This Forum article examines what the emergence of a multi-order world might mean for the future of international cooperation over global health security. It argues that recent years have seen a retreat of key states of the liberal international order from the internationalist vision of collective disease control, weakening its foundations. At the same time, leading states of other international orders, such as Russia and China, have been resistant to some of the core principles of global health security, and have primarily been interested in utilizing health as a part of their wider order-building strategies. We seem to be entering a future in which the world could splinter into multiple order-based sets of parallel cooperative arrangements. This is not a recipe for success in global health security given that transboundary disease threats cannot be addressed by individual international orders any more than they could by individual states.

PURPOSE:Mobility-assistive technology (MAT) faces significant global implementation barriers. This study applied a Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) matching tools to identify barriers to MAT provision in Saudi Arabia and generate evidence-based implementation strategies. MATERIALS AND METHODS:We triangulated findings from two published studies: a scoping review of barriers to MAT and a mixed-methods study of Saudi Arabian hospitals, including survey data, semi-structured interviews, and policy document analysis. Barriers were identified, mapped to the CFIR constructs, and translated into strategies using the CFIR-ERIC Matching Tool. RESULTS:Triangulation identified 14 distinct barriers across six categories mapped to 14 CFIR constructs within five domains. The CFIR-ERIC tool generated 49 implementation strategies. Planning (n = 17, 35%) and education (n = 13, 26%) were the predominant strategies. Top-ranked strategies included "identify and prepare champions" "conduct educational meetings", and "assess for readiness", demonstrating applicability across multiple barriers. CONCLUSION:The application of implementation science frameworks is a useful way to identify evidence-based strategies to address barriers to MAT provision. The predominance of planning and education strategies, reflecting endorsements from implementation science experts, suggests that systematic preparation and knowledge dissemination are fundamental to improving MAT accessibility. The findings provide actionable guidance for stakeholders in Saudi Arabia and similar settings. Future research should empirically evaluate strategy effectiveness.

PURPOSE:Mobility-related disabilities are the most prevalent disabilities in Saudi Arabia, significantly affecting quality of life. While mobility-assistive technologies (MATs) help mitigate impairments, unmet needs persist with a critical knowledge gap regarding barriers to their provision. This study investigated the barriers to the provision of MAT in the healthcare system of Saudi Arabia. MATERIALS AND METHODS:This mixed methods study combined a cross-sectional survey with a qualitative embedded multiple case study across three public hospitals in two Saudi regions. The survey assessed MAT availability among 67 stakeholders and facilitated recruitment for the qualitative investigation. Semi-structured interviews were conducted with 33 participants (healthcare professionals [HCPs], managers and leaders), and six policy documents were analysed. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis. RESULTS:The survey demonstrated that, while basic MATs were generally accessible, advanced devices were not and there were substantial regional disparities. The qualitative analysis identified 52 barriers across all CFIR domains, including dependence on imported devices, high costs and procurement delays, restrictive policies and regulatory ambiguities, insufficient professional healthcare training, inadequate strategic planning and clinical leadership, infrastructural constraints and sociocultural factors that influence patient acceptance. CONCLUSIONS:This study is the first comprehensive investigation of barriers to MAT provision in Saudi Arabia. These findings provide policymakers and practitioners with an evidence-based foundation for designing contextually relevant implementation strategies to enhance equitable MAT provision.

The Gates Foundation is the most influential private philanthropic foundation in global health and development. This article examines how the Foundation has developed an unparalleled capacity to rally other donors to its priorities, which include the development and distribution of technological tools to reduce the burden of infectious disease and child mortality in the world’s most impoverished regions. Using publicly available data, the article analyses the Gates Foundation’s strategic engagement in Europe, focusing on its bureaucratic presence, government relations, and grant-making in its three European focus countries: the United Kingdom (UK), Germany and France. It highlights that, since 2010, the Gates Foundation has built a bureaucratic infrastructure akin to a diplomatic service, establishing country offices in London and Berlin alongside representation in Paris, Brussels and Stockholm. Through regular engagement with elected officials and bureaucrats in these nations, the Foundation has forged many strategic partnerships, effectively leveraging European states’ diplomatic power in wider political forums and alliances. Moreover, the Foundation has disbursed billions in grants to recipients in the UK, Germany, and France to advance research and innovation on its priority health issues, implement programs in poor countries, and develop policy and advocacy related to global health and development. Combined, these efforts have contributed to securing substantial and recurrent government co-investment in Gates-supported initiatives. The article proposes that the Foundation exercises a form of ‘network diplomacy’ that entails building and maintaining wide networks across European societies with the aim of aligning donor governments’ overseas development assistance and policies with the Foundation’s strategic objectives in global health and development. The concept of network diplomacy offers a new perspective on how the Gates Foundation has consolidated and expanded its transnational political presence through an approach that is strategic, bureaucratised and institutionalised, rather than simply a product of its financial might. The findings amplify existing concerns regarding the sway of private foundations over public policy, their impact on democratic accountability and governance in donor states, and the resultant implications for the Foundation’s intended beneficiaries in low- and middle-income countries.

BACKGROUND:COVAX was designed to support the discovery, development, and distribution of COVID-19 vaccines globally, at scale and pace. This article examines how COVAX promoted vaccine equity and what lessons can be learnt. METHODS:Informed by a scoping review of lessons learnt from GHPs, we reviewed 109 documents related to COVAX and other GHPs and conducted 23 key informant interviews with representatives from GHPs, civil society, academia, and the private sector. Data were synthesised thematically using Rushton and Williams's framework. RESULTS:Data showed how the global health policy context shaped COVAX, with experience with Gavi and CEPI influencing its governance structure. We highlighted weaknesses in transparency and accountability, limited engagement with civil society organisations [CSO] and LMIC stakeholders, contested policy debates (e.g., different framing) and paradigms (e.g., prioritising technical and financial over political solutions). CONCLUSIONS:COVAX largely replicated existing GHP approaches, subsidising research and development and then paying for resulting discoveries. While recognising how this reflects global power structures, in the inevitable next global health crisis, the international health community must advocate for greater LMIC and CSO involvement in decision-making, sharing of intellectual property and technology transfer, and rebalancing of flows of innovation costs and benefits to a broader range of actors across public and private sectors.

An effective policy brief bridges the gap between research findings and policymaking, ensuring that evidence is presented succinctly and in a way that is accessible and usable for policymakers and relevant stakeholders. However, many researchers find it hard to communicate the findings of their studies to relevant policymakers, whilst policymakers note that evidence relevant to their needs is not easily accessible and is often not presented in an accessible format. Producing policy briefs is one of the approaches which academics can use to get their research noticed by policymakers. This paper is based on the authors’ research into health, health promotion, and health systems in Nepal. In order to get their findings known to relevant people, such as politicians and policymakers, many of these studies were summarised into policy briefs. This practical paper outlines some of the trials and tribulations of producing policy briefs, based on real-world research. It offers several recommendations in Box 4 to help improve the writing and dissemination of policy briefs.

Objectives There is strong evidence that mobility-assistive technologies improve occupational performance, social participation, educational and employment access and overall quality of life in people with disabilities. However, people with disabilities still face barriers in accessing mobility products and related services. This review aims to summarise and synthesise: (1) theories, models and frameworks that have been used to understand mobility-assistive technology access, (2) determinants of access and (3) gaps in knowledge.Design A scoping review using the five-step framework by Arksey and O’Malley.Data sources We searched the MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases for publications published between 2000 and 2024. We searched for articles published up to 20 March 2024.Eligibility criteria We included English-published literature in peer-reviewed journals that reported (a) barriers to the provision of mobility-assistive technologies, (b) including at least one theory, model or framework and (c) between 2000 and 2024.Data extraction and synthesis We extracted the study characteristics, theories, models, framework usage, research recommendations, key findings on mobility-assistive technology barriers and theoretical propositions. We conduct a theoretical synthesis guided by Turner’s approach.Results We included 18 articles that used 8 theories, models and frameworks, synthesised into 9 propositions. The synthesised theory emphasises that mobility is essential for human flourishing, and that certain health conditions may impose restrictions on mobility. This impact can be alleviated by two direct determinants: (1) the provision of suitable services and (2) their comprehensive provision. Policies and costs influence these services indirectly. Environmental and personal factors also affect the use of these services. Ineffectively addressing these determinants can limit access to mobility-assistive technologies and subsequent disabilities.Conclusion Our synthetic model describes the logic of providing evidence-based mobility-assistive technologies, and we identify the determinants of access that can act as targets for future work to improve the provision of mobility-assistive technologies.

Background Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country’s move to federalism on its health system, we reflect on the method’s strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach’s strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. Main body We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues – especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants’ understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. Conclusions PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders’ needs, it has great potential as a method in health policy and systems research.

Context: Since COVID-19, the European Commission (EC) has sought to expand its activities inhealth through the development of a European Health Union and within it the Health EmergenciesPreparedness and Response Authority (HERA). Methods:The authors applied a discourse analysis to documents establishing HERA to inves-tigate how the EC legitimated the creation of this institution. They focused on how it framed healthemergencies, how it framed the added value of HERA, and how it linked HERA to existing EUactivities and priorities. Findings:Their analysis demonstrates that security-based logics have been central to the EC'slegitimation of HERA in alignment with a "securitization of health" occurring worldwide in recentdecades. This legitimation can be understood as part of the EC's effort to promote future integrationin health in the absence of new competences. Conclusions:Securitization has helped the EC raise its profile in health politically without addi-tional competences, thereby laying the groundwork for potential future integration. Looking at thediscursive legitimation of HERA sheds light not only onwhetherthe EC is expanding its healthpowers but alsohowit strategizes to do so. HERA, while constrained, allows the EC to furtherdeepen security-driven integration in health.

Objective:The aim of this study is to explore how Nepal's newly federalized health system responded to the COVID-19 pandemic, using this as a basis for drawing wider lessons for health policymakers in Nepal.Method: An exploratory qualitative method was used, involving Key Informant Interviews with 145 health system stakeholders from diverse locations and all three levels of government.The resulting transcripts were thematically analysed using NVIVO software.Finding: We found significant differences in perceptions between the local and higher levels of government.At the local level, major themes identified included: i) a good ability to enact an initial response based on locally-available resources and capacities; ii) a consequent raising of the profile of health amongst local governments; iii) a feeling that they had not received the necessary support from higher levels of government.At the higher levels of government, we found: i) doubts about the capabilities of local governments to manage a health crisis; and ii) uncertainty about the roles and responsibilities of Provincial governments. Discussion:The newly-federalized health system understandably struggled to function effectively during the pandemic.However, this was not only the result of resource deficiencies or bureaucratic weaknesses.The performance of the system was also in part undermined by the continuation of a centralized mindset, especially amongst high ranking policy makers and senior officials, which was at odds with the theoretically devolved nature of decision-making under the federalized system. Conclusion:The study shows that, even outside the exceptional circumstances of the pandemic, there is a need for a change in mindset amongst Federal-level policymakers, from a command and control mentality towards supporting and empowering the lower levels in order to deliver a robust and functional federal health system.

This chapter describes a wide range of contemporary health challenges. It begins by assessing what it means to be healthy. The Covid-19 pandemic, and the response to it, have brought to the fore and shed new light on many of the issues that are core to Global Political Economy (GPE). Despite spectacular advances, there are huge inequalities in health in the world today, both within and between countries. Improving health requires both prevention and cure: public health efforts to protect and promote the health of populations, and healthcare services that are accessible to all in times of need. The chapter then considers how the social, economic, and commercial determinants of health can best be understood by adopting a GPE lens. A GPE framework can also reveal the challenges the world faces in its attempt to achieve universal access to quality healthcare.

Nepal’s move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal’s health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal’s health system as it adapts to federalisation. This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders’ practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. Our findings suggest that since federalisation, Nepal’s health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

Background Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system.Method We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews.Results Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself.Conclusions Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance.PROSPERO registration number CRD42022302013.