"Just as curry is needed to eat rice, antibiotics are needed to cure fever"-a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India.

OBJECTIVES: To understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West Bengal in India. DESIGN: Qualitative study using focus group discussions and in-depth interviews. SETTING: Two contrasting village clusters in South 24 Parganas district, West Bengal, India. Fieldwork was conducted between November 2019 and January 2020. PARTICIPANTS: 98 adult community members (42 men and 56 women) were selected purposively for 8 focus group discussions. In-depth interviews were conducted with 16 community key informants (7 teachers, 4 elected village representatives, 2 doctors and 3 social workers) and 14 community health workers. RESULTS: Significant themes at the individual level included sociodemographics (age, gender, education), cognitive factors (knowledge and perceptions of modern antibiotics within non-biomedical belief systems), affective influences (emotive interpretations of appropriate medicine consumption) and economic constraints (affordability of antibiotic courses and overall costs of care). Antibiotics were viewed as essential fever remedies, akin to antipyretics, with decisions to halt mid-course influenced by non-biomedical beliefs associating prolonged use with toxicity. Themes at the community and health system levels included the health stewardship roles of village leaders and knowledge brokering by informal providers, pharmacists and public sector accredited social health activists. However, these community resources lacked sufficient knowledge to address people's doubts and concerns. Qualified doctors were physically and socially inaccessible, creating a barrier to seeking their expertise. CONCLUSIONS: The interplay of sociodemographic, cognitive and affective factors, and economic constraints at the individual level, underscores the complexity of antibiotic usage. Additionally, community leaders and health workers emerge as crucial players, yet their knowledge gaps and lack of empowerment pose challenges in addressing public concerns. This comprehensive analysis highlights the need for targeted interventions that address both individual beliefs and community health dynamics to promote judicious antibiotic use.

The governance behaviours: a proposed approach for the alignment of the public and private sectors for better health outcomes.

Health systems are 'the ensemble of all public and private organisations, institutions and resources mandated to improve, maintain or restore health.' The private sector forms a major part of healthcare practice in many health systems providing a wide range of health goods and services, with significant growth across low-income and middle-income countries. WHO sees building stronger and more effective health systems through the participation and engagement of all health stakeholders as the pathway to further reducing the burden of disease and meeting health targets and the Sustainable Development Goals. However, there are governance and public policy gaps when it comes to interaction or engagement with the private sector, and therefore, some governments have lost contact with a major area of healthcare practice. As a result, market forces rather than public policy shape private sector activities with follow-on effects for system performance. While the problem is well described, proposed normative solutions are difficult to apply at country level to translate policy intentions into action. In 2020, WHO adopted a strategy report which argued for a major shift in approach to engage the private sector based on the performance of six governance behaviours. These are a practice-based approach to governance and draw on earlier work from Travis et al on health system stewardship subfunctions. This paper elaborates on the governance behaviours and explains their application as a practice approach for strengthening the capacity of governments to work with the private sector to achieve public policy goals.

Deliberation-based learning: strengthening neonatal care in China.

This paper presents a case example from China, where detailed deliberations were instrumental in bringing together national and subnational managers to tailor implementation protocols for neonatal care strategies at provincial and county levels. The China National Health Development Research Center (CNHDRC) organised deliberations to support the formulation of strategies for improving early essential neonatal care for rural areas. The aim was to help counties, the lowest level jurisdiction in China, learn what could work locally, and to help provinces and the national government learn what should inform national policy and be disseminated widely in China's decentralised health system. It became clear that central-level stakeholders needed to learn how to help counties support the pilots. CNHDRC staff, national-level experts and academics visited pilot provinces and counties to discuss local policies, initiatives and challenges (including with patients), build a common understanding of the project and identify local support needs including by examining health records and observing health facilities. What followed were county-specific reports with priority interventions and implementation plans, which were further refined through county-level meetings. They helped central stakeholders better understand and address variations in county capacities and needs.

Digital Health and Inequalities in Access to Health Services in Bangladesh: Mixed Methods Study.

BACKGROUND: Globally, the rapid growth of technology and its use as a development solution has generated much interest in digital health. In line with global trends, Bangladesh is also integrating technology into its health system to address disparities. Strong political endorsement and uptake of digital platforms by the government has influenced the rapid proliferation of such initiatives in the country. This paper aims to examine the implications of digital health on access to health care in Bangladesh, considering who uses electronic devices to access health information and services and why. OBJECTIVE: This study aims to understand how access to health care and related information through electronic means (digital health) is affected by sociodemographic determinants (ie, age, gender, education, socioeconomic status, and personal and household ownership of mobile phones) in a semiurban community in Bangladesh. METHODS: A cross-sectional survey of 854 households (between October 2013 and February 2014) and 20 focus group discussions (between February 2017 and March 2017) were conducted to understand (1) who owns electronic devices; (2) who, among the owners, uses these to access health information and services and why; (3) the awareness of electronic sources of health information; and (4) the role of intermediaries (family members or peers who helped to look for health information using electronic devices). RESULTS: A total of 90.3% (771/854) of households (471/854, 55.2% of respondents) owned electronic devices, mostly mobile phones. Among these, 7.2% (34/471) used them to access health information or services. Middle-aged (35-54 years), female, less (or not) educated, and poorer people used these devices the least (α=.05, α is the level of significance). The lack of awareness, discomfort, differences with regular care-seeking habits, lack of understanding and skills, and proximity to a health facility were the main reasons for not using devices to access digital health. CONCLUSIONS: Although influenced by sociodemographic traits, access to digital health is not merely related to device ownership and technical skill. Rather, it is a combination of general health literacy, phone ownership, material resources, and technical skill as well as social recognition of health needs and inequity. This study's findings should serve as a basis for better integrating technology within the health system and ensuring equitable access to health care.

The COVID-19 pandemic: diverse contexts; different epidemics-how and why?

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability-by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.

The China-UK Global Health Support Programme: looking for new roles and partnerships in changing times.

China's engagement in global affairs has changed substantially in the 2010s. One aspect of the country's global reorientation has been its increased interest in, and willingness to play a role in, global health. In the early 2010s, the UK Department for International Development (DFID) initiated a collaboration with the Chinese government on a programme to support the country to play a greater and more effective global role in health and explore how the UK and China could work together on issues of key concern and contribute to improved global development outcomes. The programme worked with key Chinese agencies to carry out capacity building, support analysis of China's approaches to engagement in global health governance and assistance, and provide support to government decision making. It also trialled several small-scale interventions in third countries through which Chinese agencies gained experience of working on health programmes overseas. The article reports on the main findings of an evaluation commissioned by DFID to learn from the programme. The programme provided support at a key time in China's global reorientation; however, there is a need for continued development of capacity and systems for China to play the role envisaged by the country's leadership. There is also a need for continued exploration on the part of China and partners of how to effectively collaborate to support improved global outcomes.

Understanding China's growing involvement in global health and managing processes of change.

BACKGROUND: Recent years have seen a rapid change in China's global engagement and a recognition that solving global challenges will need to take the changing role of China into account. The paper discusses China's growing involvement in global health. Health is an area where there is broad agreement over global priorities and, potentially, a fertile space to build new forms of collaboration that point the way towards the adaptation of global governance to a rapidly changing context. RESULTS: Drawing on previous analyses of China's management of change in its domestic health reforms and interviews with a range of stakeholders in China, the UK and Switzerland, the paper argues that China's engagement in global health is developing and diversifying rapidly in response to the central government's desire to see a greater role for China in global health. This diversification is part of a pattern of change management familiar from China's domestic reform experience. Explorations underway by a range of Chinese agencies form part of a process of rapid experimentation and experiential learning that are informing China's search for (a) new global role(s). CONCLUSIONS: China is undergoing rapid institutional innovation and developing capacity for greater global engagement, including in health; however, substantial, recent leadership commitments make clear Chinese agencies' need for continued exploration, innovation and rapid learning. How China engages globally is of significance to the world, not just China. The challenge for China, other global actors and multilateral organisations is to incorporate new approaches into existing global governance arrangements, including for the management of global health. This will require a willingness on all sides to learn from each other and invest the effort needed to build governance arrangements appropriate for the coming decades. This is not only important as a means of protecting global public health, but also as a demonstration of how governance arrangements can be adapted to the needs of a pluralistic global order in a context of rapid change.

Service Delivery Transformation for UHC in Asia and the Pacific.

This article was drafted as part of a review of strategies for making progress toward universal health coverage in the countries of Asia and the Pacific. It focuses on strengthening the delivery of services, in the context of population aging. It argues that it is important to take into account big differences in development contexts and also the rapid, interconnected changes that many countries are experiencing. The article focuses especially on countries with relatively undeveloped institutions and pluralistic and highly segmented health sectors. It argues that attempts by these countries to import institutional arrangements from outside are likely to be complicated. It argues that government needs to focus on both short-term measures to meet immediate needs and the longer-term aim of establishing effective institutional arrangements. This means that they need to take into account the political factors that influence the direction of health system change. The article emphasizes the need to strengthen the capacity of the health system to address the growing challenge of chronic noncommunicable diseases to avoid heavy political pressure to expand hospital services. It then explores the opportunities and challenges associated with the rapid expansion of digital health services. It concludes with a discussion of government stewardship and management of health system transformation to address the major challenges associated with population aging.

Evaluation and learning in complex, rapidly changing health systems: China's management of health sector reform.

Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China's healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.

Health system innovations: adapting to rapid change.

This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.

Antimicrobial resistance and universal health coverage.

The WHO launched a Global Action Plan on antimicrobial resistance (AMR) in 2015. World leaders in the G7, G20 and the UN General Assembly have declared AMR to be a global crisis. World leaders have also adopted universal health coverage (UHC) as a key target under the sustainable development goals. This paper argues that neither initiative is likely to succeed in isolation from the other and that the policy goals should be to both provide access to appropriate antimicrobial treatment and reduce the risk of the emergence and spread of resistance by taking a systems approach. It focuses on outpatient treatment of human infections and identifies a number of interventions that would be needed to achieve these policy goals. It then shows how a strategy for achieving key attributes of a health system for UHC can take into account the need to address AMR as part of a UHC strategy in any country. It concludes with a list of recommended priority actions for integrating initiatives on AMR and UHC.

Universal Health Coverage and Primary Healthcare: Lessons From Japan Comment on "Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries".

A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of achieving virtually universal coverage with primary healthcare services: the need to integrate the existing providers of primary healthcare services into the organised health system; the need to limit government commitments to finance hospital services and the need to empower providers of primary healthcare to influence decisions that influence their livelihoods. Although the context of low- and middle-income countries (LMICs) differs in many ways from Japan in the late 19th and early 20th centuries, the lesson that short-term initiatives to achieve universal coverage need to be complemented by an understanding of the factors influencing long-term change management remains highly relevant.

ICTs and the challenge of health system transition in low and middle-income countries.

The aim of this paper is to contribute to debates about how governments and other stakeholders can influence the application of ICTs to increase access to safe, effective and affordable treatment of common illnesses, especially by the poor. First, it argues that the health sector is best conceptualized as a 'knowledge economy'. This supports a broadened view of health service provision that includes formal and informal arrangements for the provision of medical advice and drugs. This is particularly important in countries with a pluralistic health system, with relatively underdeveloped institutional arrangements. It then argues that reframing the health sector as a knowledge economy allows us to circumvent the blind spots associated with donor-driven ICT-interventions and consider more broadly the forces that are driving e-health innovations. It draws on small case studies in Bangladesh and China to illustrate new types of organization and new kinds of relationship between organizations that are emerging. It argues that several factors have impeded the rapid diffusion of ICT innovations at scale including: the limited capacity of innovations to meet health service needs, the time it takes to build new kinds of partnership between public and private actors and participants in the health and communications sectors and the lack of a supportive regulatory environment. It emphasises the need to understand the political economy of the digital health knowledge economy and the new regulatory challenges likely to emerge. It concludes that governments will need to play a more active role to facilitate the diffusion of beneficial ICT innovations at scale and ensure that the overall pattern of health system development meets the needs of the population, including the poor.

Towards the just and sustainable use of antibiotics.

The emergence and spread of antibiotic resistant pathogens poses a big challenge to policy-makers, who need to oversee the transformation of health systems that evolved to provide easy access to these drugs into ones that encourage appropriate use of antimicrobials, whilst reducing the risk of resistance. This is a particular challenge for low and middle-income countries with pluralistic health systems where antibiotics are available in a number of different markets. This review paper considers access and use of antibiotics in these countries from a complex adaptive system perspective. It highlights the main areas of intervention that could provide the key to addressing the sustainable long term use and availability of antibiotics. A focus on the synergies between interventions addressing access strategies, antibiotic quality, diagnostics for low-resource settings, measures to encourage just and sustainable decision making and help seeking optimal therapeutic and dosing strategies are key levers for the sustainable future of antibiotic use. Successful integration of such strategies will be dependent on effective governance mechanisms, effective partnerships and coalition building and accurate evaluation systems at national, regional and global levels.

Addressing antimicrobial resistance in China: policy implementation in a complex context.

The effectiveness of antibiotics in treating bacterial infections is decreasing in China because of the widespread development of resistant organisms. Although China has enacted a number of regulations to address this problem, but the impact is very limited. This paper investigates the implementation of these regulations through the lens of complex adaptive systems (CAS). It presents the findings from reviews of relevant policy documents and published papers. The paper identifies different types of agent and explores their interaction with regard to the use of antibiotics and their responses to changes of the regulations. It focuses particularly on the impact of perverse financial incentives on overall patterns of use of antibiotics. Implications for the possibilities of nonlinear results, interactive relationships, and new pathways of policy implementation are discussed. The paper concludes that policy-makers need to better understand the objectives, incentives and potential adaptive behaviors of the agents when they implement interventions to improve antibiotic use and reduce the risk of emergence of resistant organisms.

Health Systems Research in a Complex and Rapidly Changing Context: Ethical Implications of Major Health Systems Change at Scale.

This paper discusses health policy and systems research in complex and rapidly changing contexts. It focuses on ethical issues at stake for researchers working with government policy makers to provide evidence to inform major health systems change at scale, particularly when the dynamic nature of the context and ongoing challenges to the health system can result in unpredictable outcomes. We focus on situations where 'country ownership' of HSR is relatively well established and where there is significant involvement of local researchers and close ties and relationships with policy makers are often present. We frame our discussion around two country case studies with which we are familiar, namely China and South Africa and discuss the implications for conducting 'embedded' research. We suggest that reflexivity is an important concept for health system researchers who need to think carefully about positionality and their normative stance and to use such reflection to ensure that they can negotiate to retain autonomy, whilst also contributing evidence for health system change. A research process informed by the notion of reflexive practice and iterative learning will require a longitudinal review at key points in the research timeline. Such review should include the convening of a deliberative process and should involve a range of stakeholders, including those most likely to be affected by the intended and unintended consequences of change.

Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts.

BACKGROUND: This paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals. METHODS: The study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities. RESULTS: The study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development. CONCLUSIONS: This history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.

Informal rural healthcare providers in North and South India.

Rural households in India rely extensively on informal biomedical providers, who lack valid medical qualifications. Their numbers far exceed those of formal providers. Our study reports on the education, knowledge, practices and relationships of informal providers (IPs) in two very different districts: Tehri Garhwal in Uttarakhand (north) and Guntur in Andhra Pradesh (south). We mapped and interviewed IPs in all nine blocks of Tehri and in nine out of 57 blocks in Guntur, and then interviewed a smaller sample in depth (90 IPs in Tehri, 100 in Guntur) about market practices, relationships with the formal sector, and their knowledge of protocol-based management of fever, diarrhoea and respiratory conditions. We evaluated IPs' performance by observing their interactions with three patients per condition; nine patients per provider. IPs in the two districts had very different educational backgrounds-more years of schooling followed by various informal diplomas in Tehri and more apprenticeships in Guntur, yet their knowledge of management of the three conditions was similar and reasonably high (71% Tehri and 73% Guntur). IPs in Tehri were mostly clinic-based and dispensed a blend of allopathic and indigenous drugs. IPs in Guntur mostly provided door-to-door services and prescribed and dispensed mainly allopathic drugs. In Guntur, formal private doctors were important referral providers (with commissions) and source of new knowledge for IPs. At both sites, IPs prescribed inappropriate drugs, but the use of injections and antibiotics was higher in Guntur. Guntur IPs were well organized in state and block level associations that had successfully lobbied for a state government registration and training for themselves. We find that IPs are firmly established in rural India but their role has grown and evolved differently in different market settings. Interventions need to be tailored differently keeping in view these unique features.