Multisectoral Actions for Health: Challenges and Opportunities in Complex Policy Environments.
ABSTRACT: Multisectoral actions for health, defined as actions undertaken by non-health sectors to protect the health of the population, are essential in the context of inter-linkages between three dimensions of sustainable development: economic, social, and environmental. These multisectoral actions can address the social and economic factors that influence the health of a population at the local, national, and global levels. This editorial identifies the challenges, opportunities and capacity development for effective multisectoral actions for health in a complex policy environment. The root causes of the challenges lie in poor governance such as entrenched political and administrative corruption, widespread clientelism, lack of citizen voice, weak social capital, lack of trust and lack of respect for human rights. This is further complicated by the lack of government effectiveness caused by poor capacity for strong public financial management and low levels of transparency and accountability which leads to corruption. The absence of or rapid changes in government policies, and low salary in relation to living standards result in migration out of qualified staff. Tobacco, alcohol and sugary drink industries are major risk factors for non-communicable diseases (NCDs) and had interfered with health policy through regulatory capture and potential law suits against the government. Opportunities still exist. Some World Health Assembly (WHA) and United Nations General Assembly (UNGA) resolutions are both considered as external driving forces for intersectoral actions for health. In addition, Thailand National Health Assembly under the National Health Act is another tool providing opportunity to form trust among stakeholders from different sectors. Capacity development at individual, institutional and system level to generate evidence and ensure it is used by multisectoral agencies is as critical as strengthening the health literacy of people and the overall good governance of a country.
Project description:<h4>Background</h4>Despite calls for the application of complex systems science in empirical studies of health promotion, there are very few examples. The aim of this paper was to use a complex systems approach to examine the key factors that influenced health promotion (HP) policy and practice in a multisectoral health system in Australia.<h4>Methods</h4>Within a qualitative case study, a schema was developed that incorporated HP goals, actions and strategies with WHO building blocks (leadership and governance, financing, workforce, services and information). The case was a multisectoral health system bounded in terms of geographical and governance structures and a history of support for HP. A detailed analysis of 20 state government strategic documents and interviews with 53 stakeholders from multiple sectors were completed. Based upon key findings and dominants themes, causal pathways and feedback loops were established. Finally, a causal loop diagram was created to visualise the complex array of feedback loops in the multisectoral health system that influenced HP policy and practice.<h4>Results</h4>The complexity of the multisectoral health system was clearly illustrated by the numerous feedback mechanisms that influenced HP policy and practice. The majority of feedback mechanisms in the causal loop diagram were vicious cycles that inhibited HP policy and practice, which need to be disrupted or changed for HP to thrive. There were some virtuous cycles that facilitated HP, which could be amplified to strengthen HP policy and practice. Leadership and governance at federal-state-local government levels figured prominently and this building block was interdependently linked to all others.<h4>Conclusion</h4>Creating a causal loop diagram enabled visualisation of the emergent properties of the case health system. It also highlighted specific leverage points at which HP policy and practice can be improved. This paper demonstrates the critical importance of leveraging leadership and governance for HP and adds urgency to the need for increased and strong advocacy efforts targeting all levels of government in multisectoral health systems.
Project description:BACKGROUND:The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for 'corruption' in the LMICs of south and south-east Asia region. 'Corruption' works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon. METHODS:A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar. A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by 'mixed studies review' method. RESULTS:Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact. CONCLUSIONS:Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.
Project description:National policy on global health (NPGH) arenas are multisectoral governing arrangements for cooperation between health, development, and foreign affairs sectors in government policy for global health governance. To explore the relationship between national and global processes for governing global health, this paper asks: in what forms of interaction between NPGH arenas and global health governance are learning and networking processes present? In a multiple case study of Norwegian and Swiss NPGH arenas, we collected data on intersectoral policy processes from semi-structured interviews with 33 informants in 2014-2015. Adapting Real-Dato's framework, we analyzed each case separately, producing monographs for comparing NPGH arenas. Analyzing both NPGH arenas for relational structures linking external resources to internal policy arena processes, we found five zones of interactions - including institutions, transgovernmental clubs, and connective forms. These interactions circulate ideas and soften arenas' boundaries. We argue that NPGH is characteristic of transnational governance of global health.
Project description:<h4>Background</h4>Child undernutrition remains the major public health problem in low and middle-income countries including Ethiopia. The effects of good governance, urbanization and public health expenditure on childhood undernutrition are not well studied in developing countries. The objective of the study is to examine the relationship between quality of governance, public health expenditures, urbanization and child undernutrition in Ethiopia.<h4>Methods</h4>This is pooled data analysis with ecological design. We obtained data on childhood undernutrition from the Ethiopian Demographic and Health Surveys (EDHS) that were conducted in 2000, 2005, 2011 and 2016. Additionally, data on quality of governance for Ethiopia were extracted from the World Governance Indicators (WGI) and public health spending and urbanization were obtained from the World Development Indicators and United Nations' World Population Prospects (WPP) respectively. Univariate and multivariate analysis were done to assess the relationship between governance, public health expenditure and urbanization with childhood undernutrition.<h4>Result</h4>Government effectiveness (adjusted odd ratio (AOR)?=?20.7; p?=?0.046), regulatory quality (AOR?=?0.0077; p?=?0.026) and control of corruption (AOR?=?0.0019; p?=?0.000) were associated with stunting. Similarly, government effectiveness (AOR?=?72.2; p?=?0.007), regulatory quality (AOR?=?0.0015; p?=?0.004) and control of corruption (AOR?=?0.0005; p?=?0.000) were associated with underweight. None of the governance indicators were associated with wasting. On the other hand, there is no statistically significant association observed between public health spending and urbanization with childhood undernutrition. However, other socio-demographic variables play a significant effect on reducing of child undernutrition.<h4>Conclusion</h4>This study indicates that good governance in the country plays a significant role for reducing childhood undernutrition along with other socio-demographic factors. Concerned bodies should focus on improving governance and producing a quality policy and at the same time monitor its implementation and adherence.
Project description:<h4>Background</h4>Over the past decade, 70% of new and re-emerging infectious disease outbreaks in East Africa have originated from the Congo Basin where Rwanda is located. To respond to these increasing risks of disastrous outbreaks, the government began integrating One Health (OH) into its infectious disease response systems in 2011 to strengthen its preparedness and contain outbreaks. The strong performance of Rwanda in responding to the on-going COVID-19 pandemic makes it an excellent example to understand how the structure and principles of OH were applied during this unprecedented situation.<h4>Methods</h4>A rapid environmental scan of published and grey literature was conducted between August and December 2020, to assess Rwanda's OH structure and its response to the COVID-19 pandemic. In total, 132 documents including official government documents, published research, newspaper articles, and policies were analysed using thematic analysis.<h4>Results</h4>Rwanda's OH structure consists of multidisciplinary teams from sectors responsible for human, animal, and environmental health. The country has developed OH strategic plans and policies outlining its response to zoonotic infections, integrated OH into university curricula to develop a OH workforce, developed multidisciplinary rapid response teams, and created decentralized laboratories in the animal and human health sectors to strengthen surveillance. To address COVID-19, the country created a preparedness and response plan before its onset, and a multisectoral joint task force was set up to coordinate the response to the pandemic. By leveraging its OH structure, Rwanda was able to rapidly implement a OH-informed response to COVID-19.<h4>Conclusion</h4>Rwanda's integration of OH into its response systems to infectious diseases and to COVID-19 demonstrates the importance of applying OH principles into the governance of infectious diseases at all levels. Rwanda exemplifies how preparedness and response to outbreaks and pandemics can be strengthened through multisectoral collaboration mechanisms. We do expect limitations in our findings due to the rapid nature of our environmental scan meant to inform the COVID-19 policy response and would encourage a full situational analysis of OH in Rwanda's Coronavirus response.
Project description:<h4>Background</h4>The Global Fund to Fight AIDS, Tuberculosis and Malaria has proven highly effective at fighting the world's major killers. Strong governance and robust development institutions are necessary, however, for improving health long-term. While some suggest that international aid can strengthen institutions, others worry that aid funding will undermine governance, creating long-term harm. The Global Fund is a unique aid institution with mechanisms designed to improve transparency and accountability, but the effectiveness of this architecture is not clear.<h4>Objectives</h4>This study seeks evidence on the effects of Fund financing over the past 15 years on national governance and development.<h4>Methods</h4>A unique dataset from 112 low- and middle-income countries was constructed with data from 2003 to 2017 on Global Fund financing and multiple measures of health, development, and governance. Building a set of regression models, we estimate the relationship between Fund financing and key indicators of good governance and development, controlling for multiple factors, including the effects of other aid programs and tests for reverse causality.<h4>Findings</h4>We find that Global Fund support is associated with improved control of corruption, government accountability, political freedoms, regulatory quality, and rule of law, though association with effective policy implementation is less clear. We also find associated benefit for overall adult mortality and human development.<h4>Conclusion</h4>Our data are not consistent with recent claims that aid undermines governance. Instead our findings support the proposition that the Global Fund architecture is making it possible to address the continuing crises of AIDS, tuberculosis, and malaria in ways that improve institutions, fight corruption, and support development. Amidst the complex political economy that produces good governance at a national level, our finding of a beneficial effect of health aid suggests important lessons for aid in other settings.
Project description:Healthcare accessibility and equity remain important issues, as corruption in the form of informal payments is still prevalent in many countries across the world. This study employs a panel data analysis over the 2006-2013 period to explore the role of different institutional factors in explaining the prevalence of informal payments. Covering 117 countries, our findings confirm the significant role of both formal and informal institutions. Good governance, a higher trust among individuals, and a higher commitment to tackling corruption are associated with diminishing informal payments. In addition, higher shares of private finance, such as out-of-pocket and domestic private health expenditure, are also correlated with a lower prevalence of informal payments. In policy terms, this displays how correcting institutional imperfections may be among the most efficient ways to tackle informal payments in healthcare.
Project description:<h4>Background</h4>Pharmaceuticals are an integral component of health care systems worldwide, thus, regulatory weaknesses in governance of the pharmaceutical system negatively impact health outcomes especially in developing countries 1. Nigeria is one of a number of countries whose pharmaceutical system has been impacted by corruption and has struggled to curtail the production and trafficking of substandard drugs. In 2001, the National Agency for Food and Drug Administration and Control (NAFDAC) underwent an organizational restructuring resulting in reforms to reduce counterfeit drugs and better regulate pharmaceuticals 2. Despite these changes, there is still room for improvement. This study assessed the perceived level of transparency and potential vulnerability to corruption that exists in four essential areas of Nigeria's pharmaceutical sector: registration, procurement, inspection (divided into inspection of ports and of establishments), and distribution.<h4>Methods</h4>Standardized questionnaires were adapted from the World Health Organization assessment tool and used in semi-structured interviews with key stakeholders in the public and private pharmaceutical system. The responses to the questions were tallied and converted to scores on a numerical scale where lower scores suggested greater vulnerability to corruption and higher scores suggested lower vulnerability.<h4>Results</h4>The overall score for Nigeria's pharmaceutical system was 7.4 out of 10, indicating a system that is marginally vulnerable to corruption. The weakest links were the areas of drug registration and inspection of ports. Analysis of the qualitative results revealed that the perceived level of corruption did not always match the qualitative evidence.<h4>Conclusion</h4>Despite the many reported reforms instituted by NAFDAC, the study findings suggest that facets of the pharmaceutical system in Nigeria remain fairly vulnerable to corruption. The most glaring deficiency seems to be the absence of conflict of interest guidelines which, if present and consistently administered, limit the promulgation of corrupt practices. Other major contributing factors are the inconsistency in documentation of procedures, lack of public availability of such documentation, and inadequacies in monitoring and evaluation. What is most critical from this study is the identification of areas that still remain permeable to corruption and, perhaps, where more appropriate checks and balances are needed from the Nigerian government and the international community.
Project description:<h4>Objective</h4>The potential for data collected in general practice to be linked and used to address health system challenges of maintaining quality care, accessibility and safety, including pandemic support, has led to an increased interest in public acceptability of data sharing, however practitioners have rarely been asked to share their opinions on the topic. This paper attempts to gain an understanding of general practitioner's perceptions on sharing routinely collected data for the purposes of healthcare planning and research. It also compares findings with data sharing perceptions in an international context. MATERIALS AND METHODS: A mixed methods approach combining an initial online survey followed by face-to-face interviews (before and during COVID-19), designed to identify the barriers and facilitators to sharing data, were conducted on a cross sectional convenience sample of general practitioners across Western Australia (WA).<h4>Results</h4>Eighty online surveys and ten face-to-face interviews with general practitioners were conducted from November 2020 - May 2021. Although respondents overwhelmingly identified the importance of population health research, their willingness to participate in data sharing programs was determined by a perception of trust associated with the organisation collecting and analysing shared data; a clearly defined purpose and process of collected data; including a governance structure providing confidence in the data sharing initiative simultaneously enabling a process of data sovereignty and autonomy.<h4>Discussion</h4>Results indicate strong agreement around the importance of sharing patient's medical data for population and health research and planning. Concerns pertaining to lack of trust, governance and secondary use of data continue to be a setback to data sharing with implications for primary care business models being raised.<h4>Conclusion</h4>To further increase general practitioner's confidence in sharing their clinical data, efforts should be directed towards implementing a robust data governance structure with an emphasis on transparency and representative stakeholder inclusion as well as identifying the role of government and government funded organisations, as well as building trust with the entities collecting and analysing the data.
Project description:BACKGROUND: Only governments sensitive to the demands of their citizens appropriately respond to needs of their nation. Based on Professor Amartya Sen's analysis of the link between famine and democracy, the following null hypothesis was tested: "Human Immunodeficiency Virus (HIV) prevalence is not associated with governance". METHODS: Governance has been divided by a recent World Bank paper into six dimensions. These include Voice and Accountability, Political Stability and Absence of Violence, Government Effectiveness, Regulatory Quality, Rule of Law and the Control of Corruption. The 2002 adult HIV prevalence estimates were obtained from UNAIDS. Additional health and economic variables were collected from multiple sources to illustrate the development needs of countries. RESULTS: The null hypothesis was rejected for each dimension of governance for all 149 countries with UNAIDS HIV prevalence estimates. When these nations were divided into three groups, the median (range) HIV prevalence estimates remained constant at 0.7% (0.05 - 33.7%) and 0.75% (0.05% - 33.4%) for the lower and middle mean governance groups respectively despite improvements in other health and economic indices. The median HIV prevalence estimates in the higher mean governance group was 0.2% (0.05 - 38.8%). CONCLUSION: HIV prevalence is significantly associated with poor governance. International public health programs need to address societal structures in order to create strong foundations upon which effective healthcare interventions can be implemented.