ABSTRACT: Tobacco consumption remains a major public health concern globally due to its significant contribution to the burden of non-communicable diseases and associated economic costs. In decentralized governance systems, the effectiveness of tobacco control policies is influenced not only by regulatory frameworks but also by fiscal commitment and institutional capacity at subnational levels. This study aims to examine the relationship between tobacco-related fiscal transfers and the implementation of smoke-free policies across regional governments in Indonesia. A quantitative research design employing panel data analysis was used to evaluate fiscal allocation patterns and policy implementation dynamics during the period 2023â2025. Secondary data were obtained from national fiscal reports, regional budget documents, and administrative policy records. The findings indicate that although tobacco excise revenue transfers increased overall, regional commitment to allocating budgets for smoke-free policy implementation remained uneven. Econometric estimation demonstrates that tobacco revenue transfers and regional tobacco tax income significantly influence policy implementation commitment, while institutional capacity moderates the effectiveness of fiscal resource utilization. These results highlight the importance of strengthening fiscal health governance mechanisms, including performance-based intergovernmental transfers and integrated policy coordination, to ensure that tobacco tax revenues effectively support preventive health interventions and contribute to improved population health outcomes.
BACKGROUND: Nepal has been undergoing demographic and epidemiological transitions, marked by an increasing burden of non-communicable diseases (NCDs) and injuries. These transitions have led to financial implications, including rising out-of-pocket (OOP) expenses. This study reviews and synthesizes evidence on the status, issues and challenges in health financing system, policies, and programs to achieve universal health coverage (UHC) in Nepal. METHODS: We conducted a scoping review of literature on Nepal's health financing system, policies, and programs. A search strategy was developed using keywords related to two core concepts: health financing and universal health coverage. Grey literature was identified from the web pages of relevant ministries and organizations. A total of 148 studies/policy documents published in Nepali and English up to 31 December 2024 were included. Policies and content related to the health financing system were reviewed to understand the status, issues and challenges of health financing functions, and UHC . A framework-guided deductive content analysis approach was employed, and findings were interpreted using the three UHC components: service coverage, population coverage, and financial coverage. RESULTS: Nepal's health policy documents prioritize financial protection for low-income people and target groups through social health protection programs/schemes. However, multiple social health protection schemes coexist with fragmented risk pooling and low efficiency in health financing. OOP expenditure is high at 54.2%, with 10% of the population facing catastrophic health expenditures. Injuries and chronic morbidities contribute significantly to this burden, with 70% of injury-related and 62% of NCD-related expenses borne through OOP payments. Despite efforts to improve financial risk protection, the National Health Insurance Program (NHIP) suffers from low population coverage (28%), low renewal rate (54%), and financial sustainability issues (as provider payments exceed revenue collection). The UHC service coverage index, though improving, was only 54 out of 100 in 2021 reflecting limited health system capacity and insufficient readiness to address health challenges, including those posed by shifting demographics and the growing burden of NCDs. Nepal's total health expenditure remains around 2% of GDP, with persistent inefficiencies in resource allocation, fiscal decentralization, and budget absorption. CONCLUSIONS: Nepal's health financing policies align with UHC goals, yet critical gaps remain in multiple dimensions . Issues such as inefficiencies, underfunding, and fragmented social health protection schemes limit equitable access to quality health care. Therefore, comprehensive structural reforms-spanning legal, institutional, and policy frameworks-are urgently needed. Key reforms include: (1) merging or harmonizing existing social health protection schemes for efficient pooling and purchasing; (2) enhancing domestic health financing through increased health funding (âĽ5% of GDP) via payroll contributions, progressive taxation, and earmarked sin taxes; (3) reforming NHIP to mandatory enrollment starting from formal sector, subsidizing premium for informal sector and free coverage for disadvantaged groups, alongside strengthening policy implementation including accrediting of health facilities, ensuring service quality, prioritising and expanding coverage packages with strategic purchasing from all public and private health facilities; and (4) equitable public financing to ensure needs-based allocation across government levels that respond to demographic and epidemiological patterns. Further research is needed to assess hybrid tax and premium based insurance models, strategic purchasing optimization, and digital health innovations for financial sustainability.
Esteban OrtizâPrado, Isaac Alexander SuĂĄrez Sangucho, Wilson Ricardo CaĂąizares Fuentes, Jorge VĂĄsconez-GonzĂĄlez ¡ 5 authors
In the past three decades, Ecuador's health system has faced frequent ministerial turnover, often appointing leaders with limited training in public health policy and management. Although many ministers have strong clinical backgrounds, their lack of public health expertise has hindered a cohesive vision, raising concerns about the leadership's capacity to tackle the nation's complex health challenges effectively. The Ministry of Health is responsible for upholding the right to health, promoting health, preventing diseases, overseeing surveillance, and providing integrated care. It also develops clinical protocols and management guidelines, delivers health services, and conducts studies comparing national and international health management best practices [5,6]. To adequately fulfill these responsibilities, a master's degree in public health should be the minimum requirement for those considered for the position of Minister of Health. While ministers are indeed supported by technical personnel, they must have enough training to understand technical matters and not be overly reliant on staff or influenced by conflicts of interest [7]. Advanced public health training equips leaders with essential knowledge about financing, management, cost-effectiveness, and health communication, enabling them to evaluate and implement comprehensive health policies [8,9].A health minister requires both managerial skills to oversee health services and advocacy skills to ensure that potential effects on population health are integrated into the work of other government departments and ministries [10]. Helath Ministers require strong knowledge of epidemiology and public health preparedness, highlighted by challenges from global health crises like COVID-19. However, the Ministry faces internal issues impacting ministerial effectiveness, including overlapping responsibilities in regulations, unclear accountability, fragmented technical programs, and departments prioritizing specific professions over broader functions [11]. Furthermore, governance within the health sector is heavily influenced by institutional power dynamics. This lack of governance can severely hinder the performance of the Ministry of Health, contributing to systemic failures [12,13].Over the past 30 years in Ecuador, most health ministers have lacked advanced degrees or experience in key areas such as public health, epidemiology, or health systems management (see Table 1). This absence of qualifications hinders effective public health leadership, which demands an integrated, evidence-based approach to address social, environmental, and behavioral health determinants [1][2][3][4].Although the primary role of a health minister is to manage and oversee the national health system, their responsibility also extends to proposing public policies that can be evaluated through tangible improvements in health indicators, such as infant mortality. We believe that this is a significant issue for health governance.Therefore, we conducted an analysis based on the significant reductions in infant mortality during specific periods, identifying the ministers in charge and the outcomes associated with their tenure, highlighting changes that could reflect the impact of effective leadership and policy implementation (Figure 1). In Ecuador, significant milestones in public health were achieved, particularly before the year 2000. Key figures during their tenure led important vaccination campaigns and successfully managed the 1991 cholera outbreak, reducing infant mortality and advancing the Comprehensive Family and Community Health Program [14]. Between 1990 and 2006, the country saw critical reforms, such as the decentralization of health management to municipalities, the formation of Cantonal Health Councils, and the proposal of Universal Health Insurance in 2005-2006 [15]. However, in 2009, these decentralization efforts were reversed with the re-centralization of the health management system [16], undoing much of the progress that had been made.During 2014, the introduction of new food labeling regulations, which made nutritional information more accessible and positioned Ecuador as a global reference in non-communicable disease prevention was an important contrbution. However, this period was also marked by controversial decisions, including the closure of the National Institute of Hygiene and Tropical Medicine, the elimination of the National Service for the Eradication of Malaria (SNEM), and the shutdown of vaccine production in Ecuador [17]. Despite these public health initiatives, the reduction in infant mortality rates (IMR) during this period was less pronounced compared to other periods. While some improvements were made, the IMR did not decrease as significantly as might have been expected, highlighting a period where public health outcomes did not fully align with the scale of reforms introduced.[Insert Table 2 here ] The COVID-19 pandemic highlighted Ecuador's severe shortage of public health expertise, resulting in one of the world's highest excess death rates. Health ministers, often lacking local experience, communication skills, and disease management knowledge, struggled to provide clear public health messaging. This was worsened by significant mismanagement and corruption, including inflated prices for essential medications and supplies, which deepened the crisis [19,20].Corruption has long plagued the health sector, with some ministers facing serious allegations. For example, several scandals have involved the procurement of ambulances and other essential supplies at inflated prices, breaching public procurement laws [21][22][23].Ecuador's health leadership has historically been marked by high ministerial turnover, driven by political interests. This instability, coupled with instances of corruption and controversial policies, has hindered effective public health initiatives and created fragmented health policies. While some achievements exist, persistent leadership issues have led to high malnutrition rates and ineffective campaigns on issues like traffic accidents and drug abuse, contrasting sharply with the successes of neighboring countries like Peru.Appointing leaders focused solely on clinical medicine without a robust public health background poses several risks:⢠Fragmented Policies: Lacking public health foundations can lead to ineffective, fragmented policies [4,24,25].⢠Curative Bias: Overreliance on treatment instead of prevention perpetuates unsustainable healthcare costs [26].⢠Insufficient Emergency Preparedness: COVID-19 underscored the need for leaders skilled in epidemiology and crisis management [27][28][29].To better manage Ecuador's health system, technical skills and public health experience should be prioritized over political considerations in minister selection. Ideal candidates would possess:⢠Advanced public health qualifications.⢠Proven experience in public health policy formulation and evaluation.⢠Active public health research engagement.⢠Strong leadership and communication skills to articulate a public health vision and make informed, evidence-based decisions.Recent ministers have lacked communication competencies, resulting in fewer public health campaigns and diminishing the perception of health ministers as public health advocates.Selecting health ministers is a nuanced task influenced by social, political, and contextual variables, particularly in developing nations like Ecuador. However, the logic and some of the evidence underscores that this process must be approached thoughtfully, prioritizing technical expertise over political considerations, to ensure sustainable public health progress. While the public often expects a Minister of Health to be an effective administrator, adept at managing public procurement and addressing operational challenges, what Ecuador urgently requires is a leader with expertise in prevention, health promotion, and ensuring equitable access to healthcare services. These competencies are often lacking in physicians focused on curative, private-sector roles. This commentary highlights systemic issues, not as a complaint but as a reflection on persistent shortcomings.For example, despite a 25-year national malnutrition prevention program, Ecuador still has one of the region's highest malnutrition rates. Even during economic booms, investment favored hospital infrastructure over essential primary healthcare. This manuscript urges Ecuadorian authorities to address these issues and adopt the recommended steps for strengthening national health leadership, shifting towards a comprehensive public health focus for sustainable health improvements.
The concepts of the economic planning in Nepal starts form the Rana regime. Rana prime minister Juddha Samsher makes a concept to apply the program for development. From the initial stage of periodic plans health has given emphasis. The paper aims to overview the health priorities in periodic plans of Nepal. From the review of the literatures and documents it is found that from the First to Fourth Plans, Nepal focused on establishing essential healthcare infrastructure such as health posts and primary healthcare centers. Maternal and child health, alongside the control of communicable diseases, formed core priorities during this phase. The Fifth to Seventh Plans emphasized expanding healthcare services into rural areas through community-based approaches, aiming to improve healthcare access and outcomes across the population. From the Eighth to Tenth Plans, Nepal underwent health sector reforms, decentralizing healthcare services and focusing on universal health coverage. The transition into the Eleventh to Thirteenth Plans aligned with global health goals, emphasizing the reduction of maternal and child mortality, combating infectious diseases like HIV/AIDS, and addressing environmental health concerns such as air pollution. From Fourteenth to Sixteenth Plans, Nepal faces new challenges such as climate change impacts and COVID-19 pandemic and focus to strengthening health infrastructure, enhancing healthcare financing mechanisms, promoting health equity, and integrating mental health services into mainstream healthcare provisions. Every, periodic plans are influenced by the issues. So far, further plans should focus on non-communicable diseases (NCDs), actions to cope with climate change health impacts, health technologies and probable health emergencies.
Through the commercial determinants of health framework, gambling has been identified as a powerful threat to health. This research critically examines cryptocurrency, which is promoted and sold as a highly gamblified product. Using the commercial determinants of health framework, the multifaceted ways in which cryptocurrency firm operations may impact health outcomes are highlighted. Political influence is exerted through substantial donations, with high-profile cases illustrating the sector's attempts to sway policy, whilst cryptocurrencies often operate in unregulated markets. Marketing strategies mirror those of traditional harmful industries, deploying immense advertising budgets and celebrity endorsements to promote highly speculative and risky financial products. Cryptocurrency mining, demanding considerable energy consumption, causes significant environmental damage. Financial practices include hundreds of outright frauds targeting low- and middle-income countries. Cryptocurrency investment, with 24/7 access and promises of huge wealth, mirrors gambling and is likely to result in public health harms through the same mechanisms as other forms of gambling. Despite the supposed potential of blockchain technology for improving payment and contract systems, the lack of realization of these benefits contrasts sharply with the immediate and growing costs associated with cryptocurrency speculation. Cryptoassets are a case study for the need for health promotion professionals to critically evaluate new technologies and advocate for regulatory measures to protect public health in the face of novel, high-risk products that overlap gambling and finance.
Kellie List, Peter Agamile, Didier YÊlognissè Alia, Peter Cherutich ¡ 13 authors
Policy implementation science (IS) is defined here as generating knowledge and deploying implementation strategies to effectively adopt and integrate evidence-based interventions into policy designs and improve policy implementation and effectiveness (1)(2)(3). Most existing policy IS scholarly works originate from the Global North (United States, Canada, and Western Europe) and describe or evaluate strategies to increase the uptake of evidence-based interventions (EBI) (4). The existing Global North generated frameworks focus less on the critical resources needed to formulate and implement a policy in diverse settings. Current approaches to policy IS lack sufficient contextual nuance to be applicable to a broader global population and limit the potential impact of policy IS in low-resource settings. Globally, there are differences in the emphasis of universal health care vs individualized health care, value of affordability vs gross domestic product or per capita spending on health, and access to health insurance and availability of primary care vs specialized care. Many countries of the Global South have health care systems that are mixed, comprising both public and private sectors, with the majority of the population relying on public health services. The governance of health systems is often a mix of centralized and decentralized models with shared responsibilities between the national government and subnational systems either as states, regions, or counties. These subnational levels have some degree of autonomy to make localized policies. Health systems in many Global South countries are characterized by considerable resource scarcity in funding, workforce, medicines and medical technologies, and equipment (5). However, there are still some intra Global South variations. For example, Colombia, a middle-income country with a mixed public-private healthcare system, has high insurance coverage. Nearly all Colombians (99%) are enrolled in a collection of state and private insurance companies, who receive annual allocations depending on their number of enrollees from a centrally managed government pool fund, giving the national government substantial oversight authority and responsibility to regulate insurers (6). Similarly, variations exist in the Global North systems. The United States, for example, has a privatized system, in contrast to the United Kingdom system, which is more public sector focused. These governance and sociopolitical differencesespecially differences in health system decentralization, resources and prioritization of outcomes (7)(8)(9), as well as the history of colonization and resulting international donor powermean that the direct application of a Global North generated policy IS framework may be less effective in a global context. Utilizing the policy cycle heuristic of agenda setting, policy formulation, and policy implementation and evaluation (10), we highlight domains within policy IS frameworks that could be strengthened with traditional IS frameworks and political science scholarship to be more applicable within heterogeneous settings. There are numerous IS frameworks that have been robustly informed by scholarship in the Global South, which reflect many types of power differentials and stress the criticality of stakeholder input and reciprocal collaboration (11,12). However, these traditional IS frameworks tend to lack explicit considerations for agenda setting, policy formulation, and policy implementation (13,14). Political science scholarship has focused extensively on the policy cycle, particularly agenda setting with dozens of relevant theories; however, few (15) have been developed explicitly outside a Global North setting. The unique case of international donors in health policy processes are less reflected in these theories. The policy IS frameworks that have been developed to bridge this gap between policy and IS have opportunities for refinement to adequately reflect the policy processes (16), and the evolving role of donors as a unique stakeholder (17). Therefore, more work is needed to expand policy IS frameworks through the incorporation of more traditional IS and political science theories to make global policy implementation scientists better stewards in global policy processes. By outlining potential concepts for future scholarship, we hope to advance the use of policy IS globally to address global goals such as reducing inequities, moving forward to a more just world, and decolonizing global health.Policy IS frameworksincluding those by Crable et al. and Bullock et al. (16,17) include an implicit or explicit assumption that the role of the researcher (or potentially the funder) is to persuade the policymaker (18,19). This results in a focus on dissemination of research findings to policy makers, and less attention on other relevant stakeholders in the process. The unidirectional assumption may be particularly inappropriate in global health settings where the policy process can be either more or less centralized, include diverse sets of stakeholders, and where the history of colonization and the outsized power of international donors are acutely likely to influence the development of national and subnational health agendas. In contrast, existing political science theories on agenda setting describe policy and policy implementation as non-linear processes. The HIV guideline and policy development process in Kenya is a good example of reciprocal relationships between researchers, donors, policy makers, community members and other stakeholders. This multiorganizational and multidisciplinary process involves multiple actors convened as a technical working group or taskforce, a deep review of existing literature on topics presented by researchers, review of lessons learned from demonstration projects, mapping of available resources at subnational levels, and identifying additional questions to be subsequently included in the research agenda. One notable example is the public sector adoption and scale-up of oral pre-exposure prophylaxis (PrEP) in Kenya from 2016 onwards. Local scientists were involved in generating the evidence that led to the adoption of PrEP globally, and large-scale demonstrations were conducted in the country. This contributed to a high level of trust and goodwill towards the evidence that supported the introduction of PrEP, and played a part in facilitating the acceptance and scaling of the PrEP program (20). In the absence of agenda-setting-oriented IS frameworks, multiple researchers have used Kingdon's "multiple streams" theory to explore health priorities in the Global South. This theory centers on an opening of a "policy window" when the appropriate problem, policy, and political streams align, which allows for a change in policy (21). This framing is easy to comprehend when the power structures for the actors within those streams ebb and flow relatively equally over time. However, in practice the balance of power among stakeholders (both internally and externally) is different in countries in the Global South due to governance structures, health system infrastructure, varied levels of resources, sources of funding, and histories of colonization (22). The power and roles of individual actors and external stakeholders (including bilateral and multilateral institutions), philanthropic actors, normative guidance institutions [e.g. World Health Organization], and communities themselves differ. The involvement of these multi-layered actors starts early and spans from the testing of evidence-based interventions to their implementation and scale up. External actors may have their own agendas and be less susceptible to influence by local actors, echoing dynamics of colonialism and international development. For example, local actors have advocated for chronic diseases to feature prominently in the health policy agenda, while external actors continue to prioritize and fund infectious disease programs (23). Often this decision-making power is linked to resource availability to fund programs. To more effectively advance the locally led health agenda setting process, policy IS frameworks and practitioners need a better understanding of how to navigate entrenched power structures. To address this, policy IS theories and frameworks can be expanded to include reciprocal relationships between policy actors and account for varying governance structures (Figure 1).Across policy formulation, there is acknowledgement that policies need to be adapted when being transferred to different country contexts. However, the process for doing this has not received the same intensity of study as the adaptation and translation of evidence-based interventions, which is common in IS frameworks (24,25). Typically, policy adaptation is conceptualized as a technocratic processupdating targets and implementation instructions based on country data. Current approaches to a benefits package design, adapted heavily from experiences in the United Kingdom (NICE), Thailand, and other European health systems, assume highly centralized, data-intensive, nominally apolitical governance structures for health, with policy formulation decision-making centered within a central figure or office, disseminating guidance to other local entities. This has proven to be an insufficient approach for decentralized systems in which significant autonomy is reserved for the local or subnational level, with broader guidelines established by a central figure or office. While countries with differing governance structures have created and implemented universal healthcare (UHC) policies, implementation has lagged in the Global South due to lack of financial and human resources (26,27), which remain key contextual factors that need to be considered when adapting policies for heterogenous settings. We present two case studies that highlight the need to adapt a policy to fit different governance structures for health, and adapt to varied financial and human resource contexts: developing a universal health coverage essential benefits package. In the most recent revision to its Essential Package of Health Services for the 12th Five-Year Plan, Pakistan identified efficiencies and alignment with evidence-based recommendations by using the normative package proposed in the 3rd edition of Disease Control Priorities (DCP3) as a framework. Through a year-long collaborative process led by the Ministry of National Health Services, Regulations & Coordination, the initial policies proposed in the DCP3 package were narrowed and adapted into a set targeted to the needs of the Pakistani population and aligned with the health system structure that centers on a community-focused delivery model (28,29). Rwanda, on the other hand, approached achievement of universal health coverage through strengthening of its primary health care infrastructure and implementation of a community-based health insurance program (Mutuelle de santĂŠ) (30). The program provides health insurance coverage to more than 90% of its population, resulting in improved health outcomes. This success is attributed to strong leadership and community partnerships. This is evidenced by the increasing governmental spending on health, above the regional average, and the role of community in its implementation (31)(32)(33). These two countries' approaches to developing a UHC demonstrate the necessary adaptation of this general policy to fit local context. Recent policy IS frameworks uniquely describe policy as the focus of adaptation. In the original Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, policy was conceptualized as a contextual "bridging factor" to connect outerand inner-context (34). In the policy-optimized version of EPIS framework, policy was conceptualized as the "thing" to be tailored (16) (Figure 1). These frameworks also have the opportunity to be expanded to reflect contextual factors such as governance structures and the role and power of external actors, areas better articulated by more traditional implementation science frameworks informed by Global South scholarship (11,12) (Figure 1).Arguably most theoretical and empirical work in policy IS to date has been conducted on the last phases of the policy cycle. The integration of implementation science concepts into policy implementation research has made great strides since Per Nilsen et al. (35) first lamented their incompatibility. However, the language used in IS research on policy still bears the assumptions of the political economy of the Global North. Frameworks stress the role of advocacy coalitions, organizational networks and capacity, and the influence of types of policy levers, but gloss over the impact of extreme resource scarcity on implementation outcomes. Policy implementation in any context, but particularly in health, is affected by the substantial heterogeneity of capacity (workforce, resources, commodities) at national, subnational, and facility levels, and in the Global South this heterogeneity is amplified not just by acute lack of funding compared to need, but also the stark lack of fungibility of resources (36). Bullock et al. (17), in their seminal work on policy implementation theory, note that the overrepresentation of studies from the United States limits the field's consideration of other resource allocation models. However, their final determinants framework does not include adequacy of resourcing in the model (Figure 1). Finally, while there is little published scholarship on whether implementation outcomes should differ for resource-rich vs resource-constrained settings, this has been a topic at recent dissemination and implementation conferences (37). As with agenda-setting and formulation, in the Global South, external funders and program implementers have unique influence on policy implementation outcomes. Development agencies and international nongovernmental organizations (NGOs) acting in the Global South limit the extent to which governments are able to fully manage the policy implementation process. This may be driven by the government expenditure on health. For example, in 2021, health expenditure in high-income countries stood at 13.13% of their gross domestic product (GDP), the corresponding figure in low-income countries was 5.25% (38). Country level comparison reveals even more stark differences in health expenditures. For example, the United States spent 17.36% of its GDP on health, while two of Africa's most populous countries, Ethiopia and Nigeria respectively only spent 3.21% and 4.08% (5). Countries with low health expenditure are dependent on financial assistance from high-income countries and this commonly comes with their set of policy priorities. Paina et al. (39), Qiu et al. (40) and Carbaugh (41) document how the 2015 President's Emergency Plan for AIDS Relief (PEPFAR) directive to their country missions to transition HIV/AIDS funding away from low burden areas to increase efficiencies in programming had an undeniable influence on HIV policy implementation in the respective countries. Government and external funders play a significant role especially in geographical prioritization and transition efforts requiring government financing. NGOs play an outsized role in policy implementation and evaluation and these NGOs are accountable to governments in complex and varying ways, a direct reflection of the history and aftermath of colonial rule. Solutions to these challenges will be multi-factorial and relate to governance and power shifting, similarly to the ways in which decolonizing global health involves critically revising power and governance relationships and structures.With regards to areas for further improvement in policy implementation and evaluation, policy IS frameworks could be refined to reflect the role and power of external actors, using insights from more traditional implementation science frameworks (Figure 1). DISCUSSION It is clear from our discussion that we need to continue to refine policy implementation science frameworks to fully embrace a global perspective addressing differences in governance, resources, and stakeholder relationships. This presents an opportunity to reduce inequities and prioritize decolonizing global health. By expanding policy IS frameworks through the incorporation of more traditional IS and political science theories, and advancing an intersectionality approach which recognizes complex relationships and the impact of power dynamics on policy making in a global setting, countries can adapt policies to their local socio-cultural, economic, and political contexts. This should occur not only at policy implementation and evaluation stages but at all upstream stages in the policy cycle, such as agenda setting and policy formulation as well. It will be essential to move beyond this theoretical work towards empirical work to make this agenda a reality. We propose that the future roadmap for this research include engaging with diverse stakeholders using formative and consensusdriving methodologies to integrate policy frameworks, implementation science frameworks, and policy IS frameworks with a global health lens. We then propose review of this integrated work by individuals in diverse contexts, applying these integrated frameworks to past case studies to determine whether they resonate more strongly than the un-adapted versions. Finally, we would propose prospective application of such frameworks to policy IS work in global contexts. Ultimately, the use of policy implementation science to promote uptake and adoption of evidence-based policy making is a unique opportunity available to countries and needs to be broadened to ensure effectiveness in the Global South. It will be essential to move beyond this theoretical work towards empirical work to make this agenda a reality. This will require more interdisciplinary work bringing together experts in implementation science, public policy, social science, and health equity among others to further advance the application of policy implementation science globally.
Achieving universal health coverage (UHC) requires commitment from a wide range of actors, including policy makers, civil society, and academics. In low- and middle-income countries, creating momentum among stakeholders can be challenging with competing priorities and limited funding. Advocacy coalitionsâgroups of like-minded organizations coalescing to achieve a common goalâhave been used to achieve UHC; however, the effectiveness of advocacy coalitions for UHC is not well understood. This policy brief reviews literature on how social network analysis (SNA)âa method âeffective in helping to understand how the stakeholders view one another, share information, cooperate, and take joint actionââhas been used in low- and middle-income countries to evaluate UHC advocacy coalitions (Abbot et al., 2022). These findings were validated using experiences from coalition members in Nigeria advocating for UHC. The literature suggests that factors contributing to network success include network cohesion, decentralized network structure, collective action, strong transparency and trust between actors within an advocacy network, and clear communication and collaboration around advocacy objectives and the roles of all involved. The interviews suggest these themes are present in Nigeria as well. Using SNA thinking to conduct interviews in Nigeria, the authors highlighted specific strengths and areas of growth for advocacy coalitions for UHC. La rĂŠalisation de la couverture santĂŠ universelle (CSU) nĂŠcessite l'engagement d'un large ĂŠventail d'acteurs, notamment les dĂŠcideurs politiques, la sociĂŠtĂŠ civile et les universitaires. Dans les pays Ă faible et revenu intermĂŠdiaire, susciter un ĂŠlan parmi les parties prenantes peut ĂŞtre difficile avec des prioritĂŠs concurrentes et un financement limitĂŠ. Les coalitions de plaidoyer - des groupes d'organisations partageant les mĂŞmes idĂŠes se regroupant pour atteindre un objectif commun - ont ĂŠtĂŠ utilisĂŠes pour rĂŠaliser la CSU ; cependant, l'efficacitĂŠ des coalitions de plaidoyer pour la CSU n'est pas bien comprise. Ce document politique passe en revue la littĂŠrature sur la manière dont l'analyse des rĂŠseaux sociaux (ARS) - une mĂŠthode "efficace pour aider Ă comprendre comment les parties prenantes se perçoivent mutuellement, partagent des informations, coopèrent et prennent des mesures conjointes" - a ĂŠtĂŠ utilisĂŠe dans les pays Ă faible et revenu intermĂŠdiaire pour ĂŠvaluer les coalitions de plaidoyer pour la CSU (Abbot et al., 2022). Ces rĂŠsultats ont ĂŠtĂŠ validĂŠs Ă l'aide des expĂŠriences des membres de la coalition au NigĂŠria plaidant en faveur de la CSU. La littĂŠrature suggère que les facteurs contribuant au succès du rĂŠseau comprennent la cohĂŠsion du rĂŠseau, la structure dĂŠcentralisĂŠe du rĂŠseau, l'action collective, une transparence et une confiance solides entre les acteurs au sein d'un rĂŠseau de plaidoyer, et une collaboration autour des objectifs de plaidoyer et des rĂ´les de tous les intervenants. Les entretiens suggèrent que ces thèmes sont ĂŠgalement prĂŠsents au NigĂŠria. En utilisant la pensĂŠe de l'ARS pour mener des entretiens au NigĂŠria, les auteurs ont mis en ĂŠvidence des forces spĂŠcifiques et des domaines de croissance pour les coalitions de plaidoyer pour la CSU.
The comment highlights the intricate health issues in Indonesia, emphasizing urban-rural gaps, healthcare financing challenges, and the government's dedication to Universal Health Coverage (UHC). The country's geographical layout amplifies the struggle of providing healthcare to rural areas, resulting in substantial health concerns like high tuberculosis rates and financial vulnerability for the impoverished. The concern raised underscores the paradox of low state healthcare spending despite high household expenditures, leading to individual payment reliance and underutilization of insurance. The analysis advocates a comprehensive healthcare approach, emphasizing prevention and curative actions. It also stresses the importance of decentralizing decision-making power to local governments for optimizing healthcare funds. The comment concludes by emphasizing the need for innovative solutions in Indonesia's healthcare landscape. It envisions a future where transformative approaches reshape the system, ensuring better health outcomes. Innovation, especially in medical technology, digital health, and healthcare delivery models, is identified as a central theme. The recommendation underscores the importance of creative solutions to address healthcare service limitations and advocates for leveraging advancements in preventive measures, education, and tackling lifestyle issues. The overall aim is to navigate Indonesia through its current healthcare challenges towards a more sustainable and effective system for the benefit of its population.
Abstract Health system is the backbone of delivering efficient preventive, promotive, curative and rehabilitative services. WHO has identified six building blocks of any health system. These include governance and leadership, infrastructure, workforce, financing, information management and access to essential medicines. Nepal has been striving to strengthen its health system despite several challenges in all WHO building blocks. Inadequate funds, geographical inequalities, insufficient health workforce, weak logistics, suboptimal health information system and inadequate health infrastructure have plagued Nepal health system for long. Natural calamities (e.g. earthquake of 2015) and COVID-19 pandemic overwhelmed the health system. In 2015, Nepal promulgated its new Constitution that devolved and decentralized several powers of generating revenue and exercising authority to sub-national governments viz the states/provinces and local civic bodies. Though functions of health system have been clearly defined at federal, state and local levels in the Constitution, transition of the erstwhile federal health system into new governance and implementation modalities continues to be challenging. There is a strong need to strengthen all building blocks of health system in Nepal at all levels of governance.
Jorge Lima de MagalhĂŁes, Daniela Flores Fernandes, VĂtor Coutinho, Filipe Telles ¡ 6 authors
The Brazilian and Portuguese healthcare systems differ in structure, financing and accessibility. They are similar in terms of decentralization of services, coexistence of public and private health providers and universality and comprehensiveness. The Unified Health System is financed by the federal, state, and municipal governments and is free for everyone. Given the territorial size and economic and social inequality in Brazil, the quality of care can vary greatly, with disparities in access to healthcare between its regions. In Portugal, the National Health Service offers universal and largely free tax-funded coverage and provides comprehensive care, but long waiting times can be a problem. Both systems face challenges such as an aging population and budget constraints. This study pointed out that in addition to appropriate financing and the reorganization of models, academic knowledge can assist in improvement actions and public policies.
Planetary health is an emergent transdisciplinary field, focused on understanding and addressing the interactions of climate change and human health, which offers interventional challenges given its complexity. While various articles have assessed the use of blockchain (web3) technologies in health, little consideration has been given to the potential use of web3 for addressing planetary health. A scoping review to explore the intersection of web3 and planetary health was conducted. Seven databases (Ovid Medline, Global Health, Web of Science, Scopus, Geobase, ACM Digital Library, and IEEE Xplore) were searched for peer-reviewed literature using key terms relating to planetary health and blockchain. Findings were reported narratively. A total of 3245 articles were identified and screened, with 23 articles included in the final review. The health focus of the articles included pandemics and disease outbreaks, the health of vulnerable groups, population health, health financing, research and medicines use, environmental health, and the negative impacts of blockchain mining on human health. All articles included the use of blockchain technology, with others additionally incorporating smart contracts, the Internet of Things, artificial intelligence and machine learning. The application of web3 to planetary health can be broadly categorised across data, financing, identity, medicines and devices, and research. Shared values that emerged include equity, decentralisation, transparency and trust, and managing complexity. Web3 has the potential to facilitate approaches towards planetary health, with the use of tools and applications that are underpinned by shared values. Further research, particularly primary research into blockchain for public goods and planetary health, will allow this hypothesis to be better tested.
Mohammed Shadrul Alam, Shahnoor Islam, AKM Khairul Basher
In Bangladesh, Government is trying to find a perfect health system that best serves its population. Here, we present the results of our study with aim to assess the opinion of various stakeholders about: what are the 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. We conducted a cross-sectional, exploratory and anonymous population-based e-survey from February to June, 2021 among individuals aged above 26 years. A semi-structured questionnaire was designed and incorporated into the Google survey tool (Google Forms) and a shareable link was generated and disseminated to physicians, Academicians/ Clinicians of Medical Colleges/ Universities, Health System administrators etc. Respondents were also given space to comment on each topic. Comments & reactions of all respondents were categorized into three main headings. These were 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. Out of 483 respondents, 476 respondents (80.5% males and 19.5% female) completed the entire survey. The mean age of respondents is 44.70 SDÂą 10.07 with age range 26-86 years. About 27% of the respondents were from faculties from medical colleges /medical universities and 1.7% were health system administrators. The high prioritized areas where the majority (>60%) of our respondents strongly agreed upon, for instance, good governance, structural referral system should be establishment, and reformation of existing health care procurement & purchasing policy. The moderate prioritized areas where 50 - 60% of our respondents strongly agreed upon, such as securing sustainable financing for health care, further development of existing health infrastructure, and establishment of Health Academy of planning and development (HAPD). The low prioritized areas where less than 50% of our respondents strongly agreed upon, such as decentralization and autonomous health system, public health-oriented infection prevention and control (IPC) program, and implement the national health insurance system (NHIS) under a separate authority etc. Good governance in health departments & health care provider organizations are essential elements for health sector reform. Health sector reform should be sustained, purposeful, planned and evidence-based and fundamental change addressing significant, strategic dimensions of health systems. J Bangladesh Coll Phys Surg 2022; 40: 84-94
Health sector in Indonesia faces many complex challenges. The enactment of the new regional government legislation has resulted in a decentralization policy design that requires the regional government to cover all the health issues. Besides, the policy on health issues is also influenced by the many changes of national strategic environment. Many findings indicate apprehensive situations in the health sector. Some of the problems include health financing, health personnel, and health regulations. Thus, it is recommended that each regional government develop a Regional Health System (RHS) as the implementation of health policy.
In the last two decades, developing countries have increasingly engaged in improving the governance of their health systems and promoting policy design to strengthen their health governance capacity. Although many well-designed national policy strategies have been promulgated, obstacles to policy implementation and compliance among localities may undermine these efforts, particularly in decentralized health systems. Studies on health governance have rarely adopted a central-local analysis to investigate in detail local governments' distinct experiences, orientations and dynamics in implementing the same national policy initiative. This study examines the policy orientations of prefectural governments in strengthening governance in health financing in China, which has transitioned from emphasizing the approach of fiscal resource input to that of marketization promotion and cost-containment regulation enforcement at the national level since 2009. Employing text-mining methodologies, we analysed health policy documents issued by multi-level governments after 2009. The analysis revealed three salient findings. Firstly, compared to higher-level authorities, prefectural governments generally opted to use fiscal resource input over marketization promotion and cost-containment regulation enforcement between 2009 and 2020. Secondly, policy choices of prefectural governments varied considerably in terms of enforcing cost-containment regulations during the same period. Thirdly, the extent of the prefectural government's orientation toward marketization promotion or cost-containment regulation enforcement was not only determined by the top-down orders of higher-level authorities but was also incentivized by the government's fiscal dependency and the policy orientations of peer governments. These findings contribute to the health governance literature by providing an overview of local discretion in policy choices and the political and fiscal dynamics of local policy orientations in promoting health governance in a decentralized health system.
Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.
The coronavirus disease 2019 (COVID-19) pandemic, with its overlapping public health and economic emergencies, is a global reminder of the importance of addressing social and environmental determinants of health and inequality, and investing in health systems oriented towards primary care, all of which are components of a primary health care (PHC) approach. PHC â the importance of which was famously articulated in the Declaration of Alma-Ata in 1978 and reaffirmed at the 2018 Astana Conference â is recognized as one of the best ways of promoting population health and well-being.[1,2,3] PHC is âa whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on peopleâs needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to peopleâs everyday environmentâ.[4] It promotes a focus on health systems oriented towards primary care, which have been shown to strengthen appropriateness, access, quality and efficiency of care, through their defining focus on people and the delivery of integrated preventive, curative and public health services.[5] However, the efficacy and impact of such primary care is understood to be intrinsically linked to, and embedded within, a broader context that is inclusive of participatory and responsive financing and governance structures, and policies and actions in non-health sectors.[6] In 2020, with the aim of supporting countries to operationalize PHC, the World Health Organization (WHO) launched its Operational framework for primary health care: transforming vision into action.[7] Showcasing evidence-based strategic and operational levers, the framework highlights the need for a whole-of-society approach. Of note, the frameworkâs emphasis â on more and better multisectoral action, empowerment of people and communities, and the urgency of strengthening primary care as the âservice frontâ[6] and programmatic engine of universal health coverage[2] â overlaps considerably with issues highlighted by the COVID-19 pandemic. In the WHO South-East Asia Region, Member States have articulated a high-level commitment to the vision of PHC as one means by which to improve health and well- being. Even before the COVID-19 pandemic, an estimated 60 million people annually in the region experienced poverty because of out-of-pocket spending on health care. Regionally, various initiatives are seeking to both build primary care capacity and implement policies and strategies that reflect a multisectoral approach. As observed in the WHO Regional Directorâs message accompanying this special issue, since 2014, achieving universal health coverage has been one of the flagship priorities across the South-East Asia Region, with service coverage improving from an average of 47% a decade ago to more than 61% in 2020. However, many challenges remain; the COVID-19 pandemic has provided opportunities for innovation and adaptation but has also presented new problems or compounded problems in relation to Member Statesâ efforts to operationalize PHC. In this supplement, South-East Asia Region authors and others reflect on the challenges and lessons learned regarding PHC during the first 12 months of the COVID-19 pandemic, highlighting among other things examples of the rapid review and extension of health workforce capability; the expedited introduction of technological solutions to maintain and strengthen health care access; and newly decentralized governance arrangements designed to enable the integration of public health functions into front-line services.[8,9] Addressing the critical issue of access to essential services, for example, Reddy et al.[10] present findings from the analysis of routine facility data in Indiaâs Telangana state, which show a positive association between a highly decentralized model of hypertension care that brings follow-up services and medicines closer to communities and indicators of service uptake and hypertension outcomes. Although identifying some decreases in service access during the pandemic-induced lockdown, the same study suggests a potentially protective effect on access to and use of hypertension follow-up services in populations covered by decentralized services compared with those covered by non-decentralized services. Zangmo et al.[11] similarly describe various adaptations to traditional models of antenatal care employed to ensure continuity of this vital service in country settings experiencing widespread social and economic lockdowns. Bezbaruah et al.[12] and Zakoji and Sundararaman[13] observe the critical importance of integrating emergency response capabilities and functions with routine community engagement and health workforce functions in support of effective and sustained emergency response measures that can be led by local stakeholders and are trusted by local populations. Bahl[14] et al. describe how, despite the reduction in immunization services and surveillance for vaccine-preventable diseases across the South-East Asia Region early in the pandemic, rapid adaptation of guidelines and action plans meant that, in most countries, immunization coverage recovered during JulyâSeptember 2020 to levels seen during the corresponding months in 2019. In fact, this was observed in Bangladesh, as reported by Wangmo et al.,[15] where the rate of fully immunized children fell by 46% between January and April 2020 but recovered to 100% by June 2020. The benefits of long-term community engagement (a key pillar of comprehensive PHC), including through investment in community health workers, is evident in several contributions (Bezbaruah et al.,[12] Zakoji and Sundararaman,[13] Reddy et al.[10]). These contributions provide further evidence of the critical role of primary care services not only in ensuring access to essential health care during public health emergencies but also in providing a platform for long-term and sustained efforts to strengthen national and subnational health systems through community engagement.[3] Even with examples of innovation and adaptation, multiple challenges to progressing PHC in the South-East Asia Region remain, particularly in the new context of the COVID-19 crisis. Zapata et al.[16] and Tangcharoensathien[17] note that, despite several decades of investment by Member States in human resources for health, huge health workforce challenges remain, with only two countries currently meeting the revised WHO threshold of 44.5 health workers per 10 000 population. The pandemic has highlighted the need to prioritize locally appropriate actions in the delivery of primary care, yet health budgets are overstretched and, as Kwon[18] points out, health governance and financing systems are too often unresponsive in the face of shifting health needs. Tandon et al.[19] observe that, in many South-East Asia Region countries, low levels of public spending on health and tied donor funding inhibit investment in primary care or the types of multisectoral action needed to realize PHC. Alongside the political economy of pharmaceutical research, development and sales, such budget constraints can influence the availability of medicines, which, despite the remarkable efforts behind the COVAX initiative, will affect the ability of different countries to access and roll out COVID-19 vaccines. Reflecting on a long-standing challenge, Khan et al.[20] observe how, despite mixed health systems being the norm in the region, attention to, and investment in, effective regulatory mechanisms to ensure the quality and affordability of nongovernment (private for-profit and not-for-profit) services remain weak. Reflecting on issues of health governance, Tangcharoensathien[17] and Guisset et al.[21] observe how, often, decisions about health service type and availability are driven by siloed governance and financing systems that are distant, if not disconnected, from the realities of both patients and frontline providers. Looking at the intersection of such governance and regulatory issues, Rajbhandary et al.[22] describe the need for urgent investment to strengthen health information systems in the South-East Asia Region, noting the growing capacity for the collection and collation of health information within regional Member States but also the still underdeveloped capacity for analysing and utilizing these data at subnational and particularly facility levels, where it is arguably most needed. Walcott and Akinola[23] reflect on the power of digital technologies, including data capture from rapidly expanding telemedicine applications, to inform on better targeted interventions and advance the universal health care agenda. Wangmo et al. present data illustrating the positive role that health information systems, and especially the collection and use of routine data, have played in Bangladesh, to help identify and inform the government response, down to the health facility level, on early reductions in coverage of essential services during the first months of the COVID-19 pandemic. Providing an important synthesis of many of these issues, Peiris et al.[24] review the literature to highlight how, even when accounting for some welcome pandemic-related health service adaptations, country-level attention to strategic functions that would strengthen underlying health systems in support of PHC remains generally weak. Challenges include many of the strategic areas identified in WHOâs operational framework, such as leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders.[7] Around the globe, the COVID-19 pandemic has laid bare the devastating impact of both structural inequities and suboptimally designed health systems. The pandemic has highlighted the pressing need to move away from brittle, uncoordinated and disease-specific responses and to reorient health systems towards a PHC approach. âBuilding back betterâ in the South-East Asia Region and beyond means taking stock of current weaknesses in often fragmented health systems and service functions and making changes to improve responsiveness, resilience and the capability to deliver better and more equitable health outcomes. This collection speaks to emerging insights and opportunities created by the willingness to adapt in the context of the COVID-19 pandemic but also to an urgent need to pay more attention to and invest more in PHC, before the health and economic impacts of the pandemic slow or reverse the progress made in recent decades. We hope that this collection serves to reinforce the need for enacted commitment to the vision of health for all, through investment in well-aligned governance, financing and structural reforms.
The unprecedented Covid-19 global pandemic has brought to the forefront many challenges associated with exclusive rights, information sharing, affordability of medical treatment, and innovation. As I wrote for STAT in July1, it has raised questions like how we provide effective diagnostics, treatments and vaccines quickly and safely to the public. More specifically, how do we ensure that sufficient quantities of these health products are produced, that they are affordable, and that they are equitably distributed globally? Trade secrets play an enormous role in vaccine development, as well as the creation of diagnostics and treatments. From information like genomic data, to biologic resources, manufacturing know-how and negative information like research dead-ends, trade secrets pervade the battle against Covid.2 In that sense, finding Covid vaccines is no different from any other innovation schema, with trade secrecy operating alongside and in conjunction with patents, copyrights, and trade marks on the incentive side of the ledger. However, in the Covid space, there are a few significant differences. At their centre is the basic issue of whether the sharing of certain trade secret information would be a net benefit for the world, resulting in more rapid development and expanded supply capacity of and/or more affordable vaccines, treatments, and diagnostics. These are open questions, but there are good reasons to think that the answers would be âyesâ because of three public health priorities: speed, adequacy of supply, and affordability. While the development of a Covid vaccine may be similar in process and methodology to any other vaccine development process, the continual loss of life, scale of economic impact, and general rendering of lives untenable, puts an enormous premium on speed. Speed, however, must not come at the cost of sacrificing oversight, safety, and efficacy. Therefore, in the interest of public health, there may be trade secrets, like discovery of vaccine development process dead-ends, that should be shared with competitors, researchers, and governments in order to speed development by avoiding time-wasting re-invention of the wheel. To be sure, sharing valuable secret information may lead to less overall revenue for an individual manufacturer, but does not automatically mean that the endeavour would be unprofitable. Pooling of resources could lead to safer and more effective vaccines, treatments, and diagnostics, which would create higher demand than a more suspect product. Given the billions of vaccine doses required by a desperate world, not to mention the related diagnostics and treatments, there should be plenty of revenue earned across related industry sectors. Moreover, because this is a global public health crisis, there is a moral and ethical mandate to assure that not only are Covid vaccines and treatments affordable for all, but that nationalism does not render them available first (or only) to wealthy countries and individuals. Unfortunately, nationalism has reared its ugly head in this battle, as governments vie for exclusive deals with pharmaceutical manufacturers, while the manufacturers seek the most lucrative results for their efforts. As Nature recently reported, âWealthy countries have struck deals to buy more than two billion doses of coronavirus vaccine in a scramble that could leave limited supplies in the coming year. Meanwhile, an international effort to acquire vaccines for low- and middle-income countries is struggling to gain traction.â3 In countries like the United States, where the dominant utilitarian theory calls for intellectual property law to create incentives for innovation, there is no corollary that requires intellectual property owners to earn every last dime from their rights. Public health concerns can predominate. However, before one condemns these true statements as too extreme, it is important to note that they may make the point too strongly by overstating the costs of information sharing. Affordability through sharing trade secret information (and thereby driving down research and development costs) does not have to come at the price of profits. As I have explained in the articles cited above, voluntary licensing can be cost-prohibitive, although the possibility exists for less costly licensing and technology transfer through the World Health Organizationâs COVID-19 Technology Access Pool (C-TAP) and the Medicines Patent Pool, if utilized. Additionally, there are no legislatively codified compulsory avenues for requiring non-registration and non-clinical trial trade secrets to be shared with competitors, much less civil society groups, or other âwatchdogâ or advocacy entities. Nonetheless, the gravity of the crisis requires creative thinking, bold measures, and a certain amount of policy risk-taking (which, as Iâve previously explained, is supported by the World Trade Organizationâs Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)). Compulsory trade secret licensing of relevant trade secrets, in which trade secret owners are compensated for their investments and compelled sharing (assuming that the existence of a trade secret is proven, a separate necessary step), should now be considered. Unfortunately, creating a compulsory trade secret licensing mechanism would require legislative action, which would likely be contentious and time-consuming. Therefore, the short-term route to information sharing might have to come from global efforts by civil society groups and like-minded public officials, as well as the public itself, to convince researchers and manufacturers to share necessary information in the interest of global public health and welfare. While it may be true that industry would like to control their trade secrets and maximize profits, public concern and the general policy aversion to monopoly pricing that is baked into intellectual property law theory could be brought to bear in finding an industry consensus around access to and sharing of trade secrets. If adopted for purposes of addressing this unprecedented public health crisis, voluntary trade secret information sharing and/or compulsory trade secret licensing could be extended to any number of other areas where trade secrecy has been a barrier to more rapid information sharing and innovation, from climate change, to energy production, to the next pandemic. Because empirical studies have shown that few blanket modes of behaviour or application apply to trade secrets broadly, and because trade secret law usage is considered on an individualized and sector level, robust trade secret information sharing and/or compulsory trade secret licensing could become a logical advance in open innovation and equitable-access modelling on an individual sector, product, or process basis. The time for considering how to share trade secrets, in the interest of global public health and all of our lives, is now.
Chrissa McFarlane, Marquesa Finch, Tiffany Gray, Jonathan M. Fuchs ¡ 6 authors
There are growing initiatives and calls for focusing greater attention to social determinants of health and their impact on population health [1]. Several emerging strategies are being used to begin to address social determinants, such as the use of health impact assessments and applying health in all policies (HiAP). These strategies and tools are being implemented in an effort to review existing and needed policies, as well as propose new policies to lessen health disparities [2]. Efforts to further integrate social determinants of health through the use of health information technology and other emerging technologies, such as distributed ledger technology both in and outside of existing health care systems are also increasing [2]. Understanding and addressing the social determinants of health through both traditional and non-traditional sectors is key to further reducing health disparities [1, 3-4]. Through exploration of the current state of social determinants of health in the healthcare industry, an analysis of blockchain technology will render the acceleration and adoption of social determinants of health to effectively provide improved health outcomes.
Blockchain has been rapidly maturing first in finance and supply chain applications, but it is also developing a foothold across other industries. In healthcare, there are a variety of potential applications from purchasing to medical devices, to pharma supply chain where it has already shown real-world value and is quickly gaining traction. The applications of blockchain in healthcare look like a microcosm of the use cases across different industries. Change Healthcare is a large United States-based health coverage organization that has gone all in to develop blockchain solutions and has begun primarily in the billing and payments area. The cost to upkeep records of providers with accurate information is significant across a variety of health and insurance systems. A trust that is even more crucial in the health science communityâas with healthcare data âit can mean the difference between life and death.â
Haiti announced in 2018 its aim to achieve universal health coverage. In this paper, we discuss what this objective means for the country and what next steps should be taken. To contextualize the notion, we framed Haiti en route to the 2030 goal and analyzed qualitatively the status quo in terms of geographic, financial, and service access. For each dimension, we focused on the context, the government's policies and political agendas, their implementation progress, and key influential factors. Our analysis found little progress and numerous challenges. Geographic access was limited due principally to the insufficient number of facilities, difficulties in reaching health facilities, and local customs. Financial coverage was low because of the government's insufficient budgets, inefficient budget allocation, and ineffective management. Service access also had room for significant improvement for a lack of basic infrastructure and resources, gaps between the essential service package guidelines, health professionals' skills, and the needs, as well as deficiencies in people-centered care. These factors affected not only health service coverage but also its quality. We found that the root causes of these issues were composed of unstable financing mechanisms, opportunistic resource allocation, and ineffective management control systems. We suggest that to overcome these issues and achieve universal health coverage with decent service quality, Haiti's health system needs to be reformed by implementing strategic financing, decentralized management systems, and community engagement in primary health care.
In Brazil, it is referred to as sanitary surveillance a complex state action that has undergone transformations since 1999, with the creation of the National Agency of Sanitary Surveillance (ANVISA) and the institution of the National Health Surveillance System (SNVS). Its area of activity covers the sanitary control of products and practices related to health, articulating to control some determinants, risks and damages to health. It represents an expressive part of health protection and, integrating the Brazilian Health System (SUS), contributes to its qualification, as well as national products submitted to sanitary regulation. In the organization of SNVS, notably in a federative country with continental dimensions and extremely diverse realities, such as Brazil, the decentralized implementation of actions and their correspondence with the loco regional context is fundamental. Being the municipality the most fragile component of the SNVS, it is imperative to study contextually the municipal services, and among them, the capitals, which concentrate resources, population and problems of various orders. This is an exploratory and descriptive study based on secondary and universal access data and covers sanitary surveillance services of the four state capitals of the southeastern region of Brazil, from 2014 to 2017, a year of reform of federal SUS financing. The capitals were characterized by sociodemographic and financial indicators and the respective sanitary surveillance services, using data from the Municipal Basic Information Survey, from the official sites and referring to their rates collection. The procedures reported by these services were described and their revenues and expenses analyzed. It was found that the sanitary surveillance of these capitals are inserted in different hierarchical levels in the organization chart of the respective SMS and that their financing is very dependent on federal transfers, which decreased in the period. The allocation of own resources was very low and amounts collected as fees and fines seems not to have been reverted to the service in one of the capitals that reported this collection. There was no uniformity in relation to the types of inspecteds establishments/activities and the licensing process. Data from the different databases were consistent. It is necessary elucidate to what type of regulation are being submitted the establishments and services located in the jurisdictional limit of the capitals and that are not regulated by them, and discuss responsibilities. As well as institutional and political factors, with the intention of explaining the non-allocation of own resources and those collected by the surveillance, or part of them, to the services themselves.