Consórcios intermunicipais de saúde (CIS) como estratégia de regionalização: um olhar a partir da literatura sobre as experiências de gestão consorciada no Brasil

A literatura defende que os Consórcios Intermunicipais de Saúde têm aptidão para enfrentar os dilemas da regionalização e entraves da descentralização pela cogestão e ampliação da oferta. A indução da gestão estadual incentiva a criação e manutenção dos CIS, mas tais arranjos enfrentam desafios na relação com a CIR, CIB e regionais de saúde. É incipiente a avaliação dos CIS como estratégia de regionalização, sendo necessários estudos adicionais.

Global, regional, and national estimates of target population sizes for covid-19 vaccination: descriptive study.

OBJECTIVE: To provide global, regional, and national estimates of target population sizes for coronavirus disease 2019 (covid-19) vaccination to inform country specific immunisation strategies on a global scale. DESIGN: Descriptive study. SETTING: 194 member states of the World Health Organization. POPULATION: Target populations for covid-19 vaccination based on country specific characteristics and vaccine objectives (maintaining essential core societal services; reducing severe covid-19; reducing symptomatic infections and stopping virus transmission). MAIN OUTCOME MEASURE: Size of target populations for covid-19 vaccination. Estimates use country specific data on population sizes stratified by occupation, age, risk factors for covid-19 severity, vaccine acceptance, and global vaccine production. These data were derived from a multipronged search of official websites, media sources, and academic journal articles. RESULTS: Target population sizes for covid-19 vaccination vary markedly by vaccination goal and geographical region. Differences in demographic structure, presence of underlying conditions, and number of essential workers lead to highly variable estimates of target populations at regional and country levels. In particular, Europe has the highest share of essential workers (63.0 million, 8.9%) and people with underlying conditions (265.9 million, 37.4%); these two categories are essential in maintaining societal functions and reducing severe covid-19, respectively. In contrast, South East Asia has the highest share of healthy adults (777.5 million, 58.9%), a key target for reducing community transmission. Vaccine hesitancy will probably impact future covid-19 vaccination programmes; based on a literature review, 68.4% (95% confidence interval 64.2% to 72.6%) of the global population is willing to receive covid-19 vaccination. Therefore, the adult population willing to be vaccinated is estimated at 3.7 billion (95% confidence interval 3.2 to 4.1 billion). CONCLUSIONS: The distribution of target groups at country and regional levels highlights the importance of designing an equitable and efficient plan for vaccine prioritisation and allocation. Each country should evaluate different strategies and allocation schemes based on local epidemiology, underlying population health, projections of available vaccine doses, and preference for vaccination strategies that favour direct or indirect benefits.

A network model of Italy shows that intermittent regional strategies can alleviate the COVID-19 epidemic.

The COVID-19 epidemic hit Italy particularly hard, yielding the implementation of strict national lockdown rules. Previous modelling studies at the national level overlooked the fact that Italy is divided into administrative regions which can independently oversee their own share of the Italian National Health Service. Here, we show that heterogeneity between regions is essential to understand the spread of the epidemic and to design effective strategies to control the disease. We model Italy as a network of regions and parameterize the model of each region on real data spanning over two months from the initial outbreak. We confirm the effectiveness at the regional level of the national lockdown strategy and propose coordinated regional interventions to prevent future national lockdowns, while avoiding saturation of the regional health systems and mitigating impact on costs. Our study and methodology can be easily extended to other levels of granularity to support policy- and decision-makers.

Reducing Infant Mortality Using Telemedicine and Implementation Science.

Optimal perinatal regionalization is a proven evidence-based strategy to lower infant mortality. Telemedicine can engage community stakeholders, providers, and patients to facilitate optimal perinatal regionalization leading to lower infant mortality. Rural community caregivers and administrators can participate in forming optimal perinatal guidelines without leaving their community. The visual picture created by telemedicine facilitates better transport decisions; ensuring infants who are transferred to larger centers truly need it while supporting smaller nurseries by providing better consultation services and back transport of patients when appropriate. Telemedicine can also provide educational opportunities to community practices, leading to better evidence-based care.

Models and methods for determining the optimal number of beds in hospitals and regions: a systematic scoping review.

BACKGROUND: Determining the optimal number of hospital beds is a complex and challenging endeavor and requires models and techniques which are sensitive to the multi-level, uncertain, and dynamic variables involved. This study identifies and characterizes extant models and methods that can be used to determine the required number of beds at hospital and regional levels, comparing their advantages and challenges. METHODS: A systematic search was conducted using Web of Science, Scopus, Embase and PubMed databases, with the search terms hospital bed capacity, hospital bed need, hospital, bed size, model, and method. RESULTS: Twenty-three studies met the criteria to be included in the review. Of these studies, a total of 11 models and 5 methods were identified, mainly designed to determine hospital bed capacity at the regional level. Common determinants of the required number of hospital beds in these models included demographic changes, average length of stay, admission rates, and bed occupancy rates. CONCLUSIONS: There are no specific norms for the required number of beds at hospital and regional levels, but some of the identified models and methods may be used to estimate this number in different contexts. Moreover, it is important to consider alternative approaches to planning hospital capacity like care pathways to fix the limitations of "bed numbers".

Automated delineation of hospital service areas as a new tool for health care planning.

OBJECTIVE: To develop an automated, reproducible method for delineating hospital service areas (HSAs). DATA SOURCES/SETTING: Discharge data from all Swiss acute care hospitals for the years 2013 to 2016. STUDY DESIGN: We derived HSAs and hospital referral regions for Switzerland using a newly developed flow-based, automated, objective, and reproducible method using all discharge data. We compared our method to the classical, partially subjective approach used to delineate the Swiss Health Care Atlas by delineating four sets of intervention-specific HSAs. PRINCIPAL FINDINGS: Based on 4 105 885 discharges, the fully automated method delineated 63 HSAs. Comparison with existing HSAs reveals good overlap and comparable measures of health utilization between the methods and shows that in the Swiss setting, our method outperforms a cluster-based approach to defining HSAs. While the classical method potentially takes an entire day to delineate the regions, our method took approximately 10 minutes. CONCLUSIONS: Hospital service areas are used to analyze differences in use of health care that may indicate underuse and overuse. Our new, fully automated, objective, and reproducible method provides a useful tool for hospital services researchers that will enable them to delineate and update patient-flow-based HSAs.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017.

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014-2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

Regionalização em saúde em Minas Gerais: uma análise da percepção dos representantes de Comissões Intergestores Regionais / Health Regionalization in Minas Gerais: An Analysis of the Perception of Representatives of Regional Inter-managerial Commissions

Resumo Este estudo tem como objetivo analisar a percepção de representantes de Comissões Intergestores Regionais (CIRs) sobre o processo de regionalização em saúde no Estado de Minas Gerais. Foram realizadas entrevistas com representantes de dez regiões de saúde do estado. Os dados, analisados por meio do software IRAMUTEQ, geraram um dendograma com dois eixos temáticos. O primeiro eixo, denominado "O papel das CIRs e dos principais atores no processo de governança regional", subdividiu-se nas classes 4, 3 e 2, que abordaram, respectivamente, o protagonismo dos apoiadores do Conselho de Secretarias Municipais de Saúde (COSEMS) nas CIRs; a CIR como espaço de pactuação das ações regionais; atores envolvidos na governança da região de saúde. O segundo, denominado "Organização da assistência nas redes de atenção", subdividiu-se nas classes 5, 1 e 6, que descreveram, respectivamente, vazios assistenciais nas regiões de saúde; fragilidades e potencialidades do processo de regionalização; dificuldades de provisão de serviços de média e alta complexidade. A regionalização em saúde em Minas Gerais, apesar de estratégias bem-sucedidas, apresenta grandes desafios. O financiamento insuficiente do SUS, em um cenário de disputas políticas, e fragmentação de recursos prejudica a provisão da atenção nas regiões de saúde. Trata-se, portanto, de um processo em construção.

Abstract This study aims to analyze the perception of representatives of Regional Inter-managerial Commissions on the process of health regionalization in the State of Minas Gerais. Interviews were conducted with representatives of 10 state health regions. The data, analyzed through IRAMUTEQ software, generated a dendogram with two thematic axes. The first axis, called "The role of CIR and key actors in the regional governance process", was subdivided into classes 4, 3 and 2, which addressed, respectively, the role of the Council of Municipal Health Secretaries supporters in the Commissions; the Commissions as a space for agreement on regional actions; the actors involved in the governance of the health region. The second, called "Organization of assistance in the care networks" was subdivided into classes 5, 1 and 6, which described, respectively, care gaps in the health regions; weaknesses and potentialities of the regionalization process; difficulties in providing medium and high complexity services. Health regionalization in Minas Gerais, despite successful strategies, brings great challenges. Insufficient financing of the SUS in a scenario of political disputes and resource fragmentation undermines the provision of care in health regions. It is a process still under construction.

Using geographic information systems to map older people's emergency department attendance for future health planning.

OBJECTIVES: This study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large hospital in Dublin. METHODS: A retrospective analysis of 2 years of data from an urban university teaching hospital ED in the southern part of Dublin was reviewed for the period 2014-2015 (n=103 022) to capture the records of attenders. All ED presentations by individuals 65 years and older were extracted for analysis. Address-matched records were analysed using QGIS, a geographic information systems (GIS) analysis and visualisation tool to determine straight-line distances travelled to the ED by age. RESULTS: Of the 49 538 non-duplicate presentations in the main database, 49.9% of the total are women and 49.1% are men. A subset comprised of 40 801 had address-matched records. When mapped, the data showed a distinct clustering of addresses around the hospital site but this clustering shows different patterns based on age cohort. Average distances travelled to ED are shorter for people 65 and older compared with younger patients. Average distances travelled for those aged 65-74 was 21 km (n=4177 presentations); for the age group 75-84, 18 km (n=2518 presentations) and 13 km for those aged 85 and older (n=2104 presentations). This is validated by statistical tests on the clustered data. Self-referral rates of about 60% were recorded for each age group, although this varied slightly, not significantly, with age. CONCLUSIONS: Health planning at a regional level should account for the significant number of older patients attending EDs. The use of GIS for health planning in particular can assist hospitals to improve their understanding of the origin of the cohort of older ED patients.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Multiple chronic conditions: the need for integrated secondary care.

Current hospital-level care is "mostly disease-specific and monodisciplinary-oriented". These three case reports show different journeys that patients with multiple chronic conditions experienced in Dutch secondary outpatient care, and aim to demonstrate why an integrated care approach might be beneficial for this group of patients.

How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners.

OBJECTIVES: To understand approaches to priority setting for healthcare service resource allocation at an operational level in a nationally commissioned but regionally delivered service. DESIGN: Qualitative study using semistructured interviews and a Framework analysis. SETTING: National Health Service dentistry commissioning teams within subregional offices in England. PARTICIPANTS: All 31 individuals holding the relevant role (dental lead commissioner in subregional offices) were approached directly and from this 14 participants were recruited, with 12 interviews completed. Both male and female genders and all regions were represented in the final sample. RESULTS: Three major themes arose. First, 'Methods of priority setting and barriers to explicit approaches' was a common theme, specifically identifying the main methods as: perpetuating historical allocations, pressure from politicians and clinicians and use of needs assessments while barriers were time and skill deficits, a lack of national guidance and an inflexible contracting arrangements stopping resource allocation. Second, 'Relationships with key stakeholders and advisors' were discussed, showing the important nature of relationships with clinical advisors but variation in the quality of these relationships was noted. Finally, 'Tensions between national and local responsibilities' were illustrated, where there was confusion about where power and autonomy lay. CONCLUSIONS: Commissioners recognised a need for resource allocation but relied on clinical advice and needs assessment in order to set priorities. More explicit priority setting was prevented by structure of the commissioning system and standard national contracts with providers. Further research is required to embed and simplify adoption of tools to aid priority setting.

Barriers to Regionalized Surgical Care: Public Perspective Survey and Geospatial Analysis.

OBJECTIVE: To describe public willingness to participate in regionalized surgical care for cancer. SUMMARY OF BACKGROUND DATA: Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described. METHODS: As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization. RESULTS: Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness. CONCLUSION: Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.

Mapeo de los Programas de Formación en Salud familiar y comunitaria. Centroamérica y República Dominicana / Mapping of the Programs of Health Training family and community. Central America and the Dominican Republic

El presente documento constituye un esfuerzo para identificar y caracterizar los programas de formación en salud familiar y comunitaria en la Subregión, como un paso que permitirá avanzar hacia la armonización de la formación en este campo y en general hacia la homologación y acreditación las carreras de salud en Centroamérica y República Dominicana.

Advantages and disadvantages of channeling Gavi's health system strengthening funds through health partners, a case study.

INTRODUCTION: Following a period of interruption of Gavi's funds for health system strengthening (HSS) in Cameroon and Chad, the two countries reprogramed their HSS grants. To implement the reprogrammed HSS, Chad committed to better management of the funds. Cameroon chose to channel the HSS funds through one of the health partners. This process is new to Gavi's HSS grants, and little is known about its effectiveness or characteristics. We investigated the advantages and disadvantages of this process to inform the global health community about the added value of this solution. MATERIALS AND METHODS: We retrospectively evaluated Gavi's HSS programs in Cameroon and Chad through a mixed methodology. To explore the pros and cons of channeling the funds through a health partner, we triangulated data from document review, key informant interviews (KIIs), field visits, and financial analysis of HSS expenditures in both countries. RESULTS: Data triangulated from multiple sources showed that channeling HSS funds thorugh a health partner in Cameroon allowed compliance with budget, the development of a stronger accounting system at the Ministry of Health (MOH), and a rigid monitoring system. However, this mechanism delayed implementation by six months, accounted for 15% of the total cost, and created a tension around roles between MOH and the health partner. Achievement of program's output indicators was average. In Chad, expenditures complied with budget as well. However, implementation was delayed longer causing a second reprogramming of the funds. While the program had fewer output indicators in Chad, these were minimally achieved. DISCUSSION: To our knowledge, this is the first study of channeling Gavi HSS funds through a health partner. This new process contributed to a higher level of implementation, stronger monitoring, and strengthened accountability in Cameroon. Recipient countries of Gavi HSS grants who lack the financial management capacity can benefit from a similar process.

Evaluación del modelo comunitario de atención a los trastornos mentales en España / Evaluation of the community mental health care model in Spain

Introducción: El objetivo de este trabajo consiste en evaluar la implementación del modelo comunitario de atención en salud mental en el Estado español en 2014. Secundariamente, se analizan los cambios que el modelo experimentó en 2008, en relación con la recesión económica. Material y Método: Se adoptó la definición de modelo comunitario que se propone en la Estrategia en Salud Mental del SNS, según la cual el modelo se rige por 8 principios y se implementa mediante 39 prácticas asistenciales. Se elaboró una encuesta dirigida a las Juntas Autonómicas de Gobierno de la Asociación Española de Neuropsiquiatría sobre el grado de cumplimiento del modelo comunitario en cada comunidad. Resultados: Se obtuvieron respuestas de 13 Juntas Autonómicas que incluyeron información sobre el 93% de la población española. Conclusión: Las carencias más importantes en la implementación del modelo comunitario en 2014 se relacionaron con la ausencia de una perspectiva de salud pública, con la mala gestión y rendición de cuentas, y la ralentización del desarrollo de equipos, servicios y redes de servicios de orientación comunitaria. El modelo se modificó poco globalmente entre 2008 y 2014, pero algunas prácticas clave, como la universalidad y gratuidad del sistema, la atención sectorizada, el acortamiento de los tiempos de espera, las subvenciones a las asociaciones de usuarios y familiares, y la aplicación de la "ley de dependencia" se contrajeron de forma sustancial en muchas comunidades. Otras prácticas, como la historia clínica informatizada, los planes Individualizados de atención y el tratamiento asertivo comunitario, incrementaron su cobertura en algunas comunidades a pesar de la recesión

Introduction: The objective of this study is to evaluate the implementation of the community mental health care model in the Spanish state in 2014. Secondly, we aim to analyze the changes experienced by the model in 2008, in relation to the economic recession. Materials and methods: We adopted the definition of community model proposed in the Strategy in Mental Health of the National Health System; according to which the model is based on 8 principles and is implemented by means of 39 care practices. The Autonomous Boards of the Spanish Association of Neuropsychiatry conducted a survey on the degree of compliance with the community model in each autonomous community. Results:Responses were obtained from 13 Autonomous Boards, which provided information on the 93% of the Spanish population. Conclusion: The most important shortcomings in the implementation of the community model in 2014 were related to the absence of a public health perspective, to poor management and accountability, and a slowdown in the diversification of community-based teams, services and networks. Globally, the model changed little between 2008 and 2014, but some key practices, such as the free and universal health coverage, the sectorization, the shortening of waiting times, the financial support to users and associations of relatives, and the implementation of the "Dependency Act", deteriorated substantially in many autonomous communities. However, other practices, such as the computerization of medical files, individualized care plans (Care Programme Approach), and the assertive community treatment, increased their coverage in some communities despite the recession

Advancing methods for health priority setting practice through the contribution of systems theory: Lessons from a case study in Ethiopia.

Setting priorities for health services is a complex and value laden process. Over the past twenty years, there has been considerable scholarly attention paid to strengthening fairness and legitimacy using the prominent ethical framework, Accountability for Reasonableness (A4R). A variety of case studies applying A4R have advanced our conceptual understanding of procedural fairness, and have highlighted the significance of context through its application. There is a paucity of research, however, that rigorously examines how and to what extent context influences health priority setting processes and the establishment of procedural fairness. We argue here that to study context rigorously requires taking a holistic view of the system by examining the dynamics and interrelationships within it. Using the Transformative Systems Change Framework (TSCF), this investigation sought to examine the influence of system factors on priority setting practice and procedural fairness. A qualitative case study of Ethiopian district health planning was undertaken in 2010 and 2011. Methods included 58 qualitative interviews with decision makers, participant observation, and document analysis. Data analysis followed in three phases: i) an inductive analysis of district health priority setting to highlight experiences across each of the three districts selected, ii) deductive analysis applying A4R and the TSCF independently; and iii) a synthesis of concepts of priority setting practice and procedural fairness within a broader, theoretical understanding of the system. Through the application of the TSCF, a nuanced understanding of priority setting practice is revealed that situates this process within a system of interdependent components that include: norms, operations, regulations, and resources. This paper offers a practical guide attuned to system features influencing the design, implementation, and sustainability of greater fairness in health priority setting practice.

Using community-based evidence for decentralized health planning: insights from Maharashtra, India.

Health planning is generally considered a technical subject, primarily the domain of health officials with minimal involvement of community representatives. The National Rural Health Mission launched in India in 2005 recognized this gap and mandated mechanisms for decentralized health planning. However, since planning develops in the context of highly unequal power relations, formal spaces for participation are necessary but not sufficient. Hence a project on capacity building for decentralized health planning was implemented in selected districts of Maharashtra, India during 2010-13. This process developed on the platform of officially supported community-based monitoring and planning, a process for community feedback and participation towards health system change. A specific project on capacity building for decentralized planning included a structured learning course and workshops for major stakeholders. An evaluation of the project, including in-depth interviews of various participants and analysis of change in local health planning processes, revealed positive changes in intervention areas, including increased capacity of key stakeholders leading to preparation of evidence-based, innovative planning proposals, significant community oriented changes in utilization of health facility funds, and inclusion of community-based proposals in village, health facility-based block and district plans. Transparency related to planning increased along with responsiveness of health providers to community suggestions. A key lesson is that active facilitation of decentralized health planning and influencing the health system to expand participation, are essential to ensure changes in planning. Effective strategies included: identifying people's health service related priorities through community-based monitoring, capacity building of diverse stakeholders regarding local health planning, and advocacy to enable participation of community-based actors in the planning process. This combination of strategies draws upon the framework of 'empowered participatory governance' which necessitates combining a degree of 'countervailing power' and acceptance of participation by the system, for new forms of governance to emerge.