ABSTRACT
BACKGROUND: Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned. MAIN BODY: Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice. CONCLUSION: Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.
Subject(s)
Developing Countries , Pandemics , Humans , Brazil , Republic of North Macedonia , Georgia (Republic)ABSTRACT
BACKGROUND: In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping 'global health' in the current era? MAIN BODY: As a group of historians, social scientists, and public health officials with experience studying the effects of the institution's investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank's position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank's influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. CONCLUSIONS: As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank's financial and technical investments in the Global South.
Subject(s)
Banking, Personal/organization & administration , Healthcare Financing , Translational Research, Biomedical/methods , Banking, Personal/trends , Financial Management , Global Health , Health Policy , Humans , Translational Research, Biomedical/organization & administrationSubject(s)
Developing Countries , Pandemics , Delivery of Health Care , Health Facilities , Humans , Income , Pandemics/prevention & controlABSTRACT
While research is linked with informed decision-making and improved healthcare delivery and patient outcomes, the process of generating and translating research evidence in practice and capturing its impact can often be challenging. Based on document and database reviews and interviews in a regional Australian health system, Brown et al discuss the challenges of assessing the impact of research investments over a ten-year period. This commentary explores three inter-related lessons from this article for developing and sustaining a research culture and supporting translation in a health system: (i) achieving a shared definition and expectation of research; (ii) the importance of stakeholder engagement particularly for research prioritisation; and (iii) enabling research across a system. In doing so, it highlights the role and value of engaging knowledge generators and end-users from clinical, management and community domains not only in research development but most importantly in research prioritisation.
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Health Services , Motivation , Humans , Australia , HospitalsABSTRACT
Task shifting (TS) is the redistribution of healthcare services from specialised to less-qualified providers. Need for TS was intensified during COVID-19. We explore what impact TS had on service delivery during the pandemic and examine how the pandemic affected TS strategies globally. We searched five databases in October 2022, namely Medline, CINAHL Plus, Elsevier, Global Health and Google Scholar. 35 citations were selected following the PRISMA-ScR guidelines. We analysed data thematically and utilised the WHO health systems framework and emergent themes to frame findings. We uncovered instances of TS in countries across all income levels. 63% (n = 22) of the articles discussed the impact of TS on healthcare services. These encompassed services related to mental healthcare, HIV, sexual and reproductive health, nutrition and rheumatoid diseases. The remaining 37% (n = 13) focused on how the pandemic altered strategies for TS, particularly in services related to mental healthcare, HIV, hypertension, diabetes and emergency care. We also found that studies differed in how they reported TS, with majority using terms "task shifting", followed by "task sharing", "task shifting and sharing" and "task delegation". Our analysis demonstrates that TS had a substantial impact across healthcare systems. Modifying roles through training and collaboration strengthened workforce and enhanced diagnostic services. Strategic leadership played a crucial role in the process. More research on the financial aspects of TS during pandemics is required. Stakeholders generally accepted TS, but transferring staff between healthcare programs caused unintended disruptions. The pandemic reshaped TS, moving training, patient care and consultations to digital platforms. Virtual interventions showed promise, but digital access remained a challenge. Healthcare organisations adapted by modifying procedures, pathways and staff precautions. We recommend refining strategies for TS, and expanding on it to address workforce shortages, improve access, and enhance services, not only during crises but also beyond.
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COVID-19 has inflicted both beneficial and damaging effects on health systems responding to antimicrobial resistance (AMR). Data shows that the positive impacts of the pandemic (including enhanced hygiene, mask wearing and widespread use of personal protective equipment), are likely to have been overshadowed by the negative effects: emerging AMR pathogens and mechanisms; further outbreaks and geographic spread of AMR to non-endemic countries; rising infections from multidrug-resistant pathogen; an overall higher burden of AMR. The multisectoral complexities of AMR and the totality of health systems challenge our ability to understand the impact of the COVID-19 pandemic on country responses to AMR. In this analysis, we synthesise international evidence characterising the role of the pandemic on the six key building blocks of health systems in responding to AMR across low- and middle-income countries (LMICs). We apply systems thinking within and between the building blocks to contextualise the impact of one pandemic on another.
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BACKGROUND: Understanding strategic commitments and policy responses to overcome antimicrobial resistance at the national, regional, and global levels is required to evaluate current progress and direct future planning. National action plans (NAPs) are the primary mechanism for guiding national strategy and action for antimicrobial resistance governance. Although several NAPs have been developed, no comprehensive content analysis of these plans exists. Using a governance framework, we aimed to assess all publicly available NAPs on antimicrobial resistance. METHODS: We systematically reviewed the contents of NAPs on antimicrobial resistance from 114 countries, applying a governance framework containing 18 domains and 54 indicators in three integral areas: policy design, implementation tools, and monitoring and evaluation. As well as manually searching NAPs and doing online and literature searches that were relevant to specific indicators from repository inception to June 1, 2022, several data sources were used to generate scores, including the Tripartite Antimicrobial Resistance Country Self-Assessment Survey, the Global Antimicrobial Resistance and Use Surveillance System, the Global Antimicrobial Resistance Research and Development Hub, and various WHO datasets. NAPs were included if the country had also submitted the NAP to the Tripartite Antimicrobial Resistance Country Self-Assessment Survey 2020-21, if the NAP was retrievable through a publicly accessible database or website, and if the NAP was either published in English or eligible for machine translation. Three researchers independently reviewed each NAP and were initially blinded to the evaluations of other researchers. They generated a score using a quantification system for each of 54 indicators. The Cochrane protocol for ensuring reliability was followed. The three researchers were then unblinded and met to resolve any disagreements in scoring to reach a consensus agreement. In each case of discrepancy, consensus was reached between the researchers. We developed criteria to standardise the process of quantifying each indicator. We also weighted and collated relevant national data from various sources to generate composite scores concordant with the key governance areas. We transformed these data to a scale of 0 (worst) to 100 (best), ranked countries on the basis of their mean scores, and used descriptive statistics to analyse global and regional trends. FINDINGS: 306 NAPs were identified and 114 were eligible for analysis. Between 2020 and 2021, the mean antimicrobial resistance governance score was 51 (SD 14). Norway had the highest governance score (mean 85 [SD 32]), and the Federated States of Micronesia had the lowest governance score (28 [37]). The highest scoring domain was participation (83 [16]), and the lowest scoring domains were accountability (30 [18]) and feedback mechanism (30 [25]). Domains relating to policy design (55 [13]) and implementation tools (54 [17]) scored similarly, whereas monitoring and evaluation (38 [20]) efforts were lower. INTERPRETATION: International efforts to control antimicrobial resistance varied considerably between countries. Monitoring and evaluation efforts need improving for continuous understanding of national and international progress. International response might not be commensurate with the scale and severity of antimicrobial resistance. FUNDING: None.
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Anti-Bacterial Agents , Drug Resistance, Bacterial , Humans , Anti-Bacterial Agents/pharmacology , Anti-Bacterial Agents/therapeutic use , Reproducibility of Results , Micronesia , NorwayABSTRACT
Background: Pneumonia is the leading cause of under-five child deaths globally and in Bangladesh. Hypoxaemia or low (<90%) oxygen concentration in the arterial blood is one of the strongest predictors of child mortality from pneumonia and other acute respiratory infections. Since 2014, the World Health Organization recommends using pulse oximetry devices in Integrated Management of Childhood Illness (IMCI) services (outpatient child health services), but it was not routinely used in most health facilities in Bangladesh until 2018. This paper describes the stakeholder engagement process embedded in an implementation research study to influence national policy and programmes to introduce pulse oximetry in routine IMCI services in Bangladesh. Methods: Based on literature review and expert consultations, we developed a conceptual framework, which guided the planning and implementation of a 4-step stakeholder engagement process. Desk review, key informant interviews, consultative workshops and onsite demonstration were the key methods to involve and engage a wide range of stakeholders. In the first step, a comprehensive desk review and key informant interviews were conducted to identify stakeholder organisations and scored them based on their power and interest levels regarding IMCI implementation in Bangladesh. In the second step, two national level, two district level and five sub-district level sensitisation workshops were organised to orient all stakeholder organisations having high power or high interest regarding the importance of using pulse oximetry for pneumonia assessment and classification. In the third step, national and district level high power-high interest stakeholder organisations were involved in developing a joint action plan for introducing pulse oximetry in routine IMCI services. In the fourth step, led by a formal working group under the leadership of the Ministry of Health, we updated the national IMCI implementation package, including all guidelines, training manuals, services registers and referral forms in English and Bangla. Subsequently, we demonstrated its use in real-life settings involving various levels of (national, district and sub-district) stakeholders and worked alongside the government leaders towards carefully resuming activities despite the COVID-19 pandemic. Results: Our engagement process contributed to the national decision to introduce pulse oximetry in routine child health services and update the national IMCI implementation package demonstrating country ownership, government leadership and multi-partner involvement, which are steppingstones towards scalability and sustainability. However, our experience clearly delineates that stakeholder engagement is a context-driven, time-consuming, resource-intensive, iterative, mercurial process that demands meticulous planning, prioritisation, inclusiveness, and adaptability. It is also influenced by the expertise, experience and positionality of the facilitating organization. Conclusions: Our experience has demonstrated the value and potential of the approach that we adopted for stakeholder engagement. However, the approach needs to be conceptualised coupled with the allocation of adequate resources and time commitment to implement it effectively.
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COVID-19 , Delivery of Health Care, Integrated , Bangladesh , Child , Humans , Oximetry , Pandemics , Policy , Stakeholder ParticipationABSTRACT
Background: Systematic assessment of childhood asthma is challenging in low- and middle-income country (LMIC) settings due to the lack of standardised and validated methodologies. We describe the contextual challenges and adaptation strategies in the implementation of a community-based asthma assessment in four resource-constrained settings in Bangladesh, India, and Pakistan. Method: We followed a group of children of age 6-8 years for 12 months to record their respiratory health outcomes. The study participants were enrolled at four study sites of the 'Aetiology of Neonatal Infection in South Asia (ANISA)' study. We standardised the research methods for the sites, trained field staff for uniform data collection and provided a 'Child Card' to the caregiver to record the illness history of the participants. We visited the children on three different occasions to collect data on respiratory-related illnesses. The lung function of the children was assessed in the outreach clinics using portable spirometers before and after 6-minute exercise, and capillary blood was examined under light microscopes to determine eosinophil levels. Results: We enrolled 1512 children, 95.5% (1476/1512) of them completed the follow-up, and 81.5% (1232/1512) participants attended the lung function assessment tests. Pre- and post-exercise spirometry was performed successfully in 88.6% (1091/1232) and 85.7% (1056/1232) of children who attempted these tests. Limited access to health care services, shortage of skilled human resources, and cultural diversity were the main challenges in adopting uniform procedures across all sites. Designing the study implementation plan based on the local contexts and providing extensive training of the healthcare workers helped us to overcome these challenges. Conclusion: This study can be seen as a large-scale feasibility assessment of applying spirometry and exercise challenge tests in community settings of LMICs and provides confidence to build capacity to evaluate children's respiratory outcomes in future translational research studies.
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Fourteen months into the SARS-CoV-2 pandemic, we identify key lessons in the global and national responses to the pandemic. The World Health Organization has played a pivotal technical, normative and coordinating role, but has been constrained by its lack of authority over sovereign member states. Many governments also mistakenly attempted to manage COVID-19 like influenza, resulting in repeated lockdowns, high excess morbidity and mortality, and poor economic recovery. Despite the incredible speed of the development and approval of effective and safe vaccines, the emergence of new SARS-CoV-2 variants means that all countries will have to rely on a globally coordinated public health effort for several years to defeat this pandemic.
Subject(s)
COVID-19/epidemiology , Communicable Disease Control , Global Health , Communicable Disease Control/methods , Communicable Disease Control/organization & administration , Communicable Disease Control/trends , Global Health/history , Global Health/trends , Government , History, 21st Century , Humans , Pandemics/history , Public Health/history , Public Health/methods , Public Health/trends , Public Health Administration/methods , Public Health Administration/standards , Public Health Administration/trends , SARS-CoV-2/physiologyABSTRACT
Background: Global tobacco control is a major public health issue, as smoking-related disease burden remains high worldwide. The World Bank and the World Health Organization (WHO) are the driving forces in global tobacco control. However, little research has focused on their development, financing, decision-making, and accountability structures. Methods: We used two strategies to identify the development and structure of global tobacco control initiatives. First, we reviewed the published literature through electronic databases. Second, we conducted grey literature searching. Results: We identified four periods in the Bank's involvement in global tobacco control, from creation of the evidence base in the 1990s to the implementation of tax reforms. We identified three phases in the WHO's efforts, from its early recognition of the link between tobacco and health risks in the 1970s to its implementation of the Framework Convention on Tobacco Control. Both organisations are financed by a handful of private philanthropies, and face similar risks for effective tobacco control: reduced accountability and resource mobilisation, poor decision-making authority due to specific donor influence, and difficulty in monitoring and evaluation. Conclusions: Continued attention should be paid not only to the primary health-related outcomes of tobacco use, but also to the decision-making and financing structures to promote tobacco control activities.
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Background: Over the past decade gender mainstreaming has gained visibility at global health organisations. The World Bank, one of the largest funders of global health activities, released two World Development Reports showcasing its gender policies, and recently announced a $1 billion initiative for women's entrepreneurship. We summarise the development of the Bank's gender policies and analyse its financing of gender projects in the health sector. This article is intended to provide background for future research on the Bank's gender and global health portfolio. Methods: First, we constructed a timeline of the Bank's gender policy development, through a review of published articles, grey literature, and Bank documents and reports. Second, we performed a health-focused analysis of publicly available Bank gender project databases, to track its financing of health sector projects with a gender 'theme' from 1985-2017. Results: The Bank's gender policy developed through four major phases from 1972-2017: 'women in development' (WID), institutionalisation of WID, gender mainstreaming, and gender equality through 'smart economics'. In the more inclusive Bank project database, projects with a gender theme comprised between 1.3% (1985-1989) and 6.2% (2010-2016) of all Bank commitments. Most funding targeted middle-income countries and particular health themes, including communicable diseases and health systems. Major gender-related trust funds were absent from both databases. The Bank reports that 98% of its lending is 'gender informed', which indicates that the gender theme used in its publicly available project databases is poorly aligned with its criteria for gender informed projects. Conclusion: The Bank focused most of its health sector gender projects on women's and girls' issues. It is increasingly embracing private sector financing of its gender activities, which may impact its poverty alleviation agenda. Measuring the success of gender mainstreaming in global health will require the Bank to release more information about its gender indicators and projects.
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India has 274 million tobacco users and a tobacco use prevalence of 38% in rural areas. Tobacco consumption causes 1 million deaths and costs the health system nearly US$23 billion annually. Tobacco control policies exist but lack proper implementation. In this article, we review the Tobacco-free Village (TfV) program conducted in Maharashtra state in India and describe its process to help villages in rural India achieve "tobacco-free" status (i.e., the sale and use of tobacco are prohibited by law). We reviewed program documents and conducted 22 qualitative interviews with program staff and village-level stakeholders. From 2008 to 2014, Salaam Mumbai Foundation implemented the TfV program in 60 villages in Maharashtra state. The program used a number of strategies to help villages become tobacco free, including collaborating with a community-based organization, leveraging existing health workers, conducting a situation analysis, training health workers, engaging stakeholders, developing TfV assessment criteria, mobilizing the community, conducting health education, imposing sanctions, and offering incentives. By 2014, 4 villages had achieved tobacco-free status according to 11 assessment criteria. Successful villages demonstrated strong local leader involvement, ownership of the program, and commitment to the cause by residents. The TfV program faced barriers including poor motivation of health workers, difficulty in changing social norms of tobacco use, and refusal of local vendors to stop tobacco sales due to financial losses. This low-cost, community-driven program holds promise for helping public health practitioners and governments implement and achieve the goals of tobacco control policies, especially in resource-scarce settings.