Healthy public policy in poor countries: tackling macro-economic policies

Large segments of the population in poor countries continue to suffer from a high level of unmet health needs, requiring macro-level, broad-based interventions. Healthy public policy, a key health promotion strategy, aims to put health on the agenda of policy makers across sectors and levels of government. Macro-economic policy in developing countries has thus far not adequately captured the attention of health promotion researchers. This paper argues that healthy public policy should not only be an objective in rich countries, but also in poor countries. This paper takes up this issue by reviewing the main macro-economic aid programs offered by international financial institutions as a response to economic crises and unmanageable debt burdens. Although health promotion researchers were largely absent during a key debate on structural adjustment programs and health during the 1980s and 1990s, the international macro-economic policy tool currently in play offers a new opportunity to participate in assessing these policies, ensuring new forms of macro-economic policy interventions do not simply reproduce patterns of (neoliberal) economics-dominated development policy.     

Translating research into action: a case study on trans fatty acid research and nutrition policy in Costa Rica

Mounting epidemiologic evidence worldwide has fostered policy regulation of industrially made trans fatty acids (TFA) in several developed countries. Despite country-specific evidence about the effects of TFA on cardiovascular disease in Costa Rica, policy regulation has yet to occur. This qualitative study uses a conceptual framework to identify factors that may impede or promote the process of translation of scientific evidence about TFA into policy in the specific context of Costa Rica. We used single case-study methodology to integrate two sources of data: review of relevant internal documents and in-depth, semi-structured interviews with 21 respondents purposively sampled from three sectors: the cooking oil and food industries, research and academia, and government entities. Content analysis, guided by a conceptual framework of research utilization, revealed 68 emergent themes divided across four categories of analysis. In brief, study participants perceived the political context suitable for discussing policies related to healthy fats. Nevertheless, TFA regulation was not part of the Costa Rican political agenda. Barriers perceived by respondents that impede knowledge translation included: (1) lack of awareness of in-country scientific studies on health effects of TFA; (2) lack of consensus or information about policy options (nutrition labelling, dietary guidelines, legislative mandates); (3) perceived distrust and disparate attitudes between sectors, believed by study participants to result in (4) limited collaboration across sectors. Commissioned task forces and other mechanisms to foster research engagement and facilitate sustained interaction and systematic collaboration among government, food industry and researcher sectors appear crucial in the consideration and adoption of nutrition policy in Costa Rica and other emerging economies.     

Brain death determination: the imperative for policy and legal initiatives in Sub-Saharan Africa

The concept of brain death (BD), defined as irreversible loss of function of the brain including the brainstem, is accepted in the medical literature and in legislative policy worldwide. However, in most of Sub-Saharan Africa (SSA) there are no legal guidelines regarding BD. Hypothetical scenarios based on our collective experience are presented which underscore the consequences of the absence of BD policies in resource-limited countries (RLCs). Barriers to the development of BD laws exist in an RLC such as Kenya. Cultural, ethnic, and religious diversity creates a complex perspective about death challenging the development of uniform guidelines for BD. The history of the medical legal process in the USA provides a potential way forward. Uniform guidelines for legislation at the state level included special consideration for ethnic or religious preferences in specific states. In SSA, medical and social consensus on the definition of BD is a prerequisite for the development BD legislation. Legislative policy will (1) limit prolonged and futile interventions; (2) mitigate the suffering of families; (3) standardise clinical practice; and (4) facilitate better allocation of scarce critical care resources in RLCs. There is a clear-cut need for these policies, and previous successful policies can serve to guide these efforts.     

Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme

The public social policy and programme decisions that are madein low-income countries have critical effects on human socialand development outcomes. Unfortunately, it would appear thatinadequate attention is paid to analysing, understanding andfactoring into attempts to reshape or change policy, the complexhistorical, social, cultural, economic, political, organizationaland institutional context; actor interests, experiences, positionsand agendas; and policy development processes that influencepolicy and programme choices. Yet these can be just as criticalas the availability of research or other evidence in influencingdecision making on policies and their accompanying programmesand the resulting degree of success or failure in achievingthe original objectives. Ghana, a low-income developing countryin sub-Saharan Africa, embarked on a national policy processof replacing out-of-pocket fees at point of service use withnational health insurance in 2001. This paper uses a case studyapproach to describe and reflect on the complex interactionsof context with actors and processes including political powerplay; and the effects on agenda setting, decision making andpolicy and programme content. This case study supports observationsfrom the literature that although availability of evidence iscritical, major public social policy and programme content canbe heavily influenced by factors other than the availabilityor non-availability of evidence to inform content decision making.In the low-income developing country context there can be imbalancesof policy decision-making power related to strong and dominantpolitical actors combined with weak civil society engagement,accountability systems and technical analyst power and position.Efforts at major reform need to consider and address these issuesalongside efforts to provide evidence for content decision-making.Without an analysis and understanding of the politics of reformand how to work within it, researchers and other technical actorsmay find their information to support reform is not appliedeffectively. Similarly, without an appreciation of the needfor critical technical analysis to support decision making ratherthan an indiscriminate use of political approaches, politicalactors may find that even with the best of intentions, desiredpolicy objectives may not be attained.     

公共卫生循证决策国际经验及新形势下中国发展思考

随着从疾病治疗到预防的新公共卫生形势的到来,公共卫生领域开展科学决策和实践的重要性愈发凸显,通过剖析发达国家循证公共卫生发展历史和经验发现,虽然中国公共卫生领域循证决策取得了一些成果,但仍处于起步阶段,存在一些亟待解决的问题。据此根据国外发展经验,对中国循证公共卫生理论建立、证据积累和数据库建立等方面提出建议,以期促进公共卫生领域循证决策的应用和推广。     

Counteracting obesity: developing a policy framework to guide action

Summary Objectives:  The purpose of this paper is to stimulate further debate regarding possible courses of policy action aimed at preventing obesity. Gostin’s framework for classifying antiobesity legal interventions is tested and extended to incorporate non-legislative policy initiatives to include a comprehensive array of policy actions available to deal with obesity. Methods:  A web search of the literature has been conducted. Initiatives from USA, Canada and the European Union were discussed in terms of their objectives and fit with the framework. Results:  Gostin’s framework was found to be a useful tool in organizing all the initiatives (legislative and non-legislative). However, sometimes a broader definition of the category was needed. As well, in some categories, few initiatives were implemented to date and several new categories have to be added to the framework to classify all the existing initiatives. Conclusions:  The theoretical developed framework will assist new initiatives assess possible courses of action as well as countries or organizations that have already implemented some measures identify what else can be done to effectively fight overweight and obesity.     

Potential of using existing injury information for injury surveillance at the local level in developing countries: experiences from Bangladesh

Although injury is a major public health problem in Bangladesh, as in other low income countries in the world, it has gained very little attention from policy makers, or even health professionals, mainly due to the lack of valid injury information in these countries. To address the injury problem, there is an urgent need to develop injury surveillance activities, based on existing sources of potential interest for obtaining injury information. This study is an evaluation of existing injury data sources in terms of prevention orientation representativeness, and sustainability with respect to the use of these sources in injury surveillance at the local level in Bangladesh. The regular injury information sources that have been used in this study include hospital records, post-mortem reports, newspaper reports, and police reports. In addition, 60 health practitioners in the area, representing various categories, were interviewed according to questionnaire, and ten others were interviewed in-depth about their opinions regarding their participation in the injury surveillance system. The information sources were then assessed for their potential to be included in the surveillance system. The validity was estimated by means of comparisons of the different sources. All the existing sources of injury information suffer from certain deficiencies such as, lack of representativeness, low prevention orientation and poor sustainability. Post-mortem reports and police reports have been found to be potential sources of mortality data but not morbidity data. Hospital records can be seen as potential sustainable sources of injury morbidity data but suffer from low prevention orientation and representativeness. The injury information was not consistent from source to source and failed to depict the true picture of injury in the area. To develop an injury surveillance system, a combination of data obtained from several different sources is necessary to compensate for inadequacies in the individual sources and to improve the overall usefulness of the system. Updated with E-codes, hospital discharge records could be used for injury morbidity surveillance, and updated police and post-mortem data can be used for mortality data in injury surveillance systems at the local level in developing countries.     

A retrospective analysis of cannabis use in a cohort of mentally ill patients in Sri Lanka and its implications on policy development

Background  

Several epidemiological studies have shown that cannabis; the most widely used illegal drug in the world, is associated with schizophrenia spectrum disorders (SSD).     

A village treatment center for malaria: community response in Sri Lanka

Early diagnosis and treatment of malaria cases is one of the basic elements of the current global malaria control strategy. In order to provide this service to people in rural areas there is a need for new cost-effective approaches. To ensure that such new approaches are acceptable to the target communities, it is important to know the rationale for people's malaria treatment-seeking behavior. The present study provides insights into the reasons for people's preferences for different types of healthcare facilities and describes variation of these preferences within a rural community in Sri Lanka. The study reports on the experiences with the establishment of a village health facility and its effect on the treatment-seeking behavior of the population. After the introduction of the village treatment center it quickly took over the role of main provider for diagnosis and treatment of malaria from the government facilities. The treatment center did not improve the response time in seeking treatment for young children, but the delay for adults was reduced by 1-2 days. Mothers with small children often preferred the government facilities since they wanted a more qualified opinion than available from the locally recruited staff of the village treatment center. The treatment center significantly reduced the stress and discomfort experienced by the elderly and handicapped segment of the community. The study indicated that the effective catchment area of a village treatment center will be influenced by the degree of initial support from key individuals in the communities, the selection procedure and training of assistants, and the history of the relationships between different villages to be served by the center. The government health services and communities across the dry zone of Sri Lanka could benefit substantially from the establishment of more village treatment centers. To ensure the long-term sustainability of these type of facilities it is necessary to assess the feasibility of charging a user fee and establishing multi-purpose clinics. Government policies and administrative procedures will need to be adjusted to make the successful operation of village treatment centers possible.     

The ethics of health systems research in low- and middle-income countries: A call to action

The increasing conduct of health systems research (HSR) in low- and middle-income countries (LMICs) has not been matched by concurrent work to clarify the field's ethical dimensions. To begin to address this gap, a two-day workshop on the ethics of HSR in LMICs was convened at Johns Hopkins University in June 2013. Participants included health systems researchers, philosophers, lawyers, bioethicists and institutional review board members from Botswana, Uganda, the UK, USA and Zambia. Based on discussions from the workshop, the paper affirms that, while HSR in LMICs raises ethical issues in relation to constructs (i.e. consent, risk, equipoise) common to international clinical research, the nature of the issues that arise often differ between the two fields. Three salient features of HSR and the ethical considerations associated with each of them in LMICs are described to demonstrate this point. Recommendations for institutional review boards’ oversight of HSR in LMICs are presented. Finally, a call is made for further action to develop thinking and guidance around the ethics of HSR in resource-poor settings.     

Determinants of health policy impact: a theoretical framework for policy analysis

Summary This paper addresses the role of policy and evidence in health promotion. The concept of von Wrights logic of events is introduced and applied to health policy impact analysis.According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.     

我国医联体建设省级政策的量化研究 ——基于政策工具、利益相关者、政策效力的三维分析框架

[目的]分析我国省级医联体建设政策,探究省级健康政策的制定实践同居民个体健康需求满足的动态耦合程度,为推进医联体建设及政策优化提出合理性的意见.[方法]检索省级政府建设医联体的政策文件,基于Rothwell和Zegveld政策工具编码分类,构建基本政策工具维度、利益相关者维度和政策效力维度的三维分析框架.[结果]最终纳...     

Prospective policy analysis: how an epistemic community informed policymaking on intentional self poisoning in Sri Lanka

Background  

Policy analysis is often retrospective and not well suited to helping policy makers decide what to do; in contrast prospective policy analysis seeks to assist in formulating responses to challenging public policy questions. Suicide in Sri Lanka is a major public health problem, with ingestion of pesticides being the primary method. Previous policy interventions have been associated with reduced mortality through restricting access to the most toxic pesticides. Additional means of reducing access are still needed.     

Childhood disadvantage and health inequalities: a framework for policy based on lifecourse research

Tackling health inequalities is moving up the policy agenda of richer societies like the UK, with governments looking for evidence to guide policy review and development. Observational studies of how childhood disadvantage compromises health in adulthood are an important part of the evidence base, but are largely inaccessible to the policy community. We develop a framework which captures the findings of these studies. Our framework highlights how disadvantage in childhood adversely affects both socio-economic circumstances and health in adulthood through a set of interlocking processes. Key among these are children's developmental health (their physical, cognitive and emotional development) and health behaviours, together with the associated educational and social trajectories. In breaking down the link between childhood disadvantage and adult health into its constituent elements, the framework provides a basis for understanding where and how policies can make a difference. The paper argues that the process of policy review and development needs to include both new programmes and the mainstream policies in which they are embedded.     

An evidence-based policy for improving choice in global health access through medical travel

Global medical travel has had an increasing trend without a comprehensive, evidence-driven policy to ensure safe and effective practice. To identify key factors that influence medical travel, we conducted a series of studies culminating with a preference and decision-making component of over 500 prospective medical travelers from a number of countries. Results indicated that quality of care was the most critical factor in the decision, followed by lower costs of procedure and shorter waiting times. Lower costs were less of a factor if the procedure was more invasive, which also increased the importance of waiting time in the decision. The most desired destinations for care were in Europe (United Kingdom, Germany) and North America (United States). Building on these insights and previous literature, we present a model that implements applications from these factors and additional insights generated across the series of studies toward an effective policy framework.     

中国生育政策的文本量化分析——基于政策工具、政策包容性、政策力度的三维分析框架

目的：对我国实施全面二孩政策以来的生育政策进行文本量化分析,为完善我国生育政策提供建议。方法：检索2016年以来发布的国家层面的生育政策文本,构建政策工具、政策包容性、政策力度三维分析框架,并对政策文本进行多维度及交叉对比分析。结果：本文共纳入45份政策文本,命令及规制性工具、能力建设性工具、激励性工具和信息及劝诫性工具占比依次为50.90%、39.16%、9.34%和9.94%;政策文本在尊重生育理念、促进生育公平、提升社会福祉三个政策包容性类型上分别占比12.14%、20.39%、67.48%;我国生育政策力度平均得分为2.67。结论：生育政策的政策工具内部均衡性不足,激励性与信息及劝诫性工具的使用有待加强;政策包容性类型丰富但使用不均衡,需要进一步促进性别平等和生育公平;政策力度整体偏弱,且与政策主体协调性不足,应进一步深化多部门参与协作,从财政、教育、文化等多个层面落实好生育配套措施,创建生育友好型社会。     

Great expectations: An analysis of researchers' and policy makers' perceptions of the potential value of the Australian indigenous burden of disease study for policy

The “Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples” was commissioned by the Australian government as part of the Australian Burden of Disease study. This paper explores the extent to which key actors in the research and policy communities expected the Indigenous Burden of Disease study's findings to inform, influence, or drive federal decisions concerning Indigenous health in Australia. This qualitative research undertook interviews with 13 key informants with significant involvement in the Indigenous Burden of Disease study: six researchers, five policy makers, and two knowledge brokers. Interviews were recorded, transcribed, and analyzed, and the findings were triangulated with a review of the literature. Policy makers and researchers anticipated that the Indigenous Burden of Disease study would improve the available information for policy deliberations about Indigenous health. Beyond that, their expectations about its policy influence differed substantially, with researchers more confident of the study's capacity to guide health priorities, and policy makers situating findings in the context of other critical inputs. Expectations of policy influence are shaped by the disciplinary perspectives of actors, and their relationship to policy outcomes and cannot be examined without also considering the policy, political, and financing context of the study being analyzed.