The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups—for example, individual companies, corporations or interest groups—representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access

A draconian law: examining the navigation of coalition politics and policy reform by health provider associations in Karnataka, India

A comprehensive picture of provider coalitions in health policymaking remains incomplete due to the lack of empirically driven insights from low- and middle-income countries. We examine the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes during 2016–2018 to develop amendments to the Karnataka Private Medical Establishments Act. Through this case, we explore how provider associations function, coalesce, and compete, and the implications of their actions on policy outcomes. We conducted in-depth interviews, document analysis, and non-participant observations of two conferences organized by associations. We find that provider associations played a major role in drafting the amendments and negotiated competing interests within and between doctors’ and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. Our analysis highlights the importance of further empirical study of the influence of professional and trade associations across a range of health policy cases in low- and middle-income countrie

Holy grail or convenient excuse? Stakeholder perspectives on the role of health system strengthening evaluation in global health resource allocation

From Springer Nature via Jisc Publications RouterHistory: received 2024-06-13, registration 2024-10-11, accepted 2024-10-11, epub 2024-10-24, online 2024-10-24, collection 2024-12-01Acknowledgements: Our thanks to Krista Kruja, Melanie Michener and Poulami Bhattacharya for their support in data collection and analysis.Publication status: PublishedFunder: The Bill and Melinda Gates Foundation; Grant(s): INV-006183, INV-006183, INV-006183, INV-006183Background: The role of evaluation evidence in guiding health systems strengthening (HSS) investments at the global-level remains contested. A lack of rigorous impact evaluations is viewed by some as an obstacle to scaling resources. However, others suggest that power dynamics and knowledge hierarchies continue to shape perceptions of rigor and acceptability in HSS evaluations. This debate has had major implications on HSS resource allocation in global-level funding decisions. Yet, few studies have examined the relationship between HSS evaluation evidence and prioritization of HSS. In this paper, we explore the perspectives of key global health stakeholders, specifically around the nature of evidence sought regarding HSS and its potential impact on prioritization, the challenges in securing such evidence, and the drivers of intra- and inter-organizational divergences. We conducted a stakeholder analysis, drawing on 25 interviews with senior representatives of major global health organizations, and utilized inductive approaches to data analysis to develop themes. Results: Our analysis suggests an intractable challenge at the heart of the relationship between HSS evaluations and prioritization. A lack of evidence was used as a reason for limited investments by some respondents, citing their belief that HSS was an unproven and potentially risky investment which is driven by the philosophy of HSS advocates rather than evidence. The same respondents also noted that the ‘holy grail’ of evaluation evidence that they sought would be rigorous studies that assess the impact of investments on health outcomes and financial accountability, and believed that methodological innovations to deliver this have not occurred. Conversely, others held HSS as a cross-cutting principle across global health investment decisions, and felt that the type of evidence sought by some funders is unachievable and not necessary – an ‘elusive quest’ – given methodological challenges in establishing causality and attribution. In their view, evidence would not change perspectives in favor of HSS investments, and evidence gaps were used as a ‘convenient excuse’. Respondents raised additional concerns regarding the design, dissemination and translation of HSS evaluation evidence. Conclusions: Ongoing debates about the need for stronger evidence on HSS are often conducted at cross-purposes. Acknowledging and navigating these differing perspectives on HSS evaluation may help break the gridlock and find a more productive way forward.pubpu

Enhanced fluorescent properties of an OmpT site deleted mutant of Green Fluorescent Protein

<p>Abstract</p> <p>Background</p> <p>The green fluorescent protein has revolutionized many areas of cell biology and biotechnology since it is widely used in determining gene expression and for localization of protein expression. Expression of recombinant GFP in <it>E. coli </it>K12 host from pBAD24M-GFP construct upon arabinose induction was significantly lower than that seen in <it>E. coli </it>B cells with higher expression at 30°C as compared to 37°C in <it>E. coli </it>K12 hosts. Since OmpT levels are higher at 37°C than at 30°C, it prompted us to modify the OmpT proteolytic sites of GFP and examine such an effect on GFP expression and fluorescence. Upon modification of one of the two putative OmpT cleavage sites of GFP, we observed several folds enhanced fluorescence of GFP as compared to unmodified GFPuv (Wild Type-WT). The western blot studies of the WT and the SDM II GFP mutant using anti-GFP antibody showed prominent degradation of GFP with negligible degradation in case of SDM II GFP mutant while no such degradation of GFP was seen for both the clones when expressed in BL21 cells. The SDM II GFP mutant also showed enhanced GFP fluorescence in other <it>E. coli </it>K12 OmpT hosts like <it>E. coli </it>JM109 and LE 392 in comparison to WT GFPuv. Inclusion of an OmpT inhibitor, like zinc with WT GFP lysate expressed from an <it>E. coli </it>K12 host was found to reduce degradation of GFP fluorescence by two fold.</p> <p>Results</p> <p>We describe the construction of two GFP variants with modified putative OmpT proteolytic sites by site directed mutagenesis (SDM). Such modified genes upon arabinose induction exhibited varied degrees of GFP fluorescence. While the mutation of K79G/R80A (SDM I) resulted in dramatic loss of fluorescence activity, the modification of K214A/R215A (SDM II) resulted in four fold enhanced fluorescence of GFP.</p> <p>Conclusions</p> <p>This is the first report on effect of OmpT protease site modification on GFP fluorescence. The wild type and the GFP variants showed similar growth profile in bioreactor studies with similar amounts of recombinant GFP expressed in the soluble fraction of the cell. Our observations on higher levels of fluorescence of SDM II GFP mutant over native GFPuv in an OmpT⁺host like DH5α, JM109 and LE392 at 37°C reiterates the role played by host OmpT in determining differences in fluorescent property of the expressed GFP. Both the WT GFP and the SDM II GFP plasmids in <it>E. coli </it>BL21 cells showed similar expression levels and similar GFP fluorescent activity at 37°C. This result substantiates our hypothesis that OmpT protease could be a possible factor responsible for reducing the expression of GFP at 37°C for WT GFP clone in K12 hosts like DH5α, JM109, LE 392 since the levels of GFP expression of SDM II clone in such cells at 37°C is higher than that seen with WT GFP clone at the same temperature.</p

The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India

Abstract Background: Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India – international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015. Methods: We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the ‘Framework’ approach in our analysis. Results: Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization. Conclusion: The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity

Social media opposition to the 2022/2023 UK nurse strikes

Previous research has established that the success of strikes, and social movements more broadly, depends on their ability to garner support from the public. However, there is scant published research investigating the response of the public to strike action by healthcare workers. In this study, we address this gap through a study of public responses to UK nursing strikes in 2022–2023, using a data set drawn from Twitter of more than 2300 publicly available tweets. We focus on negative tweets, investigating which societal discourses social media users draw on to oppose strike action by nurses. Using a combination of corpus-based approaches and discourse analysis, we identified five categories of opposition: (i) discourse discrediting nurses; (ii) discourse discrediting strikes by nurses; (iii) discourse on the National Health System; (iv) discourse about the fairness of strikers' demands and (v) discourse about potential harmful impact. Our findings show how social media users operationalise wider societal discourses about the nursing profession (e.g., associations with care, gender, vocation and sacrifice) as well as recent crises such as the Covid-19 pandemic to justify their opposition. The results also provide valuable insights into misconceptions about nursing, strike action and patient harm, which can inform strategies for public communication

Power analysis in health policy and systems research: A guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all

Power Analysis in Health Policy and Systems Research: a Guide to Research Conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all

Synergies, Strengths and Challenges: Findings on Community Capability from a Systematic Health Systems Research Literature Review

Background: Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs). Methods: We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability. Results: When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed. Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality. Conclusions: Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it