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Concept: Accountability


BACKGROUND: Research on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation. METHODS: This study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance.Results/discussion: The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers. CONCLUSIONS: The breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.

Concepts: Health care, Health care provider, Health economics, Medicine, Healthcare, Health informatics, Governance, Accountability


Universal health coverage has become a rallying cry in health policy, but it is often presented as a consensual, technical project. It is not. A review of the broader international literature on the origins of universal coverage shows that it is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics. On one hand, a variety of comparative research has shown that health coverage is associated with democratic political accountability. Democratization, and in particular left-wing parties, gives governments particular cause to expand health coverage. On the other hand, governance, the ways states make and implement decisions, shapes any decision to strive for universal health coverage and the shape of its implementation. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e3. doi:10.2105/AJPH.2015.302733).

Concepts: Health economics, Universal health care, Policy, Political philosophy, Political science, Democracy, Political party, Accountability


Integrating health and social care has long been a goal of policy-makers and practitioners. Yet, this aim has remained elusive, partly due to conflicting definitions and a weak evidence base. As part of a special edition exploring the use of the TAPIC (transparency, accountability, participation, integrity and capability) framework in different national contexts and inter-agency settings, this article examines the governance of integrated care in England since 2010, focusing on the extent to which thesefive governance attributes are applicable to integrated care in England. The plethora of English policy initiatives on integrated care (such as the ‘Better Care Fund’, personal health budgets, and ‘Sustainability and Transformation Plans’) mostly shows signs of continuity over time although the barriers to integrated care often persist. The article concludes that the contribution of integrated care to improved outcomes remains unclear and yet it remains a popular policy goal. Whilst some elements of the TAPIC framework fit less well than others to the case of integrated care, the case of integrated care can be better understood and explained through this lens.

Concepts: Evaluation, Evidence-based medicine, Policy, Explanation, Alternative medicine, Policy analysis, Governance, Accountability


Concerns about the social consequences of conservation have spurred increased attention the monitoring and evaluation of the social impacts of conservation projects. This has resulted in a growing body of research that demonstrates how conservation can produce both positive and negative social, economic, cultural, health, and governance consequences for local communities. Yet, the results of social monitoring efforts are seldom applied to adaptively manage conservation projects. Greater attention is needed to incorporating the results of social impact assessments in long-term conservation management to minimize negative social consequences and maximize social benefits. We bring together insights from social impact assessment, adaptive management, social learning, knowledge coproduction, cross-scale governance, and environmental planning to propose a definition and framework for adaptive social impact management (ASIM). We define ASIM as the cyclical process of monitoring and adaptively managing social impacts over the life-span of an initiative through the 4 stages of profiling, learning, planning, and implementing. We outline 14 steps associated with the 4 stages of the ASIM cycle and provide guidance and potential methods for social-indicator development, predictive assessments of social impacts, monitoring and evaluation, communication of results, and identification and prioritization of management responses. Successful ASIM will be aided by engaging with best practices - including local engagement and collaboration in the process, transparent communication of results to stakeholders, collective deliberation on and choice of interventions, documentation of shared learning at the site level, and the scaling up of insights to inform higher-level conservation policies-to increase accountability, trust, and perceived legitimacy among stakeholders. The ASIM process is broadly applicable to conservation, environmental management, and development initiatives at various scales and in different contexts.

Concepts: Evaluation, Assessment, Management, Sustainability, Project management, Planning, Governance, Accountability


Trade policies affect determinants of health as well as the options and resources available to health policymakers. There is therefore a need for health policymakers and related stakeholders in all contexts to understand and connect with the trade policymaking process. This paper uses the TAPIC (transparency, accountability, participation, integrity, capacity) governance framework to analyze how trade policy is commonly governed. I conclude that the health sector is likely to benefit when transparency in trade policymaking is increased, since trade negotiations to date have often left out health advocates and policymakers. Trade policymakers and negotiators also tend to be accountable to economic and trade ministries, which are in turn accountable to economic and business interests. Neither tend to appreciate the health consequences of trade and trade policies. Greater accountability to health ministries and interests, and greater participation by them, could improve the health effects of trade negotiations. Trade policies are complex, requiring considerable policy capacity to understand and influence. Nevertheless, investing in understanding trade can pay off in terms of managing future legal risks.

Concepts: Evaluation, Economics, Investment, Policy, Governance, Commerce, Political corruption, Accountability


This article presents cross-country comparisons of trends in for-profit nursing home chains in Canada, Norway, Sweden, United Kingdom, and the United States. Using public and private industry reports, the study describes ownership, corporate strategies, costs, and quality of the 5 largest for-profit chains in each country. The findings show that large for-profit nursing home chains are increasingly owned by private equity investors, have had many ownership changes over time, and have complex organizational structures. Large for-profit nursing home chains increasingly dominate the market and their strategies include the separation of property from operations, diversification, the expansion to many locations, and the use of tax havens. Generally, the chains have large revenues with high profit margins with some documented quality problems. The lack of adequate public information about the ownership, costs, and quality of services provided by nursing home chains is problematic in all the countries. The marketization of nursing home care poses new challenges to governments in collecting and reporting information to control costs as well as to ensure quality and public accountability.

Concepts: United States, United Kingdom, Nursing home, Property, Separation of church and state, Medicare and Medicaid, Private equity, Accountability


PURPOSE: Mentoring is vital to professional development in the field of medicine, influencing career choice and faculty retention; thus, the authors reviewed mentoring programs for physicians and aimed to identify key components that contribute to these programs' success. METHOD: The authors searched the MEDLINE, EMBASE, and Scopus databases for articles from January 2000 through May 2011 that described mentoring programs for practicing physicians. The authors reviewed 16 articles, describing 18 programs, extracting program objectives, components, and outcomes. They synthesized findings to determine key elements of successful programs. RESULTS: All of the programs described in the articles focused on academic physicians. The authors identified seven mentoring models: dyad, peer, facilitated peer, speed, functional, group, and distance. The dyad model was most common. The authors identified seven potential components of a formal mentoring program: mentor preparation, planning committees, mentor-mentee contracts, mentor-mentee pairing, mentoring activities, formal curricula, and program funding. Of these, the formation of mentor-mentee pairs received the most attention in published reports. Mentees favored choosing their own mentors; mentors and mentees alike valued protected time. One barrier to program development was limited resources. Written agreements were important to set limits and encourage accountability to the mentoring relationship. Program evaluation was primarily subjective, using locally developed surveys. No programs reported long-term results. CONCLUSIONS: The authors identified key program elements that could contribute to successful physician mentoring. Future research might further clarify the use of these elements and employ standardized evaluation methods to determine the long-term effects of mentoring.

Concepts: Medicine, Evaluation, Evaluation methods, Physician, Management, Coaching, Youth mentoring, Accountability


In democratic societies, good governance is the key to assuring the confidence of stakeholders and other citizens in how governments and organizations interact with and relate to them and how decisions are taken. Although defining good governance can be debatable, the United Nations Development Program (UNDP) set of principles is commonly used. The reimbursement recommendation processes of the Canadian Agency for Drugs and Technologies in Health (CADTH), which carries out assessments for all public drug plans outside Quebec, are examined in the light of the UNDP governance principles and compared with the National Institute for Health and Care Excellence system in England. The adherence of CADTH’s processes to the principles of accountability, transparency, participatory, equity, responsiveness and consensus is poor, especially when compared with the English system, due in part to CADTH’s lack of genuine independence. CADTH’s overriding responsibility is toward the governments that “own,” fund and manage it, while the agency’s status as a not-for-profit corporation under federal law protects it from standard government forms of accountability. The recent integration of CADTH’s reimbursement recommendation processes with the provincial public drug plans' collective system for price negotiation with pharmaceutical companies reinforces CADTH’s role as a nonindependent partner in the pursuit of governments' cost-containment objectives, which should not be part of its function. Canadians need a national organization for evaluating drugs for reimbursement in the public interest that fully embraces the principles of good governance - one that is publicly accountable, transparent and fair and includes all stakeholders throughout its processes.

Concepts: Evaluation, Federal government of the United States, United Nations, Non-profit organization, Governance, Democracy, Accountability, Transparency


An effective faculty mentoring program (FMP) is 1 approach that academic departments can use to promote professional fulfillment, faculty retention, and mitigate the risks of faculty burnout. Mentoring has both direct benefits for junior faculty mentees as they navigate the academic promotion process with their mentors, in addition to broader departmental and institutional benefits, with regard to recruitment, retention, and academic productivity. We describe a successful FMP model that has been adapted for use in 6 other pediatrics departments, summarizing the key personnel, mentoring process, and program evaluation methods. Important lessons learned and a generalizable mentoring “model” are provided. Program evaluation indicates a positive effect for the FMP on enhanced faculty self-efficacy, job satisfaction, and career development. The importance of communication, oversight, feedback, accountability, and valuing all faculty members is emphasized. Strategies to promote faculty engagement and the critical role of departmental leadership in prioritizing mentorship are discussed. The success of academic medical departments is inextricably linked to its commitment to the career development of individual faculty members at all levels and in all academic pathways. With our findings, we support the positive impact of a formal FMP in promoting enhanced self-efficacy and career satisfaction, which directly benefits the department and institution through enhanced productivity, retention, successful promotion, and overall professional fulfillment.

Concepts: Evaluation, Management, Coaching, Mentorship, Organizational studies and human resource management, Accountability, Program evaluation


Roma health inequities are a wicked problem. Despite concerted efforts to reduce them under the Decade of Roma Inclusion initiative, the health gap between Roma and non-Roma populations in Europe persists. To address this problem, the European Commission devised the National Roma Integration Strategies (NRIS). This paper provides a critical assessment of the implementation of the NRIS' health strand (NRIS-H) in Spain and proposes an evaluation tool to monitor Roma health policies - the Roma Health Integration Policy Index (RHIPEX). It also makes recommendations to promote Roma health governance. To achieve these goals, four community forums, 33 stakeholder interviews and a scoping review were conducted. Results show that the NRIS-H implementation is hindered by lack of political commitment and poor resource allocation. This has a negative impact on Roma’s entitlement to healthcare and on their participation in decision-making processes, jeopardising the elimination of the barriers that undermine their access to healthcare and potentially contributing to reproduce inequalities. These unintended effects point out the need to rethink Roma health governance by strengthening intersectional and intersectoral policies, enabling transformative Roma participation in policymaking and guaranteeing shared socio-political responsibility and accountability.

Concepts: European Union, Evaluation, Europe, European Commission, Policy, Problem solving, Governance, Accountability