We need to talk about 'bad' resilience.

In this analysis, we argue against seeing health system resilience as an inherently positive concept. The rise in the popularity of health system resilience has led to its increasingly normative framing. We question this widely accepted perspective by examining the underlying assumptions associated with this normative framing of 'good' resilience. Our focus is on the risks of accepting the assumption, which can lead us to ignore the social nature of health systems and overlook the consequences of change if resilience is seen as a positive, achievable objective. Finally, we suggest that seeing resilience as a normative concept can be detrimental to health system policy and research, and encourage a critical rethinking of these assumptions so that we can maintain resilience's usefulness for health systems.

"Hospitals respond to demand. Public health needs to respond to risk": health system lessons from a case study of northern Queensland's COVID-19 surveillance and response.

BACKGROUND: The vast region of northern Queensland (NQ) in Australia experiences poorer health outcomes and a disproportionate burden of communicable diseases compared with urban populations in Australia. This study examined the governance of COVID-19 surveillance and response in NQ to identify strengths and opportunities for improvement. METHODS: The manuscript presents an analysis of one case-unit within a broader case study project examining systems for surveillance and response for COVID-19 in NQ. Data were collected between October 2020-December 2021 comprising 47 interviews with clinical and public health staff, document review, and observation in organisational settings. Thematic analysis produced five key themes. RESULTS: Study findings highlight key strengths of the COVID-19 response, including rapid implementation of response measures, and the relative autonomy of NQ's Public Health Units to lead logistical decision-making. However, findings also highlight limitations and fragility of the public health system more generally, including unclear accountabilities, constraints on local community engagement, and workforce and other resourcing shortfalls. These were framed by state-wide regulatory and organisational incentives that prioritise clinical health care rather than disease prevention, health protection, and health promotion. Although NQ mobilised an effective COVID-19 response, findings suggest that NQ public health systems are marked by fragility, calling into question the region's preparedness for future pandemic events and other public health crises. CONCLUSIONS: Study findings highlight an urgent need to improve governance, resourcing, and political priority of public health in NQ to address unmet needs and ongoing threats.

Gaawaadhi Gadudha: understanding how cultural camps impact health, well-being and resilience among Aboriginal adults in New South Wales, Australia-a collaborative study protocol.

INTRODUCTION: The health and well-being of Aboriginal Australians is inextricably linked to culture and Country. Our study challenges deficit approaches to health inequities by seeking to examine how cultural connection, practice and resilience among Aboriginal peoples through participation in 'cultural camps' held on sites of cultural significance promotes health and well-being. METHODS AND ANALYSIS: The study will be undertaken in close collaboration and under the governance of traditional cultural knowledge holders from Yuwaalaraay, Gamilaraay and Yuin nation groups in New South Wales, Australia. Three cultural camps will be facilitated, where participants (n=105) will engage in activities that foster a connection to culture and cultural landscapes. A survey assessing connection to culture, access to cultural resources, resilience, self-rated health and quality of life will be administered to participants pre-camp and post-camp participation, and to a comparative group of Aboriginal adults who do not attend the camp (n=105). Twenty participants at each camp (n=60) will be invited to participate in a yarning circle to explore cultural health, well-being and resilience. Quantitative analysis will use independent samples' t-tests or χ2 analyses to compare camp and non-camp groups, and linear regression models to determine the impact of camp attendance. Qualitative analysis will apply inductive coding to data, which will be used to identify connections between coded concepts across the whole data set, and explore phenomenological aspects. Results will be used to collaboratively develop a 'Model of Cultural Health' that will be refined through a Delphi process with experts, stakeholders and policymakers. ETHICS AND DISSEMINATION: The study has ethics approval from the Aboriginal Health and Medical Research Council (#1851/21). Findings will be disseminated through a combination of peer-reviewed articles, media communication, policy briefs, presentations and summary documents to stakeholders.

Factors influencing the community participation approaches used in Aedes mosquito management in the Torres Strait, Australia.

BACKGROUND: Aedes-borne disease risk is increasing in tropical and sub-tropical regions across the globe. While Aedes-borne disease continues to disproportionally affect low- and middle-income countries, parts of high-income countries, such as the Torres Strait region in Australia are also at risk. The Torres Strait is a group of islands located between Cape York Peninsula in far north Queensland, Australia and Papua New Guinea. The Torres Strait has both Aedes albopictus and Aedes aegypti and is close to Papua New Guinea where dengue fever is endemic. Managing Aedes-borne disease risk requires a range of strategies, including community participation. Existing research shows that high-income countries tend to favour government-led (top-down) informing approaches when engaging communities in Aedes mosquito management. Little is known about the factors that influence the choice of community participation approaches in Aedes mosquito management particularly in a high-income country setting, such as Australia. This research contributes to filling this knowledge gap by exploring the community participation approaches used in Aedes mosquito management and the factors influencing these choices in the Torres Strait. METHODS: 16 semi-structured interviews were conducted with local government and state government agencies working in Aedes mosquito management in the Torres Strait. Six key mosquito management plans and policies were also reviewed. Thematic analysis was used to identify, analyse and attribute meaning from the data collected. RESULTS: A range of community participation approaches were used within the two main Aedes mosquito management programs (Aedes albopictus Elimination Program and the Torres Strait Island Regional Council, Environmental Health Program) in the Torres Strait. These approaches included door-to-door inspections, awareness raising strategies, and community clean-up events. Approaches were chosen for reasons related to regulations, attitude and beliefs, and resourcing. CONCLUSIONS: This study revealed the use of both top-down and bottom-up approaches to engaging the community in Aedes mosquito management in the Torres Strait. These findings contribute to a better understanding of why bottom-up approaches are used, which is valuable for shaping future policy decisions. This study also provides suggestions on ways to enhance community participation in the Torres Strait, which could also be considered in other similar tropical regions.

A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax.

INTRODUCTION: The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves. METHODS: Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing. RESULTS: The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys. CONCLUSION: Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

A qualitative exploration of the non-financial costs of cancer care for Aboriginal and Torres Strait Islander Australians.

OBJECTIVE: Knowledge is growing about cancer care and financial costs for Aboriginal and Torres Strait Islander people. However, much remains unknown about the true costs of cancer care, encompassing financial, emotional, and spiritual aspects. We aimed to explore and explain how non-financial costs affect the health-seeking behaviours of these clients. METHODS: Following Indigenous research protocols, this research was led by Aboriginal and Torres Strait Islander researchers and guided by Indigenous Hospital Liaison Officers. In-depth interviews and focus groups were conducted with 29 participants (Aboriginal and Torres Strait Islander cancer clients, their carers, and cancer-care professionals) at two Queensland public hospitals. RESULTS: Four interwoven themes encompass non-financial costs of healthcare: leaving home and family; loss of control during cancer treatment; health of the spirit; social costs. The Aboriginal relational concept of 'being held' is useful in considering client, family, and carer as central to care with the Indigenous Hospital Liaison Officer two-way interpreting between the care and client team. IMPLICATIONS FOR PUBLIC HEALTH: Framing the reasons that clients and carers have difficulty in engaging in treatment as 'costs' enables a focus on how the health system itself is implicated in the disengagement of Aboriginal and Torres Strait Islander clients from treatment.

Health system resilience: a critical review and reconceptualisation.

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.

National Public Health Surveillance of Corporations in Key Unhealthy Commodity Industries - A Scoping Review and Framework Synthesis.

BACKGROUND: Corporations in unhealthy commodity industries (UCIs) have growing influence on the health of national populations through practices that lead to increased consumption of unhealthy products. The use of government-led public health surveillance is best practice to better understand any emerging public health threat. However, there is minimal systematic evidence, generated and monitored by national governments, regarding the scope of UCI corporate practices and their impacts. This study aims to synthesise current frameworks that exist to identify and monitor UCI influence on health to highlight the range of practices deployed by corporations and inform future surveillance efforts in key UCIs. METHODS: Seven biomedical, business and scientific databases were searched to identify literature focused on corporate practices that impact human health and frameworks for monitoring or assessment of the way UCIs impact health. Content analysis occurred in three phases, involving (1) the identification of framework documents in the literature and extraction of all corporate practices from the frameworks; (2) initial inductive grouping and synthesis followed by deductive synthesis using Lima and Galea's 'vehicles of power' as a heuristic; and (3) scoping for potential indicators linked to each corporate practice and development of an integrated framework. RESULTS: Fourteen frameworks were identified with 37 individual corporate practices which were coded into five different themes according the Lima and Galea 'Corporate Practices and Health' framework. We proposed a summary framework to inform the public health surveillance of UCIs which outlines key actors, corporate practices and outcomes that should be considered. The proposed framework draws from the health policy triangle framework and synthesises key features of existing frameworks. CONCLUSION: Systematic monitoring of the practices of UCIs is likely to enable governments to mitigate the negative health impacts of corporate practices. The proposed synthesised framework highlights the range of practices deployed by corporations for public health surveillance at a national government level. We argue there is significant precedent and great need for monitoring of these practices and the operationalisation of a UCI monitoring system should be the object of future research.

Translating, Contexting, and Institutionalising Knowledge Translation Practices in Northern Australia: Some Reflections Comment on "Sustaining Knowledge Translation Practices: A Critical Interpretive Synthesis".

In this commentary, we reflect on how the three processes of translating, contexting, and institutionalising knowledge translation (KT) practices, as introduced in a critical interpretive synthesis on sustaining KT, might be drawn on to improve KT sustainability in the northern Australian health system, and some likely challenges. The synthesis provides a useful reminder that health systems are social systems and offers an analytical framework against which to map approaches that aim to align knowledge production and utilisation. By positioning "places" of knowledge utilisation and actor roles and networks as key to KT sustainability, the framework also offers the potential to draw attention to non-clinical settings, actors, and relationships that are central to improving health, but that may be historically neglected in KT research and scholarship.

Health System Resilience as the Basis for Explanation Versus Evaluation Comment on "The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic".

The onset and impacts of COVID-19 have prompted attention to national health system preparedness for, and capacity to adapt in response to, public health emergencies and other shocks. This preparedness and adaptive capacity are often framed as 'health system resilience' a concept previously associated more with assessments of health systems in conflict-affected and fragile states. Yet health system resilience remains a slippery concept, defined and applied in multiple ways. Reflecting on the Hodgins and colleagues' study "the COVID-19 system shock framework: capturing health system innovation during the COVID-19 pandemic," this article restates the limitations of health systems resilience as a concept capable of anchoring evaluative assessments of health system performance but stresses its value in the context of explanatory research investigating how and why health systems adapt, with due attention to the power of actors' whose choices inform the nature and direction of change.

Medical Dominance in Global Health Institutions as an Obstacle to Equity and Effectiveness Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process".

Medical professionals exercised structural and productive power in the Global Fund's Country Coordinating Mechanism (CCM) in Nigeria, directly impacting the selection of approaches to HIV/AIDS care, as described in a case study by Lassa and colleagues. This research contributes to a robust scholarship on how biomedical power inhibits a holistic understanding of health and prevents the adoption of solutions that are socially grounded, multi-disciplinary, and co-created with communities. We highlight Lassa and colleagues' findings demonstrating the 'long arm' of global health institutions in country-level health policy choices, and reflect on how medical dominance within global institutions serves as a tool of control in ways that pervert incentives and undermine equity and effectiveness. We call for increased research and advocacy to surface these conduits of power and begin to loosen their hold in the global health policy agenda.

Democratising data to address health system inequities in Australia.

Understanding the health status of a population or community is crucial to equitable service planning. Among other uses, data on health status can help local and national planners and policy makers understand patterns and trends in current or emerging health and well-being, especially how disparities relating to geography, ethnicity, language and living with disability influence access to services. In this practice paper we draw attention to the nature of Australia's health data challenges and call for greater 'democratisation' of health data to address health system inequities. Democratisation implies the need for greater quality and representativeness of health data as well as improved access and usability that enable health planners and researchers to respond to health and health service disparities efficiently and cost-effectively. We draw on learnings from two practice examples, marred by inaccessibility, reduced interoperability and limited representativeness. We call for renewed and urgent attention to, and investment in, improved data quality and usability for all levels of health, disability and related service delivery in Australia.

Experiences of Justice-Involved People Transitioning to HIV Care in the Community After Prison Release in Lusaka, Zambia: A Qualitative Study.

INTRODUCTION: In sub-Saharan Africa (SSA), incarcerated people experience a higher HIV burden than the general population. While access to HIV care and treatment for incarcerated people living with HIV (PLHIV) in SSA has improved in some cases, little is known about their transition to and post-release experience with care in the community. To address this gap, we conducted a qualitative study to describe factors that may influence post-release HIV care continuity in Zambia. METHODS: In March-December 2018, we recruited study participants from a larger prospective cohort study following incarcerated and newly released PLHIV at 5 correctional facilities in 2 provinces in Zambia. We interviewed 50 participants immediately before release; 27 (54%) participated in a second interview approximately 6 months post-release. Demographic and psychosocial data were collected through a structured survey. RESULTS: The pre-release setting was strongly influenced by the highly structured prison environment and assumptions about life post-release. Participants reported accessible HIV services, a destigmatizing environment, and strong informal social supports built through comradery among people facing the same trying detention conditions. Contrary to their pre-release expectations, during the immediate post-release period, participants struggled to negotiate the health system while dealing with unexpected stressors. Long-term engagement in HIV care was possible for participants with strong family support and a high level of self-efficacy. CONCLUSION: Our study highlights that recently released PLHIV in Zambia face acute challenges in meeting their basic subsistence needs, as well as social isolation, which can derail linkage to and retention in community HIV care. Releasees are unprepared to face these challenges due to a lack of community support services. To improve HIV care continuity in this population, new transitional care models are needed that develop client self-efficacy, facilitate health system navigation, and pragmatically address structural and psychosocial barriers like poverty, gender inequality, and substance use.

Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia.

INTRODUCTION: While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity. METHODS: We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return. RESULTS: We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression. CONCLUSIONS: While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.

The impact of oil industry-related social exclusion on community wellbeing and health in African countries.

Background: Oil is the mainstay revenue for a number of African countries. However, extraction can result in multiple impacts on the health and wellbeing of communities living in oil-rich areas. This review explored evidence of oil industry-related social exclusion on community health and wellbeing on the African continent. Methods: We used a systematic approach guided by PRISMA to search six databases for empirical and descriptive sources focused on oil industry impacts, in any African country, between 1960 to 2021. Findings were grouped according to four dimensions of the Social Exclusion Knowledge Network (SEKN) framework: political, social, economic, and cultural. Results: Fifteen articles were identified, of which 13 articles focused on Nigeria; while one focused on Sudan, and one on Côte d'Ivoire and South Africa. Evidence relating to political aspects of social exclusion encompassed marginalization of indigenous communities through land grabs and unequal representation in political decision making. Limited compensation for environmental damage and livelihood displacement caused by oil-extraction, and high rates of unemployment and poverty were key themes of the economic dimension. Evidence of social impacts included lack of government, or oil-industry investment in social infrastructure; poor health and wellbeing linked to land, air, and water pollution; homelessness and lack of social cohesion. The cultural dimension of social exclusion was comparatively underexplored and only six sources included data collection with indigenous residents, and comparatively more sources were written by non-citizens or non-residents of oil-industry affected areas. Major themes included impacts on collective identity, ways of life and values, particularly where loss of ownership or access to land was experienced. Conclusion: Oil industry activities in African countries are clearly associated with multiple exclusionary impacts. However, the narrow body of empirical research limits understanding of the lived experiences and management of social exclusion by residents of oil-rich areas themselves and is an area deserving of further attention.

Conceptual framework for systemic capacity strengthening for health policy and systems research.

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.

The population health role of academic health centres: a multiple-case exploratory study in Australia and England.

BACKGROUND: Academic health centres (AHCs) are organisations that aim to mobilise knowledge into practice by improving the responsiveness of health systems to emerging evidence. This study aims to explore the population health role of AHCs in Australia and England, where AHCs represent novel organisational forms. METHODS: A multiple-case study design using qualitative methods was used to explore population health goals and activities in four discrete AHCs in both countries during 2017 and 2018. Data from 85 interviews with AHC leaders, clinicians and researchers, direct observation, and documentation were analysed within and across the cases. RESULTS: Comparison across cases produced four cross-case themes: health care rather than population health; incremental rather than major health system change; different conceptions of "translation" and "innovation"; and unclear pathways to impact. The ability of the AHCs to define and enact a population health role was hindered during the study period by gaps in knowledge mobilisation strategies at a health system and policy level, the biomedical orientation of government designation schemes for AHCs in Australia and England, and competing expectations of the sovereign partner organisations in AHCs against a backdrop of limited operational resources. DISCUSSION: The study identifies several institutional elements that are likely to be needed for AHCs in Australia and England to deliver on both internal and external expectations of their population health role.