Health Policy & Services

Government’s 2011 mental health strategy, No Health without Mental Health , pledged to provide early support for mental health problems, and the Deputy Prime Minister’s 2014 strategy, Closing the Gap: priorities for essential change in mental health , included actions such as improving access to psychological therapies for children and young people. The Department of Health and NHS England established a Children and Young People’s Mental Health and Wellbeing Taskforce which reported in March 2015 and set out ambitions for improving care over the next five years. The Coalition Government also pledged funding for children and adolescent mental health, detailed in the briefing. The 2015 Government has announced new funding for mental health, including specific investment in perinatal services and eating disorder services for teenagers. Additionally, the Government has committed to implementing the 2016 Mental Health Taskforce’s recommendations, including specific objectives to improve treatment for children and young people by 2020/21. The Policing and Crime Bill , currently going through Parliament, legislates to end the practice of children and young people being kept in police cells as a “place of safety” whilst they await mental health assessment or treatment.

At a national level, the pilot programme very much demonstrates the potential added value of providing schools and NHS CAMHS with opportunities to engage in joint planning and training activities, improving the clarity of local pathways to specialist mental health support, and establishing named points of contact in schools and NHS CAMHS. At the same time, the evaluation has underlined the lack of available resources to deliver this offer universally across all schools at this stage within many of the pilot areas. Given the pilots show that additional resources would need to be allocated locally to deliver the offer universally across all schools, further work is needed to understand how sustainable delivery models can be developed. 60

In the March 2015 Budget, the Chancellor of the Exchequer announced £1.25 billion of additional investment in children’s mental health over the next five years (with the addition of previous announcements of £150 million for eating disorders, this has been presented as a total of £1.4 billion over the five years from 2015-16). Of the additional funding announced in March 2015, £1 billion is to be provided to start new access standards for children and adolescent services, which the 2015- 2017 Government anticipated would see 110,000 more children cared for over the next Parliament. The 2015 Government also committed to investing £118 million by 2018-19 to complete the roll-out of the Children and Young People’s IAPT (Improving Access to Psychological Therapies) programme, to ensure talking therapies are available throughout England. Alongside this, £75 million will be provided between 2015 and 2020 to provide perinatal and antenatal mental health support for women. The Department for Education will also invest £1.5 million to pilot joint training for designated leads in CAMHS services and schools to improve access to mental health services for children and young people. 17

While eliminating delivery fees is a commendable intervention, pregnancy-related mortality due to the fol- lowing “three delays” remains a concern: delays in decid- ing to seek skilled delivery services, delays in arriving at health facilities and delays in receiving adequate treat- ment and referral [7]. Cost is not the only factor hinder- ing the utilization of health facility delivery services. In Kenya, maternal and neonatal deaths have been attrib- uted to other factors, including lack of transport, long distances to health centers, poorly equipped health facil- ities, low quality of care in health facilities and trad- itional and cultural practices [8, 9]. Therefore, while elimination of delivery fees in Kenyan public health facil- ities partially addresses economic barriers to maternal health care utilization, other economic barriers, health system gaps, quality of health facility delivery services and political, social, environmental and religious factors that may influence the utilization and outcomes of ma- ternal health care in the country have not been ad- dressed [10 – 15].

This study equally provides a strong basis on which re- searchers can attune their efforts in developing and val- idating robust methods and tools to evaluate the effects and influence of KTPs [20].Indeed, the framework devel- oped by Lavis and colleagues [9] to assess country efforts to link research to policy and used elsewhere [18] provide descriptive categories for efforts (e.g.; climate, research production, push efforts, facilitate user-pull, user-pull, ex- change, and evaluation) engaged by a given country but doesn’t provide tools to assess the influence of such ef- forts. Further, the framework developed by Ward and colleagues [28] on what constitutes a knowledge bro- kering enterprise while accounting for the three main functions (e.g.; capacity building, knowledge manage- ment, and linkage and exchange) fails to account either for the effects and influence on drivers of policymaking (e.g.; institutions, interests and ideas) or the intersec- tion with contextual factors during policymaking in en- vironments permeate by cross jurisdictional learning. The need to have further reflection on the appropriate evaluative framework of KTPs remains valid [20].

confounding of the results. However, we are not able to fully capture more proximal factors that influence health coverage, such as cultural factors and quality of care. Ethiopia is a country with cultural diversity, and the ana- lyses do not fully account for this. The R2 ranges between 0.14 (FP) and 0.40 (SBA). This may indicate that factors other than those included in our model may better explain family planning. As DHS data are household-level data, we do not know whether the observed associations are due to intra-household decision-making (cultural norms, behaviour, out-of-pocket expenses, etc.) or external factors (technical provision of services or goods, etc.) [27]. The included “report of problem” factors illustrate potential barriers that were not found to give significant re- sults. As this is a cross-sectional study, we cannot rule out reverse causality.

Based on the findings from the country studies, the final paper in this collection provides cross-cutting lessons on contracting NSPs in LMIC settings to move towards UHC. Rao et al. [5] observe that governments contract with NSPs for the delivery of health services for a variety of reasons, including weak capacity and a short- age of human resources in the public sector and a large pool of non-state providers. However, the authors note that contracting NSPs has not, on its own, overcome major service delivery challenges, including attracting and retaining health workers. Second, the institutional capacity of all actors involved in the contracting process at national, sub-national and local levels greatly influ- ences the success of contracting. Governments and NSPs alike require sufficient human, financial, monitoring and administrative capacity to effectively develop and man- age contracts; they also require the flexibility to adapt to contextual differences and changes over time. Third, developing and managing good relationships between governments and NSPs was found to be a key to long-term success with contracting health services. Finally, government stewardship capacity, including to effectively

Background: Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process. Methods: We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed.

Home to over 17% of the world’s population, India is a poor country with 1.24 billion people. 1,2 Nearly 42% of the population of India lives below the poverty line, and 35% lives on less than $1 per day. 3-5 In addition to high rates of poverty, there are wide disparities in the distribution of wealth and health between the rich and the poor. Important indicators, such as the infant mortality rate (IMR) and having an institutional delivery, highlight these wide disparities. Among the poorest wealth quintile in India, the IMR is near 82 per 1,000 live births, yet only 34 infants in 1,000 live births die in the richest quintile, where pregnant women are six times more likely to deliver in an institution. 6-8 The private sector, the largest segment of the country, accounts for 58% of India’s hospitals and 81% of its doctors. 9 The World Bank report clearly shows that India’s OOP health expenditure, which is 89.2%, is a significant barrier to healthcare utilization. 10 Due to the lack of financial protection, approximately 20-28% of diseases in India remain untreated. 11 Nearly 39 million people in India become impoverished every year due to high OOP health expenditures, and only 11% of India’s population is

through such mechanisms as patient education, monitor- ing and reminders, and behavior modification programs; systematically collecting process and outcome measures; and providing a way for physicians, other providers, and the patient to obtain ongoing feedback on how care is progressing and what outcomes are being met [47]. Suc- cessful implementation of disease management programs in commercial health plans led to the establishment of the first Medicaid disease management program – Virginia's program for asthma – in the early 1990s [46]. Florida established the nation's first disease management pro- gram for a mental disorder (major depression), and the Centers for Medicare and Medicaid Services (CMS) have funded a national disease management demonstration project [48]. Disease management programs in public mental health settings are most likely to be successful for conditions that are stable over time, that can be reliably identified through screening instruments, that have well- developed and tested interventions suitable for imple- mentation, and that require a comprehensive array of services. Conditions such as childhood trauma, for exam- ple, offer an opportunity for the construction of disease management programs, which can serve as a vehicle for the implementation of EBPs for this condition [49,50]. Third, prior authorization – the requirement that provid- ers obtain approval for the use of a particular intervention or drug – is an existing approach used by over 30 states [51]. Originally developed as a cost-containment measure to control pharmacy costs, prior authorization is often combined with formularies to restrict the variety of medi- cations available to beneficiaries. Although little experi- ence exists with prior authorization for behavioral interventions, such programs could be used to restrict potentially harmful interventions being delivered to enrollees. Conversely, eliminating evidence-based inter- ventions from restrictions on session limits, modifying designated patient regulations that restrict who can receive the service, and modifying existing regulations governing session lengths can all serve to promote EBPs using this approach.

While the poor may have an unfair disadvantage, there may be an unfair advantage due to the pro-rich bias. This can be difficult to prove. Pro-rich inequity favours the rich through greater coverage and healthcare utilization [17], and because of the high corruption index [18], jumping the queue via informal connections [19] allows greater access to informal networks of healthcare. This occurs at all levels but particularly among those who have strong connections with health care providers. Jumping the queue happens from the very highest to the lowest, although there is a greater likelihood of such taking place at the higher echelons of society. Though there is no priority based on social status, one’s connections can make a large difference that can trigger even greater benefits downstream. The informal network, though not official policy, benefits the well-off more because of their connections within the system, which is encouraged by the prevalence of corrupt practices in Trinidad and Tobago, whose corruption perception index was 35 points in 2016 [18].

In addition, Community Pharmacists ensure the appropriate use of self-medication and refer at risk patients to GPs and to others in the Primary Care team. This increases the efficiency with which Primary Care resources are used. Conversely, the referral to pharmacists of patients whose conditions can be better managed using non-prescription medicines and appropriate lifestyle advice will help reduce over-dependence on Primary and Secondary Care facilities. Community Pharmacy is the second most important contributor to Primary Care and is an essential participant in providing seamless care between the Secondary and Primary Sectors. International research has shown that simply increasing access to GP care does not reduce the utilisation of Secondary Care. It is the active co-operation of Primary Care teams whether they are in health centres or

According to Hafkin and Taggart (2015), in Uruguay, the CEIBAL Plan facilitates the digital inclusion of small communities. In rural areas, the integrated use of ICT in meteorological centers improves the quality of information provided to farmers, who in this way, are able to plan crop production based on accurate and timely climate information, which ultimately increases productivity: for example, in Chile, REDAGROCLIMA offers weather alerts by e-mail and SMS to mobile phones of producers and farmers. In Central America and the Dominican Republic a platform has been developed, offering market information for fruit value chains in the region. In Costa Rica the interactive platform PLATICAR promotes the exchange of information using ICTs to support knowledge management, offering various online services. The new technological conditions imposed by the market, including ICTs, also lead to the need to change the relationship between the different levels of the agricultural value chain. In Argentina, the National Health and Quality entity (SENASA) uses new ICTs in their systems for traceability and food safety, which leads toward new relationships among stakeholders (Zelenika and Pearce, 2014). Around the world, ICT is used to provide useful disaster management data. According to Venugopal (2010), Geographic Information Systems (GIS) are used hand in hand with the Open Risk Data Initiative (OpenRDI) to minimize the effect of disaster in developing countries by encouraging them to open their disaster risk data. GIS technologies such as satellite imagery, thematic maps, and geospatial data play a big part in disaster risk management. One example is the HaitiData, where maps of Haiti containing layers of geospatial data (earthquake intensity, flooding likelihood, landslide and Tsunami hazards, overall damage, etc.) are made available which can be used by decision makers and policy makers for rehabilitation and reconstruction of the country. The areas receiving attention include natural resources information assessment, monitoring and management; water shed development, environmental planning, urban services and land use planning (Karanasios and Allen, 2013).

In the world we live today, global agendas are being increasingly shaped by the private sector. The 'for-profit' private sectors' immense resources make it an irresistible partner for public health initiatives. These arrangements can also be mutually synergistic. Governments and inter- national agencies can tap into additional resources to full fill their mandate whereas the commercial sector can ful- fill its social responsibility, for which it is being increas- ingly challenged. Additionally, the recent SARS epidemic and bio-terrorist threats should help to make the private sector understand the value of investment in health for reasons beyond fulfilling their social obligations. Active involvement of the 'non-profit' sector and donor coordi- nation in country goals is also being increasingly encour- aged within comprehensive development frameworks; this approach is synchronous and in harmony with the Poverty Reduction Strategy Paper Framework [37]. The development and health actors have highlighted the need to harness the potential that exists in collaborating with the private sector to advance public health goals. This is also becoming increasingly essential as both the public and the private sector recognize their individual inabilities to address emerging public health issues that continue to be tabled on the international and within country policy agendas. Public-private partnerships therefore seem both, unavoidable and imperative. However in building such collaborations, certain measures must be taken at a global level to assist global partnerships and set a framework within which efforts at a country level can emanate. As a first step, there is a need to develop a set of global norms and ethical principles; a broad-based agreement over these must be achieved. The transnational nature and global outlook of emerging partnerships necessitate that these stem from a broad-based international dialogue.

There has been much speculation about whether the National Institute for Health Clinical Excellence (NICE) has, or ought to have, a ‘threshold’ figure for the cost of an additional quality-adjusted life-year (QALY) above which a technology will not be recommended for use in the National Health Service (NHS). This paper argues that it is not

and mental health evaluations performed, (2) qual- ity of the evaluations, (3) medical and mental health problems identified in foster children, (4) quality of ongoing care, (5) access t[r]

There is the potential for many more target- oriented and stratified prevention strategies [52] to finally replace the “one strategy for all”. Moreover, clearly there is potential to avoid ineffective or even “faulty” preventive strategies, for example, there is already the challenge to differentiate between persons, who will respond to certain vaccinations and those who will not. Why then should those who do not respond take the risk of experiencing side-effects from a vaccination if the vaccination will be ineffective and therefore be of no benefit on an individual as well as population level? In this specific situation, which is estimated to be true for at least 10% of the population, would one not consider this kind of primary prevention to be immoral? Obesity is another example of this; obesity is not only influenced by lifestyle habits such as inactivity or nutrition, but also (in more than 60%) by several genomic factors. Furthermore, it is triggered by many other factors such as infectious diseases and social factors. At least 2% of these 60% are solely due to mutations in the MC4R-gene. Individuals carrying the MC4R-mutation are almost “resistant” to any diet and physical activity.Therefore is it not a “faulty” preventive strategy to give advice to these individuals that “five a day” or “a low-fat diet” will be effective? Would it not be a “better” (preventive) strategy to give societal support by respecting them as they are? Of course, there are many more polymorphisms involved in obesity, and there are several polymorphisms that play an important role in the effectiveness of diet and sports. There are even polymorphisms that increase the risk of dying after physical activity. Thus, it should be kept in mind that one should be a little careful about the general public health message “prevention and health promotion is good for everybody”.

Numerous frameworks have been proposed as ways to bridge the ‘know-do’ gap and utilize researcher evidence. The traditional frameworks view the path of research from creation to utilization as a logical flow [24]. While this is considered rational and mimics decision-making pro- cesses, a holistic view of all the factors and elements that can influence and facilitate the use of research in policy making is needed. A comprehensive framework that in- cludes a holistic view of the health system, addresses the barriers discussed in the literature, and recognizes the contextual influence on evidence-informed decision mak- ing has been proposed by Lavis et al. [25] and further de- veloped by Ellen et al. [26,27]. This framework outlines seven main domains that can be addressed to assist in transferring knowledge to action. These seven main do- mains are i) establishing a climate for research use, i.e., ac- tivities undertaken by the organization and/or the health system to establish a climate where research evidence is used in decision making, ii) research production efforts, i.e., activities taken by researchers, funders, and knowledge users to ensure the production of timely and relevant re- search, iii) ‘push’ efforts, i.e., activities usually undertaken by researchers or intermediaries (i.e., librarians or know- ledge brokers) to disseminate research evidence to poten- tial users, iv) ‘facilitating pull’ efforts, i.e., activities that the health system needs to undertake in order to ensure that the appropriate infrastructure is in place for knowledge users to access the necessary research evidence, v) ‘pull’ efforts, i.e., activities by health system decision-makers to enable the appropriate use of research evidence, vi) ‘link- age and exchange’ efforts, i.e., activities that focus on facili- tating relationships between researchers and knowledge users, and vii) evaluation efforts, i.e., evaluations of KTE interventions and outcomes [25,26]. While frameworks have been proposed to explain the role of research in pol- icy making, empirical evidence to support such ideas or testing of the frameworks is difficult to find [28-30]. The evidence that does exist pertains to individual initiatives (not to a whole framework or process per se) and are usu- ally based on case studies or interview studies [31,32], and therefore further work is required in this area.

AHSPR: Alliance for Health Systems Policy and Research; AMS: Afghanistan Mortality Survey; BHC: Basic Health Center; BPHS: Basic Package of Health Services; BSC: Balanced Scorecard; CHC: Comprehensive Health Center; CHW: Community Health Worker; CI: Contract In; CO: Contract Out; COI: Co- Investigator; EPHS: Essential Package of Hospital Services; EPI: Expanded program of immunization; ERC: Ethical Review Committee; EU: European Union; FGD: Focus Group Discussion; FI: Field Investigator; GCMU: Grant and Contract Management Unit; GLICS: Global Innovations Consultancy Services; HMIS: Health Management Information System; IIHMR: Indian Institute for Health Management Research; IRB: Institutional Review Board; JHU: Johns Hopkins University; KII: Key Informant Interview; M&E: Monitoring and Evaluation; MoPH: Ministry of Public Health; MSH: Management Sciences for Health; NGO: Non-Governmental Organization; NSP: Non-State Provider; PBI: Performance-Based Initiative; PI: Primary Investigator; PPHD: Provincial Public Health Director; RBF: Results-Based Financing; RC: Research Coordinator; SEHAT: System Enhancement for Health Actions in Transition; USAID: United States Agency for International Development; WB: The World Bank; WHO: World Health Organization

CHA postings in the three study districts ran from Au- gust 2011 through June 2015. CHA services included household visits and the mobilization of men and women groups for topic-specific interventions, including FP. CHA provided FP counseling to dispel method mis- conceptions, and distributed condoms and oral contra- ceptive pills for recurring users at the household level in a manner that would respect the need for privacy and address concerns about access. Workers were instructed to refer first time users and clients who sought other methods to the nearest health center or community dis- pensary, where depot- medroxyprogesterone acetate (DMPA), intra-uterine devices (IUDs), and implants were available (19). The focus on referral for injectable and long acting methods was mandated by policy; as such, the Connect Project CHA were not trained to pro- vide such services.