"Do Their Own Thing": Radical Health Care and the Fair Haven Community Health Center.

Radical health reform movements of the 1960s inspired two widely adopted alternative health care models in the United States: free clinics and community health centers. These groundbreaking institutions attempted to realize bold ideals but faced financial, bureaucratic, and political obstacles. This article examines the history of Fair Haven Community Health Care (FHCHC) in New Haven, Connecticut, an organization that spanned both models and typified innovative aspects of each while resisting the forces that tempered many of its contemporaries' progressive practices. Motivated by a tradition of independence and struggling to address medical neglect in their neighborhood, FHCHC leaders chose not to affiliate with the local academic hospital, a decision that led many disaffected community members to embrace the clinic. The FHCHC also prioritized grant funding over fee-for-service revenue, thus retaining freedom to implement creative programs. Furthermore, the center functioned in an egalitarian manner, enthusiastically employing nurse practitioners and whole-staff meetings, and was largely able to avoid the conflicts that strained other community-controlled organizations. The FHCHC proved unusual among free clinics and health centers and demonstrated strategies similar institutions might employ to overcome common challenges. (Am J Public Health. 2021;111(10): 1806-1814. https://doi.org/10.2105/AJPH.2021.306417).

Local Health Departments' Spending on the Foundational Capabilities.

Improving our nation's public health system requires a detailed understanding of public health expenditures and related revenue sources, yet no comprehensive data source exists that contains such information for governmental health agencies at all levels. Using pilot study data of a standardized financial accounting framework for public health agencies-in the form of a uniform chart of accounts crosswalk-this article presents local health departments' (LHDs') expenditures on the foundational capabilities, that is, crosscutting skills and capacities needed to support all of an LHD's programs and activities. Among 16 sample LHDs from 4 states, per capita foundational capabilities spending ranged from $1.10 to $26.19, with a median of $7.67. Larger LHDs and LHDs with greater financial resources spent more per capita, as did accredited LHDs. Future work using data from a larger sample of LHDs is needed to examine agency and community-level characteristics associated with adequate funding for the foundational capabilities.

The Funding, Administrative, and Policy Influences on the Evaluation of Primary Prevention Programs in Australia.

Evaluation of primary prevention and health promotion programs contributes necessary information to the evidence base for prevention programs. There is increasing demand for high-quality evaluation of program impact and effectiveness for use in public health decision making. Despite the demand for evidence and known benefits, evaluation of prevention programs can be challenging and organizations face barriers to conducting rigorous evaluation. Evaluation capacity building efforts are gaining attention in the prevention field; however, there is limited knowledge about how components of the health promotion and primary prevention system (e.g., funding, administrative arrangements, and the policy environment) may facilitate or hinder this work. We sought to identify the important influences on evaluation practice within the Australian primary prevention and health promotion system. We conducted in-depth semi-structured interviews with experienced practitioners and managers (n = 40) from government and non-government organizations, and used thematic analysis to identify the main factors that impact on prevention program evaluation. Firstly, accountability and reporting requirements impacted on evaluation, especially if expectations were poorly aligned between the funding body and prevention organization. Secondly, the funding and political context was found to directly and indirectly affect the resources available and evaluation approach. Finally, it was found that participants made use of various strategies to modify the prevention system for more favorable conditions for evaluation. We highlight the opportunities to address barriers to evaluation in the prevention system, and argue that through targeted investment, there is potential for widespread gain through improved evaluation capacity.

Science, Technology and Innovation as Social Goods for Development: Rethinking Research Capacity Building from Sen's Capabilities Approach.

Science and technology are key to economic and social development, yet the capacity for scientific innovation remains globally unequally distributed. Although a priority for development cooperation, building or developing research capacity is often reduced in practice to promoting knowledge transfers, for example through North-South partnerships. Research capacity building/development tends to focus on developing scientists' technical competencies through training, without parallel investments to develop and sustain the socioeconomic and political structures that facilitate knowledge creation. This, the paper argues, significantly contributes to the scientific divide between developed and developing countries more than any skills shortage. Using Charles Taylor's concept of irreducibly social goods, the paper extends Sen's Capabilities Approach beyond its traditional focus on individual entitlements to present a view of scientific knowledge as a social good and the capability to produce it as a social capability. Expanding this capability requires going beyond current fragmented approaches to research capacity building to holistically strengthen the different social, political and economic structures that make up a nation's innovation system. This has implications for the interpretation of human rights instruments beyond their current focus on access to knowledge and for focusing science policy and global research partnerships to design approaches to capacity building/development beyond individual training/skills building.

Building a national eye-care service in post-conflict Timor-Leste.

PROBLEM: Violent conflict left Timor-Leste with a dismantled health-care workforce and infrastructure after 2001. The absence of existing health and tertiary education sectors compounded the challenges of instituting a national eye-care system. APPROACH: From 2001, the East Timor Eye Program coordinated donations and initially provided eye care through visiting teams. From 2005, the programme reoriented to undertake concerted workforce and infrastructure development. In 2008 full-time surgical services started in a purpose-built facility in the capital city. In 2014 we developed a clinical training pipeline for local medical graduates to become ophthalmic surgeons, comprising a local postgraduate diploma, with donor funding supporting master's degree studies abroad. LOCAL SETTING: In the population of 1.26 million, an estimated 35 300 Timorese are blind and an additional 123 500 have moderate to severe visual impairment, overwhelmingly due to cataract and uncorrected refractive error. RELEVANT CHANGES: By April 2018, six Timorese doctors had completed the domestic postgraduate diploma, three of whom had enrolled in master's degree programmes. Currently, one consultant ophthalmologist, seven ophthalmic registrars, two optometrists, three refractionists and four nursing staff form a tertiary resident ophthalmic workforce, supported by an international advisor ophthalmologist and secondary eye-care workers. A recorded 12 282 ophthalmic operations and 117 590 consultations have been completed since 2001. LESSONS LEARNT: International organizations played a pivotal role in supporting the Timorese eye health system, in an initially vulnerable setting. We highlight how transition to domestic funding can be achieved through the creation of a domestic training pipeline and integration with national institutions.

The institutional development award states pediatric clinical trials network: building research capacity among the rural and medically underserved.

PURPOSE OF REVIEW: The institutional development award (IDeA) program was created to increase the competitiveness of investigators in states with historically low success rates for National Institutes of Health (NIH) research funding applications. IDeA states have high numbers of rural and medically underserved residents with disproportionately high rates of infant mortality, obesity, and poverty. This program supports the development and expansion of research infrastructure and research activities in these states. The IDeA States Pediatric Clinical Trials Network (ISPCTN) is part of the environmental influences on child health outcomes program. Its purpose is to build research capacity within IDeA states and provide opportunities for children in IDeA states to participate in clinical trials. This review describes the current and future activities of the network. RECENT FINDINGS: In its initial year, the ISPCTN created an online series on clinical trials, initiated participation in a study conducted by the pediatric trials network, and proposed two novel clinical trials for obese children. Capacity building and clinical trial implementation will continue in future years. SUMMARY: The ISPCTN is uniquely poised to establish and support new pediatric clinical research programs in underserved populations, producing both short and long-term gains in the understanding of child health.

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study.

BACKGROUND: China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China. METHODS: This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model. RESULTS: First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs. CONCLUSION: The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.

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

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

HTA Implementation Roadmap in Central and Eastern European Countries.

The opportunity cost of inappropriate health policy decisions is greater in Central and Eastern European (CEE) compared with Western European (WE) countries because of poorer population health and more limited healthcare resources. Application of health technology assessment (HTA) prior to healthcare financing decisions can improve the allocative efficiency of scarce resources. However, few CEE countries have a clear roadmap for HTA implementation. Examples from high-income countries may not be directly relevant, as CEE countries cannot allocate so much financial and human resources for substantiating policy decisions with evidence. Our objective was to describe the main HTA implementation scenarios in CEE countries and summarize the most important questions related to capacity building, financing HTA research, process and organizational structure for HTA, standardization of HTA methodology, use of local data, scope of mandatory HTA, decision criteria, and international collaboration in HTA. Although HTA implementation strategies from the region can be relevant examples for other CEE countries with similar cultural environment and economic status, HTA roadmaps are not still fully transferable without taking into account country-specific aspects, such as country size, gross domestic product per capita, major social values, public health priorities, and fragmentation of healthcare financing.

Policy dialogues - the "bolts and joints" of policy-making: experiences from Cabo Verde, Chad and Mali.

BACKGROUND: Policy processes that yield good outcomes are inherently complex, requiring interactions of stakeholders in problem identification, generation of political will and selection of practical solutions. To make policy processes rational, policy dialogues are increasingly being used as a policy-making tool. Despite their increasing use for policy-making in Africa, evidence is limited on how they have evolved and are being used on the continent or in low and middle income countries elsewhere. METHODS: This was an exploratory study using qualitative methods. It utilised data related to policy dialogues for three specific policies and strategies to understand the interplay between policy dialogue and policy-making in Cabo Verde, Chad and Mali. The specific methods used to gather data were key informant interviews and document review. Data were analysed inductively and deductively using thematic content analysis. RESULTS: Participation in the policy dialogues was inclusive, and in some instances bottom-up participatory approaches were used. The respondents felt that the execution of the policy dialogues had been seamless, and the few divergent views expressed often were resolved in a unanimous manner. The policies and strategies developed were seen by all stakeholders as relating to priority issues. Other specific process factors that contributed to the success of the dialogues included the use of innovative approaches, good facilitation, availability of resources for the dialogues, good communication, and consideration of the different opinions. Among the barriers were contextual issues, delays in decision-making and conflicting coordination roles and mandates. CONCLUSIONS: Policy dialogues have proved to be an effective tool in health sector management and could be a crucial component of the governance dynamics of the sector. The policy dialogue process needs to be institutionalised for continuity and maintenance of institutional intelligence. Other essential influencing factors include building capacity for coordination and facilitation of policy dialogues, provision of sustainable financing for execution of the dialogues, use of inclusive and bottom-up approaches, and timely provision of reliable evidence. Ensuring continued participation of all the actors necessitates innovation to allow dialogue outside the formal frameworks and spaces that should feed into the formal dialogue processes.

CAPACITY BUILDING IN AGENCIES FOR EFFICIENT AND EFFECTIVE HEALTH TECHNOLOGY ASSESSMENT.

OBJECTIVES: Health technology assessment (HTA) yields information that can be ideally used to address deficiencies in health systems and to create a wider understanding of the impact of different policy considerations around technology reimbursement and use. The structure of HTA programs varies across different jurisdictions according to decision-maker needs. Moreover, conducting HTA requires specialized skills. Effective decision making should include multiple criteria (medical, economic, technical, ethical, social, legal, and cultural) and requires multi-disciplinary teams of experts working together to produce these assessments. A workshop explored the multi-disciplinary skills and competencies required to build an effective and efficient HTA team, with a focus on low- and middle-income settings. METHODS: This proceeding summarizes main points from a workshop on capacity building, drawing on presentations and group discussions among attendees including different points of view. RESULTS AND CONCLUSIONS: The workshop and thus this study would have benefited from a larger variety of stakeholders. Therefore, the conclusions arising from the workshop are not the opinion of a representative sample of HTA professionals. Nonetheless, organizations and speakers were carefully selected to provide a valuable approach to this theme. Thus, these proceedings highlight some of the gaps and needs in the education and training programs offered worldwide and calls for further investigation.

The Road Traffic Injuries Research Network: a decade of research capacity strengthening in low- and middle-income countries.

Road traffic crashes have been an increasing threat to the wellbeing of road users worldwide; an unacceptably high number of people die or become disabled from them. While high-income countries have successfully implemented effective interventions to help reduce the burden of road traffic injuries (RTIs) in their countries, low- and middle-income countries (LMICs) have not yet achieved similar results. Both scientific research and capacity development have proven to be useful for preventing RTIs in high-income countries. In 1999, a group of leading researchers from different countries decided to join efforts to help promote research on RTIs and develop the capacity of professionals from LMICs. This translated into the creation of the Road Traffic Injuries Research Network (RTIRN) - a partnership of over 1,100 road safety professionals from 114 countries collaborating to facilitate reductions in the burden of RTIs in LMICs by identifying and promoting effective, evidenced-based interventions and supporting research capacity building in road safety research in LMICs. This article presents the work that RTIRN has done over more than a decade, including production of a dozen scientific papers, support of nearly 100 researchers, training of nearly 1,000 people and 35 scholarships granted to researchers from LMICs to attend world conferences, as well as lessons learnt and future challenges to maximize its work.

Building coherence and synergy among global health initiatives.

BACKGROUND: The fast growth of global health initiatives (GHIs) has raised concerns regarding achievement of coherence and synergy among distinct, complementary and sometimes competing activities. Herein, we propose an approach to compare GHIs with regard to their main purpose and operational aspects, using the Special Programme for Research and Training in Tropical Diseases (TDR/WHO) as a case study. The overall goal is to identify synergies and optimize efforts to provide solutions to reduce the burden of diseases. METHODS: Twenty-six long-established GHIs were identified from among initiatives previously associated/partnered with TDR/WHO. All GHIs had working streams that would benefit from linking to the capacity building or implementation research focus of TDR. Individual profiles were created using a common template to collect information on relevant parameters. For analytical purposes, GHIs were simultaneously clustered in five and eight groups according to their 'intended outcome' and 'operational framework', respectively. A set of specific questions was defined to assess coherence/alignment against a TDR reference profile by attributing a score, which was subsequently averaged per GHI cluster. GHI alignment scores for intended outcome were plotted against scores for operational framework; based on the analysis of coherence/alignment with TDR functions and operations, a risk level (high, medium or low) of engagement was attributed to each GHI. RESULTS: The process allowed a bi-dimensional ranking of GHIs with regards to how adequately they fit with or match TDR features and perspectives. Overall, more consistence was observed with regard to the GHIs' main goals and expected outcomes than with their operational aspects, reflecting the diversity of GHI business models. Analysis of coherence indicated an increasing common trend for enhancing the engagement of developing country stakeholders, building research capacity and optimization of knowledge management platforms in support of improved access to healthcare. CONCLUSIONS: The process used offers a broader approach that could be adapted by other GHIs to build coherence and synergy with peer organizations and helps highlight the potential contribution of each GHI in the new era of sustainable development goals. Emerging opportunities and new trends suggest that engagement between GHIs should be selective and tailored to ensure efficient collaborations.

Promoting sustainable research partnerships: a mixed-method evaluation of a United Kingdom-Africa capacity strengthening award scheme.

BACKGROUND: Research partnerships between high-income countries (HICs) and low- or middle-income countries (LMICs) are a leading model in research capacity strengthening activities. Although numerous frameworks and guiding principles for effective research partnerships exist, few include the perspective of the LMIC partner. This paper draws out lessons for establishing and maintaining successful research collaborations, based on partnership dynamics, from the perspectives of both HIC and LMIC stakeholders through the evaluation of a research capacity strengthening partnership award scheme. METHODS: A mixed-method retrospective evaluation approach was used. Initially, a cross-sectional survey was administered to all award holders, which focused on partnership outputs and continuation. Fifty individuals were purposively selected to participate in interviews or focus group discussions from 12 different institutions in HICs and LMICs; the sample included the research investigators, research assistants, laboratory scientists and post-doctoral students. The evaluation collected data on critical elements of research partnership dynamics such as research outputs, nature of the partnership, future plans and research capacity. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach. RESULTS: The majority of United Kingdom and African award holders stated they would like to pursue future collaborations together. Key aspects within partnerships that appeared to influence this were; the perceived benefits of the partnership at the individual and institutional level such as publication of papers or collaborative grants; ability to influence 'research culture' and instigate critical thinking among mid-career researchers; previous working relationships, for example supervisor-student relationships; and equity within partnerships linked to partnership formation and experience of United Kingdom partners within LMICs. Factors which may hinder development of long term partnerships were also identified such as financial control or differing expectations of partners. CONCLUSIONS: This paper provides evidence of what encourages international research partnerships for capacity strengthening to continue past award tenure, from the perspective of researchers in high and LMICs. Although every partnership is unique and individual experiences subjective, this paper provides extension and support of key principles and mechanisms that can contribute to successful research partnerships between researchers.

Capacity Building and Financing Oral Health in the African and Middle East Region.

Many low- and middle-income countries do not yet have policies to implement effective oral health programs. A reason is lack of human and financial resources. Gaps between resource needs and available health funding are widening. By building capacity, countries aim to improve oral health through actions by oral health care personnel and oral health care organizations and their communities. Capacity building involves achieving measurable and sustainable results in training, research, and provision of care. Actions include advancement of knowledge, attitudes and skills, expansion of support, and development of cohesiveness and partnerships. The aim of this critical review is to review existing knowledge and identify gaps and variations between and within different income levels in relation to the capacity building and financing oral health in the African and Middle East region (AMER). A second aim is to formulate research priorities and outline a research agenda for capacity building and financing to improve oral health and reduce oral health inequalities in the AMER. The article focuses on capacity building for oral health and oral health financing in the AMER of the IADR. In many communities in the AMER, there are clear and widening gaps between the dental needs and the existing capacity to meet these needs in terms of financial and human resources. Concerted efforts are required to improve access to oral health care through appropriate financing mechanisms, innovative health insurance schemes, and donor support and move toward universal oral health care coverage to reduce social inequality in the region. It is necessary to build capacity and incentivize the workforce to render evidence-based services as well as accessing funds to conduct research on equity and social determinants of oral health while promoting community engagement and a multidisciplinary approach.

Delivering opioid maintenance treatment in rural and remote settings.

OBJECTIVE: This study explored the delivery of opioid maintenance treatment (OMT) from a specialist program in rural and remote New South Wales (NSW), focusing on the viability of the model and strategies for its improvement. DESIGN: Program evaluation examining configuration and delivery, client characteristics and trends in demand, using policy documents, service data and stakeholder consultations (n = 28). SETTING: The Greater Western Area Health Service, a sparsely populated and large geographic area in NSW. RESULTS: There were four service hubs or primary sites. Three sites were co-located with hospitals and one within community health, with all sites providing assessment, prescribing, dispensing and limited case management. Staff were mainly trained nurses, while prescribers were visiting specialists or sessional GPs. There was minimal OMT provision by community prescribers and dispensers. In 2009, there were 638 clients. They were younger on average than those in OMT across Australia. The most common principal drug of concern was heroin (37-85% of clients), while around one-fifth of clients identified prescription opioids (18-23%). There was a substantial increase in OMT provision between 2006 and 2009 at three program sites. Staff at the sites had limited capacity to engage primary health services and thus reduce their client load. CONCLUSIONS: Findings indicate the need to adjust funding to account for increased demand for OMT and to establish a financial incentive for GP prescribers. Dedicated resourcing is needed for a capacity building role to support the uptake of prescribing and dispensing in community services.

Enhancement of health department capacity for health care-associated infection prevention through Recovery Act-funded programs.

OBJECTIVES: We evaluated capacity built and outcomes achieved from September 1, 2009, to December 31, 2011, by 51 health departments (HDs) funded through the American Recovery and Reinvestment Act (ARRA) for health care-associated infection (HAI) program development. METHODS: We defined capacity for HAI prevention at HDs by 25 indicators of activity in 6 categories: staffing, partnerships, training, technical assistance, surveillance, and prevention. We assessed state-level infection outcomes by modeling quarterly standardized infection ratios (SIRs) for device- and procedure-associated infections with longitudinal regression models. RESULTS: With ARRA funds, HDs created 188 HAI-related positions and supported 1042 training programs, 53 surveillance data validation projects, and 60 prevention collaboratives. All states demonstrated significant declines in central line-associated bloodstream and surgical site infections. States that implemented ARRA-funded catheter-associated urinary tract infection prevention collaboratives showed significantly greater SIR reductions over time than states that did not (P = .02). CONCLUSIONS: ARRA-HAI funding substantially improved HD capacity to reduce HAIs not targeted by other national efforts, suggesting that HDs can play a critical role in addressing emerging or neglected HAIs.