"Research ends with publication": a qualitative study on the use of health policy and systems research in Ethiopia.

BACKGROUND: Decision-making about the design and implementation of health care policies should be supported by research evidence. This article reports on a qualitative study on the experiences of both research institutes and policymakers in Ethiopia in generating and using research evidence to inform health policy decision-making. METHODS: Semi-structured interviews were conducted from January through March 2020, with representatives of research institutes and with policymakers in Ethiopia. The data collected during the interviews were analyzed thematically. RESULTS: Half of the institutions represented had engaged in health policy and systems research (HPSR). These institutes' capacities were limited by multiple factors, including unsupportive research environments; the limited number of researchers with extensive experience; high turnover among senior researchers; lack of staff motivation mechanisms; underdeveloped research culture; limited technical and analytical capacity among researchers; lack of core funding for HPSR; ineffective financial management; and, lack of connections with health policy platforms. Research institutes also lacked the capacity in strategic packaging of findings to influence policy decision-making, although some programs have recently improved in this area. Meanwhile, there lacked a culture of using evidence in policymaking settings. In general, we found that policymakers had poor attitudes towards the quality or value of the evidence, and had little capacity to interpret evidence and apply findings to policy options. As a result, much of the research produced by the institutes have only been relevant academically, with little impact on policy. However, respondents reported that the environment is slowly changing, and the recent creation of a Research Advisory Council at the Ministry of Health offers a promising model. CONCLUSIONS: Despite some recent changes, in Ethiopia researchers and policymakers alike often tend to consider health policy and systems research (HPSR) to be not very valuable since the findings generated are rarely used for evidence-informed policy development. Research institutes and researchers need to strengthen their technical, analytical, and administrative capacities (through, among other efforts, seeking more funding for research, and better incentives to attract, retain and build skills among qualified researchers); they also need to improve their understanding of the evidence-to-policy cycle and how to engage effectively with policymakers.

A global research agenda on public health and social measures during emergencies.

The importance of strong coordination for research on public health and social measures was highlighted at the Seventy-fourth World Health Assembly in 2021. This article describes efforts undertaken by the World Health Organization (WHO) to develop a global research agenda on the use of public health and social measures during health emergencies. This work includes a multistep process that started with a global technical consultation convened by WHO in September 2021. The consultation included experts from around the world and from a wide range of disciplines, such as public health, education, tourism, finance and social sciences, and aimed to identify research and implementation approaches based on lessons learnt during the coronavirus disease 2019 pandemic. To prepare for future epidemics and pandemics, it is essential to adopt a more robust, comparable and systematic research approach to public health and social measures. Such comprehensive approach will better inform agile, balanced and context-specific implementation decisions during future emergencies. This article describes the methods used to develop global research priorities for public health and social measures and the next steps needed.

La soixante-quatorzième Assemblée mondiale de la Santé en 2021 a souligné l'importance d'une coordination solide pour la recherche sur la santé publique et les mesures sociales. Le présent article décrit les efforts entrepris par l'Organisation mondiale de la santé (OMS) pour élaborer un programme de recherche mondial sur l'utilisation des mesures de santé publique et des mesures sociales lors de situations d'urgence sanitaire. Ce travail comprend un processus en plusieurs étapes qui a commencé par une consultation technique mondiale organisée par l'OMS en septembre 2021. La consultation a réuni des experts du monde entier issus d'un large éventail de disciplines telles que la santé publique, l'éducation, le tourisme, la finance et les sciences sociales. Elle visait à identifier des approches de recherche et de mise en œuvre fondées sur les enseignements tirés de la pandémie de maladie à coronavirus de 2019. Pour se préparer aux futures épidémies et pandémies, il est essentiel d'adopter une approche de recherche plus solide, comparable et systématique en matière de santé publique et de mesures sociales. Cette approche globale permettra de mieux éclairer les décisions de mise en œuvre agiles, équilibrées et adaptées au contexte lors des futures situations d'urgence. Le présent article décrit les méthodes appliquées pour définir les priorités mondiales de recherche en matière de santé publique et de mesures sociales, ainsi que les prochaines étapes à franchir.

En la 74.ª Asamblea Mundial de la Salud, celebrada en 2021, se destacó la importancia de una sólida coordinación en la investigación sobre salud pública y medidas sociales. Este artículo describe los esfuerzos que ha emprendido la Organización Mundial de la Salud (OMS) para desarrollar un programa mundial de investigación sobre el uso de medidas sociales y de salud pública durante las emergencias sanitarias. Este trabajo incluye un proceso de varios pasos que comenzó con una consulta técnica mundial que convocó la OMS en septiembre de 2021. La consulta incluyó a expertos de todo el mundo y de una gran variedad de disciplinas, como la salud pública, la educación, el turismo, las finanzas y las ciencias sociales, y tuvo como objetivo identificar enfoques de investigación y aplicación basados en las lecciones aprendidas durante la pandemia de la enfermedad por coronavirus de 2019. Para prepararse ante futuras epidemias y pandemias, es esencial adoptar un enfoque de investigación más sólido, comparable y sistemático en materia de salud pública y medidas sociales. Este enfoque integral informará mejor las decisiones de aplicación ágiles, equilibradas y adaptadas al contexto durante futuras emergencias. En este artículo se describen los métodos utilizados para elaborar las prioridades mundiales de investigación sobre salud pública y medidas sociales, así como los próximos pasos necesarios.

Normalizing the political economy of improving health.

Problem: Political economy factors are important in determining the adoption and implementation of health policies. Yet these factors are often overlooked in the development of policies that have the potential to influence health. Approach: Political economy analysis provides a way to take into consideration political and social realities, whether at the community, subnational, national, regional or global levels. We aim to demonstrate the value of political economy analysis and to promote its wider use in technical programmes of work. Local setting: We provide examples from across a range of World Health Organization areas of work, including participatory governance, health financing, health taxes, malaria prevention and control, capacity-building and direct country support. Relevant changes: Existing examples of how political economy analysis can be incorporated into technical support demonstrate the variability of this analytical approach, as well as its potential to support policy progress. Applying political economy analysis within the specified programmes of work has enabled more contextually relevant technical support to enhance the likelihood of advancing countries' health-related objectives. Lessons learnt: Embedding political economy into technical work has many benefits, including: enhancing voice and participation in health policies; supporting the adoption and implementation feasibility of technically sound policies; and building capacity to incorporate and understand political factors that influence health-related priorities.

Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India.

BACKGROUND: Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme's operation. METHODS: Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019. RESULTS: Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background. CONCLUSIONS: There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme's IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states.

BACKGROUND: The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. METHODS: A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. RESULTS: In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. CONCLUSIONS: Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.

The rise and fall of global health issues: an arenas model applied to the COVID-19 pandemic shock.

BACKGROUND: The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to make claims about the agenda status of issues. We draw on Kingdon's definition of the agenda and Hilgartner and Bosk's public arenas model to conceptualize the global health agenda as those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at any given time. We propose an arenas model for global health agenda setting and illustrate its potential utility by assessing priority indicators in five arenas, including international aid, pharmaceutical industry, scientific research, news media and civil society. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer's disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19). RESULTS: Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events. The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other issues showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases suggesting that the agenda for global health issues expanded in some arenas in 2020- COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer's disease, though it might have for other issues. CONCLUSIONS: We advance an arenas model as a novel means of addressing conceptual and measurement challenges that often undermine the validity of claims concerning the global health agenda status of problems and contributing causal factors. Our presentation of the model and illustrative analysis lays the groundwork for more systematic investigation of trends in global health agenda setting. Further specification of the model is needed to ensure accurate representation of vital national and transnational arenas and their interactions, applicability to a range of disease-specific, health systems, governance and policy issues, and sensitivity to subtler influences on global health agenda setting than pandemic shocks.

Cross-cutting lessons from the Decision-Maker Led Implementation Research initiative.

BACKGROUND: Almost 20 million children under one year of age did not receive basic vaccines in 2019, and most of these children lived in low- and middle-income countries. Implementation research has been recognized as an emerging area that is critical to strengthen the implementation of interventions proven to be effective. As a component of strengthening implementation, WHO has called for greater embedding of research within decision-making processes. One strategy to facilitate the embedding of research is to engage decision-makers as Principal Investigators of the research. Since 2015, the Alliance for Health Policy and Systems Research within the WHO and the United Nations Children's Fund have supported decision-maker led research by partnering with Gavi, the Vaccine Alliance, in an initiative called "Decision-Maker Led Implementation Research". This synthesis paper describes the cross-cutting lessons from the initiative to further understand and develop future use of the decision-maker led strategy. METHODS: This study used qualitative methods of data collection, including a document review and in-depth interviews with decision-makers and researchers engaged in the initiative. Document extraction and thematic content analysis were applied. The individual project was the unit of analysis and the results were summarized across projects. RESULTS: Research teams from 11 of the 14 projects participated in this study, for an overall response rate of 78.6%. Most projects were carried out in countries in Africa and conducted at the sub-state or sub-district level. Seven enablers and five barriers to the process of conducting the studies or bringing about changes were identified. Key enablers were the relevance, acceptability, and integration of the research, while key barriers included unclear results, limited planning and support, and the limited role of a single study in informing changes to strengthen implementation. CONCLUSIONS: Decision-maker led research is a promising strategy to facilitate the embedding of research into decision-making processes and contribute to greater use of research to strengthen implementation of proven-effective interventions, such as immunization. We identified several lessons for consideration in the future design and use of the decision-maker led strategy.

Contracting non-state providers for universal health coverage: learnings from Africa, Asia, and Eastern Europe.

BACKGROUND: Formal engagement with non-state providers (NSP) is an important strategy in many low-and-middle-income countries for extending coverage of publicly financed health services. The series of country studies reviewed in this paper - from Afghanistan, Bangladesh, Bosnia & Herzegovina, Ghana, South Africa, Tanzania and Uganda - provide a unique opportunity to understand the dynamics of NSP engagement in different contexts. METHODS: A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. RESULTS: Governments contracted NSPs for a variety of reasons - limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. CONCLUSION: For countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.

Moving towards universal health coverage: engaging non-state providers.

This editorial provides an overview of the special issue "Moving towards UHC: engaging non-state providers". It begins by describing the rationale underlying the Alliance's choice of a research program addressing issues of non-state providers and briefly discusses the research process this entailed. This is followed by a summary of the findings and key messages of each of the eight articles included in the issue. The editorial concludes with a series of reflections regarding lessons learnt about the engagement of non-state providers, methodological challenges, areas for future research as well as the contribution of the research program towards efforts to build capacity and strengthen health systems towards universal health coverage.

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation.

BACKGROUND: Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented. METHODS: We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically. RESULTS: The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania's long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. CONCLUSIONS: Tanzania's central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.

Donor funding health policy and systems research in low- and middle-income countries: how much, from where and to whom.

BACKGROUND: The need for sufficient and reliable funding to support health policy and systems research (HPSR) in low- and middle-income countries (LMICs) has been widely recognised. Currently, most resources to support such activities come from traditional development assistance for health (DAH) donors; however, few studies have examined the levels, trends, sources and national recipients of such support - a gap this research seeks to address. METHOD: Using OECD's Creditor Reporting System database, we classified donor funding commitments using a keyword analysis of the project-level descriptions of donor supported projects to estimate total funding available for HPSR-related activities annually from bilateral and multilateral donors, as well as the Bill and Melinda Gates Foundation, to LMICs over the period 2000-2014. RESULTS: Total commitments to HPSR-related activities have greatly increased since 2000, peaked in 2010, and have held steady since 2011. Over the entire study period (2000-2014), donors committed a total of $4 billion in funding for HPSR-related activities or an average of $266 million a year. Over the last 5 years (2010-2014), donors committed an average of $434 million a year to HPSR-related activities. Funding for HPSR is heavily concentrated, with more than 93% coming from just 10 donors and only represents approximately 2% of all donor funding for health and population projects. Countries in the sub-Saharan African region are the major recipients of HPSR funding. CONCLUSION: Funding for HPSR-related activities has generally increased over the study period; however, donor support to such activities represents only a small proportion of total DAH and has not grown in recent years. Donors should consider increasing the proportion of funds they allocate to support HPSR activities in order to further build the evidence base on how to build stronger health systems.

Institutional capacity to generate and use evidence in LMICs: current state and opportunities for HPSR.

BACKGROUND: Evidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs. METHODS: The paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence. RESULTS: Findings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake. CONCLUSION: The findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

Incorporating research evidence into decision-making processes: researcher and decision-maker perceptions from five low- and middle-income countries.

BACKGROUND: The 'Sponsoring National Processes for Evidence-Informed Policy Making in the Health Sector of Developing Countries' program was launched by the Alliance for Health Policy and Systems Research, WHO, in July 2008. The program aimed to catalyse the use of evidence generated through health policy and systems research in policymaking processes through (1) promoting researchers and policy advocates to present their evidence in a manner that is easy for policymakers to understand and use, (2) creating mechanisms to spur the demand for and application of research evidence in policymaking, and (3) increased interaction between researchers, policy advocates, and policymakers. Grants ran for three years and five projects were supported in Argentina, Bangladesh, Cameroon, Nigeria and Zambia. This paper seeks to understand why projects in some settings were perceived by the key stakeholders involved to have made progress towards their goals, whereas others were perceived to have not done so well. Additionally, by comparing experiences across five countries, we seek to illustrate general learnings to inform future evidence-to-policy efforts in low- and middle-income countries. METHODS: We adopted the theory of knowledge translation developed by Jacobson et al. (J Health Serv Res Policy 8(2):94-9, 2003) as a framing device to reflect on project experiences across the five cases. Using data from the projects' external evaluation reports, which included information from semi-structured interviews and quantitative evaluation surveys of those involved in projects, and supplemented by information from the projects' individual technical reports, we applied the theoretical framework with a partially grounded approach to analyse each of the cases and make comparisons. RESULTS AND CONCLUSION: There was wide variation across projects in the type of activities carried out as well as their intensity. Based on our findings, we can conclude that projects perceived as having made progress towards their goals were characterized by the coming together of a number of domains identified by the theory. The domains of Jacobson's theoretical framework, initially developed for high-income settings, are of relevance to the low- and middle-income country context, but may need modification to be fully applicable to these settings. Specifically, the relative fragility of institutions and the concomitantly more significant role of individual leaders point to the need to look at leadership as an additional domain influencing the evidence-to-policy process.

Comparing priority received by global health issues: a measurement framework applied to tuberculosis, malaria, diarrhoeal diseases and dengue fever.

INTRODUCTION: The relative priority received by issues in global health agendas is subjected to impressionistic claims in the absence of objective methods of assessment of priority. To build an approach for conducting structured assessments of comparative priority health issues receive, we expand the public arenas model (2021) and offer a framework for future assessments of health issue priority in global and national health agendas. METHODS: We aimed to develop a more comprehensive set of measures for conducting multiyear priority comparisons of health issues in six agenda-setting arenas by identifying possible measures and data sources, selecting indicators based on feasibility and comparability of measures and gathering the data on selected indicators. We applied these measures to four communicable diseases-tuberculosis (TB), malaria, diarrhoeal diseases and dengue fever-given their differing impressionistic claims of priority. Where possible, we analysed the annual and/or 5-year trends from 2000 through 2022. RESULTS: We observed that TB and malaria received the highest priority for most periods in the past two decades in most arenas. However, a stagnation in development funding for these two conditions over the last 8-10 years may have fuelled the neglect claims. Despite having a higher disease burden, diarrhoea has been slipping in global priority with reduced spending, fewer clinical trials and stagnating publications. Dengue remains a low-priority condition but has witnessed a sharp rise in attention from the pharmaceutical industry. DISCUSSIONS: We expanded the arenas model by including a transnational arena (international representation) and additional measurements for various arenas. This analysis presents an approach to enable comparative trend analysis of the markers of agenda status over a multiyear period. More such analyses can bring much-desired objectivity in understanding how attention to global or national health issues changes over time in different arenas, potentiating a more equitable allocation of resources.

The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21).

Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.

Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions. From a contextual standpoint, these factors relate to favourable economic and political environments for domestic systems to prioritize coverage for donor-supported interventions. Clear and transparent transition processes also enabled a smoother transition. How the donor-supported initiatives and services were organized within the context of the overall health system was found to be critically important, both before and during the transition process. This includes a targeted approach to integrate, strengthen and align key elements of the governance, financing, input management and service delivery arrangements with domestic systems. The findings of this analysis have important implications for how both donors and country policy makers can better structure external assistance that enables sustained coverage regardless of the source of funding. In particular, donors can better support sustained coverage through supporting long-term structural and institutional reform, clear co-financing policies, ensuring alignment with local salary scales and engaging with communities to ensure a continued focus on equitable access post-transition.

Shifting patterns and competing explanations for infectious disease priority in global health agenda setting arenas.

The highly decentralized nature of global health governance presents significant challenges to conceptualizing and systematically measuring the agenda status of diseases, injuries, risks and other conditions contributing to the collective disease burden. An arenas model for global health agenda setting was recently proposed to help address these challenges. Further developing the model, this study aims to advance more robust inquiry into how and why priority levels may vary among the array of stakeholder arenas in which global health agenda setting occurs. We analyze order and the magnitude of changes in priority for eight infectious diseases in four arenas (international aid, scientific research, pharmaceutical industry and news media) over a period of more than two decades in relation to five propositions from scholarship. The diseases vary on burden and prominence in United Nations Sustainable Development Goal 3 for health and well-being, including four with specific indicators for monitoring and evaluation (HIV/AIDS, tuberculosis, malaria, hepatitis) and four without (dengue, diarrheal diseases, measles, meningitis). The order of priority did not consistently align with the disease burden or international development goals in any arena. Additionally, using new methods to measure the scale of annual change in resource allocations that are indicative of priority reveals volatility at the disease level in all arenas amidst broader patterns of stability. Insights around long-term patterns of priority within and among arenas are integral to strengthening analyses that aim to identify pivotal causal mechanisms, to clarify how arenas interact, and to measure the effects they produce.

Using health policy and systems research to influence national health policies: lessons from Mexico, Cambodia and Ghana.

Health system reforms across Africa, Asia and Latin America in recent decades demonstrate the value of health policy and systems research (HPSR) in moving towards the goals of universal health coverage in different circumstances and by various means. The role of evidence in policy making is widely accepted; less well understood is the influence of the concrete conditions under which HPSR is carried out within the national context and which often determine policy outcomes. We investigated the varied experiences of HPSR in Mexico, Cambodia and Ghana (each selected purposively as a strong example reflecting important lessons under varying conditions) to illustrate the ways in which HPSR is used to influence health policy. We reviewed the academic and grey literature and policy documents, constructed three country case studies and interviewed two leading experts from each of Mexico and Cambodia and three from Ghana (using semi-structured interviews, anonymized to ensure objectivity). For the design of the study, design of the semi-structured topic guide and the analysis of results, we used a modified version of the context-based analytical framework developed by Dobrow et al. (Evidence-based health policy: context and utilisation. Social Science & Medicine 2004;58:207-17). The results demonstrate that HPSR plays a varied but essential role in effective health policy making and that the use, implementation and outcomes of research and research-based evidence occurs inevitably within a national context that is characterized by political circumstances, the infrastructure and capacity for research and the longer-term experience with HPSR processes. This analysis of national experiences demonstrates that embedding HPSR in the policy process is both possible and productive under varying economic and political circumstances. Supporting research structures with social development legislation, establishing relationships based on trust between researchers and policy makers and building a strong domestic capacity for health systems research all demonstrate means by which the value of HPSR can be materialized in strengthening health systems.