What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies

Background All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems. Methods The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases. Results The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence. Conclusions These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning.This work was conducted with funding from the Bill and Melinda Gates Foundation. The funding body was involved in the overall design of the study. However, the funders had no involvement in data collection, analysis, interpretation and writing of the paper

What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies

Sophie Witter - orcid: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Background - All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems.Methods - The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases.Results - The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence.Conclusions - These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning.This work was conducted with funding from the Bill and Melinda Gates Foundation. The funding body was involved in the overall design of the study. However, the funders had no involvement in data collection, analysis, interpretation and writing of the paper.17 [9]pubpu

Cost-Effectiveness of Preventing Loss to Follow-up in HIV Treatment Programs: A Côte d'Ivoire Appraisal

Based on data from West Africa, Elena Losina and colleagues predict that interventions to reduce dropout rates from HIV treatment programs (such as eliminating copayments) will be cost-effective

Towards Predicting the Response of a Solid Tumour to Chemotherapy and Radiotherapy Treatments: Clinical Insights from a Computational Model

In this paper we use a hybrid multiscale mathematical model that incorporates both individual cell behaviour through the cell-cycle and the effects of the changing microenvironment through oxygen dynamics to study the multiple effects of radiation therapy. The oxygenation status of the cells is considered as one of the important prognostic markers for determining radiation therapy, as hypoxic cells are less radiosensitive. Another factor that critically affects radiation sensitivity is cell-cycle regulation. The effects of radiation therapy are included in the model using a modified linear quadratic model for the radiation damage, incorporating the effects of hypoxia and cell-cycle in determining the cell-cycle phase-specific radiosensitivity. Furthermore, after irradiation, an individual cell's cell-cycle dynamics are intrinsically modified through the activation of pathways responsible for repair mechanisms, often resulting in a delay/arrest in the cell-cycle. The model is then used to study various combinations of multiple doses of cell-cycle dependent chemotherapies and radiation therapy, as radiation may work better by the partial synchronisation of cells in the most radiosensitive phase of the cell-cycle. Moreover, using this multi-scale model, we investigate the optimum sequencing and scheduling of these multi-modality treatments, and the impact of internal and external heterogeneity on the spatio-temporal patterning of the distribution of tumour cells and their response to different treatment schedules

Removing user fees in Africa: more than a technical challenge

The introduction of user fees (formal payments at the time of seeking care at public health facilities) to finance healthcare in Low- and Middle-Income Countries (LMICs) in the 1980s has been, and remains, a controversial topic. User fees represent a key financial barrier to accessing care, particularly for poor people who may be further impoverished as a result of seeking care. The economic arguments in favour of user fees have been contested. Yet, despite the mounting evidence against them, user fees persist across most African countries. This thesis seeks to answer the following research questions: Why have user fees persisted as a health financing mechanism in face of evidence that they present a financial barrier to access? What has constrained efforts to remove user fees, and particularly, what are the relative contributions of technical factors versus complex political interests that may have shaped these health systems policies? The thesis takes the form of five papers and uses a combination of literature reviews, qualitative and quantitative methods. The first paper, Witter S, Anderson I, Annear P, Awosusi A, Bhandari N, Brikci N , Blandine B, Chanturidze T , Gilbert K , Jensen C, Lievens T , McPake B , Raichowdhury S and Jones A (2019), starts with a scoping review on the content of learning across health systems, a scoping review of institutions and platforms that facilitate learning, and a review of international health policy transfer studies. It includes the results of key informant interviews (KIIs). The second, McPake B, Brikci N, Cometto G, Schmidt A and Araujo A (2011), reviews studies on user fees experiences in developing countries, and on Uganda specifically. The third, Witter S, Brikci N, Harris T et al (2018), reviews regional experiences in removing user fees and Sierra Leone specific efforts in strengthening its health system to remove user fees. It also analyses the results of KIIs and Focus Group Discussions (FGDs), as well as the fiscal space for free health care in Sierra Leone. The fourth, Mathauer I, Koch K, Zita S, Murray A, Traore M, Bitho N and Brikci N (2019), presents a review of innovative taxes in Low- and Middle-Income Countries (LMICs), findings from a multistakeholder consultation, and a feasibility analysis of various taxes. The last, Brikci N. (2023), provides a systematic literature review of innovative domestic financing mechanisms for health. The research contributes to the literature on health financing and removal of user fees in three interrelated ways. First, it shows that the identification of the removal of user fees as a national priority was the result of a complex interaction of primarily locally determined factors and the meeting of technical solutions with the interest of actors and institutions through a political window of opportunity. The absence of this window of opportunity may explain why user fees persist. Secondly, the work highlights the fundamental importance of integrating technical aspects and those that reflect the wider context affecting health systems. Indeed, the formulation and implementation of user fee removal requires (1) a systematic, step-by-step strengthening of each of the health systems pillars and (2) a careful consideration of the interests of actors impacted by the reform, of the readiness of formal and informal institutions to implement and accept the reform, and of the ideas and ideologies that the reform would challenge. Thirdly, the work discusses the alternatives to user fees, specifically the role of domestic ‘innovative’ financing mechanisms to replace them. It shows that these financing mechanisms may not offer much additional resource for health, although they represent a useful avenue for dialogue between Ministries of Health (MoH) and Ministries of Finance (MoF)

Validity of 3D reconstruction of a new tool for postural assessmentbased on a single optical camera

International audienc

Influence of regular dance practice on the postural stability during quiet standing in healthy women

International audienc