Targeting anticorruption interventions at the front line: developmental governance in health systems

In 2008, Vian reported an increasing interest in understanding how corruption affects healthcare outcomes and asked what could be done to combat corruption in the health sector. Eleven years later, corruption is seen as a heterogeneous mix of activity, extensive and expensive in terms of loss of productivity, increasing inequity and costs, but with few examples of programmes that have successfully tackled corruption in low-income or middle-income countries. The commitment, by multilateral organisations and many governments to the Sustainable Development Goals and Universal Health Coverage has renewed an interest to find ways to tackle corruption within health systems. These efforts must, however, begin with a critical assessment of the existing theoretical models and approaches that have underpinned action in the health sector in the past and an assessment of the potential of innovations from anticorruption work developed in sectors other than health. To that end, this paper maps the key debates and theoretical frameworks that have dominated research on corruption in health. It examines their limitations, the blind spots that they create in terms of the questions asked, and the capacity for research to take account of contextual factors that drive practice. It draws on new work from heterodox economics which seeks to target anticorruption interventions at practices that have high impact and which are politically and economically feasible to address. We consider how such approaches can be adopted into health systems and what new questions need to be addressed by researchers to support the development of sustainable solutions to corruption. We present a short case study from Bangladesh to show how such an approach reveals new perspectives on actors and drivers of corruption practice. We conclude by considering the most important areas for research and policy.

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Identifying health policy and systems research priorities on multisectoral collaboration for health in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2018-000970 ◽

2018 ◽

Vol 3 (Suppl 4) ◽

pp. e000970 ◽

Cited By ~ 11

Author(s):

Douglas Glandon ◽

Ankita Meghani ◽

Nasreen Jessani ◽

Mary Qiu ◽

Sara Bennett

Keyword(s):

Low Income ◽

Health Sector ◽

Research Priorities ◽

Implementation Strategies ◽

Health Coverage ◽

Middle Income ◽

The Sustainable Development ◽

Middle Income Countries ◽

Systems Research ◽

Review Articles

IntroductionWhile efforts to achieve Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) have reinvigorated interest in multisectoral collaborations (MSCs) among the global health and development community, there remains a plethora of questions about how best to conceptualise, plan, implement, evaluate and sustain MSCs. The objective of this paper is to present research priorities on MSC for health from researchers and policymakers around the globe, with an emphasis on low-income and middle-income countries.MethodsThe authors identified 30 priority research questions from two sources: (1) 38 review articles on MSC for health, and (2) interviews and focus groups with a total of 81 policymakers, including government officials (largely from ministries of health and state/provincial departments of health, but also offices of planning, public service, social development, the prime minister and others), large multilateral or bilateral organisations, and non-governmental organisations. In a third phase, questions were refined and ranked by a diverse group of researchers from around the globe using an online voting platform.ResultsThe top-ranked questions focused predominantly on pragmatic questions, such as how best to structure, implement and sustain MSCs, as well as how to build stakeholder capacity and community partnerships. Despite substantial variation between review articles, policymakers’ reflections and online ranking by researchers, two topics emerged as research priorities for all three: (1) leadership, partnership and governance structures for MSCs; and (2) MSC implementation strategies and mechanisms. The review articles underscored the need for more guidance on appropriate study designs and methods for investigating MSCs, which may be a prerequisite for other identified research priorities.ConclusionThese findings could inform efforts within and beyond the health sector to better align research objectives and funding with the evidence needs of policymakers grappling with questions about how best to leverage MSCs to achieve UHC and the SDGs.

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Allocating resources to support universal health coverage: policy processes and implementation in Malawi

BMJ Global Health ◽

10.1136/bmjgh-2020-002766 ◽

2020 ◽

Vol 5 (8) ◽

pp. e002766 ◽

Cited By ~ 1

Author(s):

Pakwanja Twea ◽

Gerald Manthalu ◽

Sakshi Mohan

Keyword(s):

Resource Allocation ◽

Low Income ◽

Health Sector ◽

Health Resources ◽

Health Coverage ◽

Middle Income ◽

Middle Income Countries ◽

Distribution Of Resources ◽

The Government ◽

Limited Health

Optimising the use of limited health resources in low-income and middle-income countries towards the maximisation of health outcomes requires efficient distribution of resources across health services and geographical areas. While technical research exists on how efficiencies can be achieved in resource allocation, there is limited guidance on the policy processes required to convert these technical inputs into practicable solutions. In this article, we discuss Malawi’s experience in 2019 of revising its resource allocation formula (RAF) for the geographical distribution of the government health sector budget to the decentralised units in-charge of delivering primary and secondary healthcare. The policy process to revise the RAF in Malawi was initiated by district assemblies seeking a more equitable distribution of government resources, with the Ministry of Health and Population (MOHP) leading the technical and deliberative work. This article discusses all the steps undertaken by MOHP, Malawi to date as well as the steps necessary looking forward to legally establish the newly developed RAF and to start implementing it. We highlight the practical and political considerations in ensuring the acceptability and implementation feasibility of a revised RAF. It is hoped that this discussion will serve as guidance to other countries undergoing a revision of their resource allocation frameworks.

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Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-001501 ◽

2019 ◽

Vol 4 (3) ◽

pp. e001501 ◽

Cited By ~ 5

Author(s):

Helen Elsey ◽

Irene Agyepong ◽

Rumana Huque ◽

Zahidul Quayyem ◽

Sushil Baral ◽

...

Keyword(s):

Health Systems ◽

Urban Health ◽

Low Income ◽

Service Providers ◽

Health Sector ◽

Determinants Of Health ◽

Middle Income ◽

Middle Income Countries ◽

Systems Model ◽

Health Service Providers

The world is now predominantly urban; rapid and uncontrolled urbanisation continues across low-income and middle-income countries (LMICs). Health systems are struggling to respond to the challenges that urbanisation brings. While better-off urbanites can reap the benefits from the ‘urban advantage’, the poorest, particularly slum dwellers and the homeless, frequently experience worse health outcomes than their rural counterparts. In this position paper, we analyse the challenges urbanisation presents to health systems by drawing on examples from four LMICs: Nigeria, Ghana, Nepal and Bangladesh. Key challenges include: responding to the rising tide of non-communicable diseases and to the wider determinants of health, strengthening urban health governance to enable multisectoral responses, provision of accessible, quality primary healthcare and prevention from a plurality of providers. We consider how these challenges necessitate a rethink of our conceptualisation of health systems. We propose an urban health systems model that focuses on: multisectoral approaches that look beyond the health sector to act on the determinants of health; accountability to, and engagement with, urban residents through participatory decision making; and responses that recognise the plurality of health service providers. Within this model, we explicitly recognise the role of data and evidence to act as glue holding together this complex system and allowing incremental progress in equitable improvement in the health of urban populations.

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Our Blind Spots in the Fight Against Health Systems Corruption Comment on "We Need to Talk About Corruption in Health Systems"

International Journal of Health Policy and Management ◽

10.15171/ijhpm.2019.81 ◽

2019 ◽

Vol 9 (1) ◽

pp. 34-38

Author(s):

Reinhard Huss

Keyword(s):

Health Systems ◽

Low Income ◽

Health Workers ◽

Social Systems ◽

Health Sector ◽

Low Income Countries ◽

Financial Flows ◽

The Sustainable Development ◽

Systemic Corruption

The health sector often appears prominent in surveys of perceived corruption, because citizens experience the symptoms of systemic corruption most distressingly during their interaction with frontline health workers. However, the underlying drivers of systemic corruption in society may be located in other social systems with the health system demonstrating the symptoms but not the path how to exit the situation. We need to understand the mechanisms of systemic corruption including the role of corrupt national and international leaders, the role of transnational corporations and international financial flows. We require a corruption definition which goes beyond an exclusive focus on the corrupt individual and considers social systems and organisations facilitating corruption. Finally there is an urgent need to address the serious lack of funding and research in the area of systemic corruption, because it undermines the achievement of the Sustainable Development Goals (SDGs) in many low income countries with the most deprived populations.

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Call to action for health systems integration of point-of-care testing to mitigate the transmission and burden of sexually transmitted infections

Sexually Transmitted Infections ◽

10.1136/sextrans-2019-054358 ◽

2020 ◽

Vol 96 (5) ◽

pp. 342-347 ◽

Cited By ~ 3

Author(s):

Igor Toskin ◽

Veloshnee Govender ◽

Karel Blondeel ◽

Maurine Murtagh ◽

Magnus Unemo ◽

...

Keyword(s):

Health Systems ◽

Low Income ◽

System Integration ◽

Policy Design ◽

Point Of Care ◽

Health Coverage ◽

Point Of Care Testing ◽

Programme Implementation ◽

Correct Treatment ◽

Middle Income

ObjectivesIn 2016, WHO estimated 376 million new cases of the four main curable STIs: gonorrhoea, chlamydia, trichomoniasis and syphilis. Further, an estimated 290 million women are infected with human papillomavirus. STIs may lead to severe reproductive health sequelae. Low-income and middle-income countries carry the highest global burden of STIs. A large proportion of urogenital and the vast majority of extragenital non-viral STI cases are asymptomatic. Screening key populations and early and accurate diagnosis are important to provide correct treatment and to control the spread of STIs. This article paints a picture of the state of technology of STI point-of-care testing (POCT) and its implications for health system integration.MethodsThe material for the STI POCT landscape was gathered from publicly available information, published and unpublished reports and prospectuses, and interviews with developers and manufacturers.ResultsThe development of STI POCT is moving rapidly, and there are much more tests in the pipeline than in 2014, when the first STI POCT landscape analysis was published on the website of WHO. Several of the available tests need to be evaluated independently both in the laboratory and, of particular importance, in different points of care.ConclusionThis article reiterates the importance of accurate, rapid and affordable POCT to reach universal health coverage. While highlighting the rapid technical advances in this area, we argue that insufficient attention is being paid to health systems capacity and conditions to ensure the swift and rapid integration of current and future STI POCT. Unless the complexity of health systems, including context, institutions, adoption systems and problem perception, are recognised and mapped, simplistic approaches to policy design and programme implementation will result in poor realisation of intended outcomes and impact.

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Strengthening medical specialisation policy in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-002053 ◽

2020 ◽

Vol 5 (2) ◽

pp. e002053 ◽

Cited By ~ 1

Author(s):

Veena Sriram ◽

Sara Bennett

Keyword(s):

Health Systems ◽

Low Income ◽

Medical Tourism ◽

Policy Formulation ◽

Health Systems Strengthening ◽

Health Coverage ◽

Secondary Importance ◽

Middle Income ◽

Medical Specialties ◽

Middle Income Countries

The availability of medical specialists has accelerated in low-income and middle-income countries (LMICs), driven by factors including epidemiological and demographic shifts, doctors’ preferences for postgraduate training, income growth and medical tourism. Yet, despite some policy efforts to increase access to specialists in rural health facilities and improve referral systems, many policy questions are still underaddressed or unaddressed in LMIC health sectors, including in the context of universal health coverage. Engaging with issues of specialisation may appear to be of secondary importance, compared with arguably more pressing concerns regarding primary care and the social determinants of health. However, we believe this to be a false choice. Policy at the intersection of essential health services and medical specialties is central to issues of access and equity, and failure to formulate policy in this regard may have adverse ramifications for the entire system. In this article, we describe three critical policy questions on medical specialties and health systems with the aim of provoking further analysis, discussion and policy formulation: (1) What types, and how many specialists to train? (2) How to link specialists’ production and deployment to health systems strengthening and population health? (3) How to develop and strengthen institutions to steer specialisation policy? We posit that further analysis, discussion and policy formulation addressing these questions presents an important opportunity to explicitly determine and strengthen the linkages between specialists, health systems and health equity.

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Operational research to support equitable non-communicable disease policy in low-income and middle-income countries in the sustainable development era: a scoping review

BMJ Global Health ◽

10.1136/bmjgh-2019-002259 ◽

2020 ◽

Vol 5 (6) ◽

pp. e002259

Author(s):

Naomi Gibbs ◽

Joseph Kwon ◽

Julie Balen ◽

Peter J Dodd

Keyword(s):

Sustainable Development ◽

Low Income ◽

Operational Research ◽

Communicable Disease ◽

Health Coverage ◽

Differential Impact ◽

Middle Income ◽

The Sustainable Development ◽

Middle Income Countries ◽

Disadvantaged Groups

IntroductionNon-communicable diseases (NCDs) represent a growing health burden in low-income and middle-income countries (LMICs). Operational research (OR) has been used globally to support the design of effective and efficient public policies. Equity is emphasised in the Sustainable Development Goal (SDG) framework introduced in 2015 and can be analysed within OR studies.MethodsWe systematically searched MEDLINE, Embase, Scopus and Web of Science for studies published between 2015 and 2018 at the intersection of five domains (OR, LMICs, NCDs, health and decision-making and/or policy-making). We categorised the type of policy intervention and described any concern for equity, which we defined as either analysis of differential impact by subgroups or, policy focus on disadvantaged groups or promoting universal health coverage (UHC).ResultsA total of 149 papers met the inclusion criteria. The papers covered a number of policy types and a broad range of NCDs, although not in proportion to their relative disease burden. A concern for equity was demonstrated by 88 of the 149 papers (59%), with 8 (5%) demonstrating differential impact, 47 (32%) targeting disadvantaged groups, and 68 (46%) promoting UHC.ConclusionOverall, OR for NCD health policy in the SDG era is being applied to a diverse set of interventions and conditions across LMICs and researchers appear to be concerned with equity. However, the current focus of published research does not fully reflect population needs and the analysis of differential impact within populations is rare.

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Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge

BMJ Global Health ◽

10.1136/bmjgh-2018-000880 ◽

2018 ◽

Vol 3 (Suppl 4) ◽

pp. e000880 ◽

Cited By ~ 14

Author(s):

Sara Bennett ◽

Douglas Glandon ◽

Kumanan Rasanathan

Keyword(s):

Case Studies ◽

Low Income ◽

Health Sector ◽

Political Commitment ◽

Middle Income ◽

The Sustainable Development ◽

Middle Income Countries ◽

Development Goals ◽

Bureaucratic Agencies ◽

High Level

Multisectoral action is key to addressing many pressing global health challenges and critical for achieving the Sustainable Development Goals, but to-date, understanding about how best to promote and support multisectoral action for health is relatively limited. The challenges to multisectoral action may be more acute in low-income and middle-income countries (LMICs) where institutions are frequently weak, and fragmentation, even within the health sector, can undermine coordination. We apply the lens of governance to understand challenges to multisectoral action. This paper (1) provides a high level overview of possible disciplines, frameworks and theories that could be applied to enrich analyses in this field; (2) summarises the literature that has sought to describe governance of multisectoral action for health in LMICs using a simple political economy framework that identifies interests, institutions and ideas and (3) introduces the papers in the supplement. Our review highlights the diverse, but often political nature of factors influencing the success of multisectoral action. Key factors include the importance of high level political commitment; the incentives for competition versus collaboration between bureaucratic agencies and the extent to which there is common understanding across actors about the problem. The supplement papers seek to promote debate and understanding about research and practice approaches to the governance of multisectoral action and illustrate salient issues through case studies. The papers here are unable to cover all aspects of this topic, but in the final two papers, we seek to develop an agenda for future action. This paper introduces a supplement on the governance of multisectoral action for health. While many case studies exist in this domain, we identify a need for greater theory-based conceptualisation of multisectoral action and more sophisticated empirical investigation of such collaborations.

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Digital health in the Americas: advances and challenges in connected health

BMJ Innovations ◽

10.1136/bmjinnov-2017-000258 ◽

2018 ◽

Vol 4 (3) ◽

pp. 123-127 ◽

Cited By ~ 7

Author(s):

David Novillo-Ortiz ◽

Elsy Maria Dumit ◽

Marcelo D’Agostino ◽

Francisco Becerra-Posada ◽

Edward Talbott Kelley ◽

...

Keyword(s):

Information And Communication Technologies ◽

Mobile Health ◽

Low Income ◽

Digital Health ◽

Health Sector ◽

Developed Countries ◽

High Income ◽

Low Income Countries ◽

Health Coverage ◽

Middle Income

In 2005, all WHO Member States pledged to fight for universal health coverage (UHC). The availability of financial, human and technological resources seems to be necessary to develop efficient health policies and also to offer UHC. One of the main challenges facing the health sector comes from the need to innovate efficiently. The intense use of information and communication technologies (ICTs) in the health field evidences a notable improvement in results obtained by institutions, health professionals and patients, principally in developed countries. In the Americas, the relationship between economic development and health innovation is not particularly evident. Data from 19 of 35 countries surveyed in the 2015 Third Global Survey on eHealth for the region of the Americas were analysed. 52.6% of the countries of the Americas have a national policy or strategy for UHC. 57.9% of the countries in the sample indicate that they have a national eHealth policy or strategy, but only 26.3% have an entity that supervises the quality, safety and reliability regulations for mobile health applications. The survey data indicate that high-income and low-income to middle-income countries show higher percentages in relation to the existence of entities that promote innovation. These countries also exceed 60%—compared with 40% and 50% in lower-income countries—in all cases regarding the use of eHealth practices, such as mobile health, remote patient monitoring or telehealth. 100% of low-income countries report offering ICT training to healthcare professionals, compared with 83% of wealthy countries and 81% of middle-income to high-income countries.

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Evaluating medical education regulation changes in Brazil: workforce impact

Human Resources for Health ◽

10.1186/s12960-021-00580-5 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Alexandre Medeiros Figueiredo ◽

Danette Waller McKinley ◽

Adriano Massuda ◽

George Dantas Azevedo

Keyword(s):

Medical Education ◽

Public Schools ◽

Low Income ◽

School Enrollment ◽

Health Coverage ◽

Continuous Assessment ◽

Middle Income ◽

Unified Health System ◽

Medical Undergraduate ◽

The Impact

Abstract Background Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians’ distribution. Methods This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. Results From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013–2015 period. Increase in physician supply improved access to antenatal care. Conclusions There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.

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