-screening Platform for COVID-19 and Its Effectiveness in Iran.

Abstract: Background The most recent emerging infectious disease, coronavirus disease 2019 (COVID-19), is pandemic now. Iran is a country with community transmission of the disease. Telehealth tools have been proved to be useful in controlling public health disasters. We developed an online self-screening platform to offer a population-wide strategy to control the massive influx to medical centers. Methods We developed a platform operating based on given history by participants, including sex, age, weight, height, location, primary symptoms and signs, and high risk past medical histories. Based on a decision-making algorithm, participants were categorized into four levels of suspected cases, requiring diagnostic tests, supportive care, not suspected cases. We made comparisons with Iran STEPs (STEPwise approach to Surveillance) 2016 study and data from the Statistical Centre of Iran to assess population representativeness of data. Also, we made a comparison with officially confirmed cases to investigate the effectiveness of the platform. A multilevel mixed-effects Poisson regression was used to check the association of visiting platform and deaths caused by COVID-19. Results About 310 000 individuals participated in the online self-screening platform in 33 days. The majority of participants were in younger age groups, and males involved more. A significant number of participants were screened not to be suspected or needing supportive care, and only 10.4% of males and 12.0% of females had suspected results of COVID-19. The penetration of the platform was assessed to be acceptable. A correlation coefficient of 0.51 was calculated between suspected results and confirmed cases of the disease, expressing the platform's effectiveness. Conclusion Implementation of a proper online self-screening tool can mitigate population panic during wide-spread epidemics and relieve massive influx to medical centers. Also, an evidence-based education platform can help fighting infodemic. Noticeable utilization and verified effectiveness of such platform validate the potency of telehealth tools in controlling epidemics and pandemics.

Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases.

Abstract: BACKGROUND: Non-communicable diseases (NCDs) are increasingly recognized as a significant threat to health and development globally, and United Nations (UN) Member States adopted the Political Declaration of the Third High-level Meeting (HLM) on the prevention and control of NCDs in 2018. The negotiation process for the Declaration included consultations with Member States, intergovernmental organizations (IGOs), and non-state actors such as non-governmental organizations (NGOs) and the private sector. With NCD responses facing charges of inadequacy, it is important to scrutinize the governance process behind relevant high-level global decisions and commitments. METHODS: Through a review of 159 documents submitted by stakeholders during the negotiation process, we outline a typology of policy positions advocated by various stakeholders in the development of the Declaration. We document changes in text from the draft to the final version of the Declaration to analyse the extent to which various positions and their proponents were influential. RESULTS: NGOs and low- and middle-income countries (LMICs) generally pursued 'stricter' governance of NCD risk factors including stronger regulation of unhealthy products and improved management of conflicts of interest that arise when health-harming industries are involved in health policy-making. The private sector and high-income countries generally opposed greater restrictions on commercial factors. The pattern of changes between the draft and final Declaration indicate that advocated positions tended to be included in the Declaration if there was no clear opponent, whereas opposed positions were either not included or included with ambiguous language. CONCLUSION: Many cost-effective policy options to address NCDs, such as taxation of health-harming products, were opposed by high-income countries and the private sector and not well-represented in the Declaration. To ensure robust political commitments and action on NCDs, multi-stakeholder governance for NCDs must consider imbalances in power and influence amongst constituents as well as biases and conflicts in positioning.

COVID-19 Lockdown and Social Capital Changes Among Youths in China.

Abstract: Social capital refers to the effective functioning of social groups through networks of relationships. The lockdown measures due to coronavirus disease 2019 (COVID-19) may change the social capital among youths. This study aimed to evaluate changes in social capital before and during COVID-19 lockdown among Chinese youths. It was based on the online COVID-19 Impact on Lifestyle Change Survey (COINLICS) conducted among 10 540 youths at three educational levels, including high/vocational school, undergraduate, and graduate, before and during COVID-19 lockdown. Measures of perceptions of social capital were adapted from a validated Chinese version of Health-related Social Capital Measurement based on youths' characteristics of living and studying environment. Social capital was measured at four dimensions, including individual social capital (ISC), family social capital (FSC), community social capital (CSC), and society social capital (SSC). Overall, compared to before lockdown, ISC and CSC scores decreased, while FSC and SSC scores increased during lockdown. When stratified by educational levels, the trends for each dimension of social capital were consistent with the overall population. There were 43.9%, 5.7%, 32.1%, and 3.7% of the participants showing decreased scores during lockdown for ISC, FSC, CSC, and SSC, respectively, while 7.2%, 24.0%, 15.3%, and 10.7% of participants showed increased scores for ISC, FSC, CSC, and SSC, respectively. Our timely, large-scale study showed decreased social capital in individual and community dimensions and increased social capital in family and society dimensions during lockdown.

Evidence-Informed Deliberative Processes for Health Benefit Package Design – Part II: A Practical Guide

Abstract: Background Countries around the world are using health technology assessment (HTA) for health benefit package design. Evidence-informed deliberative processes (EDPs) are a practical and stepwise approach to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. This paper reports on the development of practical guidance on EDPs, while the conceptual framework of EDPs is described in a companion paper.Methods The first guide on EDPs (2019) is further developed based on academic knowledge exchange, surveying 27 HTA bodies and 66 experts around the globe, and the implementation of EDPs in several countries. We present the revised steps of EDPs and how selected HTA bodies (in Australia, Brazil, Canada, France, Germany, Scotland, Thailand and the United Kingdom) organize key issues of legitimacy in their processes. This is based on a review of literature via PubMed and HTA bodies’ websites.Results HTA bodies around the globe vary considerable in how they address legitimacy (stakeholder involvement ideally through participation with deliberation; evidence-informed evaluation; transparency; and appeal) in their processes. While there is increased attention for improving legitimacy in decision-making processes, we found that the selected HTA bodies are still lacking or just starting to develop activities in this area. We provide recommendations on how HTA bodies can improve on this.Conclusion The design and implementation of EDPs is in its infancy. We call for a systematic analysis of experiences of a variety of countries, from which general principles on EDPs might subsequently be inferred.

A Framing Analysis of Consultation Submissions on the WHO Global Strategy to Reduce the Harmful Use of Alcohol: Values and Interests.

Abstract: Background In response to the magnitude of harms caused by alcohol, the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol (GAS) was endorsed in 2010. We analysed submissions to the 2019 WHO consultation on the implementation of the GAS to identify how different stakeholders frame alcohol use and control; and to assess how stakeholders engage with the consultation process, with possibly harmful consequences for public health policy. Methods All submissions from WHO Member States, international organisations, non-governmental organisations (NGOs), academic institutions and private sector entities were identified and used as data for an inductive framing analysis. This involved close reading and data familiarisation, thematic coding and identifying emergent framings. Through the analysis of texts, framing analysis can give insights into the values and interests of stakeholders. Because framing influences how issues are conceptualised and addressed, framing analysis is a useful tool to study policy-making processes. Results We identified 161 unique submissions and seven attachments. Emerging frames were grouped according to their function: defining the problem, assigning causation, proposing solutions, or justifying and persuading. Submissions varied in terms of the framing they deployed and how this was presented, eg, how the problem was defined. Proposed policy solutions also varied. Targeted solutions emphasising individual responsibility tended to be supported by industry and some Member States. Calls for universal regulation and global mobilisation often came from NGOs and academia. Stakeholders drew on evidence and specific value systems to support the adoption of certain problem and solution ideas and to oppose competing framing. Conclusion Alcohol control is a contested policy field in which different stakeholders use framing to set the agenda and influence what policy solutions are considered legitimate. WHO should consider which interests are served by these different framings and how to weigh different stakeholders in the consultation process.

Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?

Abstract: Background Hospital professionals are “dual agents” who may face dilemmas between their commitment to patients’ clinical needs and hospitals’ financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems. Methods We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning. Results Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include ‘reshaping management,’ such as better planning of the entire course of treatment and improvement of the coding; and ‘reframing decision- making,’ which involves working with averages and developing tool-kits for decision- making. Conclusion Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision- making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.

Implications of COVID-19: The Effect of Working From Home on Financial and Mental Well-Being in the UK.

Abstract: In response to the threat posed by coronavirus disease 2019 (COVID-19), the UK prime minister announced on the 23rd of March strict lockdowns and introduced a new way of living and working, at least temporarily. This included working from home (WHF) wherever possible. Many experts from the IT industry were long arguing about the potential for WFH, which suddenly now became indisputable. The objective of this study is to evaluate the impact of WFH on the individuals' perception about their future financial situation and their mental well-being. We apply a difference-in-differences (DiD) framework using data from the UK Household Longitudinal Study (UKHLS) combined with the UKHLS COVID-19 survey conducted in April 2020. Our findings suggest that those who have not experienced a shift from working at the employer's premises to WFH became more concerned about their future financial situation. However, we find that WFH has a negative impact on mental well-being. On the other hand, we find no difference in the mental well-being when we consider those who work from home on occasion. The findings of this study have policy implications for government, firms and health practitioners. In particular, a balance between WFH and at the employer's premises may provide both financial security and maintain the mental and psychological well-being at satisfying levels.

Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada.

Abstract: Background Resilience, a system’s ability to maintain a desired level of performance when circumstances disturb its functioning, is an increasingly important concept in healthcare. However, empirical investigations of resilience in healthcare (RiH) remain uncommon, particularly those that examine how government actions contribute to the capacity for resilient performance in the healthcare setting. We sought to investigate how governmental actions during the coronavirus disease 2019 (COVID-19) pandemic related to the concept of resilience, how these actions contributed to the potential for resilient performance in healthcare, and what opportunities exist for governments to foster resilience within healthcare systems. Methods We conducted case studies of government actions pertaining to the COVID-19 pandemic in New South Wales, Australia and Ontario, Canada. Using media releases issued by each government between December 2019 and August 2020, we performed qualitative content analysis to identify themes relevant to the resilience potentials (anticipate, monitor, respond, learn) and RiH. Results Direct references to the term ‘resilience’ appeared in the media releases of both governments. However, these references focused on the reactive aspects of resilience. While actions that constitute the resilience potentials were evident, the media releases also revealed opportunities to enhance learning (eg, a need to capitalize on opportunities for double-loop learning and identify strategies appropriate for complex systems) and anticipating (eg, incorporating the concept of hedging into frameworks of RiH). Conclusion Though fostering RiH through government action remains a challenge, this study suggests opportunities to realize this goal. Articulating a proactive vision of resilience and recognizing the complex nature of current systems could enhance governments’ ability to coordinate resilient performance in healthcare. Reflection on how anticipation relates to resilience appears necessary at both the practical and conceptual levels to further develop the capacity for RiH.

Prohibit, Protect, or Adapt? The Changing Role of Volunteers in Palliative and Hospice Care Services During the COVID-19 Pandemic. A Multinational Survey (Covpall).

Abstract: Background Volunteers are common within palliative care services, and provide support that enhances care quality. The support they provided, and any role changes, during the coronavirus disease 2019 (COVID-19) pandemic are unknown. The aim of this study is to understand volunteer deployment and activities within palliative care services, and to identify what may affect any changes in volunteer service provision, during the COVID-19 pandemic. Methods Multi-national online survey disseminated via key stakeholders to specialist palliative care services, completed by lead clinicians. Data collected on volunteer roles, deployment, and changes in volunteer engagement. Analysis included descriptive statistics, a multivariable logistic regression, and analysis of free-text comments using a content analysis approach. Results 458 respondents: 277 UK, 85 rest of Europe, and 95 rest of the world. 68.5% indicated volunteer use preCOVID-19 across a number of roles (from 458): direct patient facing support (58.7%), indirect support (52.0%), back office (48.5%) and fundraising (45.6%). 11% had volunteers with COVID-19. Of those responding to a question on change in volunteer deployment (328 of 458) most (256/328, 78%) indicated less or much less use of volunteers. Less use of volunteers was associated with being an in-patient hospice, (odds ratio [OR] = 0.15, 95% CI = 0.07-0.3, P < .001). This reduction in volunteers was felt to protect potentially vulnerable volunteers, with policy changes preventing volunteer support. However, adapting was also seen where new roles were created, or existing roles pivoted to provide virtual support. Conclusion Volunteers were mostly prevented from supporting many forms of palliative care which may have quality and safety implications given their previously central roles. Volunteer re-deployment plans are needed that take a more considered approach, using volunteers more flexibly to enhance care while ensuring safe working practices. Consideration needs to be given to widening the volunteer base away from those who may be considered to be most vulnerable to COVID-19.

Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study.

Abstract: Background Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi- stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies. Methods We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders’ power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals’ associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007–2020) through literature review was used to frame the interviews by means of a chronic care policy timeline. Results In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform. Conclusion The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.

The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic.

Abstract: Background Coronavirus disease 2019 (COVID-19) has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children's Hospitals Network (SCHN), the largest provider of children's health services in the Southern hemisphere. Methods We used ethnographic methods, guided by the CSSF, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the emergency operations centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN's response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN. Results The CSSF captured SCHN's complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN's response to the pandemic included principles of equity of healthcare delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN's resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision. Conclusion Using the CSSF, we found that SCHN's ability to innovate was key to ensuring its resilience during the pandemic.

Exploring the Role of Leadership in Facilitating Change to Improve Cancer Survival: An Analysis of Experiences in Seven High Income Countries in the International Cancer Benchmarking Partnership (ICBP).

Abstract: Background The differences in cancer survival across countries and over time are well recognised, with progress varying even among high-income countries with comparable health systems. Previous research has examined several possible explanations, but the role of leadership in systems providing cancer care has attracted little attention. As part of the International Cancer Benchmarking Partnership (ICBP), this study looked at diverse aspects of leadership to identify drivers of change and opportunities for improvement across seven high-income countries. Methods Key informants in 13 jurisdictions were interviewed: Australia (2 states), Canada (3 provinces), Denmark, Ireland, New Zealand, Norway and United Kingdom (4 countries). Participants represented a range of stakeholders at different tiers of the system. They were recruited through a combination of purposive and ‘snowball’ strategies and participated in semi-structured telephone interviews. Interview transcripts were analysed thematically drawing on the World Health Organization (WHO) health systems framework and previous work analysing national cancer control programmes (NCCPs). Results Several facets of leadership were perceived as important for improving outcomes. These included political leadership to initiate and maintain progress, intellectual leadership to support those engaged in local implementation of national policies and drive change, and a coherent vision from leaders at different levels of the system. Clinical leadership was also viewed as vital for translating policy into action. Conclusion Certain aspects of cancer care leadership emerged as underpinning and sustaining improvements, such as appointing a central agency, involving clinicians at every stage, ensuring strong leadership of cancer care with a consistent political mandate. Improving cancer outcomes is challenging and complex, but it is unlikely to be achieved without effective leadership, both political and clinical.

A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa.

Abstract: Background “Achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all” is the Sustainable Development Goal (SDG) 3.8 target. Although most high-income countries have achieved or are very close to this target, low- and middle-income countries (LMICs) especially those in sub-Saharan Africa (SSA) are still struggling with its achievement. One of the observed challenges in SSA is that even where services are supposed to be “free” at point-of-use because they are covered by a health insurance scheme, out-of-pocket fees are sometimes being made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from the published literature on the ‘what’ and ‘why’ of this policy implementation gap in SSA. Methods The study drew on Lipsky’s street level bureaucracy (SLB) theory, the concept of practical norms, and Taryn Vian’s framework of corruption in the health sector to explore this policy implementation gap through a narrative synthesis review. The data from selected literature were extracted and synthesized iteratively using a thematic content analysis approach. Results Insured clients paid out-of-pocket for a wide range of services covered by insurance policies. They made formal and informal cash and in-kind payments. The reasons for the payments were complex and multifactorial, potentially explained in many but not all instances, by coping strategies of street level bureaucrats to conflicting health sector policy objectives and resource constraints. In other instances, these payments appeared to be related to structural violence and the ‘corruption complex’ governed by practical norms. Conclusion A continued top-down approach to health financing reforms and UHC policy is likely to face implementation gaps. It is important to explore bottom-up approaches – recognizing issues related to coping behaviour and practical norms in the face of unrealistic, conflicting policy dictates.

Enhancing the Understanding of Resilience in Health Systems of Low- and Middle-Income Countries: A Qualitative Evidence Synthesis.

Abstract: BACKGROUND: A country's health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications. METHODS: The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study. RESULTS: Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms. CONCLUSION: The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.