The COVID-19 pandemic catalyzed global discourse on pandemic preparedness and the role of communities in prevention, response and readiness efforts. Yet community engagement in pandemic prevention, preparedness and response (PPPR) remains narrowly framed and reduced to social mobilization, sidelining essential lessons from outbreaks that demand communities' endogenous roles in governance. In this paper, we highlight multiple layers of "silences" in literature, policy, and practice across three domains: undefined and invisible engagement structures from community health facility committees interfacing service users, leaders, and providers, to district assemblies, national health assemblies linking subnational units, and supranational civil society mechanisms; power asymmetries that positions communities as tokenistic observers rather than active, equal partners whose local insights shape decisions, exacerbated by elite capture, financial dependence, and exclusion from technical discussions under assumptions of incapacity; and evaluative logics that prioritize health outcomes over process enablers like capacity-building, clear rules of inclusion, adequate resourcing, accountability, and contextual factors. These silences misattribute institutional barriers to community inadequacies. Reversing them requires; deliberate investment in visible and functioning multi-level engagement structures with communities playing a central role in defining them; recognition of communities as equal partners in PPPR discussions and processes whose knowledge and contributions carry equal weight; and evaluation approaches that prioritises agency, accountability and contextual enablers, rather than treating community engagement as a technical intervention judged only by downstream health outcomes.

The use and the application of health security, both as a frame and a set of practices, have increased and become central to global health governance. Nigeria navigates complex pressure in health priority setting, shaped by domestic political realities, economic constraints and a longstanding relationship with international donors. Yet how the framing of health as security interacts with these dynamics, and how the actors involved shape health system priorities and practices, remains under-examined. We conducted 28 realist-informed interviews with national and state government actors, actors working at international organisations, and implementing partners across eight states and the Federal Capital Territory. Analysis was informed by an existing realist framework and focused on how contextual conditions activate actor reasoning (uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) to generate the outcomes of securitised responses. We identified four interrelated outcome patterns (1) centralisation of governance, where priorities were steered by global agendas and reinforced through federal structures; (2) shaping of resource allocation, often prioritising diseases of international concern over locally salient health needs; (3) reconfiguration of health services, including vertical programming and administrative reporting burdens; and (4) institutionalisation of security norms, normalising military and security actor involvement in health response. Our findings show that health security is more than a technical exercise; it is a dynamic phenomenon co-created across multiple dimensions, including global norms and domestic governance. To mitigate the negative consequences of this phenomenon, we recommend that policy, practice, and research actors – internationally, in Nigeria, and elsewhere – engage more critically with global framings of health and security.

Health systems globally face increasingly complex, multifaceted challenges, cross-cutting many of which is multimorbidity. While rising to multimorbidity has been a slow and incremental process, the recent US funding cuts and rupture of vertical disease programmes may be a pivotal moment for health systems to become at once more integrated, adaptive and self-reliant towards this end. This article considers learning health systems (LHS) as a framework for building such systems, with multimorbidity a core priority and focal point for operationalizing LHS in practice. To illustrate, we draw from an interdisciplinary initiative to catalyse and evaluate a multimorbidity-learning health system in Zimbabwe, centred on three domains of sociotechnical infrastructure: reengineered electronic health records (EHR) to integrate and democratize parallel research, data and decision-support systems; deliberative platforms to support multi-condition sense-making and knowledge translation; and investment in learning sites at service delivery level to facilitate the practical development and iteration of integrated treatment and prevention models. Strategies to build LHS must necessarily be tailored to particular contexts. However, the infrastructural domains and specific mechanisms presented may be valuable for many lower-income countries seeking to emerge from the current funding crisis with the in-house learning capabilities needed to address the complex needs of older, multimorbid populations with less external funding and technical support.

As global framings of health continue to expand their reach, the Philippines, like many other countries, must navigate the overlapping pressures of donors, international institutions, and domestic political agendas in setting priorities. One such framing is the framing of health as a security issue. This study examines how health security framing—how it is interpreted and operationalized—influences priority-setting in the Philippines. Drawing on 25 interviews with government (at national and sub-national levels) and non-government actors and using a realist approach, this study sought to identify the outcomes of health security framing (as triggered or reinforced by mechanisms such as uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) and the context in which the outcomes manifest. Findings show that health security framing reshapes priorities by reinforcing centralized, top-down approaches at both international and national levels. These framings influence not only what is prioritized but also which actors make decisions and how those decisions are justified. At the implementation level, it manifests in health workers facing misaligned operational frameworks, vertical programming, and burdensome reporting requirements tied to donor funding. Security norms become institutionalized with the involvement of military and security actors in health. The study demonstrates that health security is not a static concept, but a dynamic phenomenon co-constructed through global discourses, donor agendas, and domestic governance practices, all of which are shaped by power relations and history. While health security mobilizes resources and political attention, it also introduces trade-offs that risk exacerbating inequities and diverting attention from the structural determinants of health.

The realist approach seeks to understand underlying mechanisms that explain how and why complex interventions, programmes, and policies work in specific contexts, making it particularly valuable in health policy and systems research (HPSR). We draw on reflexive practice of realist evaluations from several realist evaluation practitioners and on insights from an organized session at the Eighth Health Systems Research Symposium in Nagasaki, Japan, in 2024, where we engaged a diverse group of practitioners and researchers on how to use realist approaches in HPSR. Examples from our studies, while situated in distinct contexts, highlight common challenges in applying realist methodologies including identifying and refining context-mechanism-outcome configurations. Building on these examples, we illustrate how realist evaluations, if conducted rigorously and with the purpose of advancing justice in health systems, could do so through exposing structural barriers to health justice, amplifying local voices and fostering epistemic justice in knowledge production.

ABSTRACT Although the term “health security” is continuously gaining prominence and there are increasing calls to “strengthen” it, the term remains conceptually ambiguous. This ambiguity creates uncertainty about exactly what is being advanced in policy and practice when health security is invoked, and what consequences this has for priority‐setting in health systems. Extending existing scholarship on health security, this article draws on insights from the authors' long‐term engagement across various countries, their participation in global discussions and forums, and their study on health securitisation in Nigeria and the Philippines, to explore how health actors understand “health security” and critically analyse the implications of this conceptual pluralism. Our analysis reveals four main interpretations of health security: as (1) state protection and national security , (2) preparedness for infectious disease outbreaks , (3) a political or geopolitical framework , and (4) public health and population protection . These interpretations are not mutually exclusive; rather, they represent meanings that coexist and sometimes compete in practice. We argue that this conceptual plurality enables “health security” to function as a flexible framing that accommodates diverse objectives, with uneven consequences across actors, populations, and health systems. Rather than resolving the definition of health security, this commentary interrogates its utility as a guiding concept.

Over the last decade, there has been an increase in calls and efforts to change knowledge practices in global health, from within the field, in the fields that intersect with it, and from outside the field. While these calls and efforts are often aimed at rethinking or reimagining the field, they often fall short. Based on interviews with researchers who have participated in change efforts within and around global health, we developed criteria for distinguishing change efforts between first-order change, which seeks to adjust the current system for efficiency and effectiveness while keeping things the same; second-order change, which seeks to reform the current system to meet the needs of stakeholders; and third-order change, which seeks the total transformation of the system. In addition to the schema, our findings illustrate how the desired order of change is not simply a choice but rather dynamically determined in the interaction between change seekers and the institutions and systems they seek to change. This study offers a tool to clearly articulate the nature of a particular change effort, to distinguish and allow for comparison between change efforts, and to think through the kinds and extents of change required to achieve desired transformational change.

Structural inequities remain deeply embedded in global health governance and knowledge production, shaping which voices are heard and whose expertise and priorities are valued. Attempts to understand patterns of systematic exclusion have inspired numerous initiatives to assess the demographic diversity of those producing knowledge and governing global health. However, in the absence of systematically reported demographic data, scholars often rely on proxy self-identification (eg, cued language in online biographies assumed to be authored or endorsed by the person themself) or external inference methods (eg, based on name, photo, or language) for demographic characteristics. This Review critically examines the strengths, limitations, and ethical concerns of these different approaches, and proposes guidance based on five pillars that support their more responsible use: (1) practising critical refusal; (2) prioritising self-reported methods; (3) aligning methods with purpose and context; (4) embedding safeguards in data storage, reporting, and sharing; and (5) ensuring transparency and reflexivity. Ultimately, the challenges that these quantitative assessments seek to address, and the pitfalls of their methods, can be avoided altogether with the fundamental transformation of the norms and practices underpinning global health.

To address challenges in the real-world implementation of digital health for mental healthcare in Nigeria, this study conducted a process evaluation of five World Health Organization-recommended digital tools within a state-wide primary health care program in Lagos. Employing a convergent mixed-methods design across five facilities, we measured implementation fidelity through observation and platform analytics, and assessed stakeholder perceptions via validated surveys and interviews. The findings revealed a sharp divergence in success. Administrative tools that streamlined workflows, such as drug stock notification and automated client reminders, achieved high fidelity (>90% adherence). In contrast, clinical tools that altered provider-patient interactions, including a decision support app and a client helpline, demonstrated low fidelity (<66% adherence). Qualitative analysis attributed this gap to the successful tools' seamless workflow integration versus the clinical tools' disruption of practice and introduction of perceived professional and liability risks. The study concludes that digital health adoption is determined less by technological sophistication than by its integration into human systems. Scaling these innovations effectively requires prioritizing tools that align with existing workflows and developing a supportive policy ecosystem to address the professional concerns of frontline health workers.

Background The sustainability of integrating mental health into primary health care (PHC) in low- and middle-income countries (LMICs) is uncertain, often failing beyond pilot stages. This study examines the policy and governance factors shaping the sustainability of the Mental Health in Primary Care (MeHPriC) project in Lagos, Nigeria, a state-led MNS integration initiative. Methods This qualitative study combined a systematic document review with 15 in-depth interviews with state policymakers and MeHPriC managers. Guided by the Integrated Sustainability Framework (ISF) and Supporting the Use of Research Evidence (SURE) framework, we explored how policy, financing, and coordination influence sustainability. Data were analysed thematically and triangulated to map implementation pathways. Findings Lagos State demonstrated strong formal commitment via policies, task-shifting guidelines, and a mental health law. However, sustainability was constrained by implementation gaps, weak supervision, inconsistent budget execution, and high workforce turnover. Leadership enabled early momentum, but coordination was limited and informal. Community engagement diminished post-investment. Findings suggest sustainability depends on enforcement, ownership, and embedded financing and accountability mechanisms, not just policy presence. Interpretation Sustainable mental health integration requires more than scaling clinical protocols; it demands structural alignment across policy, leadership, financing, and community domains. The MeHPriC case underscores the importance of treating sustainability as a deliberate, systemic priority from the outset. Policymakers in LMICs must institutionalise governance and financing pathways to ensure long-term resilience. Funding This study was funded by the UK Medical Research Council (MRC) under the Global Health Systems Research programme [Grant number: MR/T021845/1].

Background Many low- and middle-income countries (LMICs) face a vast mental health treatment gap. Digital health offers scalable solutions, but successful implementation requires assessing health system readiness. This study developed and applied an integrated framework to assess this readiness in an urban LMIC.Methods In Lagos, Nigeria, our mixed methods study used an integrated framework combining systematic policy appraisal (adapted Appraisal of Guidelines for Research and Evaluation II) with granular ecosystem mapping of national repositories and local infrastructure.Results The assessment revealed a strategic implementation gap. Lagos State has strong policy readiness (score: 75.8/100) and a robust technology ecosystem with Nigeria's highest mobile density (nearly 26 million active lines). However, readiness was misaligned with implementation: a granular analysis of 45 national digital health projects found mental health constitutes only an estimated 2-3% of the portfolio's focus, with no dedicated platforms. This strategic oversight persists in new national digital health architecture.Conclusions Health system readiness is multidimensional and assessments focused on isolated components can be misleading. Our findings highlight a strategic gap between an enabling policy environment and actual implementation. The integrated framework offers a replicable model for LMIC policymakers to diagnose these gaps and guide evidence-based digital health investments to bridge the mental health treatment gap.

Background:Mental health interventions in low- and middle-income countries (LMICs) face significant sustainability challenges, often leading to 'programme drift' (protocol deviation ) and 'voltage drop' (reduced effectiveness). While implementation science frameworks emphasise fidelity, they often fail to explain how frontline providers in resource-constrained settings maintain services. Here, we investigate how adaptive mechanisms function as legitimate sustainability strategies within Lagos, Nigeria's Mental Health in Primary Care programme, which contends with chronic underfunding, high staff turnover, and community stigma. Methods:We conducted a convergent mixed-methods study in six Lagos local government areas. Data were collected from 130 stakeholders (policymakers, managers, health workers, care recipients) through quantitative surveys and from a nested subsample of 70 participants through in-depth interviews and institutional ethnography. We analysed quantitative data using multiple regression and qualitative data using thematic analysis, systematically integrating the findings through triangulation to produce meta-inferences about sustainability dynamics. Results:Systemic constraints, particularly underfunding (<2% of health budget) and high staff turnover (30% annually), drove programme drift and community stigma, deterring 40% of patients and contributing to voltage drop. However, this drift often manifested through constructive adaptive mechanisms, including informal peer mentoring networks and role flexibility, which maintained service continuity. Multiple regression (R2 = 0.45) identified leadership (β = 0.42), infrastructure (β = -0.35), and stigma (β = -0.30) as significant predictors of sustainability. Mixed-methods integration revealed these adaptations were the primary mechanism through which effective leadership operated - a dynamic invisible to quantitative measures alone. Conclusions:Adaptive mechanisms represent legitimate and necessary sustainability strategies in resource-constrained settings, not implementation failures. We propose 'functional fidelity' (maintaining core outcomes through flexible processes) and 'adaptive capacity' as crucial theoretical extensions for implementation science in LMICs. Sustainable mental health integration requires frameworks that recognise and support frontline innovation while ensuring quality safeguards are maintained, offering a more realistic pathway to closing the global mental health treatment gap.

Scaling up effective public health interventions is crucial for achieving universal health coverage, yet remains challenging. We report the use of the Plan-Do-Study-Act (PDSA) quality improvement model to support the iterative scale-up of a community-based cardiovascular disease risk management program in Malang District, East Java, Indonesia. A pragmatic implementation study comprising three PDSA cycles was conducted in 10 'test of scale-up' villages between April 2021 and December 2022. Each cycle included: 1) the capture of quantitative outcomes, such as the number of new community members screened per month and diagnostic summaries with predicted risk status; and 2) semi-structured interviews and focus group discussions with health care workers, community members, and community health workers in each village to assess acceptability, adoption, adaptations and perceived effectiveness. Based on identified implementation barriers, local Technical Working Groups designed change strategies, which were implemented and evaluated in subsequent cycles. The COVID-19 pandemic disrupted program delivery in the first two PDSA cycles, reducing screening to an average of 112 and 7, respectively. In cycle 3, 463 community members were screened. Across the 10 participating villages, 42 interviews and 30 focus group discussions were conducted per PDSA cycle. Key barriers included difficulty reaching male community members, inadequate resourcing, limited essential medications and poor integration with existing health information systems. Change strategies included centralising screening activities, leveraging instant messaging platforms, additional activities to engage men and streamlined procurement processes. Each village demonstrated versatility in addressing implementation challenges. These findings highlight the utility of the PDSA model in supporting the iterative scale-up of a community-based cardiovascular disease risk management programs in real-world settings, even amid significant disruptions such as the COVID-19 pandemic.

BACKGROUND:Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in Indonesia. Despite the importance of identifying individuals at high risk of CVDs for Indonesian health planners in designing effective intervention strategies, the CVD situation in the country has not been well-documented. This study aimed to estimate the distribution of the estimated 10-year risk of CVD and the associated socio-demographic factors and healthcare access in Indonesia. METHODS:This study was a community-based study in which the data were collected using interviews and the taking of physical measurements of 903,130 adults aged 40 years and older in 390 villages in Malang District, East Java Province, Indonesia, from January 2020 to February 2024. The estimated 10-year risk of CVD was calculated based on the World Health Organization/International Society of Hypertension's region-specific charts for the Southeast Asia Region (SEAR B). We performed multilevel logistic regression modelling to examine the associations between individual and healthcare provider densities and the estimated 10-year risk of CVD, as well as receiving optimal preventive treatment, defined as at least one blood pressure-lowering drug and a statin for all high-risk individuals, and an antiplatelet drug for those with prior diagnosed CVD. RESULTS:Among 903,130 participants, 169,758 (18.8%; 95% Confidence Intervals 18.7% - 18.9%) had high cardiovascular risk. The proportion of high CVD risk was greater (<0.001) in urban (19.6%) than in rural areas (18.3%). Only 25.7% of all the respondents with high CVD risk received optimal preventive treatment, with high-risk males who live in urban areas showing better treatment. The availability of community-based health care (Posbindu), medical doctor at primary healthcare, nurses, and health insurance were associated with lower odds of having high CVD risk. CONCLUSION:Around one-fifth of the population aged 40+ in Malang District, Indonesia is estimated to have high 10-year CVD risks, as assessed by the WHO/ISH risk prediction charts, and three-quarters of those with high risk did not receive optimal preventive treatment. Ensuring that individuals with high CVD risk get the optimal treatment is important, especially in low- and middle-income countries. The accessibility of preventive care is vital in primary care to address the sex and geographical gap of CVD risk management.

In this practice paper, we reflect on our practices, experiences and observations of teaching global and public health, with a focus on navigating the upstream-downstream tension. The concept of upstream determination of health encompasses how the social, structural and systemic drivers shape health and well-being. This paper discusses the challenges of foregrounding this concept in pedagogy through four key themes: (1) a lack of uniformity in integrating upstream concepts across disciplines related to health, and the ways in which it could be better integrated specifically into global health curricula; (2) helping students navigate the upstream-downstream tension by reflecting on why downstream solutions are more prevalent and how to better understand the structural responses, which are needed for achieving health equity; (3) why upstream thinking is hard to teach and learn, given that upstream determination can be complex, less familiar and abstract (we outline conceptual barriers and pedagogical challenges, common missteps and potential strategies to overcome them); (4) looking upstream in global health roles; how future graduates may consider ways to work upstream in their role as global health professionals, given that many job opportunities tend to focus downstream. This paper highlights the challenges of teaching upstream determination in global health, with a call to more uniformly integrate its concepts into curricula and offers potential strategies for teachers to meaningfully and collectively foreground such concepts within pedagogical delivery.

This paper promotes reflexive consideration of health research practices using a decolonisation lens. We propose both incremental and more radical action in five domains: knowledge production, funding and programmes, dissemination, uptake, and education and training. We suggest four steps towards transformation and share a reflexive tool to operationalise these steps.