Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work.

Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.

Planning for post-pandemic cancer care delivery: Recovery or opportunity for redesign?

The delivery of cancer care has never changed as rapidly and dramatically as we have seen with the coronavirus disease 2019 (COVID-19) pandemic. During the early phase of the pandemic, recommendations for the management of oncology patients issued by various professional societies and government agencies did not recognize the significant regional differences in the impact of the pandemic. California initially experienced lower than expected numbers of cases, and the health care system did not experience the same degree of the burden that had been the case in other parts of the country. In light of promising trends in COVID-19 infections and mortality in California, by late April 2020, discussions were initiated for a phased recovery of full-scale cancer services. However, by July 2020, a surge of cases was reported across the nation, including in California. In this review, the authors share the response and recovery planning experience of the University of California (UC) Cancer Consortium in an effort to provide guidance to oncology practices. The UC Cancer Consortium was established in 2017 to bring together 5 UC Comprehensive Cancer Centers: UC Davis Comprehensive Cancer Center, UC Los Angeles Jonsson Comprehensive Cancer Center, UC Irvine Chao Family Comprehensive Cancer Center, UC San Diego Moores Cancer Center, and the UC San Francisco Helen Diller Family Comprehensive Cancer Center. The interventions implemented in each of these cancer centers are highlighted, with a focus on opportunities for a redesign in care delivery models. The authors propose that their experiences gained during this pandemic will enhance pre-pandemic cancer care delivery.

Long COVID Definitions and Models of Care : A Scoping Review.

BACKGROUND: Definitions of long COVID are evolving, and optimal models of care are uncertain. PURPOSE: To perform a scoping review on definitions of long COVID and provide an overview of care models, including a proposed framework to describe and distinguish models. DATA SOURCES: English-language articles from Ovid MEDLINE, PsycINFO, the Cochrane Library, SocINDEX, Scopus, Embase, and CINAHL published between January 2021 and November 2023; gray literature; and discussions with 18 key informants. STUDY SELECTION: Publications describing long COVID definitions or models of care, supplemented by models described by key informants. DATA EXTRACTION: Data were extracted by one reviewer and verified for accuracy by another reviewer. DATA SYNTHESIS: Of 1960 screened citations, 38 were included. Five clinical definitions of long COVID varied with regard to timing since symptom onset and the minimum duration required for diagnosis; 1 additional definition was symptom score-based. Forty-nine long COVID care models were informed by 5 key principles: a core "lead" team, multidisciplinary expertise, comprehensive access to diagnostic and therapeutic services, a patient-centered approach, and providing capacity to meet demand. Seven characteristics provided a framework for distinguishing models: home department or clinical setting, clinical lead, collocation of other specialties, primary care role, population managed, use of teleservices, and whether the model was practice- or systems-based. Using this framework, 10 representative practice-based and 3 systems-based models of care were identified. LIMITATIONS: Published literature often lacked key model details, data were insufficient to assess model outcomes, and there was overlap between and variability within models. CONCLUSION: Definitions of long COVID and care models are evolving. Research is needed to optimize models and evaluate outcomes of different models. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (Protocol posted at https://effectivehealthcare.ahrq.gov/products/long-covid-models-care/protocol.).

Leveraging health systems data to characterize a large effect variant conferring risk for liver disease in Puerto Ricans.

The integration of genomic data into health systems offers opportunities to identify genomic factors underlying the continuum of rare and common disease. We applied a population-scale haplotype association approach based on identity-by-descent (IBD) in a large multi-ethnic biobank to a spectrum of disease outcomes derived from electronic health records (EHRs) and uncovered a risk locus for liver disease. We used genome sequencing and in silico approaches to fine-map the signal to a non-coding variant (c.2784-12T>C) in the gene ABCB4. In vitro analysis confirmed the variant disrupted splicing of the ABCB4 pre-mRNA. Four of five homozygotes had evidence of advanced liver disease, and there was a significant association with liver disease among heterozygotes, suggesting the variant is linked to increased risk of liver disease in an allele dose-dependent manner. Population-level screening revealed the variant to be at a carrier rate of 1.95% in Puerto Rican individuals, likely as the result of a Puerto Rican founder effect. This work demonstrates that integrating EHR and genomic data at a population scale can facilitate strategies for understanding the continuum of genomic risk for common diseases, particularly in populations underrepresented in genomic medicine.

Githinji Gitahi: developing resilient health systems for universal coverage.

Githinji Gitahi talks to Gary Humphreys about the value of cross-sectoral collaboration and health system assessment in the drive towards universal health coverage (UHC).

Effectiveness of greenhouse gas mitigation intervention for health-care systems: a systematic review.

Objective: To identify evidence-based interventions that reduce greenhouse gas emissions in health-care systems in low- and middle-income countries and explore potential synergies from these interventions that aid climate change adaptation while mitigating emissions. Methods: We systematically searched 11 electronic databases for articles published between 1990 and March 2023. We assessed risk of bias in each article and graded the quality of evidence across interventions in health-care operations, energy and supply chains. Findings: After screening 25 570 unique records, we included 22 studies published between 2000 and 2022 from 11 countries across six World Health Organization regions. Identified articles reported on interventions spanning six different sources of emissions, namely energy, waste, heating and cooling, operations and logistics, building design and anaesthetic gases; all of which demonstrated potential for significant greenhouse gas emission reductions, cost savings and positive health impacts. The overall quality of evidence is low because of wide variation in greenhouse gas emissions measuring and reporting. Conclusion: There are opportunities to reduce the greenhouse gas emissions from health-care systems in low- and middle-income countries, but gaps in evidence were identified across sources of emissions, such as the supply chain, as well as a lack of consideration of interactions with adaptation goals. As efforts to mitigate greenhouse gas intensify, rigorous monitoring, evaluation and reporting of these efforts are needed. Such actions will contribute to a strong evidence base that can inform policy-makers across contexts.

Multisectoral interventions and health system performance: a systematic review.

Objective: To conduct a systematic review on the effects of multisectoral interventions for health on health system performance. Methods: We conducted a systematic review according to the preferred reporting items for systematic review and meta-analysis protocols. We searched for peer-reviewed journal articles in PubMed®, Scopus, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews on 31 August 2023 (updating on 28 February 2024). We removed duplicates, screened titles and abstracts, and then conducted a full-text eligibility and quality assessment. Findings: We identified an initial 1118 non-duplicate publications, 62 of which met our inclusion and exclusion criteria. The largest proportions of reviewed studies focused on multisectoral interventions directly related to specific health outcomes (66.1%; 41 studies) and/or social determinants of health (48.4%; 30 studies), but without explicit reference to overall health system performance. Most reviewed publications did not address process indicators (83.9%; 52/62) or discuss sustainability for multisectoral interventions in health (72.6%; 45/62). However, we observed that the greatest proportion (66.1%; 41/62) considered health system goals: health equity (68.3%; 28/41) and health outcomes (63.4%; 26/41). Although the greatest proportion (64.5%; 40/62) proposed mechanisms explaining how multisectoral interventions for health could lead to the intended outcomes, none used realistic evaluations to assess these. Conclusion: Our review has established that multisectoral interventions influence health system performance through immediate improvements in service delivery efficiency, readiness, acceptability and affordability. The interconnectedness of these effects demonstrates their role in addressing the complexities of modern health care.

Climate finance opportunities for health and health systems.

Climate change poses significant risks to health and health systems, with the greatest impacts in low- and middle-income countries - which are least responsible for greenhouse gas emissions. The Conference of Parties 28 at the 2023 United Nations Climate Change Conference led to agreement on the need for holistic and equitable financing approaches to address the climate and health crisis. This paper provides an overview of existing climate finance mechanisms - that is, multilateral funds, voluntary market-based mechanisms, taxes, microlevies and adaptive social protection. We discuss these approaches' potential use to promote health, generate additional health sector resources and enhance health system sustainability and resilience, and also explore implementation challenges. We suggest that public health practitioners, policy-makers and researchers seize the opportunity to leverage climate funding for better health and sustainable, climate-resilient health systems. Emphasizing the wider benefits of investing in health for the economy can help prioritize health within climate finance initiatives. Meaningful progress will require the global community acknowledging the underlying political economy challenges that have so far limited the potential of climate finance to address health goals. To address these challenges, we need to restructure financing institutions to empower communities at the frontline of the climate and health crisis and ensure their needs are met. Efforts from global and national level stakeholders should focus on mobilizing a wide range of funding sources, prioritizing co-design and accessibility of financing arrangements. These stakeholders should also invest in rigorous monitoring and evaluation of initiatives to ensure relevant health and well-being outcomes are addressed.

Le changement climatique fait peser des risques considérables sur la santé et les systèmes de santé, affectant principalement les pays à revenu faible et intermédiaire ­ alors qu'ils contribuent le moins aux émissions de gaz à effet de serre. Lors de la Conférence des Nations Unies sur le changement climatique de 2023, la 28e Conférence des Parties a abouti à un accord sur la nécessité d'adopter des approches de financement équitables et holistiques pour résoudre la crise climatique et sanitaire. Le présent document offre un aperçu des dispositifs de financement climatique existants ­ à savoir des fonds multilatéraux, des mécanismes de marché volontaires, des micro-taxes et une protection sociale adaptative. Nous évoquons la possibilité de recourir à ces approches en vue de promouvoir la santé, de générer des ressources supplémentaires pour le secteur de la santé et de renforcer la viabilité et la résilience des systèmes de santé; nous nous intéressons également aux défis que représente leur mise en œuvre. Nous suggérons que les professionnels de la santé publique, les responsables politiques et les chercheurs profitent de cette occasion pour obtenir des fonds climatiques afin d'améliorer la santé et de développer des systèmes de santé durables et adaptés au changement climatique. Souligner tout l'intérêt, pour l'économie, d'investir dans la santé peut aider à inscrire la santé en priorité dans les initiatives de financement climatique. Réaliser des progrès significatifs implique que la communauté internationale prenne conscience des enjeux sous-jacents en matière d'économie politique, enjeux qui ont jusqu'à présent limité le potentiel du financement climatique dans l'atteinte des objectifs de santé. Pour y remédier, nous devons restructurer les institutions financières afin d'accroître l'autonomie des communautés en première ligne face à la crise climatique et sanitaire, et de faire en sorte que leurs besoins soient satisfaits. Les efforts des parties prenantes à l'échelle nationale et mondiale doivent porter sur la mobilisation d'un large éventail de sources de financement, en mettant l'accent sur la conception conjointe et l'accessibilité des modalités financières. Ces parties prenantes doivent en outre investir dans un suivi étroit et une évaluation rigoureuse des initiatives pour veiller à obtenir des résultats pertinents en termes de santé et de bien-être.

El cambio climático plantea riesgos importantes para la salud y los sistemas sanitarios, con mayores impactos en los países de ingresos bajos y medios, que son los menos responsables de las emisiones de gases de efecto invernadero. La 28.ª Conferencia de las Partes en la Conferencia de las Naciones Unidas sobre el Cambio Climático de 2023 condujo a un acuerdo sobre la necesidad de enfoques de financiación holísticos y equitativos para abordar la crisis climática y sanitaria. Este documento ofrece una visión general de los mecanismos de financiación climática existentes, es decir, los fondos multilaterales, los mecanismos voluntarios basados en el mercado, los impuestos, los microimpuestos y la protección social adaptable. Analizamos el uso potencial de estos enfoques para promover la salud, generar recursos adicionales para el sector sanitario y mejorar la sostenibilidad y la resiliencia de los sistemas sanitarios. Sugerimos que los profesionales de la salud pública, los responsables de formular las políticas y los investigadores aprovechen la oportunidad de utilizar la financiación climática para mejorar la salud y los sistemas sanitarios sostenibles y resilientes al cambio climático. Destacar los beneficios más amplios de invertir en salud para la economía puede ayudar a priorizar la salud dentro de las iniciativas de financiación climática. Para lograr avances significativos será necesario que la comunidad mundial reconozca los problemas de economía política subyacentes que hasta ahora han limitado el potencial de la financiación para abordar los objetivos de salud. Para superar estos desafíos, necesitamos reestructurar las instituciones financieras para empoderar a las comunidades que se encuentran en primera línea de la crisis climática y sanitaria y asegurar que se satisfacen sus necesidades. Los esfuerzos de las partes interesadas a nivel mundial y nacional deben centrarse en movilizar una gran variedad de fuentes de financiación y priorizar el diseño conjunto y la accesibilidad de los acuerdos de financiación. Estas partes interesadas también deben invertir en la supervisión y evaluación rigurosas de las iniciativas para garantizar que se abordan los resultados pertinentes en materia de salud y bienestar.

Health system performance assessment and reforms, Oman.

Problem: To prioritize key areas of action and investment for the next strategic cycle of national development plans (2026-2031) in Oman, we needed a holistic view of the country's health system and its main deficiencies and inefficiencies. Approach: Informed by the World Health Organization framework, our team of seven national health ministry staff and two international experts conducted a rapid health system performance assessment. We used already available data to identify system bottlenecks and their potential root causes, verifying our findings with key informant interviews. Local setting: Oman's 4.9 million population is relatively young (average age 28 years) but ageing, with a mounting burden of chronic diseases. While health-care services are free for Omani nationals, more than 1.5 million expatriates rely on out-of-pocket payments for health-care services. Strengthening primary health care, improving the quality of care, providing financial protection, and ensuring that public and private health-care providers operate within the same legal and procedural framework are recognized as key national priorities. Relevant changes: Our assessment highlighted the need to extend health service coverage to the whole population, strengthen private health-care sector governance, improve health education, increase financial investment, and expand the country's capacity for data collection and analysis. Lessons learnt: The assessment framework allowed us to identify areas where information is lacking and use already available data to analyse multiple health outcomes. As well as identifying issues that need to be addressed during the next policy development cycle, our findings have contributed towards the preparation of a more extensive assessment.

Population assessment of health system performance in 16 countries.

Objective: To demonstrate how the new internationally comparable instrument, the People's Voice Survey, can be used to contribute the perspective of the population in assessing health system performance in countries of all levels of income. Methods: We surveyed representative samples of populations in 16 low-, middle- and high-income countries on health-care utilization, experience and confidence during 2022-2023. We summarized and visualized data corresponding to the key domains of the World Health Organization universal health coverage framework for health system performance assessment. We examined correlation with per capita health spending by calculating Pearson coefficients, and within-country income-based inequities using the slope index of inequality. Findings: In the domain of care effectiveness, we found major gaps in health screenings and endorsement of public primary care. Only one in three respondents reported very good user experience during health visits, with lower proportions in low-income countries. Access to health care was rated highest of all domains; however, only half of the populations felt secure that they could access and afford high-quality care if they became ill. Populations rated the quality of private health systems higher than that of public health systems in most countries. Only half of respondents felt involved in decision-making (less in high-income countries). Within countries, we found statistically significant pro-rich inequalities across many indicators. Conclusion: Populations can provide vital information about the real-world function of health systems, complementing other system performance metrics. Population-wide surveys such as the People's Voice Survey should become part of regular health system performance assessments.

Assessing health system performance.

The post-pandemic era presents an opportunity to prioritize health system performance assessment. Adèle Sulcas reports.

Resilience dimensions in health system performance assessments, European Union.

Objective: To explore the definition and operationalization of resilience in health system performance assessments in European Union countries. Methods: We conducted multiple empirical case study analyses. We identified relevant cases through a literature review from 2014 to 2023 using Google Scholar and through a snowball technique to retrieve additional information. We included only documents that explicitly mentioned resilience in health system performance assessments. We performed a content analysis to identify common patterns in defining resilience. Findings: The final sample consisted of six countries: Belgium, Croatia, Czechia, Estonia, Ireland and Italy. Each country adopted a distinct approach to conceptualizing resilience, with countries prioritizing specific aspects based on lessons learnt from the coronavirus disease 2019 (COVID-19) pandemic. Some countries focused on maintaining essential health-care services and protecting vulnerable groups. Other countries prioritized management capacity, staff preparedness, digital health utilization and strengthening of primary health care. Content analysis revealed six resilience definitions derived from the key performance indicators: addressing unmet needs and maintaining outcomes; protecting vulnerable groups; acquiring and using resources; having trained and prepared staff in place; using digital health; and strengthening primary health care. Conclusion: Integration of resilience into the health profiles of European Union countries preceded its inclusion in national health system performance assessments, the latter of which became more prominent after the COVID-19 pandemic. Variations in interpretations within health system performance assessments reflect differences in indicators and policy responses.

Toward a Climate-Ready Health Care System: Institutional Motivators and Workforce Engagement.

Policy Points The US health care system faces mounting pressure to reduce greenhouse gas emissions and adapt to the impacts of climate change; motivated institutions and an engaged health care workforce are essential to the development, implementation, and maintenance of a climate-ready US health care system. Health care workers have numerous profession-specific and role-specific opportunities to address the causes and impacts of climate change. Policies must address institutional barriers to change and create incentives aligned with climate readiness goals. Institutions and individuals can support climate readiness by integrating content on the health care implications of climate change into educational curricula.

Commentary: importance of considering sex and gender when designing cancer care programs.

Due to perceived methodological complications, scientific studies have often excluded females. As a result, male-based findings have been generalized to females, despite physiological and biological differences between sexes. Gender has been even less considered in the literature, with little exploration specifically beyond traditional man/woman representation. This practice is compounded by a lack of what sex and gender encompass, including their erroneous use as synonyms. Sex- and gender-based differences, which are not clearly defined and recognized in scientific literature, are disregarded in health care delivery and, specifically relevant to the focus of this commentary, the development of cancer care programs. Conversely, accounting for sex- and gender in anti-cancer treatments and pathways can help create effective and personalized programming which could lead to an increased likelihood of adoption and adherence to treatment protocols. Although sex- and gender-specific programming may not be necessary in all situations, awareness of the concepts and possible impact on cancer care programs is paramount as more inclusive and personalized methodologies take shape. The goals of this commentary are to (a) clarify the terms sex and gender and (b) raise awareness of their applications and considerations for cancer care program design.

Approaches for delivery of refractive and optical care services in community and primary care settings.

BACKGROUND: Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states. OBJECTIVES: To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery. SELECTION CRITERIA: We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002. DATA COLLECTION AND ANALYSIS: Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme. MAIN RESULTS: We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services. AUTHORS' CONCLUSIONS: We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels. FUNDING: This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership. REGISTRATION: The protocol of this scoping review was published in the Open Source Framework.

Commissioning and co-production in health and care services in the United Kingdom and Ireland: An exploratory literature review.

INTRODUCTION: This exploratory literature review seeks to examine the literature around commissioning processes in the co-production of health and care services, focusing on two questions: How do health and care commissioning processes facilitate and/or pose barriers to co-production in service design and delivery? What are the contextual factors that influence these processes? METHOD: A systematic search of three databases (Medline, Public Health and Social Policy and Practice) and a search platform (Web of Science) was conducted for the period 2008-2023. A total of 2675 records were retrieved. After deduplication, 1925 were screened at title and abstract level. Forty-seven reports from 42 United Kingdom and Ireland studies were included in the review. A thematic synthesis of included studies was conducted in relation to the research questions. RESULTS: The review identified one overarching theme across the synthesised literature: the complexity of the commissioning landscape. Three interconnected subthemes illuminate the contextual factors that influence this landscape: commissioners as leaders of co-production; navigating relationships and the collective voice. CONCLUSION: Commissioning processes were commonly a barrier to the co-production of health and care services. Though co-production was an aspiration for many commissioners, the political and economic environment and service pressures meant that it was often not fully realised. More flexible funding models, longer-term pilot projects, an increased emphasis in social value across the health and care system and building capacity for strong leadership in commissioning is needed. PATIENT AND PUBLIC CONTRIBUTION: Patients and the public did not contribute to this review as it was a small piece of work following on from a completed project, with no budget for public involvement.

Differential impacts of health systems and sociocultural environment on vulnerable populations during the COVID-19 pandemic: lessons from four Asia-Pacific countries.

BACKGROUND: This study aims to evaluate healthcare systems and pandemic responses in relation to marginalized and vulnerable groups, identify populations requiring urgent care, and assess the differential impacts on their health during the pandemic. METHODS: Data were collected by the Asia-Pacific Observatory on Health Systems and Policies (APO)-National University of Singapore and APO-International Health Policy Program consortium members: Korea, Indonesia, Philippines, and Singapore. Data were collected through a combination of semi-structured interviews, policy document reviews, and analysis of secondary data. RESULTS: Our findings reveal that the pandemic exacerbated existing health disparities, particularly affecting older adults, women, and children. Additionally, the study identified LGBTI individuals, healthcare workers, slum dwellers, and migrant workers as groups that faced particularly severe challenges during the pandemic. LGBTI individuals encountered heightened discrimination and limited access to health services tailored to their needs. Healthcare workers suffered from immense stress and risk due to prolonged exposure to the virus and critical working conditions. Slum dwellers struggled with healthcare access and social distancing due to high population density and inadequate sanitation. Migrant workers were particularly hard hit by high risks of virus transmission and stringent, often discriminatory, isolation measures that compounded their vulnerability. The study highlights the variation in the extent and nature of vulnerabilities, which were influenced by each country's specific social environment and healthcare infrastructure. It was observed that public health interventions often lacked the specificity required to effectively address the needs of all vulnerable groups, suggesting a gap in policy and implementation. CONCLUSIONS: The study underscores that vulnerabilities vary greatly depending on the social environment and context of each country, affecting the degree and types of vulnerable groups. It is critical that measures to ensure universal health coverage and equal accessibility to healthcare are specifically designed to address the needs of the most vulnerable. Despite commonalities among groups across different societies, these interventions must be adapted to reflect the unique characteristics of each group within their specific social contexts to effectively mitigate the impact of health disparities.

Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation.

BACKGROUND: Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Maori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. METHODS: This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. RESULTS: The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. DISCUSSION: Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. CONCLUSIONS: Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. OTHER: This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).