Background: This comparative study examines responsibilities for coordination of healthcare and long-term care (LTC) in Germany, the Netherlands, Sweden, and Switzerland. As populations age, frailty and multimorbidity are increasing, leading to greater care needs and coordination of care between sectors. We analyze how coordination responsibilities among healthcare professionals and organizations vary between different healthcare and LTC systems and what strategies are used for better coordination. Methods: Fifty qualitative expert interviews were conducted with participants from local government agencies, social health insurances, various healthcare organizations, and professionals directly involved in healthcare and LTC provision. Data were analyzed with qualitative content analysis. The comparative research is based on existing healthcare and LTC typologies. Results: This study shows the need for clear lines of responsibilities and financial allocation to minimize fragmentation of care coordination. Sweden and the Netherlands assign formal coordination roles to general practitioners (GPs), district nurses, and municipal services. Germany’s approach heavily relies on the family, and in Switzerland, public and private LTC providers are often responsible for coordination. Digital technologies are increasingly used for communication and coordination. In Germany and Switzerland, where GPs have no gatekeeping role and primary healthcare centers are less developed, older GPs are unwilling to invest in digitalization. In Sweden and the Netherlands, where GPs coordinate primary healthcare and referrals to specialists, there is a strong interest in digitalization to improve communication and coordination. Still, digital systems for healthcare and LTC are not fully harmonized. Conclusion: The comparative study shows the need for clear responsibilities, systemic support, and financial recognition of care coordination to facilitate patient-centered care coordination. Digital technologies and in particularly integrated electronic records across sectors are reported as important tools that can facilitate care coordination across healthcare and LTC.
Background: Implementing diagnosis-related groups (DRGs) reform under the guidance of value-based healthcare (VBH) is of great significance for China to curb the rapid rise of medical costs and promote the allocation and utilization of medical resources. However, current research evaluating the effectiveness of China’s DRGs reform lacks a value-based oriented approach to healthcare and has not yet explored whether different types of diseases and population characteristics will affect policy implementation. Methods: A total of 16 564 acute myocardial infarction (AMI) and 74 356 cancer inpatients were included in this single-center study during 2018-2022. Interrupted time series models were used to estimate post-reform level and slope changes. Exploratory subgroup analyses were conducted by gender, age, and disease type. Hospital-level outcomes included risk-adjusted success per cost (SPC), cost per success (CPS), and net monetary benefit (NMB). Individual-level outcomes included total hospitalization cost, length of stay, mortality, successful outcomes, and 30-day readmission. Results: DRG reform was associated with changes in VBH indicators, with AMI mainly showing slope changes and cancer mainly showing level changes. However, individual-level analyses showed that some clinical outcomes did not improve consistently, which differed from the hospital-level results. Conclusion: The findings suggest that DRG reform was associated with changes in selected hospital-level VBH indicators, while some individual-level clinical outcomes did not show consistent improvement. Future payment reform should combine disease-specific clinical pathways, stronger risk adjustment, and routine monitoring of patient-level quality outcomes, especially for acute and high-risk conditions.
Background: The COVID-19 pandemic posed an unprecedented public health challenge, causing over one hundred thousand deaths in Germany alone. As elsewhere, policy-makers in Germany sought expert advice to navigate uncertainty and urgency, including through ad hoc advisory committees. We aimed to identify committees operating between 2021-2023, assess their composition, and analyse their work processes with a particular focus on structures, expert deliberations and evidence use. Methods: We conducted a systematic document analysis of government documents and semi-structured interviews with committee members in April/May 2024. We identified documents (parliamentary inquiries and freedom of information requests) through systematic searches in digital government archives; and purposively sampled experts from identified committee member lists. Documents were analysed using abridged content analysis, and interview transcripts were analysed using codebook thematic analysis. Results: We screened 984 documents, analysed 43 documents, and conducted 12 interviews. Ultimately, we identified six ad hoc advisory committees which met our inclusion criteria. These committees advised the German national government and the state governments of Bavaria, North Rhine-Westphalia, Rhineland-Palatinate, Schleswig-Holstein, and Thuringia. These were dominated by academic experts, especially from bio-medical disciplines. Structure of the advisory process: Consultations were direct (in person/online meeting) or indirect (written reports). Direct consultations typically included short presentations/input, followed by discussions to reach a consensus opinion. Expert deliberations drew on expert opinion, reports, pre-prints, and peer-reviewed studies. Multi-disciplinary exchange was valued but faced time constraints; opinions differed on whether a successful multi-disciplinary exchange was achieved. Reflections: Committee members were aware of the limits of their advisory role but occasionally struggled with the political nature of the work. Conclusion: German policy-makers continued to involve ad hoc advisory committees after the first year of the pandemic. Where it was achieved and meaningful, multidisciplinary work was perceived as valuable. Political decisions deviating from expert advice required justification under certain circumstances.
Background: In England, the National Institute for Health and Care Excellence (NICE) guidance recommends that women under 43 years old are offered 3 cycles of in vitro fertilisation (IVF) on the publicly funded healthcare system if they have not conceived after two years. However, regional commissioners decide the funding allocated for IVF. Our study aims to assess socio-economic and regional factors associated with having a live birth after using IVF over time to determine if decreases in funding for IVF increase regional inequalities in live birth success rates. Methods: We use Understanding Society Survey data from 2009-2022 employing a random effects probit model to estimate the determinants associated with a live birth via IVF among women having given birth in the previous year. Next, we estimate a random effects probit model to compare the determinants of live birth from IVF between 2009-2018 and 2019-2022 to assess the impact of unequal decreases in funding across different regions of England. Results: Between 2009-2022, living in London, being older, in employment, degree level or higher education, and owning/mortgage home are positively and statistically significantly associated with a live birth using IVF. Comparing 2009-2018, to 2019-2022 with less generous funding we find that in Yorkshire and Humber, there is a decrease in women successfully conceiving using IVF. Married/cohabiting women are three percentage points more likely to have a live birth with IVF compared to single women in 2019-2022 compared to 2009-2018. Women living in a middle deprivation quintile area (3) are three percentage points more likely to have a live birth from IVF in 2019-2022 compared to 2009-2018. Conclusion: Lack of individual resources in conjunction with regional difference in in IVF funding contribute to inequalities in reproductive autonomy by reducing opportunities to access IVF.
Background: Language barriers in primary care contribute to health inequalities, limiting access to services and affecting patient outcomes. Professional interpreting services are emphasised in UK guidance, but evidence on how policy-makers and commissioners deliver these services is lacking. This study aimed to explore the commissioning and implementation of interpreting services in UK primary care from the perspectives of commissioners, policy-makers, interpreters, and interpreting service providers. Methods: Semi-structured interviews were conducted with 31 participants (12 national policy-makers, 6 commissioners, 7 interpreters, and 6 interpreting service providers). Thematic analysis was conducted to explore delivery and identify best practices and key challenges in delivery. Results: The study found variation in commissioning models, with some areas favouring large national providers for widened scope and cost efficiency, while others prioritised local interpreting services for higher quality. The UK was seen as world-leading in interpreting provision, however fragmentation, lack of standardisation, accountability gaps, funding constraints within a publicly-funded healthcare system, and varied interpreter competencies and renumeration led to inconsistency in delivery. The healthcare sector was reported as having lower interpreting standards compared with other UK public sectors. Technological solutions were used in delivery and offered key advantages but sometimes failed to meet patient and provider needs. Conclusion: Strengthening national regulation, funding allocation, and service integration is essential to addressing systemic issues and improving interpreting service delivery in UK primary care. Policy recommendations include promoting "what good looks like," standardising interpreter qualifications and adopting approaches tailored to local population needs.
Background: Strategic health purchasing is a critical lever for advancing universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). Across Southeast Asia, countries are reforming their purchasing functions to enhance the efficiency, equity, and quality of primary healthcare (PHC). This study assesses the extent and progress of strategic purchasing for PHC in four Association of Southeast Asian Nations (ASEAN) member states: Indonesia, the Philippines, Thailand, and Vietnam. Methods: We applied the Strategic Health Purchasing Progress Tracking Framework to conduct a structured comparative assessment across five purchasing dimensions: financial management, benefits specification, contracting arrangements, provider payment, and performance monitoring. Data was collected through semi-structured interviews with national stakeholders, supplemented by grey literature and policy document reviews. The data was analysed, triangulated and validated through expert consultation and thematic analysis. Results: All four countries have taken steps toward institutionalising strategic purchasing through national health insurance (NHI) schemes, though the depth and coherence of reforms vary. Thailand’s universal coverage scheme (UCS) demonstrates the most advanced implementation, characterised by performance-based payment mechanisms and relatively strong monitoring systems. Indonesia and the Philippines are implementing pilots to align payments with service delivery goals, though challenges persist in integrating PHC with broader health system functions. Vietnam maintains high insurance coverage but exhibits limited strategic purchasing practices, particularly for PHC. Across all countries, gaps in data systems and governance capacity constrain effective implementation. Conclusion: Strategic purchasing reforms in Southeast Asia are progressing but remain uneven in scope and institutional maturity. Strengthening policy coherence, investing in health information systems and aligning public financing with PHC priorities will be critical to advancing these reforms. In particular, Thailand’s experience offers relevant lessons for broader regional efforts to operationalise strategic purchasing for more resilient and equitable PHC systems.
Background: The right to adequate food (RtAF) is increasingly incorporated into domestic food and nutrition legal frameworks to inform policy-making. Mexico’s General Law on Adequate and Sustainable Food (LGAAS), enacted in April 2024, is the country’s first law to operationalize the RtAF, which has been recognized in Article 4 of the Mexican Constitution since 2011, within domestic food policy. We examined informant insights on the LGAAS, focusing on its policy formulation and informant perspectives on the RtAF in the law. Methods: We conducted a review of legislative documents and semi-structured key informant interviews. The document review covered the period from the law’s introduction to parliament (2020) to its approval (2024). Interviews (13) were conducted with informants from the Mexican government, academia, international development partners, and civil society involved in or influencing the formulation of the LGAAS. The health policy triangle framework informed the interview guide development, while both deductive and inductive thematic approaches guided the analysis. Results: Informants identified how the following key factors affected the formulation of the LGAAS: regional action influenced RtAF legislation, national intersectoral collaboration fostered accountability, coalition building sustained momentum, and an enabling policy environment supported prioritization of the LGAAS. Political contentions and perceived industry influence also impacted negotiations. Informants consistently framed the RtAF as a cross-cutting concept linked to food security and food sovereignty, but there were differing interpretations of the state’s role in the progressive realization of the RtAF to deliver food system transformation in Mexico. Conclusion: The LGAAS positions Mexico among a small number of countries adopting a rights-based framework to address food system reform. Its formulation highlights the role of several key factors in supporting the operationalization of the RtAF into an actionable framework law, though implementation is yet to occur.
Background: Employee green behavior (EGB) refers to environmentally responsible actions undertaken by employees in the workplace. Although interest in EGB is growing, hospitals represent a uniquely complex environment where clinical demands, operational constraints, and regulatory pressures may shape such behavior in distinct ways. To date, no review has synthesized literature on EGB within hospital settings. This scoping review synthesizes existing research to clarify how EGB has been conceptualized and studied in hospitals, identify factors associated with EGB, and inform future research and sustainability efforts in healthcare organizations. Methods: This scoping review followed the Joanna Briggs Institute (JBI) methodology and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. Seven databases (PubMed, CINAHL, Embase, Web of Science, Scopus, APA PsycINFO, and Emerald) and grey literature were searched from inception to January 31, 2025. Studies examining EGB among hospital employees were included. Results: Twenty-three studies met the inclusion criteria, with most published after 2021. The majority employed quantitative survey designs and focused on nurses, although some included multidisciplinary staff. Considerable variation was observed in how EGB was defined and measured across studies. Factors reported in relation to EGB were organized into four levels: individual, team, leadership, and organizational. Qualitative findings highlighted barriers such as time constraints, insufficient training, limited knowledge, and lack of leadership support, as well as facilitators including individual motivation, environmental awareness, shared responsibility, and access to sustainability resources and education. Conclusion: EGB in hospital settings has been defined and examined inconsistently in the existing literature. This review proposes a working definition of EGB as employee actions in the workplace that minimize environmental harm and promote sustainability. The findings indicate that EGB in hospitals is influenced by multiple factors, and effective sustainability efforts in healthcare organizations require coordinated multilevel approaches. Registry Name and Number: The review protocol was registered with the Open Science Framework (osf.io/kd57r).
This commentary examines Agudelo-Hernández and Giraldo-Álvarez’s article as an important contribution to intercultural mental health policy in Colombia. The study illustrates how coproduction can move beyond consultation by translating community meanings of mental health into a territorial route with political relevance and administrative uptake. However, this achievement should be understood as an initial step rather than evidence of full epistemic transformation. Using Colombia’s Indigenous Intercultural Health System (Sistema Indígena de Salud Propia e Intercultural, SISPI) as a policy lens, we argue that intercultural implementation requires Indigenous decision-making authority, protection of ancestral knowledge, sustainable financing, and community-defined indicators of recovery, harmony, and collective well-being. Yet transformative effects cannot be assumed in advance. Current documentation on SISPI provides limited empirical evidence regarding operationalization, financing mechanisms, territorial coordination, and measurable outcomes, underscoring the need for ongoing evaluation as intercultural governance structures move into practice.
This commentary builds on a policy-oriented understanding of recovery as a co-produced route of well-being, spiritual harmony, and community participation. It examines therapeutic hybridization: the negotiated articulation of biomedical care, ancestral practices, spiritual resources, family support, territorial meanings, and community-based recovery. Rather than treating these arrangements as informal adaptations or cultural supplements, health systems must govern, finance, evaluate, and protect plural forms of care without subordinating Indigenous knowledge. Drawing primarily on Colombian cases and wider literature on community health systems, cultural safety, and intercultural policy, the commentary proposes six domains of preparedness: governance, care pathways, financing, workforce, clinical safety, and learning systems. The agenda is intended as an adaptable, non-exhaustive framework for settings where plural therapeutic systems already interact and where communities can share authority over design and evaluation. Therapeutic hybridization is therefore presented as a test of whether health systems can redistribute legitimacy, resources, and decision-making authority.
Background: Power is routinely invoked to explain health inequities and governance failures in global health, yet existing work is conceptually fragmented, weakly connected to empirical analysis, and prone to what is referred to as the "power-as-resource fallacy": the conflation of power bases (what actors possess) with power relationships (how actors influence one another). This narrative review examines how power is conceptualized and operationalized in global health discourse, identifies systematic analytical gaps, and proposes a relational framework to address them. Methods: We conducted a narrative review of literature that explicitly engages with power in relation to global health, governance, or health systems. We synthesized the included texts thematically and, as a supplementary systems-thinking component, developed a causal loop diagram (CLD) based on a subset of quantitative studies to illustrate how different constellations of power interact with health outcomes over time. Results: In global health, power is pervasively invoked but rarely operationalized. We organized the reviewed texts into six thematic domains: (1) power as a determinant of health; (2) structural power (class, race, gender, geopolitical hierarchies); (3) power asymmetry; (4) power and governance for health; (5) power and health securitization; and (6) power constellations and health outcomes. Across these domains, we find that discussions of power remain largely qualitative and often stop short of clear operationalization. The CLD translates these insights into interacting feedback loops, illustrating how specific power constellations are associated with particular patterns of policy response and health outcomes, highlighting potential leverage points for governance reform. Conclusion: This review maps the existing knowledge on power in global health and provides an actionable framework for future research and governance design. It underscores that power is the fundamental thread connecting global political economy to local health inequities.
Background: An innovative payment method, the diagnosis-intervention packet (DIP), has been piloted in China since 2020 and was fully implemented in City A in November 2022. However, its specific impact on private hospitals remains inadequately explored. This study aimed to examine how the reform influenced inpatient care behaviours in private hospitals. Methods: Using a dataset comprising 38 296 inpatient reimbursement records from 2021 to 2023 in a western city in China, 5 private hospitals included in the first batch of pilot institutions were selected as the treatment group, while 3 non-pilot private hospitals constituted the control group. Difference-in-differences (DID) analyses was conducted to estimate policy effects on providers’ inpatient care behaviours across four dimensions: cost control, service-volume adjustment, patient type, and quality risk. Results: Following the reform, significant changes were observed across several outcome dimensions. Regarding service-volume adjustment, the average length of stay decreased significantly (-1.94; 95% CI: -3.75 to -0.13), and average monthly admissions also declined (-30.36; 95% CI: -59.52 to -1.20). No statistically significant change was observed in patient type. For cost control, the average expenditure per admission decreased significantly by US $670.50 (95% CI: -1149.80 to -191.18). Out-of-pocket (OOP) expenditure per admission also declined by US $118.89 (95% CI: -188.88 to -48.90), although the share of OOP expenditure in total costs increased slightly (0.02; 95% CI: 0.05-4.64). As for quality risk, peri-hospitalisation outpatient visits increased significantly (1.473; 95% CI: 0.252-2.694). Conclusion: The DIP payment reform in private hospitals contributed to cost containment and process optimisation. However, the structural tension between standardised payment mechanisms and market-oriented hospital operations may generate short-term adjustments that prioritise cost control over quality improvement. Under strict cost-control incentives, hospitals may adopt strategic responses such as shortening inpatient stays and adjusting patient composition, which could pose potential risks to healthcare quality.
