IJHG Review 28.1

Citation

MacVane Phipps, F.E. (2023), "IJHG Review 28.1", International Journal of Health Governance, Vol. 28 No. 1, pp. 4-9. https://doi.org/10.1108/IJHG-03-2023-152

Introduction

The IJHG Review section consists of short reviews of each article included in the current issue. Each mini-review starts with the phrase: “this review is based on …” followed by the author(s) and title of the article in question. This allows readers to prioritise subject matter which reflects their own interests or areas of expertise. The Review Editor includes additional commentary based on external sources as appropriate.

(1) This review is based on, Kazemikhasragh and Buoni Pineda (2023), inclusive policies for health financing towards universal health coverage in Pakistan: direct or indirect taxes

Pakistan's health expenditure represents a low percentage of government spending; this has changed very little over the past decade. While the World Health Organisation (WHO) recommends universal health care financing as a way to reduce heath inequalities and improve public health (World Health Organisation, 2022), reliance on funding health coverage through indirect taxation is unable to provide a sustainable method of achieving this. However, Pakistan has recently taken steps to alleviate health care inequality with the introduction of a health card scheme for all residents of the Punjab region; this ensures the provision of hospital treatment for both chronic and acute infectious conditions (Farooq et al., 2022). The challenge for the government of Pakistan will be to raise sufficient taxes to make this new scheme, which ultimately is due to be rolled out across all regions, sustainable in the long term. To help kick start these and other improvements in Pakistan's health services, the World Bank has allocated over 250 million USD funding for the National Health Support Programme (NHSP) with the goals of health quality and coverage, and improved healthcare financing (World Bank, 2022).

Kazemikhasragh and Buoni Pineda (2023) demonstrate the increased efficiency of direct taxation to provide long-term funding for universal health care. The authors recommend dialogue to define effective frameworks for achieving this as a step towards increasing social equity.

(2) This review is based on, Liu (2023), deregulation on branded and generic drugs price and its effect: a study of Chinese pharmaceutical market.

Price capping and referencing are both common strategies used to regulate drug prices. However, some critics claim that deregulation would result in both lower prices for consumers and higher profits for drug companies. In response to this, the Chinese government approved the deregulation of pharmaceutical product pricing in 2015. This in effect provides a natural policy experiment in which prices and profits can be compared pre and post deregulation using an interrupted time series analysis (ITSA).

ITSA is increasingly the research design of choice for the evaluation of public health policy implemented on a particular population during a defined time span (Bernal et al., 2017). Pre-intervention trends can be compared to data collected from the same population after the intervention has been implemented.

Liu compared a pharmaceutical company's revenue from nine categories of drugs before and after deregulation; these included oncology, diabetic, cardiology and antibiotic medications. Findings indicated that there is a direct relation between levels of competition and drug revenue. When competition is low, generic drug revenue increases but where competition is high, branded drugs demonstrate a better performance. Although generic drugs have the same formulation as their branded competitors, there have been questions raised about their quality in the Chinese industry, with higher income consumers electing to purchase branded medication. These concerns will need to be addressed to afford generic drugs a more competitive share of the pharmaceutical market.

(3) This review is based on, Mourajid et al. (2023), governance in Moroccan public hospitals: critical analysis and perspectives for action

The Moroccan government has been implementing reform and restructuring strategies to improve hospital governance since the early years of the 21st century. While this has gone some way towards establishing a culture of accountability, significant deficiencies remain; these include ageing hospital structures, a low bed-to-population ratio, staff absenteeism and excessive length of hospital stays. These defects were made even more apparent by the recent COVID pandemic. Therefore, this study was undertaken in order to shed light on hospital governance in Morocco in order to expose the major dysfunctions in governance structure and implementation.

The authors selected a conceptual framework to evaluate governance models. There are a number of frameworks which can be used for this purpose; they tend to vary in their derivation and thence their interpretation of the key elements of governance. Some frameworks have been developed from economic theory, some from social theory and others from political science (Pyone et al., 2017). The validated framework selected by Mourajid et al. (2023) encompassed the dimensions of: institutional arrangements, financial arrangements, accountability arrangements and decision-making. These were explored through a multiple case study approach in which semi-structured interviews were conducted with a range of hospital managers.

Problems identified by the researchers included a lack of long-term project planning, a very unequal budget allocation of public funds between public and private hospitals, and the appointment of hospital directors without the background or training to manage the complex governance of a modern hospital. The authors were able to make some key recommendations around the restructuring of financing, management and accountability to improve the Moroccan health care system.

(4) This review is based on, Wiig et al. (2023), backstage researching resilience researchers – dilemmas and principles for data collection in healthcare research programme.

Resilience has become a buzzword in discussions concerning health governance. Resilience in healthcare can be defined as a quality of adaptability that ensures high level care can be maintained even in the presence of unexpected problems or challenges. An example might be the challenges created by the COVID-19 pandemic and the ways in which both institutions and healthcare providers used resilience to continue providing a high level of care (Sagan et al., 2021).

Resilience is a very valued attribute in today's workplace, particularly in health care. However, resilience, rather than being a strength, can become a weakness when overused. Chamarro-Premuzik and Lask (2017) cite two examples of this. The first is when staff resilience is used to neglect needed structural changes. This would be an example of poor governance. The other example is when staff continue to waste time working towards unobtainable goals, the “never give up” attitude, which can prevent more realistic and obtainable goal setting. Both of these can lead to burnout in healthcare staff.

The current paper introduces a novel twist by reporting on researching the researchers that is using health resilience researchers themselves as a source of data. The authors explore some of the dilemmas and difficulties inherent in this approach but make a valid case for insider research as a legitimate methodology. Indeed, the reflexivity which this approach necessitates can be seen as a positive factor for both the individual health resilience researcher as well as a means of ensuring rigour and validity in the research.

(5) This review is based on, Martin et al. (2023), applying a new approach to the governance of healthcare quality at Board level.

In the world of health governance, health boards play a significant role in ensuring safety, quality and value for money in all aspects of clinical governance. Various stakeholders' perspectives are considered at board level due to the inclusion of managers, clinicians, patients and representatives of the public. However, perspectives can only be developed and thus discussed and debated if the information on which they are based is both accurate and relevant.

Martin et al. (2023) describe an approach developed by two of the authors to improve the ability of a health board to oversee and improve quality and safety by identifying actionable steps that can be undertaken following each board meeting. Called the Picture-Understanding-Actions approach, this aims to provide an accurate picture of the issues, topics and problems under consideration, to ensure that all board members understand these issues and the contexts within which they occur, and then to identify actions which can be implemented towards the necessary quality and safety improvements.

Issues for effective implementation and delivery of this approach include the importance of high level data skills training for board members, together with updating their knowledge of current health management trends, sufficient time allocation for board meetings and adequate auditing of improvements implemented as a result of board decisions. According to Hut-Mossel et al. (2021) understanding the how and why of clinical audit is an essential skill in healthcare improvements. They argue that audit often fails to lead to intended improvements because of a lack of understanding of the audit process and why, when and how audits should be done. This recommendation for deep understanding complements the “Picture-Understanding-Actions” approach to health board management proposed by Martin et al. (2023).

(6) This review is based on, Magerøy and Wiig (2023), the effect of full-time culture on quality and safety of care – a literature review.

Full-time culture is a term indicating that the normal working pattern in health care is for nursing and other care staff to work full time (40 h weeks) within whatever shift arrangements are currently in place. Maintaining a staffing rota of full-time workers is considered more cost and time effective than juggling the various schedules of part-time workers. In healthcare today shift patterns are often made up of two 12-h shifts rather than the traditional three 8-h shifts. Again this is considered a more efficient use of personnel as fewer handovers are required. While 12-h shifts staffed by full-time employees may represent an efficient use of resources, there are often human costs. Nurses working in a full-time culture with a long shift pattern have been known to suffer from burnout and often report plans to leave their immediate jobs if not the nursing or caring professions themselves. This is especially true of older employees. Issues about patient safety must also be raised in discussions about full-time culture as some studies have indicated that clinical errors are more likely to occur when staff are fatigued or have been working long hours. A systematic review and meta-analysis published within the last four years demonstrated a clear association between nurse burnout and decreasing patient safety (de Lima Garcia et al., 2019).

Magerøy and Wiig (2023) conducted a literature review to determine the effect of full-time culture on nurses' experience and on patient safety. The authors identified four recurring themes in the literature they reviewed: (1) length of shifts, (2) fatigue and burnout, (3) autonomy and empowerment, (4) system and structure. While the article explores these four main themes, no clear answers emerge. However, there were indicators that staffing pressures increase in line with healthcare demands, and this can lead to difficulties in retention of existing staff and recruitment of new staff. Although most staff did not equate their own fatigue with patient safety issues, the authors suggest that raising awareness of the relationship between these issues is a management responsibility. Strategies to reduce burnout such as scheduling adequate meal breaks was also identified as a management responsibility, however with staff shortages and high patient numbers, allocating adequate breaks while continuing to care for patients may be impossible. During the recent COVID-19 pandemic, lack of breaks was found to be a contributing factor to nursing burnout (Gemine et al., 2020).

Staff empowerment in the form of feeling of control over scheduling and shift patterns seemed to be a mitigating factor which served to reduce work-related stress. However this may not be congruent with shift patterns based on cost and efficiency rather than those placing greater value on human factors.

(7) This review is based on, Ud Din et al. (2023), inter-state disparities in Government Health Expenditure in India: a study of National Rural Health Mission (NRHM)

In India spending on health as a proportion of GDP is low, even in comparison to other countries in similar stages of development. The problem of inadequate health spending is compounded by disparities between states. This has resulted in gross health inequalities based on location. For instance, in 2020, the infant mortality rate in Mizoram was a low 3/1000, while in Madhya Pradesh it was a high 43/1000.

Lowering health inequalities is essential in the quest to establish a healthy population able to be economically active and in reducing social inequalities. One strategy adopted by the Indian government was the introduction of the NRHM. Launched in 2005, the NRHM had a strong focus on community control, monitoring progress against accepted standards and using flexible financing to achieve goals (Nandan, 2010). According to Ud Din et al. (2023), the main goals of the NRHM were (1) to incorporate traditional forms of healthcare such as Ayurvedic medicine and homeopathy into the government funded health service, (2) to increase access to affordable primary health care for rural communities, (3) to reduce child and maternal mortality, (4) to control infectious disease and (5) to reduce disparities between available healthcare and health outcomes in different Indian states. The authors focus primarily on this last goal in their report that indicates progress towards convergence in health statistics was effected through the strategy of directing higher levels of resources to poorer-performing areas.

Conclusion

The IJHG is unique in its clear focus on healthcare governance in all that this entails. Starting life as the British Journal of Clinical Governance, the journal has evolved to encompass an international perspective, inviting authors from around the world for contributions and thus attracting an international readership. While readers may home in on articles perceived as most relevant to their own healthcare environment, the Review Editor believes that expanding one's focus to include articles that may not seem immediately relevant can reveal hidden treasures. In the world of clinical healthcare, healthcare management and health professional education, we all have much to learn from each other.