An assessment on the new impetus of green energy development and its impact on climate change: a non-linear perspective.

The purpose of this article is to investigate the new driving forces behind China's green energy and further assess the impact of green energy on climate change. The existing literature has used linear methods to investigate green energy, ignoring the non-linear relationships between economic variables. The nonparametric models can accurately simulate nonlinear relationships between economic variables. This paper constructs a nonparametric additive model and uses it to explore green energy. The empirical results show that the impact of green finance on green energy is more prominent in the later stage (a U-shaped impact). Fiscal decentralization also exerts a positive U-shaped impact, meaning that expanding local fiscal autonomy has contributed to green energy growth in the later stage. Similarly, the impact of oil prices and foreign direct investment demonstrates a positive U-shaped pattern. However, the nonlinear impact of environmental pressure displays an inverted U-shaped pattern. Furthermore, this article explores the impact of green energy on climate change and its impact mechanisms. The results exhibit green energy generates a positive U-shaped impact on climate change, meaning that the role of green energy in mitigating climate change gradually becomes prominent over time. Mechanism analysis exhibits that industrial structure and energy structure both produce a nonlinear influence on climate change.

How does technological innovation affect the fiscal decentralization of local governments? Evidence from China.

Technological innovation is a pivotal driver of high-quality economic development, and China's distinctive fiscal decentralization model stands out as a crucial institutional factor behind the country's economic growth miracle. Despite its significant academic and practical implications, there is a noticeable scarcity of literature on examining government fiscal decentralization through the lens of technological innovation. This paper addresses fundamental research questions regarding the relationship between technological innovation and fiscal decentralization. Leveraging balanced panel data from 30 provinces in China spanning 2005 to 2020, our findings indicate that technological innovation positively impacts the fiscal decentralization of local governments. Specifically, for each standard deviation increase in technological innovation, there is a corresponding 0.1508 standard deviation in fiscal decentralization. The mechanism driving this relationship lies in technological innovation's ability to enhance enterprise profit levels, increasing tax and non-tax revenues for local governments. Importantly, when non-tax revenue at the central government level surpasses tax revenue, the resulting augmentation in local government revenue contributes to an elevated level of fiscal decentralization. In conclusion, this paper offers valuable insights into the government's endeavors to promote scientific and technological innovation while enhancing local fiscal decentralization. These insights contribute to an improved quality of economic development.

Decoding the impact of fiscal decentralization on urban pollution intensity in China: A spatial econometric analysis.

Utilizing city-level data from China, the paper employs a spatial econometric analysis to investigate the impact of fiscal decentralization on urban pollution. Empirical evidence indicates: (1) In the context of the emphasis of ecological civilization construction in China, an increase of fiscal autonomy for local governments is conducive to mitigating urban pollution intensity. Specifically, fiscal decentralization in one city not only promotes a reduction in local pollution intensity but alleviates environmental pollution problems in adjacent cities through spatial spillover effects. (2) Industrial structure upgrading and green technology progress become crucial measures for local governments to realize pollution reduction targets through fiscal expenditure. (3) Heterogeneity analysis reveals that the positive significance of decentralization is most prominent in the eastern China, while local governments with fiscal autonomy in central region tend to transfer pollution to neighboring cities. (4) There is a threshold characteristic for fiscal decentralization to promote a reduction in urban pollution intensity, and its marginal effect becomes more significant accompanied by continuous introduction of sophisticated foreign direct investment. Finally, the paper summarizes the potential significance of fiscal decentralization among Chinese local governments against the background of "Chinese-style decentralization" and proposes corresponding policy recommendations.

Tracking the Development of Community Engagement Over Time: Realist Qualitative Study.

BACKGROUND: A growing interest in engaging communities in the development of health care services and communities has not automatically led to progress or consensus as to how to engage communities successfully, despite the evidence base showing how to leverage enablers and alleviate barriers. OBJECTIVE: To bridge the gap between the evidence base and which community engagement (CE) approaches have actually been applied in practice over time, this study aims to investigate how CE approaches have changed over the past 4 years in 6 different regions in the Netherlands and citizens' and professionals' experiences underlying these changes. METHODS: For the last stage of a multiple case study following the development of CE approaches in 6 different regions in the Netherlands, a realist qualitative case study was conducted. To investigate how CE approaches had changed over the past 4 years, data from the entire 4 years of the study were used, including documents, interview transcripts, and observations. To examine citizens' and professionals' experiences underlying these changes, new interviews were conducted. The latest interview results were discussed with a panel to ensure the results had face validity. RESULTS: The regions had implemented different types of CE approaches over the past 4 years and were adapting these approaches over time. Many of the (remaining) approaches may be operating on a smaller scale. The study identified the following overarching themes along which CE had been adapted: fewer region-wide approaches and more community-focused approaches, more focus on building relationships with (already engaged) citizens and community-led initiatives, and more focus on practical and tangible health promotion and social cohesion activities and less focus on complex "abstract" programs. The study identified a further 4 overarching themes highlighting citizens' and professionals' experiences underlying these changes in the CE approaches: a lack of engagement environment, need for facilitative leadership from organizations, need for a clear and shared vision underscoring the importance of CE, and misalignment between citizens' and professionals' perspectives and motivations for CE. All participants had experienced the engagement environment as insufficient. To support CE, professionals experienced the need to develop and receive more facilitative leadership and to develop approaches better equipped to involve citizens in the decision-making process. Citizens experienced the need to better align citizens' and professionals' motivations and aims for CE approaches and to receive longer-term financial support for their community-led initiatives. CONCLUSIONS: This study suggests that CE has not yet been embedded within organizational cultures. This has arguably meant that the (remaining) CE approaches are operating on a smaller scale. To enable the further development of CE approaches, an investment in the engagement environment and a shared vision is required. Only then could CE within the regions move beyond the more seemingly smaller-scale CE approaches.

Fiscal decentralization, leader localization, and reduction of pollution and carbon emissions -empirical evidence from China's fiscal "province-managing-county" reform.

The fiscal system plays an important role in the government's environmental governance efforts. There is currently no consensus on how fiscal structure adjustments impact pollution and carbon reduction. This paper uses China's fiscal "province-managing-county" reform (FPMCR) implemented in 2004 as a quasi-natural experiment, utilizing panel data from 1670 counties in China from 2000 to 2020 to investigate the impact of fiscal decentralization on reduction pollution and carbon emissions (RPCE), as well as its underlying mechanisms. The results show that (1) from 2000 to 2020, China's RPCE shows an overall trend of fluctuating increase, with its value turning positive after 2013. China's RPCE exhibits a spatial pattern characterized by "lower in the north, higher in the south; higher in the east, lower in the west". (2) After implementing FPMCR, the RPCE levels in reformed counties decreased by -1.44%, showing that reformed county-level governments prioritize economic development over environmental protection. (3) The mechanism analysis found that after implementing FPMCR, reformed counties experienced a 9.16% increase in nighttime light intensity (NLI), and a 3.99% and 4.34% increase in the number of large-scale industrial enterprises (NLIE) and industrial agglomeration (IA), respectively. This suggests that FPMCR leads to radical urbanization and rapid industrialization in counties, which is detrimental to the improvement of RPCE levels. (4) The spatial heterogeneity analysis found that FPMCR's impact coefficient on RPCE levels in the eastern regions is -1.96%, while in the western regions it is -1.16%. This indicates that reformed counties in the eastern regions are more likely to invest expanded fiscal resources in economic development projects, leading to a decrease in RPCE levels. (5) The temporal heterogeneity analysis found that after the promulgation of the "Three-Year Action Plan to Win the Blue Sky Defense Battle" in 2018, the adverse impact of FPMCR on RPCE is completely reversed, leading to a 1.76% increase in RPCE levels. (6) Further analysis reveals that localizing leaders can slow down the promotion of county-level urbanization and industrialization by the FPMCR, benefiting the improvement of RPCE levels. In other words, "the outsider monk will not recite scriptures as well as a local one". This study has clarified the causal relationship and underlying mechanisms between fiscal decentralization and environmental governance, providing reliable theoretical support for optimizing grassroots fiscal systems and reducing environmental pollution in other transitional economies. It enriches the field of environmental economics related to fiscal decentralization.

Nurturing transformative local structures of multisectoral collaboration for primary health care: qualitative insights from select states in India.

BACKGROUND: Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs. METHODS: Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration. RESULTS: Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency. CONCLUSION: This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.

Decentralization and immunization program in a single-party state: the case of the Lao People's Democratic Republic.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle-income country, lags behind other Southeast Asian countries in immunization coverage for children under two years of age. The organization of health services is a key determinant of the functionality of immunization programs. However, this aspect, and in particular its decentralization component of the healthcare system, has never been studied. METHODS: A case study in the Lao National Immunization Program was performed using a neo-institutional theory-based conceptual framework, highlighting the structure (rules, laws, resources, etc.) and interpretative schemes (dominant beliefs and ideas) that underlie the state of decentralization of the healthcare system that support the conduct of the immunization program. Twenty-two semi-structured interviews were conducted with representative actors from various government levels, external donors, and civil society, in four provinces. Data were complemented with information retrieved from relevant documents. RESULTS: The Lao healthcare system has a deconcentrated form of decentralization. It has a largely centralized structure, albeit with certain measures promoting the decentralization of its immunization programs. The structure underlying the state of centralization of immunization services provided is coherent with a shared dominant interpretive scheme. However, the rapid economic, technical, and educational changes affecting the country suggest that the coherence between structure and interpretative schemes is bound to change. CONCLUSION: Unprecedented opportunities to access quality higher education and the use of social networks are factors in Lao PDR that could affect the distribution of responsibilities of the different levels of government for public health programs such as the National Immunization Program.

Government fiscal decentralization and haze and carbon reduction: Evidence from the fiscal Province-Managing-County reform.

Government governance reform is not only a vital motivation for high economic quality but also an important factor in stimulating the government's environmental governance responsibility. The article empirically examines the fiscal Province-Managing-County (PMC) pilot reform on the synergic governance of haze and carbon reduction and its mechanism. The results show that the policy helps to realize the synergic governance of haze and carbon reduction, and the reform of fiscal Province-Managing-County promotes regional haze and carbon reduction mainly through structural effect, innovation effect, and fiscal expenditure responsibility effect. The heterogeneity analysis shows that the policy has an asymmetric effect on haze and carbon reduction under different administrative structures, economic structures and levels of government intervention. Further analysis shows a policy linkage effect between this policy and the Green Fiscal Policy. The policy has the situation of blood-sucking in the provincial capital city and leads to an increase in financial funds. The above results prove that the policy can help to realize haze and carbon reduction and provide practical ideas for the further expansion of the policy. At the same time, it provides the direction for the local government to realize the double-carbon goal.

Sand cat swarm optimization algorithm and its application integrating elite decentralization and crossbar strategy.

Sand cat swarm optimization algorithm is a meta-heuristic algorithm created to replicate the hunting behavior observed by sand cats. The presented sand cat swarm optimization method (CWXSCSO) addresses the issues of low convergence precision and local optimality in the standard sand cat swarm optimization algorithm. It accomplished this through the utilization of elite decentralization and a crossbar approach. To begin with, a novel dynamic exponential factor is introduced. Furthermore, throughout the developmental phase, the approach of elite decentralization is incorporated to augment the capacity to transcend the confines of the local optimal. Ultimately, the crossover technique is employed to produce novel solutions and augment the algorithm's capacity to emerge from local space. The techniques were evaluated by performing a comparison with 15 benchmark functions. The CWXSCSO algorithm was compared with six advanced upgraded algorithms using CEC2019 and CEC2021. Statistical analysis, convergence analysis, and complexity analysis use statistics for assessing it. The CWXSCSO is employed to verify its efficacy in solving engineering difficulties by handling six traditional engineering optimization problems. The results demonstrate that the upgraded sand cat swarm optimization algorithm exhibits higher global optimization capability and demonstrates proficiency in dealing with real-world optimization applications.

Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal.

INTRODUCTION: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. METHODS: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. RESULTS: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. CONCLUSIONS: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Blockchain Based Decentralized and Proactive Caching Strategy in Mobile Edge Computing Environment.

In the mobile edge computing (MEC) environment, the edge caching can provide the timely data response service for the intelligent scenarios. However, due to the limited storage capacity of edge nodes and the malicious node behavior, the question of how to select the cached contents and realize the decentralized security data caching faces challenges. In this paper, a blockchain-based decentralized and proactive caching strategy is proposed in an MEC environment to address this problem. The novelty is that the blockchain was adopted in an MEC environment with a proactive caching strategy based on node utility, and the corresponding optimization problem was built. The blockchain was adopted to build a secure and reliable service environment. The employed methodology is that the optimal caching strategy was achieved based on the linear relaxation technology and the interior point method. Additionally, in a content caching system, there is a trade-off between cache space and node utility, and the caching strategy was proposed to solve this problem. There was also a trade-off between the consensus process delay of blockchain and the caching latency of content. An offline consensus authentication method was adopted to reduce the influence of the consensus process delay on the content caching. The key finding was that the proposed algorithm can reduce latency and can ensure the security data caching in an IoT environment. Finally, the simulation experiment showed that the proposed algorithm can achieve up to 49.32%, 43.11%, and 34.85% improvements on the cache hit rate, the average content response latency, and the average system utility, respectively, compared to the random content caching algorithm, and it achieved up to 9.67%, 8.11%, and 5.95% increases, successively, compared to the greedy content caching algorithm.

Why does a public health issue (not) get priority? Agenda setting for the national burns programme in India.

There is growing scholarly interest in what leads to global or national prioritization of specific health issues. By retrospectively analysing agenda setting for India's national burn programme, this study aimed to better understand how the agenda-setting process influenced its design, implementation and performance. We conducted document reviews and key informant interviews with stakeholders and used a combination of analytical frameworks on policy prioritization and issue framing for analysis. The READ (readying material, extracting data, analysing data and distilling findings) approach was used for document reviews, and qualitative thematic analysis was used for coding and analysis of documents and interviews. The findings suggest three critical features of burns care policy prioritization in India: challenges of issue characteristics, divergent portrayal of ideas and its framing as a social and/or health issue and over-centralization of agenda setting. First, lack of credible indicators on the magnitude of the problem and evidence on interventions limited issue framing, advocacy and agenda setting. Second, the policy response to burns has two dimensions in India: response to gender-based intentional injuries and the healthcare response. While intentional burns have received policy attention, the healthcare response was limited until the national programme was initiated in 2010 and scaled up in 2014. Third, over-centralization of agenda setting (dominated by a few homogenous actors, located in the national capital, with attention focused on the national ministry of health) contributed to limitations in programme design and implementation. We note following elements to consider when analysing issues of significant burden but limited priority: the need to analyse how actors influence issue framing, the particularities of issues, the inadequacy of any one dominant frame and the limited intersection of frames. Based on this analysis in India, we recommend a decentralized approach to agenda setting and for the design and implementation of national programmes from the outset.

The determinants of legislation for radiofrequency electromagnetic fields (RF-EMFs) with the onset of 5G: An empirical analysis with a worldwide cross-sectional dataset.

The unprecedented exposure of radiofrequency electromagnetic field (RF-EMF) to humans from mobile communications raises serious public concern about the possibility of unexpected adverse health effects and has stimulated authorities to adopt precautionary exposure limits. These limits are distinctly different across countries, and the causes of these differences are unclear from the literature. This article is the first empirical analysis on the determinants of RF-EMF exposure legislation, using a novel cross-sectional database of 164 countries worldwide. The analysis shows that decentralization and mobile competition in countries with low mobile network deployment tend to promote more stringent RF-EMF exposure limits across the dataset with 164 countries. In more decentralized countries, the regions had a greater influence on national legislation and could accommodate local demands with the advent of mobile technology in the 2000s. In contrast, decentralization and mobile competition in countries with high levels of mobile network deployment tend to relax RF-EMF exposure limits in the sample of 61 countries with fifth-generation (5G) technology. Indeed, restrictive RF-EMF exposure limits are constraining 5G deployment in a context of the widespread adoption of mobile-broadband technologies. These results should be useful for policymakers and mobile operators alike to anticipate the outcome of legislation in countries that have yet to introduce 5G technology. The results should also be useful when reviewing policies and strategies for the implementation of the upcoming 6G technology in frequency bands that will be increasingly higher (above 6 GHz up to THz for very local usage), and hence where the health effects on humans are less well studied.

Decentralizing Health Care: History and Opportunities of Web3.

This paper explores the relationship between the development of the internet and health care, highlighting their parallel growth and mutual influence. It delves into the transition from the early, static days of Web 1.0, akin to siloed physician expertise in health care, to the more interactive and patient-centric era of Web 2.0, which was accompanied by advancements in medical technologies and patient engagement. This paper then focuses on the emerging era of Web3-the decentralized web-which promises a transformative shift in health care, particularly in how patient data are managed, accessed, and used. This shift toward Web3 involves using blockchain technology for decentralized data storage to enhance patient data access, control, privacy, and value. This paper also examines current applications and pilot projects demonstrating Web3's practical use in health care and discusses key questions and considerations for its successful implementation.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

Vertical policy coordination of COVID-19 testing in Sweden: an analysis of policy-specific demands and institutional barriers.

PURPOSE: The build-up of large-scale COVID-19 testing required an unprecedented effort of coordination within decentralized healthcare systems around the world. The aim of the study was to elucidate the challenges of vertical policy coordination between non-political actors at the national and regional levels regarding this policy issue, using Sweden as our case. DESIGN/METHODOLOGY/APPROACH: Interviews with key actors at the national and regional levels were analyzed using an adapted version of a conceptualization by Adam et al. (2019), depicting barriers to vertical policy coordination. FINDINGS: Our results show that the main issues in the Swedish context were related to parallel sovereignty and a vagueness regarding responsibilities and mandates as well as complex governmental structures and that this was exacerbated by the unfamiliarity and uncertainty of the policy issue. We conclude that understanding the interaction between the comprehensiveness and complexity of the policy issue and the institutional context is crucial to achieving effective vertical policy coordination. ORIGINALITY/VALUE: Many studies have focused on countries' overall pandemic responses, but in order to improve the outcome of future pandemics, it is also important to learn from more specific response measures.

Toward Verification of DAG-Based Distributed Ledger Technologies through Discrete-Event Simulation.

As the potential of directed acyclic graph (DAG)-based distributed ledgers in IoT systems unfolds, a need arises to understand their intricate dynamics in real-world scenarios. It is well known that discrete event simulations can provide high-fidelity evaluations of protocols. However, there is a lack of public discrete event simulators capable of assessing DAG-based distributed ledgers. In this paper, a discrete-event-based distributed ledger simulator is introduced, with which we investigate a custom Python-based implementation of IOTA's Tangle DAG protocol. The study reveals the dynamics of Tangle (particularly Poisson processes in transaction dynamics), the efficiency and intricacies of the random walk in Tangle, and the quantitative assessment of node convergence. Furthermore, the research underscores the significance of weight updates without depth limitations and provides insights into the role, challenges, and implications of the coordinator/validator in DAG architectures. The results are striking, and although the findings are reported only for Tangle, they demonstrate the need for adaptable and versatile discrete event simulators for DAG architectures and tip selection methodologies in general.

Does the healthcare decentralization provide better public health security capacity and health services satisfaction? An analysis of OECD countries.

PURPOSE: Decentralization has profound implications for many health systems. This study investigates the effect of health system decentralization in Organization for Economic Co-operation and Development (OECD) countries on public health security capacity and health service satisfaction. DESIGN/METHODOLOGY/APPROACH: Multiple linear regression analyses were employed for variables related to the level of health security capacity and satisfaction with the healthcare system while controlling for all socio-demographic variables from the European Social Survey, including over 44,000 respondents from 25 OECD countries. The Health Systems in Transition series of countries were used for assessing the decentralization level. FINDINGS: The result of multiple linear regression analyses showed that the level of decentralization in health systems was significantly associated with higher health security capacity (ß-coefficient 3.722, 95% confidence interval (CI) [3.536 3.908]; p=<0.001) and health service satisfaction (ß-coefficient 1.463, 95% CI [1.389 1.536]; p=<0.001) in the study. Countries with a higher level of decentralization in health policy tasks and areas were significantly likely to have higher health services satisfaction, whereas this satisfaction had a significant negative relation with the lower level of decentralization status of secondary/tertiary care services in OECD countries (ß-coefficient -5.250, 95% CI [-5.757-4.743]; p = 0.001). ORIGINALITY/VALUE: This study contributes to a better understanding of the extent to which decentralization of health services affects public health safety capacity and satisfaction with health services, whereas the level of decentralization in OECD countries varies considerably. Overall, the findings highlight the importance of public health security and satisfaction with health care delivery in assessing the effects of decentralization in health services.

Implementing health system and the new federalism in Somalia: challenges and opportunities.

In the 21st century, healthcare stands out as a formidable, contentious social responsibility for governments due to its high costs. This study delves into Somalia's healthcare system under Federal Government leadership, scrutinizing the complexities of health governance and financing. The Federal Government (FGS), along with governmental states (FMS) and regional authorities, collectively shoulder leadership and governance roles within Somalia's healthcare framework. Vital to resilient and inclusive development, the health sector holds a pivotal role. A strategic investment in healthcare not only drives substantial demographic dividends through enhanced life expectancy and reduced fertility rates, but also paves Somalia's trajectory toward progress. The Federal Government of Somalia confronts a multitude of challenges in its pursuit of effective healthcare implementation. A prominent obstacle lies in health financing. Somalia relies heavily on international and private sources for health support, primarily due to limited government revenue generation. This financial shortfall restrains the government's capacity to allocate ample funds for public services and critical investments, including healthcare. This paper sheds light on the present healthcare landscape in Somalia and expounds on the hurdles confronted by healthcare systems under federal governance. Moreover, it delves into the historical evolution of Somalia's healthcare system and the advent of new federalist principles. In doing so, this study comprehensively examines the dynamics of healthcare governance, financing, and historical progression in Somalia.

Decentralized Clinical Trials: Scientific Considerations Through the Lens of the Estimand Framework.

While industry and regulators' interest in decentralized clinical trials (DCTs) is long-standing, the Covid-19 pandemic accelerated and broadened the adoption and experience with these trials. The key idea in decentralization is bringing the clinical trial design, typically on-site, closer to the patient's experience (on-site or off-site). Thus, potential benefits of DCTs include reducing the burden of participation in trials, broadening access to a more diverse population, or using innovative endpoints collected off-site. This paper helps researchers to carefully evaluate the added value and the implications of DCTs beyond the operational aspects of their implementation. The proposed approach is to use the ICH E9(R1) estimand framework to guide the strategic decisions around each decentralization component. Furthermore, the framework can guide the process for clinical trialists to systematically consider the implications of decentralization, in turn, for each attribute of the estimand. We illustrate the use of this approach with a fully DCT case study and show that the proposed systematic process can uncover the scientific opportunities, assumptions, and potential risks associated with a possible use of decentralization components in the design of a trial. This process can also highlight the benefits of specifying estimand attributes in a granular way. Thus, we demonstrate that bringing a decentralization component into the design will not only impact estimators and estimation but can also correspond to addressing more granular questions, thereby uncovering new target estimands.