Role of Directorates in Promoting Nursing and Midwifery Across the Various States of India: Call for Leadership for Reforms

Background:While the roles and responsibilities of nursing professionals have multiplied over the years, but there are huge concerns with regard to the development of the nursing workforce and human resources (HR) issues for their career growth. The major lacuna is in not involving the nursing professionals in policy framing and decision-making. As a result, there is a leadership crisis of the nursing workforce across India.Objectives:The paper, is part of the WHO supported study, entitled “Study on Nursing and Midwifery in India: a critical review”, is developed with the objective to review the current organizational and management structure for the nursing positions at the State Directorates in India and obtain a Leadership perspective to strengthen nursing management capacities to address maternal health issues.Results:Since none of the states have neither a Nursing Cell nor the post of Director Nursing, final decision-making powers rest with state health secretaries and medical directors. The nursing management structure majorly managed by senior policy makers from the medical fraternity, and provides very little scope for nursing professionals to participate in policy decision making to bring about reforms. There is no uniformity on HR issues concerning career graphs and pay structures across the states.Conclusions:In order to strengthen nursing as a profession and for facilitating their role at the policy level, more powers and autonomy needs to be given to them and this requires HR policy guidelines for nurses. Setting up a separate nursing directorate, to be headed by a senior nursing professional, is suggested in every state along with a strong nursing division at the National level. This total paradigm shift will empower nursing professionals to take up the leadership role at the policy level to bring about necessary reforms. Across the country, nursing professionals repeatedly echoed one requirement: To reframe nursing leadership at all levels.     

Effects of the COVID-19 pandemic in India: An analysis of policy and technological interventions

ObjectivesFollowing a surge in cases of coronavirus disease 2019 (COVID-19) in June 2020, India became the third-worst affected country worldwide. This study aims to analyse the underlying epidemiological situation in India and explain possible impacts of policy and technological changes.MethodsSecondary data were utilized, including recently published literature from government sources, the COVID-19 India website and local media reports. These data were analysed, with a focus on the impact of policy and technological interventions.ResultsThe spread of COVID-19 in India was initially characterized by fewer cases and lower case fatality rates compared with numbers in many developed countries, primarily due to a stringent lockdown and a demographic dividend. However, economic constraints forced a staggered lockdown exit strategy, resulting in a spike in COVID-19 cases. This factor, coupled with low spending on health as a percentage of gross domestic product (GDP), created mayhem because of inadequate numbers of hospital beds and ventilators and a lack of medical personnel, especially in the public health sector. Nevertheless, technological advances, supported by a strong research base, helped contain the damage resulting from the pandemic.ConclusionsFollowing nationwide lockdown, the Indian economy was hit hard by unemployment and a steep decline in growth. The early implementation of lockdown initially decreased the doubling rate of cases and allowed time to upscale critical medical infrastructure. Measures such as asymptomatic testing, public–private partnerships, and technological advances will be essential until a vaccine can be developed and deployed in India.Public interest summaryThe spread of COVID-19 in India was initially characterized by lower case numbers and fewer deaths compared with numbers in many developed countries. This was mainly due to a stringent lockdown and demographic factors. However, economic constraints forced a staggered lockdown exit strategy, resulting in a spike in COVID-19 cases in June 2020. Subsequently, India became the third-worst affected country worldwide. Low spending on health as a percentage of gross domestic product (GDP) meant there was a shortage of hospital beds and ventilators and a lack of medical personnel, especially in the public health sector. Nevertheless, technological advances, supported by a strong research base, helped contain the health and economic damage resulting from the pandemic. In the future, measures such as asymptomatic testing, public–private partnerships, and technological advances will be essential until a vaccine against COVID-19 can be developed and rolled-out in India.     

Fulfilling the Promise of Artificial Intelligence in the Health Sector: Let’s Get Real

ObjectivesThis study aimed to showcase the potential and key concerns and risks of artificial intelligence (AI) in the health sector, illustrating its application with current examples, and to provide policy guidance for the development, assessment, and adoption of AI technologies to advance policy objectives.MethodsNonsystematic scan and analysis of peer-reviewed and gray literature on AI in the health sector, focusing on key insights for policy and governance.ResultsThe application of AI in the health sector is currently in the early stages. Most applications have not been scaled beyond the research setting. The use in real-world clinical settings is especially nascent, with more evidence in public health, biomedical research, and “back office” administration. Deploying AI in the health sector carries risks and hazards that must be managed proactively by policy makers. For AI to produce positive health and policy outcomes, 5 key areas for policy are proposed, including health data governance, operationalizing AI principles, flexible regulation, skills among health workers and patients, and strategic public investment.ConclusionsAI is not a panacea, but a tool to address specific problems. Its successful development and adoption require data governance that ensures high-quality data are available and secure; relevant actors can access technical infrastructure and resources; regulatory frameworks promote trustworthy AI products; and health workers and patients have the information and skills to use AI products and services safely, effectively, and efficiently. All of this requires considerable investment and international collaboration.     

Aspekte gesundheitsökonomischer Evaluationen als Beitrag zur Priorisierungsdebatte

Decision-making in healthcare is a priority-setting process. Tools used in health economic evaluation support decision-making by outlining complex interdependences, simulating short- and long-term consequences, and quantifying formal comparisons of health technologies. Key elements in health economic evaluations are patient-relevant outcomes and cost parameters. Costing of healthcare services is demanding and reflects only an approximation to reality, particularly in Germany, as the reimbursement schemes neither fully provide all details nor the different costing perspectives. Hence, in order to obtain uniform and cross-indication applicable cost parameters, a German standard cost dataset is necessary. In addition, patient-relevant and indication-specific sets of outcomes parameters should be agreed upon in order to also enable a reliable clinical product development. Economic aspects could be applied in a two-step decision-making approach, where initially the anticipated indication-specific technical efficiency level in terms of cost per adjusted life years would be assessed from a health system perspective. The second step would employ prioritization based on indication-relevant outcomes and ranking criteria in the individual patient decision situation. Health economic evaluations are relevant tools to support prioritization of health technologies, both on an individual as well as public health level.     

Social values and health priority setting in Australia: An analysis applied to the context of health technology assessment

ObjectiveTo describe the role of social values in priority setting related to health technology assessment processes and decision-making in Australia.ApproachThe processes and decision criteria of the Pharmaceutical and Medical Benefits Advisory Committees are described based on literature and policy sources, and analysed using a framework for identifying social values in priority-setting.FindingsTransparency and accountability of processes are apparent. Participation balances inclusiveness and effectiveness of decision-making, but presents an opportunity to enhance priority setting processes. Clinical and cost-effectiveness are important content considerations. Social values related to justice/equity are considered, without quantification of criteria weights for equity relative to other factors. HTA processes support solidarity through subsidising approved technologies for all Australians, whilst retaining autonomy by permitting non-subsidised technologies to be accessed privately, leading to possible tension between the values of solidarity, autonomy and equity.ConclusionsPriority setting related to health technology subsidy incorporates a range of inter-related social values in the processes and content of decision-making. Participation in decision-making could arguably be improved if a patient and public engagement policy were to be formulated alongside more widespread changes across processes to assess social values using approaches such as the Citizens’ Jury.     

Conceptual frameworks and key dimensions to support coverage decisions for vaccines

BackgroundHealth policy makers often have to face decisions on whether and how to incorporate new vaccines into immunisation plans. This study aims to review and catalogue the relevant current frameworks and taxonomies on vaccines and connect these to the DECIDE Evidence to Decision framework (EtD), a general framework based on evidence-based criteria to guide decision-making on intervention adoption.MethodsWe systematically searched MEDLINE, EMBASE, Cochrane Library and funding agency websites from 1990 to 2013. We included systematic reviews and primary studies presenting decision-making tools for community vaccine adoption. We qualitatively summarised the reports by purpose, targeted country, principal results, and decisional models. We then extracted and compared the dimensions adopted by vaccine frameworks across studies.ResultsFourteen studies (five systematic reviews and nine primary studies) were included. Several factors frequently influenced decision-makers’ views on vaccines: the most frequent political-context factors considered were Importance of illness or problem, Vaccine characteristics, Resource use, and Feasibility. Others such as Values and preferences and Acceptability were less consistently reported. We did not find evidence on the reasons why a framework for vaccine adoption differs from that for decisions on the adoption of an intervention in general, such as the EtD. There are limited data on how dimensions are explained in practical factors and directly linked to coverage decisions.ConclusionsThis review summarises conceptual models and taxonomy of a heterogeneous and evolving area in health policy decisions. A shared and comprehensive framework on vaccine coverage remains to be achieved with its single dimensions (epidemiologic, effectiveness, economic, and social) valued differently across studies. A generic tool such as the EtD conceptualises all relevant dimensions, and might reduce inconsistencies.     

Public perspectives on health improvement within a remote‐rural island community

BackgroundRural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health.ObjectiveTo identify and describe shared perspectives within a remote‐rural community on how to improve rural health.MethodUsing Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews.ResultsSixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services.Discussion and conclusionsFactors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice.Public ContributionMembers of the public were involved in the development and piloting of the statement set.     

National decision-making for the introduction of new vaccines: A systematic review, 2010–2020

BackgroundCompeting priorities make using a transparent and evidence-based approach important when deciding to recommend new vaccines. We conducted a literature review to document the processes and frameworks for national decision-making on new vaccine introductions and explored which key features have evolved since 2010.MethodsWe searched literature published on policymaking related to vaccine introduction from March 2010 to August 2020 in six databases. We screened articles for eligibility with the following exclusion criteria: non-human or hypothetical vaccines, the sole focus on economic evaluation or decision to adopt rather than policy decision-making. We employed nine broad categories of criteria from the 2012 review for categorization and abstracted data on the country, income level, vaccine, and other relevant criteria.ResultsOf the 3808 unique references screened, 116 met eligibility criteria and were classified as: a) framework of vaccine adoption decision-making (27), b) studies that analyse empirical data on or examples of vaccine adoption decision-making (45), c) theoretical and empirical articles that provide insights into the vaccine policymaking process (44 + 17 already included in the previous categories). Commonly reported criteria for decision-making were the burden of disease; vaccine efficacy/effectiveness, safety; impact on health and non-health outcomes; economic evaluation and cost-effectiveness of alternative interventions. Programmatic and acceptability aspects were not as often considered. Most (50; 82%) of the 61 articles describing the process of vaccine introduction policymaking highlighted the role of country, regional, or global evidence-informed recommendations and a robust national governance as enabling factors for vaccine adoption.ConclusionsThe literature on vaccine adoption decision-making has expanded since 2010. We found that policymakers and expert advisory committee members (e.g., National Immunization Technical Advisory Group [NITAG]) increasingly value the interventions based on economic evaluations. The results of this review could guide discussions on evidence-informed immunization decision-making among country, sub-regional, and regional stakeholders.     

Adoption of new health products in low and middle income settings: how product development partnerships can support country decision making

When a new health product becomes available, countries have a choice to adopt the product into their national health systems or to pursue an alternate strategy to address the public health problem. Here, we describe the role for product development partnerships (PDPs) in supporting this decision-making process. PDPs are focused on developing new products to respond to health problems prevalent in low and middle income settings. The impact of these products within public sector health systems can only be realized after a country policy process. PDPs may be the organizations most familiar with the evidence which assists decision making, and this generally translates into involvement in international policy development, but PDPs have limited reach into endemic countries. In a few individual countries, there may be more extensive involvement in tracking adoption activities and generating local evidence. This local PDP involvement begins with geographical prioritization based on disease burden, relationships established during clinical trials, PDP in-country resources, and other factors. Strategies adopted by PDPs to establish a presence in endemic countries vary from the opening of country offices to engagement of part-time consultants or with long-term or ad hoc committees. Once a PDP commits to support country decision making, the approaches vary, but include country consultations, regional meetings, formation of regional, product-specific committees, support of in-country advocates, development of decision-making frameworks, provision of technical assistance to aid therapeutic or diagnostic guideline revision, and conduct of stakeholder and Phase 4 studies. To reach large numbers of countries, the formation of partnerships, particularly with WHO, are essential. At this early stage, impact data are limited. But available evidence suggests PDPs can and do play an important catalytic role in their support of country decision making in a number of target countries.     

Challenges in the Development and Reimbursement of Personalized Medicine—Payer and Manufacturer Perspectives and Implications for Health Economics and Outcomes Research: A Report of the ISPOR Personalized Medicine Special Interest Group

BackgroundPersonalized medicine technologies can improve individual health by delivering the right dose of the right drug to the right patient at the right time but create challenges in deciding which technologies offer sufficient value to justify widespread diffusion. Personalized medicine technologies, however, do not neatly fit into existing health technology assessment and reimbursement processes.ObjectivesIn this article, the Personalized Medicine Special Interest Group of the International Society for Pharmacoeconomics and Outcomes Research evaluated key development and reimbursement considerations from the payer and manufacturer perspectives.MethodsFive key areas in which health economics and outcomes research best practices could be developed to improve value assessment, reimbursement, and patient access decisions for personalized medicine have been identified.ResultsThese areas are as follows: 1 research prioritization and early value assessment, 2 best practices for clinical evidence development, 3 best practices for health economic assessment, 4 addressing health technology assessment challenges, and 5 new incentive and reimbursement approaches for personalized medicine.ConclusionsKey gaps in health economics and outcomes research best practices, decision standards, and value assessment processes are also discussed, along with next steps for evolving health economics and outcomes research practices in personalized medicine.     

Public place restrictions on smoking in Canada: assessing the role of the state, media, science and public health advocacy

While much is known about the impact of law and public policy, we know considerably less about their antecedents. Theories of policy adoption suggest that a variety of policy inputs help to shape legislative change. This research considers the enactment of municipal smoking bylaws in Canada between 1970 and 1995. The emergence of second-hand smoke (SHS) has been offered as a viable explanation for the increased enactment of local smoking restrictions. A number of indicators confirm the rising public health concern around SHS. Using Health Canada data on municipal smoking bylaw enactment in Canada, this paper employs an event history analysis to trace the role of four indicators of the increased recognition of SHS as a public health concern-scientific research, parliamentary debate, print media, and health advocacy. Findings indicate that the print media and health advocacy play the strongest role in explaining the increase in the adoption of municipal smoking bylaws in Canada. Results lend support to the quantitative study of the policy adoption process and to theories of policy making that consider multiple influences on policy adoption.     

Priorización de medidas para la consolidación de la toma de decisiones compartidas en las prestaciones del Sistema Nacional de Salud español

ObjectiveIdentify and prioritize according to their relevance, measures, interventions and indispensable instruments to support the establishment of a strategic framework in the Spanish National Health System to enable the responsible and informed exercise of the autonomy of its users and patients for shared decision-making.MethodGroup consultation, structured according to procedures adapted from brainstorming techniques, nominal group and Rand consensus method.ResultsThe 10 panellists proposed 53 possible actions focusing on “macro” structural measures (legal support and explicit prioritization of shared decision-making on health policy, curricular measures of the teaching system and dynamisation of cultural change), “meso” (generation and dissemination of accredited information by specific research lines and instruments to help shared decision-making), and “micro” activities (measures to stimulate the introduction of shared decision-making in the agency relationship with citizen and users of the healthcare system).ConclusionsThe consensus emerging from the consultation points to the need to incorporate into the strategic priorities of health policy, structural measures that support and encourage the development of shared decision-making in a number of specific areas of evolution and change in the relationship between health professionals and patients as an attribute of quality in access to the benefits and services of the public healthcare system.     

India’s Proposed Universal Health Coverage Policy: Evidence for Age Structure Transition Effect and Fiscal Sustainability

Background

India’s High Level Expert Group on Universal Health Coverage in 2011 recommended a universal, public-funded and national health coverage policy. As a plausible forward-looking macroeconomic reform in the health sector, this policy proposal on universal health coverage (UHC) needs to be evaluated for age structure transition effect and fiscal sustainability to strengthen its current design and future implementation.

Objective

Macroeconomic analyses of the long-term implications of age structure transition and fiscal sustainability on India’s proposed UHC policy.

Methods

A new measure of age-specific UHC is developed by combining the age profile of public and private health consumption expenditure by using the National Transfer Accounts methodology. Different projections of age-specific public health expenditure are calculated over the period 2005–2100 to account for the age structure transition effect. The projections include changes in: (1) levels of the expenditure as gross domestic product grows, (2) levels and shape of the expenditure as gross domestic product grows and expenditure converges to that of developed countries (or convergence scenario) based on the Lee–Carter model of forecasting mortality rates, and (3) levels of the expenditure as India moves toward a UHC policy. Fiscal sustainability under each health expenditure projection is determined by using the measures of generational imbalance and sustainability gap in the Generational Accounting methodology.

Results

Public health expenditure is marked by age specificities and the elderly population is costlier to support for their healthcare needs in the future. Given the discount and productivity growth rates, the proposed UHC is not fiscally sustainable under India’s current fiscal policies except for the convergence scenario. However, if the income elasticity of public expenditure on social welfare and health expenditure is less than one, fiscal sustainability of the UHC policy is attainable in all scenarios of projected public health expenditures. These new results strengthen the proposed UHC policy by accounting for age structure transition effect and justifying its sustainability within the framework of India’s current fiscal policies.

Conclusion

The age structure transition effect is important to incorporate the age-specific cost and benefit of the proposed UHC policy, especially as India moves toward an ageing society. Fiscal sustainability is essential to ensure that the proposed UHC is implementable on a long-term basis and within the framework of current fiscal policies.

     

荷兰卫生技术评估体系分析及对我国的启示*

目的：介绍荷兰卫生技术评估体系和政策转化现状，为完善我国价值医疗体系、提高卫生改革决策水平提供借鉴。方法：通过查阅国内外相关文献，描述荷兰的卫生技术评估体系，分析其常规应用的转化特点，综合评价其在新冠肺炎疫情中急性护理服务的网络构建特点。结果：荷兰卫生体系被称为“欧洲最佳医疗体系”，卫生技术评估在荷兰卫生系统决策中发挥了重要作用，特别是在降低医疗成本层面。相比荷兰，我国卫生技术评估政策转化成果相对较少。结论：我国需要完善卫生技术评估机构体系，加强研究人员与政策制定者的沟通，提升决策科学性及加快卫生技术评估转化效率。同时，筑牢分级诊疗体系，提升卫生技术评估综合性评价标准，进而推动实践价值医疗，促进我国卫生健康事业发展。     

Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy

BackgroundThe WHO's 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants’ perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia.MethodsTwenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area.FindingsThe results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions.ConclusionsThis paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health.     

COVID-19 Data Utilization in North Carolina: Qualitative Analysis of Stakeholder Experiences

BackgroundAs the world faced the pandemic caused by the novel coronavirus disease 2019 (COVID-19), medical professionals, technologists, community leaders, and policy makers sought to understand how best to leverage data for public health surveillance and community education. With this complex public health problem, North Carolinians relied on data from state, federal, and global health organizations to increase their understanding of the pandemic and guide decision-making.ObjectiveWe aimed to describe the role that stakeholders involved in COVID-19–related data played in managing the pandemic in North Carolina. The study investigated the processes used by organizations throughout the state in using, collecting, and reporting COVID-19 data.MethodsWe used an exploratory qualitative study design to investigate North Carolina’s COVID-19 data collection efforts. To better understand these processes, key informant interviews were conducted with employees from organizations that collected COVID-19 data across the state. We developed an interview guide, and open-ended semistructured interviews were conducted during the period from June through November 2020. Interviews lasted between 30 and 45 minutes and were conducted by data scientists by videoconference. Data were subsequently analyzed using qualitative data analysis software.ResultsResults indicated that electronic health records were primary sources of COVID-19 data. Often, data were also used to create dashboards to inform the public or other health professionals, to aid in decision-making, or for reporting purposes. Cross-sector collaboration was cited as a major success. Consistency among metrics and data definitions, data collection processes, and contact tracing were cited as challenges.ConclusionsFindings suggest that, during future outbreaks, organizations across regions could benefit from data centralization and data governance. Data should be publicly accessible and in a user-friendly format. Additionally, established cross-sector collaboration networks are demonstrably beneficial for public health professionals across the state as these established relationships facilitate a rapid response to evolving public health challenges.     

Development of EASY-Care,for Brief Standardized Assessment of the Health and Care Needs of Older People; With Latest Information About Cross-National Acceptability

IntroductionThe EASY-Care system has been developed in the past 20 years in the United States and Europe as a brief standardized method for assessing the perceptions of older people about their health and care needs and priorities for a service response. More recently, it has been adapted and tested for use in poor, middle-income, and rich countries across the world. In this article we review its development and report the latest data for cross-cultural acceptability to older people and their clinicians in 6 countries across 4 continents.MethodWe used a multicenter, mixed-method (quantitative and qualitative) approach to assess clinician (n = 37) and patient (n = 115) perspectives of acceptability of the EASY-Care Standard (2010) instrument. Data were collected between 2008 and 2012 in Iran, Colombia, India, Lesotho, Tonga, and the United Kingdom.ResultsKey strengths identified included high levels of acceptability from both clinician and patient perspectives, with the tools seen as useful for identification of unmet need. Key recommendations included enhancing clarity in certain questions, ensuring it is not too long. Recommendations included minor context-specific adaptations, effective use of the screening questionnaire, and use of context-specific interviewer prompts.ConclusionsThe EASY-Care Standard has high levels of acceptability from both clinicians and patients across poor, middle-income, and rich countries and has the potential to become a global gold standard for holistic person-centered assessment.     

A framework for medical power in two case studies of health policymaking in India and Niger

ABSTRACT

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s–2012) and emergency medicine specialisation in India (early 1990s–2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking. Medical doctors, mainly specialists, utilised their power to shape policy differently in each case. In Niger, a small, connected group of paediatricians pursued a policy of task-shifting after a powerful non-medical actor, the country’s president, shifted the debate by enacting broad health systems improvements. In India, a more fragmented group of specialists prioritised tertiary-level healthcare policies likely to benefit only a small subset of the population. Compared to high-income settings, medical power in these cases was channelled and expressed with greater variability in the profession’s ability to organise and influence policymaking. Taken together, both cases provide evidence that a concentration of medical power in health policymaking can result in the medicalisation of public health issues.