Peter Stewart Hill

In the absence of documented health workforce deployment policies and limited access to key job history data, existing health systems research methods are inadequate for examining policy implementation. The analysis of self-reported job histories offers a valuable research method for overcoming these limitations; however, its application and usefulness remain largely unexamined in health system and policy research, particularly in the context of health workforce and policy implementation. In this paper, we reflect on our experiences of using self-reported job histories to investigate the experiences of public sector doctors with deployment systems related to recruitment, initial posting, and transfers. We interviewed 33 public sector doctors from two Indian states to gain insight into their experiences with policies and systems related to deployment. The initial interview process revealed a pattern in which the doctors developed a work-life chronology to organize their responses. This was formalized in subsequent interviews, creating structured chronological job histories. Job histories serve as a useful and flexible research method for understanding the complexities of how health workforce deployment systems operate and are experienced by health workers. Commentary by doctors regarding these job histories revealed negative perceptions of transfer practice, disruptions in their career trajectories, and gaps in policy implementation. The recollection process of forming job histories is organic and fluid, rich in qualitative data, and its construction involves making sense of diverse work-related stories of health workers. Job histories offer flexibility for collecting data in a more structured manner through a simple set of quantitative questions. Despite their usefulness, constraints such as the inability to triangulate and recall bias exist. Beyond research, job history analysis has practical implications; it is useful for policy implementers and researchers through a more nuanced analysis of challenges related to effective workforce management systems, thereby improving workforce planning, policies, and systems.

The deployment of the health workforce, carried out through initial and subsequent posting and transfer (PT), is a key element of health workforce management. However, the focus of the currently available PT literature is mostly on subsequent PT, and the distinction between initial and subsequent PT has received little research attention. Drawing on this gap, in this paper, we examine how doctors experience their subsequent PT compared with their initial postings in two states in India. The distinctions have been drawn using the prism of six norms that we developed as evidence for implied policy in the absence of documented policy. This mixed-methods study used in-depth interviews of doctors and key informants, with job histories providing quantitative data from their accounts of their PT experience. Based on the interviews of these frontline doctors and other key policy actors, this paper brings to light key differences between initial and subsequent postings as perceived by the doctors: compared with initial postings, where the State demands to meet service needs dominated, in subsequent postings, doctors exercised greater agency in determining outcomes, with native place a central preoccupation in their choices. Our analysis provides a nuanced understanding of PT environment through this shift in doctors’ perceptions of their own position and power within the system, with a significant change in the behaviour of doctors in subsequent PT compared with their initial postings. The paper brings to light the changing behaviour of doctors with subsequent PT, providing a deeper understanding of PT environment, expanding the notion of PT beyond the simple dichotomy between service needs and doctors’ requests.

Posting and Transfer (PT) refers to deployment of the health workforce in ways that ensure appropriate numbers and distribution. Although PT is a crucial aspect of health workforce governance, it remains under-researched from the viewpoint of implementation, health workforce and governance. The aim of this paper is to examine public sector doctors’ experience of their initial postings, in the context of local policy from two Indian states. We carried out a review search for policy documentation. A total 61 in-depth interviews were conducted in both states with 33 doctors, as subjects of the study. There were 28 key informant (KI) interviews of health administrators and other policy actors to understand their perspectives of PT policies and implementation. Thematic analysis was used to analyse data. Job histories were constructed from the doctors’ interviews to track their experience with the PT system, and analysed using location, duration and postings. Despite search for state policy for PT, we were unable to identify any policy documentation. However, participants referred to PT practices that suggested expectations of what the poliy meant to them. These expectations were corroborated by KI, and the job histories and interview data enabled the authors to construct a series of norms, interpreted as evidence of implied policy. The main norms identified relate to service need, native place, request, gender and posting duration. The norm related to state need had strong face validity, while other norms based on request, gender and duration were less consistent in application. In the absence of documented policies, the construction of norms from the qualitative data proved useful to examine the dynamics of health workers’ interactions with the initial PT systems This construction of norms provides a methodological innovation allowing health policy and systems researchers to compensate for the absence of documented policy in exploring PT functions.

Australia has committed to the 17 Sustainable Development Goals (SDGs) goals under the UN’s 2030 Agenda. However, these goals may not be fully achieved in Australia under current policy settings. Australia reports success in achieving the goal for quality and access to safe drinking water and sanitation (SDG 6), though for Australians living in remote Indigenous communities, the experience is very different. Furthermore, the burden of disease is higher in remote communities (SDG 3). Many of these diseases are waterborne or hygiene-related, including prevalence in some remote Indigenous communities of endemic trachoma eye infection, preventable through access to functioning water services and available soap. This research provides a case for identifying, then understanding the interlinkages between SDGs 3, 6, and others locally, as well as nationally. This will enable governments to enact policies for long-term sustainable solutions for remotely-located and marginalised peoples in Australia in line with Agenda 2030 commitments.

Background: The third Sustainable Development Goal (SDG − 3) aims to ensure healthy lives and promote well-being for all at all ages. SDG-3 has a specific target on universal health coverage (UHC), which emphasizes the importance of all people and communities having access to quality health services without risking financial hardship. The objective of this study is to review progress towards UHC using antiretroviral treatment (ART) as a case study. Methods: We used a mixed-methods design including qualitative and quantitative approaches. We reviewed and synthesised the evidence on the evolution of the WHO HIV treatment guidelines between 2002 and 2019. We calculated ART coverage over time by gender, age group, and location. We also estimated ART coverage differences and ratios. Findings: ART guidelines have evolved from “treating the sickest” to “treating all”. ART coverage increased globally from under 7% in 2005 to 62% in 2018. There have been successes in increasing ART coverage in all populations and locations. However, progress varies by population and location in many regions. There is inequity in ART coverage: women (68%) versus men (55%), and adults (62%) versus children (54%). This inequity has widened over time, and with expanded ART eligibility criteria. On the other hand, data from at least one high-burden country (Ethiopia) shows that inequity among regions has narrowed over time due to the improvements in the primary health care systems and implementation of the public health approach in the country. Conclusion: ART coverage has increased at global, regional and national levels to all population groups. However, the gains have not been equitable among locations and populations. Policies towards universality may widen the inequity in resource-limited settings unless countries take precautions and “put the last first”. We argue that primary health care and public health approaches, with multi-sectoral actions and community engagement, are vital to minimize inequity, achieve UHC and leave no one behind.

The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance—even veto—of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure—federal systems, user fees, pre-existing insurance schemes—needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.

Background: In 2018, the Australian Government, through a Senate-led Parliamentary Inquiry, sought the views of diverse stakeholders on Sustainable Development Goal (SDG) implementation both domestically and as part of Australia’s Overseas Development Assistance (ODA) program. One hundred and sixty-four written submissions were received. The submissions offered perspective and guidance from a rich cross-section of those involved, and with keen interest in, Australia’s ODA-SDG commitment. This article identifies and explores the submissions to that Inquiry which placed impetus on Australia’s ODA-SDG and health and development nexus. It then compares how the synthesized views, concerns and priorities of selected Inquiry stakeholders align with and reflect the Australian Government’s treatment of SDG 3 in its SDG Voluntary National Review (VNR), as well as with the final Inquiry report summarizing submission content. Results: Four key themes were synthesized and drawn from the thirty-one stakeholder submissions included in our analysis. Disconnect was then found to exist between the selected stakeholder views and the Australian Government’s SDG-VNR’s treatment of SDG 3, as well as with the content of the Parliamentary Inquiry’s final report with respect to the ODA-SDG and health and development nexus. Conclusions: We situate the findings of our analysis within the wider strategic context of the Australian Government’s policy commitment to “step up” in the Pacific region. This research provides an insight into both multi-stakeholder and Federal Government views on ODA in the Indo-Pacific region, especially at a time when Australia’s Pacific engagement has come to the forefront of both foreign and security policy. We conclude that the SDG agenda, including the SDG health and development agenda, could offer a unique vehicle for enabling a paradigm shift in the Australian Government’s development approach toward the Pacific region and its diverse peoples. This potential is strongly reflected in stakeholder perspectives included in our analysis. However, study findings remind that the political determinants of health, and overlapping political determinants of SDG achievement, will be instrumental in the coming decade, and that stakeholders from different sectors need to be genuinely engaged in SDG-ODA policy-related decision-making and planning by governments in both developed and developing countries alike.

Internationally, mental health and social care systems face significant challenges when implementing policy to prevent and respond to domestic violence (DV). This paper reviews the policy process pertaining to the national law on domestic violence prevention and control (DVPC) within the health system in Vietnam from 2003 to 2018, and critically examines the policy-making process and content, the involvement of key actors and the barriers to implementation within the health system. 63 policy documents, 36 key informant interviews and 4 focus group discussions were conducted in Hanoi city, Bac Giang and Hai Duong provinces. The policy triangle framework was used to analyse the development and implementation process of the Law on DVPC. The Vietnamese government developed the law on DVPC in response to the Millennium Development Goals reporting requirements. The development was a top–down process directed by state bodies, but it was the first time that international agencies and civil society groups had been involved in the health policy development process. The major themes that emerged in the analysis include: policy content, policymaking and implementation processes, the nature of actors’ involvement, contexts, and mechanisms for policy implementation. Policy implementation was slow and delayed due to implementation being optional, decentralization, socio-cultural factors related especially to sensitivity, insufficient budgets, and insufficient cooperation between various actors within the health system and other related DV support systems. The initial development process for DVPC Law in Vietnam was pressured by external and internal demands, but the subsequent implementation within the health system experienced protracted delays. It is recommended that the policy be revised to emphasise a rights-based approach. Implementation would be more effective if monitoring and evaluation mechanisms are improved, the quality of training for health workers is enhanced, and cooperation between the health sector and related actors in the community is required and becomes routine in daily work.

Ethiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services. We conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies. The HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP. The HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.

From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia. This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility. Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms. The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.