The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review.

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups-for example, individual companies, corporations or interest groups-representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access.

Social media opposition to the 2022/2023 UK nurse strikes.

Previous research has established that the success of strikes, and social movements more broadly, depends on their ability to garner support from the public. However, there is scant published research investigating the response of the public to strike action by healthcare workers. In this study, we address this gap through a study of public responses to UK nursing strikes in 2022-2023, using a data set drawn from Twitter of more than 2300 publicly available tweets. We focus on negative tweets, investigating which societal discourses social media users draw on to oppose strike action by nurses. Using a combination of corpus-based approaches and discourse analysis, we identified five categories of opposition: (i) discourse discrediting nurses; (ii) discourse discrediting strikes by nurses; (iii) discourse on the National Health System; (iv) discourse about the fairness of strikers' demands and (v) discourse about potential harmful impact. Our findings show how social media users operationalise wider societal discourses about the nursing profession (e.g., associations with care, gender, vocation and sacrifice) as well as recent crises such as the Covid-19 pandemic to justify their opposition. The results also provide valuable insights into misconceptions about nursing, strike action and patient harm, which can inform strategies for public communication.

Associations, unions and everything in between: contextualising the role of representative health worker organisations in policy.

Associations, unions and other organised groups representing health workers play a significant role in the development, adoption and implementation of health policy. These representative health worker organisations (RHWOs) are a key interface between employers, governments and their members (both actual and claimed), with varying degrees of influence and authority within and across countries. Existing research in global health often assumes-rather than investigates-the roles played by RHWOs in policy processes and lacks analytical specificity regarding the definitional characteristics of RHWOs. In this article, we seek to expand and complicate conceptualisations of RHWOs as key actors in global health by unpacking the heterogeneity of RHWOs and their roles in policy processes and by situating RHWOs in context. First, we define RHWOs, present a typology of RHWO dimensions and discuss perceived legitimacy of RHWOs as policy actors. Next, we unpack the roles of RHWOs in policy processes and distinguish RHWO roles in regulation from those of regulatory agencies. The final sections situate RHWOs in political and labour relations contexts, and in sociohistorical contexts, with attention to institutional frameworks, professional hierarchies and intersectional factors such as race, gender, sexuality, class, caste and religion. We conclude by outlining research gaps in the study of RHWOs and policy, and by encouraging global health researchers and practitioners to incorporate an expanded focus on these actors. Taking this approach will generate a wider range of strategies to better engage these organisations in policy processes and will ensure stronger health workforce policies globally.

Coloniality, Elite Networks and Intersectionality: Key Concepts in Understanding Biomedical Power and Equity in Health Policy Processes Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process".

To understand the role of power in health policy processes in low- and middle-income country (LMIC) contexts, it is necessary to engage with global and local power structures and their historical contexts. In this commentary, we outline three dimensions that shape a dominant power in health policy processes-the biomedical power. We propose that understanding the linkages between medical power and colonialism; the close connection of public health, medicine and elite networks; and the intersectionalities that shape the powers of medical professionals can offer the means to examine the biomedical hegemony in health policy processes. Additionally we suggest that a more nuanced understanding of the interaction of local powers with global funding can offer some entry points to achieving more equitable and interdisciplinary health policy processes in LMICs.

Interest Groups and Health Facility Regulation - Future Directions for Health Policy and Systems Research Comment on "What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya's Health Facility Inspection Reforms".

In their paper, Tama and colleagues observe that one key challenge in a pilot, multi-component intervention to strengthen health facility regulation was the reaction from health facility owners and providers to regulatory processes. In this commentary, we propose that future research and action on health facility regulation in low- and middle-income countries (LMICs) contexts adopt an explicit focus on addressing the role of interests and interest groups in health systems 'hardware' and 'software.' Research on policy processes in LMICs consist of fewer investigations into the political economy of national or sub-national interest groups, such as physician associations or associations of health facility owners. A growing body of literature explores supply-side and demand-side interest groups, power relations within and between these stakeholders, and their advocacy approaches within LMIC health sector policy processes. We posit that such analyses will also help identify facilitators and challenges to implementation and scale-up of similar reforms to health facility regulation.

Investigating the influence of institutions, politics, organizations, and governance on the COVID-19 response in British Columbia, Canada: a jurisdictional case study protocol.

BACKGROUND: Research on public health responses to COVID-19 globally has largely focused on understanding the virus' epidemiology, identifying interventions to curb transmission, and assessing the impact of interventions on outcomes. Only recently have studies begun to situate their findings within the institutional, political, or organizational contexts of jurisdictions. Within British Columbia (BC), Canada, the COVID-19 response in early 2020 was deemed highly coordinated and effective overall; however, little is understood as to how these upstream factors influenced policy decisions. METHODS: Using a conceptual framework we developed, we are conducting a multidisciplinary jurisdictional case study to explore the influence of institutional (I), political (P), organizational (O), and governance (G) factors on BC's COVID-19 public health response in 2020-2021. A document review (e.g. policy documents, media reports) is being used to (1) characterize relevant institutional and political factors in BC, (2) identify key policy decisions in BC's epidemic progression, (3) create an organizational map of BC's public health system structure, and (4) identify key informants for interviews. Quantitative data (e.g. COVID-19 case, hospitalization, death counts) from publicly accessible sources will be used to construct BC's epidemic curve. Key informant interviews (n = 15-20) will explore governance processes in the COVID-19 response and triangulate data from prior procedures. Qualitative data will be analysed using a hybrid deductive-inductive coding approach and framework analysis. By integrating all of the data streams, our aim is to explore decision-making processes, identify how IPOG factors influenced policy decisions, and underscore implications for decision-making in public health crises in the BC context and elsewhere. Knowledge users within the jurisdiction will be consulted to construct recommendations for future planning and preparedness. DISCUSSION: As the COVID-19 pandemic evolves, governments have initiated retrospective examinations of their policies to identify lessons learned. Our conceptual framework articulates how interrelations between IPOG contextual factors might be applied to such analysis. Through this jurisdictional case study, we aim to contribute findings to strengthen governmental responses and improve preparedness for future health crises. This protocol can be adapted to and applied in other jurisdictions, across subnational jurisdictions, and internationally.

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients.

OBJECTIVE: To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models. DESIGN: Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis. SETTING: In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care). PARTICIPANTS: Twelve standard care and 12 CCP patients were interviewed. RESULTS: Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination). CONCLUSION: Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Power analysis in health policy and systems research: a guide to research conceptualisation.

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India.

BACKGROUND: In India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, 'bundled' approach to strengthening rural distribution and retention of doctors. METHODS: We utilized three forms of data collection for this study - document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019. RESULTS: We found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level. CONCLUSION: Building on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency.

The impact of colonial-era policies on health workforce regulation in India: lessons for contemporary reform.

BACKGROUND: Regulation is a critical function in the governance of health workforces. In many countries, regulatory councils for health professionals guide the development and implementation of health workforce policy, but struggle to perform their responsibilities, particularly in low- and middle-income countries (LMICs). Few studies have analyzed the influence of colonialism on modern-day regulatory policy for health workforces in LMICs. Drawing on the example of regulatory policy from India, the goals of this paper is to uncover and highlight the colonial legacies of persistent challenges in medical education and practice within the country, and provide lessons for regulatory policy in India and other LMICs. MAIN BODY: Drawing on peer-reviewed and gray literature, this paper explores the colonial origins of the regulation of medical education and practice in India. We describe three major aspects: (1) Evolution of the structure of the apex regulatory council for doctors-the Medical Council of India (MCI); (2) Reciprocity of medical qualifications between the MCI and the General Medical Council (GMC) in the UK following independence from Britain; (3) Regulatory imbalances between doctors and other cadres, and between biomedicine and Indian systems of medicine. CONCLUSIONS: Challenges in medical education and professional regulation remain a major obstacle to improve the availability, retention and quality of health workers in India and many other LMICs. We conclude that the colonial origins of regulatory policy in India provide critical insight into contemporary debates regarding reform. From a policy perspective, we need to carefully interrogate why our existing policies are framed in particular ways, and consider whether that framing continues to suit our needs in the twenty-first century.

Visualizing the drivers of an effective health workforce: a detailed, interactive logic model.

BACKGROUND: A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making. METHODS: We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool. RESULTS: Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms. CONCLUSIONS: The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy.

A Draconian Law: Examining the Navigation of Coalition Politics and Policy Reform by Health Provider Associations in Karnataka, India.

A comprehensive picture of provider coalitions in health policy making remains incomplete because of the lack of empirically driven insights from low- and middle-income countries. The authors examined the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes between 2016 and 2018 for developing amendments to the Karnataka Private Medical Establishments Act. Through this case, they explore how provider associations function, coalesce, and compete and the implications of their actions on policy outcomes. They conducted in-depth interviews, document analysis, and nonparticipant observations of two conferences organized by associations. They found that provider associations played a major role in drafting the amendments and negotiating competing interests within and between doctors and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. The authors' analysis highlights the importance of further empirical study on the influence of professional and trade associations across a range of health policy cases in low- and middle-income countries.

Perceptions of the Doctor-Patient Relationship Among Patients in a Private, Secondary-Level Hospital in Southern India.

Introduction: An epidemic of non-communicable diseases (NCDs) in India is fueling a growing demand for primary care and hospitalization services. Difficulties in coordinating inpatient and outpatient care create significant barriers to providing high-quality medical care. In this paper, we describe patient experiences, perceptions, and expectations of doctor-patient relationships in a secondary-level private hospital in Karnataka, India. Methods: We conducted a cross-sectional, mixed-method needs assessment with surveys and in-depth interviews at Dr. TMA Pai Hospital (TMAPH), a secondary-level, private sector hospital in Karnataka, India. Inclusion criteria included all adults over 18 years old hospitalized at TMAPH in the past year. Patients were consecutively recruited from August 2019-October 2019 and asked to rate aspects of their relationship with their primary care provider (PCP). Descriptive statistics and multivariable logistic regression were used to analyze predictors of the doctor-patient relationship. Patients were interviewed regarding their perceptions of care coordination and doctor-patient relationships. General Thematic Analysis was utilized to analyze qualitative data and develop themes. Quantitative and qualitative findings were then merged to interpret the various dimensions of doctor-patient relationships. Results: A total of 150 patients (47.3% male) enrolled. Ten patients underwent qualitative interviews. The median patient age was 67 years (IQR 56-76). 112 (74.7%) of patients identified a PCP either at or outside of TMAPH. 89% had diabetes and/or hypertension. Compared to patients without a PCP, having a PCP led to a significantly higher adjusted odds of always spending optimal time with their doctors (aOR 2.7, 95% CI 1.1-6.8, p = 0.04), and always receiving clear instructions on managing their medical conditions (aOR 2.5, 95% CI 1.0-6.1, p = 0.04). The following themes were developed from patient interviews: (1) patients trusted and respected their PCP believing they were receiving high quality care; and (2) despite perceived fragmentation in care, patients spoke favorably of their relationships with their doctors. Conclusions: Among a sample of recently hospitalized patients, those with a PCP reported more positive doctor-patient relationships, though rates of dissatisfaction with doctors were still high. Further research and strategies are required to optimize continuity of care and doctor-patient relationships across the entire continuum of outpatient and inpatient care.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework.

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure, explicit and functional) and "soft" (de facto, tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.