Effectiveness and implementation of decentralized, community- and primary care-based strategies in promoting hepatitis B testing uptake: a systematic review and meta-analysis.

Background: Expanding chronic hepatitis B (CHB) testing through effective implementation strategies in primary- and community-care setting is crucial for elimination. Our study aimed to determine the effectiveness of all available strategies in the literature and evaluate their specifications and implementation outcomes, thereby informing future programming and policymaking. Methods: We conducted a systematic review and meta-analysis (PROSPERO CRD42023455781), searching Scopus, Embase, PubMed, and CINAHL databases up to June 05, 2024, for randomized controlled trials investigating primary- and community-care-based implementation strategies to promote CHB testing. Studies were screened against a priori eligibility criteria, and their data were extracted using a standardized protocol if included. ROB-2 was used to assess the risk of bias. Implementation strategies' components were characterized using the Behavior Change Wheel (BCW) framework. Random-effect models were applied to pool the effectiveness estimate by strategy. Mixed-effect meta-regression was employed to investigate if effectiveness varied by the number of strategy's BCW components. Findings: 7146 unique records were identified. 25 studies were eligible for the review, contributing 130,598 participants. 19 studies were included in the meta-analysis. No studies were conducted in low-and-middle-income countries. Implementation outcomes were reported in only ten studies (40%). Community-based strategies included lay health workers-led education (Pooled Risk Difference = 27.9% [95% Confidence Interval = 3.4-52.4], I2 = 99.3%) or crowdsourced education on social media (3.1% [-2.2 to 8.4], 0.0%). Primary care-based strategies consisted of electronic alert system (8.4% [3.7-13.1], 95.0%) and healthcare providers-led education (HCPs, 62.5% [53.1-71.9], 27.5%). The number of BCW-framework-driven strategy components showed a significant dose-response relationship with effectiveness. Interpretation: HCPs-led education stands out, and more enriched multicomponent strategies had better effectiveness. Future implementation strategies should consider critical contextual factors and policies to achieve a sustainable impact towards hepatitis B elimination targets. Funding: Tran Dolch Post-Doctoral Fellowship in Hepatology, Johns Hopkins University School of Medicine, Baltimore MD, USA.

Modeling method of local financial dependence: Evidence from Mongolia.

Many countries have been striving to equalize the balance between the central government and sub-government financial disparities without considering political interference. This paper aims to summarize the theory of local financial federalism and propose an unprecedented model for identifying the factors that affect local financial dependence. The proposed model is based on a theoretical framework incorporating five assumptions and is applied through panel regression analysis. Utilizing panel data from 2013 to 2022 in 21 provinces of Mongolia, a total of nine variables have been identified and econometrically tested within the proposed model. The findings from the panel regression analysis reveal that local budget investment, local personal income tax, local property tax, and other local taxes positively impact the reduction of local financial dependence. However, it is observed that an increase in local budget expenditures and GDP leads to an escalation in local financial dependence.

Enhancing clinical drug trial monitoring with blockchain technology.

BACKGROUND: Clinical drug trials are intricate, involving numerous stakeholders, substantial data, and stringent regulations. Traditional systems for recording, storing, and sharing trial data often face data integrity, transparency, security, and interoperability challenges. The utilization of blockchain technology has emerged as a transformative influence in various industries, and its potential within healthcare, particularly in clinical drug trials, is increasingly gaining recognition. METHODS: Blockchain technology presents a decentralized and immutable ledger system that holds promise in effectively addressing these challenges. As the healthcare industry continues its journey of digital transformation, the incorporation of blockchain technology for monitoring clinical drug trials represents a paradigm shift that can result in more reliable, efficient, and transparent trials. RESULTS AND CONCLUSION: This review explores the innovative application of blockchain technology in transforming the monitoring and management of clinical drug trials and provides a comprehensive overview of the possibilities, challenges, and future directions of blockchain-based monitoring in the context of clinical drug trials, contributing to the progress of both blockchain technology and healthcare research practices.

The impact of financial decentralization and investments in green power on the ecology in the European union: How does the governance of institutions moderate this relationship?

There has been a growing emphasis in recent scholarship on the environmentalist movement, necessitating robust data to substantiate claims regarding the impacts of financial decentralization and investments in green power on the ecology. This study investigates the multifaceted impact of these factors within a subset of EU member states from 2000 to 2020, with a particular focus on their implications for environmental sustainability. Employing an advanced-panel method, the investigation utilizes enhanced self-regressive distribution delays (CS-ARDL) to analyze the cumulative and immediate connections between financial decentralization, green power investments, and environmental outcomes. The study reveals that effective governance of institutions plays a crucial role in moderating this relationship, influencing the extent to which financial decentralization and green energy investments contribute to environmental preservation. Preliminary findings indicate that regions with decentralized financial systems and substantial investments in green power exhibit reduced carbon dioxide emissions and improved environmental quality. This positive impact is further amplified by sound institutional oversight, ensuring that investments in clean energy align with ecological sustainability goals.The study also underscores the importance of a coordinated approach, where financial decentralization, investments in green power, and institutional governance synergistically contribute to environmental resilience and sustainable development. These efforts not only mitigate environmental challenges but also stimulate economic growth, job creation, and technological innovation in the renewable energy sector. The impact of financial decentralization and investments in green power on environmental sustainability in the European Union is significant, with governance playing a pivotal role in shaping positive outcomes. This study provides valuable insights for policymakers and stakeholders seeking to promote a greener and more sustainable future within the EU.

Decentralized wage bargaining and health.

This study examines the association between decentralized wage bargaining and worker health in Finland. We utilize unique data on collective agreements matched with total population administrative data on mental health disorders and sickness absence for the 2005-2013 period. We find that decentralized wage bargaining is related to mental health among blue-collar workers. Specifically, local wage increase allowances are associated with improved mental health in firms with a high concentration of white-collar employees, whereas this association is reversed in firms where blue-collar workers predominate. No consistent links to sickness absences are observed. Further analyses indicate that higher earnings under local wage agreements may explain the observed improvement in mental health in white-collar intensive firms, whereas decreased employment could partially explain the worsened mental health in blue-collar intensive firms.

The state of decentralization of the healthcare system and nutrition programs in the Lao People's Democratic Republic: an organizational study.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle income country, has a higher malnutrition rate than other Southeast Asian countries. The decentralization of healthcare is a determinant of the effectiveness of programs to reduce malnutrition, but no study has focused on this factor in this country. This organizational study explores the state of decentralization of the healthcare system in Lao PDR that underlies the nutrition programs in the country. METHODS: A qualitative study, which is based on a neo-institutional theory conceptual framework, explored factors related to dominant structure (laws, regulations, resources) and interpretative schemes (dominant ideas and beliefs) that characterize the nutrition services provided in the Lao healthcare system. Twenty-four semistructured interviews were performed with representatives of healthcare institutions involved in nutrition programs at different government levels, external donors and civil society organizations. The interviews were completed with relevant documents. The analysis focused on the convergence of interpretative schemes of the organizations concerned and the coherence between the structure underpinning the nutrition programs and the interpretative schemes. RESULTS: Services deployed to reduce malnutrition in the Lao PDR remain largely centralized, despite factors specific to the country that led it to promote decentralization of its services. The convergence of interpretive schemes and the coherence between the observed structure and the interpretative schemes of actors at all governance levels ensure the stability of this state of decentralization, which has persisted for almost 50 years. CONCLUSION: Nutrition programs in the Laos PDR are largely under the responsibility of the central government. The transformations in the healthcare system, notably with the use of new information technologies and the fact that the provinces are populated by a growing number of professionals trained in nutrition in addition to factors that push the system to be decentralized, such as ethnic diversity, the increasing availability of human resources in provinces, and the use of communication technologies, are not strong enough to change the balance of power between governance levels. The deconcentration that characterizes decentralization is therefore likely to continue for the foreseeable future.

India Hypertension Control Initiative: decentralization of hypertension care to health wellness centres in Punjab and Maharashtra, India, 2018-2022.

INTRODUCTION: The India Hypertension Control Initiative (IHCI) emphasizes decentralized patient-centric care to boost hypertension control in public healthcare facilities. We documented the decentralization process, enrolment pattern by facility type, and treatment outcomes in nine districts of Punjab and Maharashtra states, India, from 2018-2022. METHODS: We detailed the shift in hypertension care from higher facilities to Health and Wellness Centres (HWCs) using the World Health Organization (WHO) health system pillar framework. We reviewed hypertension treatment records in 4,045 public facilities from nine districts in the two states, focusing on indicators including registration numbers, the proportion of controlled, uncontrolled blood pressure (BP), and missed visits among those under care. RESULTS: The decentralization process involved training, treatment protocol provision, supervision, and monitoring. Among 394,038 individuals registered with hypertension from 2018-2021, 69% were under care in 2022. Nearly half of those under care (129,720/273,355) received treatment from HWCs in 2022. Care of hypertensive individuals from district hospitals (14%), community health centres (20%), and primary health centres (24%) were decentralized to HWCs. Overall BP control rose from 20% (4,004/20,347) in 2019 to 58% (157,595/273,355) in 2022, while missed visits decreased from 61% (12,394/20,347) in 2019 to 26% (70,894/273,355) in 2022. This trend was consistent in both states. HWCs exhibited the highest BP control and the lowest missed visits throughout the study period compared to other facility types. CONCLUSION: We documented an increase in decentralized access to hypertension treatment and improved treatment outcomes over four years. We recommend operationalizing hypertension care at HWCs to other districts in India to improve BP control.

Navigating the innovation policy dilemma: How subnational governments balance expenditure competition pressures and long-term innovation goals.

In the pursuit of economic growth, the role of innovation has become increasingly important, posing dilemmas for subnational governments as they navigate the balance between expenditure competition and long-term investments in innovation. This study aimed to investigate the intricate relationship between fiscal pressures and the pursuit of innovation goals faced by regional authorities. To achieve this, a systematic literature review was conducted, synthesizing more than 150 studies published within the past 15 years. Keyword searches were conducted across multiple databases, and additional scholarly articles were incorporated through citation tracking. Rigorous qualitative analysis techniques, including inductive coding and thematic analysis, were employed to distill conceptual insights from the literature. The analysis performed in this review reveals extensive discussions regarding the influence of competition on innovation outcomes, encompassing a wide range of perspectives. The potential advantages of localization are emphasized by some viewpoints, while others caution against the risks of inadequate investment. The effective coordination of policies across multiple levels of governance to maximize synergies between national and subnational innovation systems emerges as a complex yet crucial challenge. It is observed that collaborative networks, which facilitate knowledge exchange through industrial clustering and public-private linkages, play a significant role in leveraging regional innovation assets. Strategic approaches that successfully balance competition with long-term capacity development have been demonstrated by leading jurisdictions. These findings highlight the significance of tailored policy frameworks that account for the unique contexts of each region, providing opportunities to harness competitive motivations while sustaining investments in innovation. Ongoing coordination is essential to strike a balance between responsiveness and coherence across diverse territories. This study offers practical guidance and academic insights on strategies to align decentralized imperatives, aiming to optimize prosperity through knowledge creation within evolving multi-level innovation systems. By shedding light on these strategies, the research contributes to both practical and academic understandings of how to effectively navigate and capitalize on the dynamics of such systems.

The plurivocal university: Typologizing the diverse voices of a research university on social media.

Science communication has diversified in the wake of the digital transformation of communication and media ecosystems. Social media enable universities, but also academics and institutions affiliated with them, to expand their communication. This leads to increasing plurivocality of universities, yet the many different voices remain largely unexplored. This study develops a typology to conceptually distinguish eight voices by their representational role, hierarchical embeddedness, type, and affiliation. Based on a quantitative content and social network analysis of more than 600 Twitter accounts linked to a research university, it identifies six types of voices empirically. The study compares interactions among these voices, showing differences between central and decentral, as well as institutional and individual voices, and highlighting closer exchanges between voices within the same disciplinary communities. It also examines topics and tonality, revealing that decentral institutional voices engage most in science-related topics, and that only current and former students express critical views.

Healthcare workers' views on decentralized primary health care management in Lesotho: a qualitative study.

BACKGROUND: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. METHODS: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. RESULTS: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. CONCLUSION: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.

Does carbon reduction and sequestration conflict with food security in rural China?-What, why and how?

Based on panel data of 31 provinces in rural China from 1997 to 2020, this manuscript first applies a carbon reduction and sequestration (CRS) model from the perspective of agricultural carbon emissions and agricultural carbon sinks. We then construct a food security evaluation system to examine the four dimensions of quantity, quality, ecological and economic security. Finally, the study uses a spatial Durbin model to empirically analyze the impact of CRS on food security and the moderating effect of fiscal decentralization. The relevant results: First, from 1997 to 2020, carbon emissions rose from 221.9794 million tons (1997) to 251.1368 million tons (2020), representing an increase of 13.14 %. The total amount of carbon sinks increased from 518.259 million tons (1997) to 758.887 million tons (2020); an increase of 46.43 %. CRS exhibited a fluctuating downward trend, falling from 0.98 (1997) to 0.90 (2020). However, food security showed an increasing trend, rising 0.12 (1997) to 0.32 (2020), with an average annual growth rate of 6.94 %. Second, in the short term, national CRS has had a significantly negative impact on food security, whereas the long term the result is exactly the opposite. In terms of control variables, planting structure, openness to the world, and economic development have significantly positive impact on food security, and urbanization, technological progress, and environmental regulation have significantly negative impact on food security. Regional heterogeneity is evident in the three functional attribute areas. Third, fiscal decentralization can enhance the negative impact of CRS on food security in the short term and weaken the positive impact of CRS on food security in the long term. Similarly, some regional heterogeneity is found among different regions.

Digital economy and fiscal decentralization: Drivers of green innovation in China.

The impact of government behavior under a fiscal decentralization system on the interplay between the digital economy and both the quality and efficiency of green innovation poses an intriguing question. To address this, the present study employs two-way fixed-effects models, instrumental variables, and spatial econometric techniques, using data from 30 provinces and cities in China spanning 2004 to 2019. The findings reveal that the advancement of the digital economy significantly enhances the quality and efficiency of green innovation. In the context of China's fiscal decentralization, local governments frequently employ a "race to the top" strategy, amplifying the digital economy's beneficial impact on green innovation. This effect is particularly pronounced in economically prosperous regions that prioritize environmental assessments. Additionally, the study identifies a spatial demonstration effect, indicating that fiscal decentralization bolsters the digital economy's influence in adjacent regions. Consequently, policy recommendations include deepening the digital economy, advocating for increased fiscal autonomy for local governments, refining the performance appraisal systems for local officials, and establishing a well-calibrated environmental transfer mechanism. Further, leveraging the positive spatial correlations among local governments can foster a competitive yet collaborative landscape for green innovation.

Correction: Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

[This corrects the article DOI: 10.5334/gh.1313.].

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China.

Objectives: Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective. Data and methods: This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes. Results: Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents. Conclusion: The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

Digital Tools for Boosting the Impact of Fiscal Decentralization in Africa's Local Economies.

Background: Fiscal decentralization offers potential for stimulating local economic development in Africa, empowering subnational governments to control revenue and spending. However, challenges such as urbanization, poverty, inequality, insufficient infrastructure, and governance issues hinder the successful implementation of the core tenets of fiscal decentralization. This paper explores the role of digital technologies in promoting greater fiscal decentralization and revenue enhancement, as a strategic response to these local economic development challenges in Africa. Method: Through a systematic literature review, this study explores the role of fiscal decentralization in driving local economic development, with a focus on leveraging digital technologies to boost revenue generation and strengthen governance and institutional capacity at the subnational level. Results: The research underscores the importance of investing in digital infrastructure, skill development, and regulatory frameworks, while addressing data privacy and security concerns. Conclusion: By emphasizing the transformative impact of digital technologies fiscal decentralization and property taxation, this paper contributes to the existing literature and highlights avenues for promoting local economic development across Africa.

An assessment on the new impetus of green energy development and its impact on climate change: a non-linear perspective.

The purpose of this article is to investigate the new driving forces behind China's green energy and further assess the impact of green energy on climate change. The existing literature has used linear methods to investigate green energy, ignoring the non-linear relationships between economic variables. The nonparametric models can accurately simulate nonlinear relationships between economic variables. This paper constructs a nonparametric additive model and uses it to explore green energy. The empirical results show that the impact of green finance on green energy is more prominent in the later stage (a U-shaped impact). Fiscal decentralization also exerts a positive U-shaped impact, meaning that expanding local fiscal autonomy has contributed to green energy growth in the later stage. Similarly, the impact of oil prices and foreign direct investment demonstrates a positive U-shaped pattern. However, the nonlinear impact of environmental pressure displays an inverted U-shaped pattern. Furthermore, this article explores the impact of green energy on climate change and its impact mechanisms. The results exhibit green energy generates a positive U-shaped impact on climate change, meaning that the role of green energy in mitigating climate change gradually becomes prominent over time. Mechanism analysis exhibits that industrial structure and energy structure both produce a nonlinear influence on climate change.

Decentralization and immunization program in a single-party state: the case of the Lao People's Democratic Republic.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle-income country, lags behind other Southeast Asian countries in immunization coverage for children under two years of age. The organization of health services is a key determinant of the functionality of immunization programs. However, this aspect, and in particular its decentralization component of the healthcare system, has never been studied. METHODS: A case study in the Lao National Immunization Program was performed using a neo-institutional theory-based conceptual framework, highlighting the structure (rules, laws, resources, etc.) and interpretative schemes (dominant beliefs and ideas) that underlie the state of decentralization of the healthcare system that support the conduct of the immunization program. Twenty-two semi-structured interviews were conducted with representative actors from various government levels, external donors, and civil society, in four provinces. Data were complemented with information retrieved from relevant documents. RESULTS: The Lao healthcare system has a deconcentrated form of decentralization. It has a largely centralized structure, albeit with certain measures promoting the decentralization of its immunization programs. The structure underlying the state of centralization of immunization services provided is coherent with a shared dominant interpretive scheme. However, the rapid economic, technical, and educational changes affecting the country suggest that the coherence between structure and interpretative schemes is bound to change. CONCLUSION: Unprecedented opportunities to access quality higher education and the use of social networks are factors in Lao PDR that could affect the distribution of responsibilities of the different levels of government for public health programs such as the National Immunization Program.

Decentralization of the health system - experiences from Pakistan, Portugal and Brazil.

BACKGROUND: Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal. MAIN BODY: This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. CONCLUSION: Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

Fiscal decentralization, leader localization, and reduction of pollution and carbon emissions -empirical evidence from China's fiscal "province-managing-county" reform.

The fiscal system plays an important role in the government's environmental governance efforts. There is currently no consensus on how fiscal structure adjustments impact pollution and carbon reduction. This paper uses China's fiscal "province-managing-county" reform (FPMCR) implemented in 2004 as a quasi-natural experiment, utilizing panel data from 1670 counties in China from 2000 to 2020 to investigate the impact of fiscal decentralization on reduction pollution and carbon emissions (RPCE), as well as its underlying mechanisms. The results show that (1) from 2000 to 2020, China's RPCE shows an overall trend of fluctuating increase, with its value turning positive after 2013. China's RPCE exhibits a spatial pattern characterized by "lower in the north, higher in the south; higher in the east, lower in the west". (2) After implementing FPMCR, the RPCE levels in reformed counties decreased by -1.44%, showing that reformed county-level governments prioritize economic development over environmental protection. (3) The mechanism analysis found that after implementing FPMCR, reformed counties experienced a 9.16% increase in nighttime light intensity (NLI), and a 3.99% and 4.34% increase in the number of large-scale industrial enterprises (NLIE) and industrial agglomeration (IA), respectively. This suggests that FPMCR leads to radical urbanization and rapid industrialization in counties, which is detrimental to the improvement of RPCE levels. (4) The spatial heterogeneity analysis found that FPMCR's impact coefficient on RPCE levels in the eastern regions is -1.96%, while in the western regions it is -1.16%. This indicates that reformed counties in the eastern regions are more likely to invest expanded fiscal resources in economic development projects, leading to a decrease in RPCE levels. (5) The temporal heterogeneity analysis found that after the promulgation of the "Three-Year Action Plan to Win the Blue Sky Defense Battle" in 2018, the adverse impact of FPMCR on RPCE is completely reversed, leading to a 1.76% increase in RPCE levels. (6) Further analysis reveals that localizing leaders can slow down the promotion of county-level urbanization and industrialization by the FPMCR, benefiting the improvement of RPCE levels. In other words, "the outsider monk will not recite scriptures as well as a local one". This study has clarified the causal relationship and underlying mechanisms between fiscal decentralization and environmental governance, providing reliable theoretical support for optimizing grassroots fiscal systems and reducing environmental pollution in other transitional economies. It enriches the field of environmental economics related to fiscal decentralization.

Nurturing transformative local structures of multisectoral collaboration for primary health care: qualitative insights from select states in India.

BACKGROUND: Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs. METHODS: Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration. RESULTS: Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency. CONCLUSION: This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.