Participatory policy analysis in health policy and systems research: reflections from a study in Nepal.

BACKGROUND: Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country's move to federalism on its health system, we reflect on the method's strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach's strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. MAIN BODY: We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues - especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants' understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. CONCLUSIONS: PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders' needs, it has great potential as a method in health policy and systems research.

HERA-lding More Integration in Health? Examining the Discursive Legitimation of the European Commission's New Health Emergency Preparedness and Response Authority.

CONTEXT: Since COVID-19, the European Commission (EC) has sought to expand its activities in health through the development of a 'European Health Union' and within it, the Health Emergencies Preparedness and Response Authority (HERA). METHODS: We applied a discourse analysis on documents establishing HERA to investigate how the creation of this institution was legitimated by the EC. We focused on how it framed health emergencies; how it framed the added value of HERA; and how it linked HERA to existing EU activities and priorities. FINDINGS: Our analysis demonstrates that security-based logics have been central to the EC's legitimation of HERA - in alignment with a 'securitization of health' occurring worldwide in recent decades. This legitimation can be understood as part of the EC's effort to promote future integration in health in the absence of new competencies. CONCLUSIONS: Securitization has helped the EC raise its profile in health politically, without additional competencies, thereby laying the groundwork for potential future integration. Looking at the discursive legitimation of HERA sheds light not only on whether the EC is expanding its health powers, but also how it strategizes to do so. HERA, while constrained, allows the EC to further deepen security-driven integration in health.

Retinotopic connectivity maps of human visual cortex with unconstrained eye movements.

Human visual cortex contains topographic visual field maps whose organization can be revealed with retinotopic mapping. Unfortunately, constraints posed by standard mapping hinder its use in patients, atypical subject groups, and individuals at either end of the lifespan. This severely limits the conclusions we can draw about visual processing in such individuals. Here, we present a novel data-driven method to estimate connective fields, resulting in fine-grained maps of the functional connectivity between brain areas. We find that inhibitory connectivity fields accompany, and often surround facilitatory fields. The visual field extent of these inhibitory subfields falls off with cortical magnification. We further show that our method is robust to large eye movements and myopic defocus. Importantly, freed from the controlled stimulus conditions in standard mapping experiments, using entertaining stimuli and unconstrained eye movements our approach can generate retinotopic maps, including the periphery visual field hitherto only possible to map with special stimulus displays. Generally, our results show that the connective field method can gain knowledge about retinotopic architecture of visual cortex in patients and participants where this is at best difficult and confounded, if not impossible, with current methods.

Overcoming the challenges facing Nepal's health system during federalisation: an analysis of health system building blocks.

INTRODUCTION: Nepal's move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal's health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal's health system as it adapts to federalisation. METHODS: This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders' practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. RESULTS: Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. CONCLUSION: Our findings suggest that since federalisation, Nepal's health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

Determinants affecting utilisation of health services and treatment for children under-5 in rural Nepali health centres: a cross-sectional study.

BACKGROUND: Large inequalities in child health remain in Nepal, with caste, ethnicity and sex being major determinants of deprivation and negative outcomes. The purpose of this study was to explore whether key demographics of under 5s were associated with health seeking behaviours, utilisation of health care, and treatment received. METHODS: Data came from Integrated Management of Neonatal & Childhood Illness (IMNCI) records of 23 health centres across five districts. After digitising the paper records, the data was analysed by district, caste/ethnicity, sex, and age to investigate differences in the time taken to present at a health facility after the onset of symptoms of ARI, diarrhoea and fever; accuracy of diagnosis for pneumonia; and whether the correct treatment was prescribed for pneumonia as per IMNCI guidelines. RESULTS: From 116 register books spanning 23 health centres, 30,730 child patient records were considered for analysis. The median age of attendance was 18 months (Inter-Quartile Range = 10, 32), while were more male children that attended (55.7% vs. 44.3% for females). There were statistically significant differences for the time taken to attend a health centre between different districts for ARI, diarrhoea and fever, with children in the remote Humla and Mugu districts taking significantly longer to present at a health facility after the onset of symptoms (all p < 0.001, except Mugu for ARI days). Children from underprivileged ethnic groups, Madhesi and Dalit, were less likely to be given a correct diagnosis of pneumonia (p = 0.014), while males were more likely to receive a correct diagnosis than females (73% vs. 67%, p = 0.001). This sex difference remained in the adjusted regression models for diagnosis of pneumonia (p < 0.001) but not for treatment of pneumonia (p = 0.628). All districts, in comparison to Gorkha, had increased odds of correct diagnosis and treatment of pneumonia, but only significant in children from Mugu after adjustment (p ≤ 0.001). CONCLUSION: Significant demographic differences were found based on ethnicity, sex, and district when examining health seeking behaviours for ARI, diarrhoea, and fever. Significant associations were seen for these same factors when exploring accuracy of diagnoses of pneumonia, but not for treatment. This study has emphasised the importance of a digitalised healthcare system, where inequalities can be identified without the reliance on anecdotal evidence.

Re-examining critiques of resilience policy: evidence from Barpak after the 2015 earthquake in Nepal.

This paper examines three common critiques of 'resilience': (i) that it is a 'top-down' policy discourse that pays too little regard to local specificities; (ii) that resilience policy represents a neoliberal shift towards the responsibilisation of communities and a retreat of the state from its role in providing protection; and (iii) that the focus on resilience tends to divert attention from the underlying causes of vulnerability. Using data collected after the 2015 earthquake in Nepal, the paper argues that these critiques have mixed salience in this context, but that (i) and (iii) in particular point to important problems in how the central government and its international partners have approached enhancing the resilience of communities. While there are benefits to considering resilience at the local level, it is important to recognise the inequalities within communities, how these might be reflected in differential degrees of vulnerability, and how they might be reinforced through resilience-building programmes.

Further Evidence That People Rely on Egocentric Information to Guide a Cursor to a Visible Target.

Everyday movements are guided by objects' positions relative to other items in the scene (allocentric information) as well as by objects' positions relative to oneself (egocentric information). Allocentric information can guide movements to the remembered positions of hidden objects, but is it also used when the object remains visible? To stimulate the use of allocentric information, the position of the participant's finger controlled the velocity of a cursor that they used to intercept moving targets, so there was no one-to-one mapping between egocentric positions of the hand and cursor. We evaluated whether participants relied on allocentric information by shifting all task-relevant items simultaneously leaving their allocentric relationships unchanged. If participants rely on allocentric information they should not respond to this perturbation. However, they did. They responded in accordance with their responses to each item shifting independently, supporting the idea that fast guidance of ongoing movements primarily relies on egocentric information.

Detection of scene-relative object movement and optic flow parsing across the adult lifespan.

Moving around safely relies critically on our ability to detect object movement. This is made difficult because retinal motion can arise from object movement or our own movement. Here we investigate ability to detect scene-relative object movement using a neural mechanism called optic flow parsing. This mechanism acts to subtract retinal motion caused by self-movement. Because older observers exhibit marked changes in visual motion processing, we consider performance across a broad age range (N = 30, range: 20-76 years). In Experiment 1 we measured thresholds for reliably discriminating the scene-relative movement direction of a probe presented among three-dimensional objects moving onscreen to simulate observer movement. Performance in this task did not correlate with age, suggesting that ability to detect scene-relative object movement from retinal information is preserved in ageing. In Experiment 2 we investigated changes in the underlying optic flow parsing mechanism that supports this ability, using a well-established task that measures the magnitude of globally subtracted optic flow. We found strong evidence for a positive correlation between age and global flow subtraction. These data suggest that the ability to identify object movement during self-movement from visual information is preserved in ageing, but that there are changes in the flow parsing mechanism that underpins this ability. We suggest that these changes reflect compensatory processing required to counteract other impairments in the ageing visual system.

Choosing not to weaponize healthcare: politics and health service delivery during Nepal's civil war, 1996-2006.

Healthcare has often been 'weaponized' during armed conflicts, with parties to the conflict interfering with or violently attacking health facilities and personnel for their own strategic ends. In this exploratory study of the civil war in Nepal (1996-2006), by contrast, we look at a case in which both sides (with some exceptions) came to see it as in their interests to avoid targeting health facilities or deliberately disrupting healthcare delivery. Drawing on key informant interviews and documentary analysis, we identify four factors that appear to have contributed to the two sides making this choice: i) their interest in the continued functioning of the health systems (specifically, the need of the Maoists to access government-run facilities for treatment of their cadres, and the fact that Maoist healthcare provision ensured that at least some service delivery continued in areas under their control; ii) the fact that healthcare did not become an important 'ideological battleground' in the conflict; iii) the roles played by humanitarian and development organizations in shaping the behaviour of both the warring sides; and iv) the part played by health professionals in navigating the pressures on them and quickly mobilizing to resist more sustained attempts at interference with healthcare.

The Primary Role of Flow Processing in the Identification of Scene-Relative Object Movement.

Retinal image motion could be due to the movement of the observer through space or an object relative to the scene. Optic flow, form, and change of position cues all provide information that could be used to separate out retinal motion due to object movement from retinal motion due to observer movement. In Experiment 1, we used a minimal display to examine the contribution of optic flow and form cues. Human participants indicated the direction of movement of a probe object presented against a background of radially moving pairs of dots. By independently controlling the orientation of each dot pair, we were able to put flow cues to self-movement direction (the point from which all the motion radiated) and form cues to self-movement direction (the point toward which all the dot pairs were oriented) in conflict. We found that only flow cues influenced perceived probe movement. In Experiment 2, we switched to a rich stereo display composed of 3D objects to examine the contribution of flow and position cues. We moved the scene objects to simulate a lateral translation and counter-rotation of gaze. By changing the polarity of the scene objects (from light to dark and vice versa) between frames, we placed flow cues to self-movement direction in opposition to change of position cues. We found that again flow cues dominated the perceived probe movement relative to the scene. Together, these experiments indicate the neural network that processes optic flow has a primary role in the identification of scene-relative object movement.SIGNIFICANCE STATEMENT Motion of an object in the retinal image indicates relative movement between the observer and the object, but it does not indicate its cause: movement of an object in the scene; movement of the observer; or both. To isolate retinal motion due to movement of a scene object, the brain must parse out the retinal motion due to movement of the eye ("flow parsing"). Optic flow, form, and position cues all have potential roles in this process. We pitted the cues against each other and assessed their influence. We found that flow parsing relies on optic flow alone. These results indicate the primary role of the neural network that processes optic flow in the identification of scene-relative object movement.

The predictability of a target's motion influences gaze, head, and hand movements when trying to intercept it.

Does the predictability of a target's movement and of the interception location influence how the target is intercepted? In a first experiment, we manipulated the predictability of the interception location. A target moved along a haphazardly curved path, and subjects attempted to tap on it when it entered a hitting zone. The hitting zone was either a large ring surrounding the target's starting position (ring condition) or a small disk that became visible before the target appeared (disk condition). The interception location gradually became apparent in the ring condition, whereas it was immediately apparent in the disk condition. In the ring condition, subjects pursued the target with their gaze. Their heads and hands gradually moved in the direction of the future tap position. In the disk condition, subjects immediately directed their gaze toward the hitting zone by moving both their eyes and heads. They also moved their hands to the future tap position sooner than in the ring condition. In a second and third experiment, we made the target's movement more predictable. Although this made the targets easier to pursue, subjects now shifted their gaze to the hitting zone soon after the target appeared in the ring condition. In the disk condition, they still usually shifted their gaze to the hitting zone at the beginning of the trial. Together, the experiments show that predictability of the interception location is more important than predictability of target movement in determining how we move to intercept targets. NEW & NOTEWORTHY We show that if people are required to intercept a target at a known location, they direct their gaze to the interception point as soon as they can rather than pursuing the target with their eyes for as long as possible. The predictability of the interception location rather than the predictability of the path to that location largely determines how the eyes, head, and hand move.

Lateral visual occlusion does not change walking trajectories.

Difficulties with walking are often reported following brain damage that causes a lateralized loss of awareness on one side. Whether lateralized loss of awareness has a direct causal impact on walking is unknown. A review of the literature on visually guided walking suggests several reasons why a lateralized loss of visual awareness might be expected to lead to difficulties walking. Here, we isolated and examined the effect of lateralized vision loss on walking behavior in real and virtual environments. Healthy young participants walked to a target placed within a real room, in a virtual corridor, or on a virtual ground plane. In the ground-plane condition, the scene either was empty or contained three obstacles. We reduced vision on one side by occluding one eye (Experiment 1 and 2) or removing one hemifield, defined relative to either the head or trunk (Experiment 2), through use of eye patching (Experiment 1) and a virtual-reality system (Experiment 2). Visual-field restrictions did not induce significant deviations in walking paths in any of the occlusion conditions or any of the environments. The results provide further insight into the visual information that guides walking in humans, and suggest that lateralized vision loss on its own is not the primary cause of walking difficulties.

Ability to identify scene-relative object movement is not limited by, or yoked to, ability to perceive heading.

During locomotion humans can judge where they are heading relative to the scene and the movement of objects within the scene. Both judgments rely on identifying global components of optic flow. What is the relationship between the perception of heading, and the identification of object movement during self-movement? Do they rely on a shared mechanism? One way to address these questions is to compare performance on the two tasks. We designed stimuli that allowed direct comparison of the precision of heading and object movement judgments. Across a series of experiments, we found the precision was typically higher when judging scene-relative object movement than when judging heading. We also found that manipulations of the content of the visual scene can change the relative precision of the two judgments. These results demonstrate that the ability to judge scene-relative object movement during self-movement is not limited by, or yoked to, the ability to judge the direction of self-movement.

The (Mis)appropriation of HIV/AIDS advocacy strategies in Global Mental Health: towards a more nuanced approach.

BACKGROUND: Mental health is increasingly finding a place on global health and international development agendas. Advocates for Global Mental Health (GMH), and international organizations such as the World Health Organization (WHO) and the World Bank, argue that treatments available in high-income countries should also be made available in low- and middle-income countries. Such arguments are often made by comparing mental health to infectious diseases, including the relative disease and economic burdens they impose, and pointing to the applicability of the right to access treatment for mental health, not only infectious diseases. HIV/AIDS advocacy in particular has been held up by GMH advocates as offering an appropriate strategy for generating global commitment. DISCUSSION: There is a need to assess how health issues are framed not only in relation to social goods outside of health (such as human rights, security or development), but also in relation to other health or disease models, and how health policy and practice is shaped as a result. The article debates the merits and consequences of likening mental health to HIV/AIDS, and identifies four major problems with the model for GMH advocacy being developed through these analogies: 1. An inappropriately universalizing global approach to context-specific problems; 2. A conception of human rights that focuses on the right to access treatment at the expense of the right to refuse it; 3. A tendency to treat poverty as a psychiatric issue, rather than recognizing that mental distress can be the result of poverty and other forms of inequality; 4. The prioritization of destigmatization of disease over social justice models. CONCLUSION: There are significant problems with the wholesale adoption of an (often simplified) version of HIV/AIDS advocacy as a model for GMH. Yet critical engagement with the important and nuanced differences between HIV/AIDS and mental health may nevertheless point to some possibilities for productive engagement and cross-fertilisation between advocates, activists and scholars in both fields.

Global health security: the wider lessons from the west African Ebola virus disease epidemic.

The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security--its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

Perceptuo-motor, cognitive, and description-based decision-making seem equally good.

Classical studies suggest that high-level cognitive decisions (e.g., choosing between financial options) are suboptimal. In contrast, low-level decisions (e.g., choosing where to put your feet on a rocky ridge) appear near-optimal: the perception-cognition gap. Moreover, in classical tasks, people appear to put too much weight on unlikely events. In contrast, when people can learn through experience, they appear to put too little weight on unlikely events: the description-experience gap. We eliminated confounding factors and, contrary to what is commonly believed, found results suggesting that (i) the perception-cognition gap is illusory and due to differences in the way performance is assessed; (ii) the description-experience gap arises from the assumption that objective probabilities match subjective ones; (iii) people's ability to make decisions is better than the classical literature suggests; and (iv) differences between decision-makers are more important for predicting peoples' choices than differences between choice tasks.

The Holy See on sexual and reproductive health rights: conservative in position, dynamic in response.

The Holy See has engaged extensively in United Nations negotiations on issues concerning sexual and reproductive health rights as they have emerged and evolved in a dynamic global agenda over the past two decades. A meta-narrative review of the mission's official statements was conducted to examine the positions, discourses and tensions across the broad range of agendas. The Holy See represents a fundamentally conservative and stable position on a range of sexual and reproductive health rights concerns. However, the mission has been dynamic in the ways in which it has forwarded its arguments, increasingly relying upon secularised technical claims and empirical evidence; strategically interpreting human rights norms in ways consistent with its own position; and framing sexuality and reproduction in the context of "the family". Seen in the broader context of a "religious resurgence" in international relations, and in light of the fact that the Holy See has frequently sought to form alliances with conservative State and non-State actors, these findings make an important contribution to understanding the slow progress as well as the potential obstacles that lie ahead in the battle to realise sexual and reproductive health rights in a changing global political environment.

Spared ability to perceive direction of locomotor heading and scene-relative object movement despite inability to perceive relative motion.

BACKGROUND: All contemporary models of perception of locomotor heading from optic flow (the characteristic patterns of retinal motion that result from self-movement) begin with relative motion. Therefore it would be expected that an impairment on perception of relative motion should impact on the ability to judge heading and other 3D motion tasks. MATERIAL AND METHODS: We report two patients with occipital lobe lesions whom we tested on a battery of motion tasks. Patients were impaired on all tests that involved relative motion in plane (motion discontinuity, form from differences in motion direction or speed). Despite this they retained the ability to judge their direction of heading relative to a target. A potential confound is that observers can derive information about heading from scale changes bypassing the need to use optic flow. Therefore we ran further experiments in which we isolated optic flow and scale change. RESULTS: Patients' performance was in normal ranges on both tests. The finding that ability to perceive heading can be retained despite an impairment on ability to judge relative motion questions the assumption that heading perception proceeds from initial processing of relative motion. Furthermore, on a collision detection task, SS and SR's performance was significantly better for simulated forward movement of the observer in the 3D scene, than for the static observer. This suggests that in spite of severe deficits on relative motion in the frontoparlel (xy) plane, information from self-motion helped identification objects moving along an intercept 3D relative motion trajectory. CONCLUSIONS: This result suggests a potential use of a flow parsing strategy to detect in a 3D world the trajectory of moving objects when the observer is moving forward. These results have implications for developing rehabilitation strategies for deficits in visually guided navigation.

Theories, models and frameworks to understand barriers to the provision of mobility-assistive technologies: a scoping review.

OBJECTIVES: There is strong evidence that mobility-assistive technologies improve occupational performance, social participation, educational and employment access and overall quality of life in people with disabilities. However, people with disabilities still face barriers in accessing mobility products and related services. This review aims to summarise and synthesise: (1) theories, models and frameworks that have been used to understand mobility-assistive technology access, (2) determinants of access and (3) gaps in knowledge. DESIGN: A scoping review using the five-step framework by Arksey and O'Malley. DATA SOURCES: We searched the MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases for publications published between 2000 and 2024. We searched for articles published up to 20 March 2024. ELIGIBILITY CRITERIA: We included English-published literature in peer-reviewed journals that reported (a) barriers to the provision of mobility-assistive technologies, (b) including at least one theory, model or framework and (c) between 2000 and 2024. DATA EXTRACTION AND SYNTHESIS: We extracted the study characteristics, theories, models, framework usage, research recommendations, key findings on mobility-assistive technology barriers and theoretical propositions. We conduct a theoretical synthesis guided by Turner's approach. RESULTS: We included 18 articles that used 8 theories, models and frameworks, synthesised into 9 propositions. The synthesised theory emphasises that mobility is essential for human flourishing, and that certain health conditions may impose restrictions on mobility. This impact can be alleviated by two direct determinants: (1) the provision of suitable services and (2) their comprehensive provision. Policies and costs influence these services indirectly. Environmental and personal factors also affect the use of these services. Ineffectively addressing these determinants can limit access to mobility-assistive technologies and subsequent disabilities. CONCLUSION: Our synthetic model describes the logic of providing evidence-based mobility-assistive technologies, and we identify the determinants of access that can act as targets for future work to improve the provision of mobility-assistive technologies.