How can Health in All Policies approaches support the transition to the well-being economy?

Health in All Policies approaches support the integration of health considerations into the policies of traditionally siloed governance systems. These siloed systems are often ignorant of the fact that health is created outside of the health system and starts long before you see a health professional. Thus, the purpose of Health in All Policies approaches is to raise the importance of the broad-based impacts on health from these public policies and to implement healthy public policy that delivers human rights for all. This approach requires significant adjustments to current economic and social policy settings. A well-being economy similarly aspires to create policy incentives that increase the importance of social and non-monetized outcomes, such as increased social cohesion environmental sustainability and health. These outcomes can evolve deliberately alongside economic benefits and are impacted by economic and market activities. The principles and functions underpinning Health in All Policies approaches, such as joined-up policy making can be helpful to transition towards a well-being economy. Governments will need to move beyond the currently held principle of "economic growth and profit above all else" if countries are to tackle growing societal inequity and catastrophic climate changes. Rapid digitization and globalization have further entrenched the focus on monetary economic outcomes rather than other aspects of human welfare. This has created an increasingly difficult context within which to prioritize social policies and efforts aimed to achieve primarily social and not profit-oriented goals. In the face of this larger context, alone, Health in All Policies approaches will not bring about the needed transformation to achieve healthy populations and economic transition. However, Health in All Policies approaches do offer lessons and a rationale that is aligned with, and can support the transition to, a well-being economy. Transforming current economic approaches to a well-being economy is imperative to achieve equitable population health, social security and climate sustainability.

Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission.

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission.

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

Priority-setting for achieving universal health coverage.

Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation's resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost-effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities - implicitly or explicitly - it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Les gouvernements des pays à revenu faible et intermédiaire sont en train de légitimer la mise en place de la couverture sanitaire universelle (CSU), suite à une résolution des Nations Unies de 2012 sur la CSU et à son entérinement dans les objectifs de développement durable fixés en 2015. La CSU variera selon les pays, en fonction de leur contexte et de leurs besoins, ainsi qu'en fonction de la demande et de l'offre de soins. Des questions fondamentales ont ainsi été soulevées par les responsables politiques et les parties prenantes, portant notamment sur les objectifs, les utilisateurs et le rapport coût-efficacité de la CSU. Si les autorités sanitaires déterminent quotidiennement des priorités, de façon implicite ou explicite, la marche à suivre pour définir les priorités en matière de CSU n'a pas été clairement établie. Nous justifions ici la nécessité de définir explicitement les priorités dans le domaine de la santé tout en donnant des orientations aux pays pour définir les priorités en matière de CSU.

Los gobiernos de países con ingresos bajos y medios están legitimando la implementación de una cobertura sanitaria universal (CSU) tras un acuerdo de las Naciones Unidas acerca de la cobertura sanitaria universal en 2012 y su consolidación en los objetivos de desarrollo sostenible establecidos en 2015. Cada país tendrá una cobertura sanitaria universal distinta, según el contexto y las necesidades de cada uno, así como la oferta y la demanda de atención sanitaria. Por tanto, los responsables políticos y partes interesadas han abordado los asuntos fundamentales como los objetivos, los usuarios y la rentabilidad de la cobertura sanitaria universal. A pesar de que las autoridades sanitarias han establecido prioridades diarias (de forma implícita o explícita), no se ha aclarado cómo se debería gestionar el establecimiento de prioridades para la cobertura sanitaria universal. Se ofrece una justificación para el establecimiento de prioridades sanitarias explícitas y orientación a los países en la definición de prioridades para la cobertura sanitaria universal.

Women Who Lead: Successes and Challenges of Five Health Leaders.

Women make up approximately 75% of the health workforce and yet their representation at higher levels of health leadership is limited. Untapped potential of women in health undermines the contribution they could make to effective leadership for health systems strengthening. Lived experiences of women leaders can help understand how to unlock this potential by identifying the challenges, highlighting enablers, and sharing successful strategies used to become effective health leaders. This article uses phenomenological inquiry to understand the subjective experiences of five influential women in their paths to health leadership. Interviews were conducted with these women and key messages were identified. A grounding theme-defined as the essential element for the subjective experience of leading as a woman in the health system-was revealed to be the women's "drive for equity." This drive motivated them to pursue a career in health and to break through perceived gender-related barriers. Three figural themes around how to practice effective health leadership to promote equity were identified: (1) challenging status quos and norms; (2) leading by listening and leveraging others' expertise to build a common vision for health; and (3) having social support early on to develop confidence and credibility. Stories from the individual women's experiences are presented. Finally, three recommendations are made for system-level mechanisms that could contribute to expanding the number of women leaders in health.

[Equity-oriented monitoring in the context of universal health coverage]. / El monitoreo orientado a la equidad en el contexto de la cobertura universal de salud.

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

El monitoreo orientado a la equidad en el contexto de la cobertura universal de salud / Equity-oriented monitoring in the context of universal health coverage

El monitoreo de las desigualdades en la salud es fundamental para el logro progresivo y equitativo de la cobertura universal de salud. Para que tenga éxito, el monitoreo global de las desigualdades debe ser lo suficientemente intuitivo a fin de que pueda adoptarse ampliamente y debe mantener al mismo tiempo su credibilidad técnica. En este artículo se analizan algunas consideraciones metodológicas para el monitoreo de la cobertura universal de salud orientado a la equidad y se proponen recomendaciones con respecto al monitoreo y el establecimiento de metas. La desigualdad es multidimensional, de modo que el grado de desigualdad puede variar considerablemente entre distintas dimensiones, como la posición económica, la educación, el sexo y la residencia urbana o rural. Por ello, el monitoreo global debe incluir dimensiones complementarias de la desigualdad (como la posición económica y la residencia urbana o rural) y el sexo. Para una dimensión dada de la desigualdad, deben establecerse subgrupos para el monitoreo considerando la aplicabilidad de los criterios entre los países y la heterogeneidad de los subgrupos. En el caso de la desigualdad asociada a la posición económica, recomendamos formar subgrupos utilizando quintiles y para la desigualdad por residencia urbana o rural, recomendamos una categorización binaria. La desigualdad abarca las poblaciones, por lo que los enfoques apropiados para el monitoreo deben basarse en comparaciones entre dos subgrupos (enfoque de brecha) o entre múltiples subgrupos (enfoque de gradiente o espectro completo). Al medirse la desigualdad, las mediciones absolutas y relativas deben comunicarse al mismo tiempo, junto con los datos desagregados; la desigualdad debe informarse junto con el promedio nacional. Recomendamos establecer metas que se basen en reducciones proporcionales de la desigualdad absoluta en los grupos poblacionales. Crear la capacidad de monitorear las desigualdades en la salud es oportuno, pertinente e importante. El desarrollo de sistemas de información de salud de alta calidad, incluidas la recolección, el análisis y la interpretación de los datos y las prácticas de presentación de informes vinculadas a los ciclos de revisión y evaluación en los sistemas de salud, permitirá realizar un monitoreo eficaz de las desigualdades en la salud a escala mundial y nacional. Estas medidas apoyarán el logro progresivo de la cobertura universal de salud orientado a la equidad.

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

Equity-oriented monitoring in the context of universal health coverage.

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS).

Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Barreras y facilitadores para el control prenatal en adolescentes: resultados de un estudio cualitativo en Chile / Barriers and facilitators to antenatal care in adolescents: results of a qualitative study in Chile

Objetivo. Analizar barreras y facilitadores de acceso a control prenatal en adolescentes urbanas de 15-19 años en Santiago, Chile. Material y métodos. Estudio cualitativo con 17 madres adolescentes basado en la teoría fundamentada. Se realizaron 11 entrevistas semiestructuradas y un grupo focal. Resultados. La negación y ocultamiento del embarazo es la principal barrera para ingresar a control en el grupo de acceso tardío; no se identificaron facilitadores. Para mantenerse en control, todas las participantes identifican como facilitador contar con una figura de apoyo. La vulnerabilidad familiar y social explica que algunas adolescentes ingresen a control tardíamente. Conclusión. La presencia de facilitadores es determinante para el ingreso oportuno y mantenerse en control, ya que reduce o anula el efecto de las barreras. El sistema de salud debe constituirse en un facilitador que acompañe desde muy temprano a las adolescentes favoreciendo un vínculo de confianza y respeto.

Objective. Analyze barriers and facilitators of access to prenatal care in pregnant urban adolescents between 15-19 years of age in Santiago, Chile. Materials and methods. Qualitative study based on grounded theory with 17 adolescent mothers. Eleven semi-structured interviews and one focus group were conducted. Results. The denial and concealment of pregnancy is the main barrier to start the prenatal care in the "delayed access group". This group does not identify facilitators. For maintenance in antenatal care, all participants identified a support figure as a facilitator. Family and social vulnerabilities explain why some adolescents start the prenatal care late. Conclusion. The presence of facilitators is crucial for both, the timely entry and the maintenance in antenatal care because they reduce or nullify the effect of barriers. The health system must become a facilitator to accompany adolescents and promote a bond of trust and respect.