https://www.ijhpm.com/ International Journal of Health Policy and Management en daily 1 Tue, 01 Dec 2026 00:00:00 +0330 Tue, 01 Dec 2026 00:00:00 +0330 https://www.ijhpm.com/article_4871.html The systematic destruction of academic infrastructure, termed scholasticide, has been normalised across the Eastern Mediterranean Region (EMR) over more than two decades. The doctrine has operated through two coexisting modalities: the targeted assassination of individual scholars and the physical destruction of institutions, escalating in scale from selective killings and partial looting to the dismantling of entire academic systems. Drawing on evidence from several EMR countries, we describe a causal cascade through which acute military strikes and chronic structural exclusion, including sanctions, platform over-compliance, and visa barriers, produce generational health workforce depletion, disrupt core public health functions, and cause population-level health harms. We argue that academic institutions constitute a distinct, upstream structural determinant of population health whose destruction is an attack on health systems, not merely on education. We propose five categories of action, implemented through standing regional and international mechanisms, to protect academic infrastructure across the EMR whenever and wherever it is attacked. https://www.ijhpm.com/article_4921.html Background Korea has experienced rapid growth in healthcare expenditure alongside increasing enrollment in indemnity-type private health insurance (PHI), which reduces out-of-pocket costs. Prior studies have shown higher utilization among PHI subscribers, but little is known about whether patients’ disclosure of PHI enrollment to providers is associated with outpatient utilization and whether this association differs between clinic- and hospital-level institutions.Methods Using nationally representative data from the 2023 Korea Health Panel, we analyzed 4948 adults enrolled in indemnity-type PHI. Disclosure was assessed by whether respondents reported informing any outpatient provider of their PHI enrollment during the past 12 months. Outcomes were outpatient visits and average out-of-pocket cost per visit. We used negative binomial regression for visit counts and a gamma generalized linear model with a log link for costs, overall and by institution type.Results Overall, 10.9% of respondents reported disclosing their PHI enrollment. Disclosure was associated with higher outpatient visit frequency (incidence rate ratio [IRR] = 1.157, 95% CI: 1.077–1.244), corresponding to approximately 15.7% more visits among disclosers than non-disclosers. It was also associated with higher average out-of-pocket cost per visit (coefficient = 0.145, 95% CI: 0.028–0.262), corresponding to approximately 15.6% higher per-visit out-of-pocket costs. At clinic-level institutions, disclosure was significantly associated with more visits and higher per-visit costs; no significant associations were observed at hospital-level institutions.Conclusion Patients’ disclosure of indemnity-type PHI enrollment is associated with higher outpatient visit frequency and per-visit out-of-pocket costs, particularly at clinic-level institutions. Insurance-status information may contribute to higher outpatient utilization in settings with strong fee-for-service incentives; however, these associations do not establish provider-induced demand. https://www.ijhpm.com/article_4882.html This editorial examined the enduring ties between medicine and political power, highlighting how the World Medical Association (WMA) arose in response to recurring ethical crises involving physicians. Created after the Second World War alongside new international institutions, the WMA aimed to protect professional autonomy and defend medical neutrality. Over the decades, it has acted as an ethical counterbalance within global health governance, especially through collaboration with the World Health Organization (WHO). Yet history shows that political pressures have repeatedly compromised medical practice, generating dual-loyalty dilemmas, human rights violations, and scandals that erode public trust. The WMA has sometimes responded firmly—suspending national associations, issuing statements during conflicts, or challenging unethical state policies—though its actual influence remains contested. Internal political divisions have often slowed or limited its actions. Today’s (ie, mid-March 2026) severe degradation of health systems in conflict zones reinforces the need to renew core ethical principles through collective responsibility and vigilance. https://www.ijhpm.com/article_4922.html Background This paper contrasts and examines the perceptions of policy communities on the dynamics and factors shaping intersectoral collaboration in governance of health emergencies, drawing on the example of public space regulation during COVID-19 in four Canadian provinces, with the goal of exploring variation and perceived quality of policy responses.Methods We compared public space regulation in four Canadian provinces—British Columbia (BC), Nova Scotia (NS), Ontario (ON) and Québec (QC)—during COVID-19 from 2020 to 2022. The study was designed as a comparative, qualitative, and explanatory case study, utilizing in-depth interviews and documents. We conducted 103 interviews with a diverse range of stakeholders, including senior government and non-government leaders, reviewed selected policy documents, and media reports. We utilized multisite qualitative analysis to analyze our data and develop within- and cross-case themes.Results Respondents reported vastly different provincial approaches to intersectoral collaboration within government and with non-governmental stakeholders in the management of public spaces, ranging from higher (BC, NS) to lower (ON, QC) levels of collaboration in governance, as reflected in the access of government and non-government stakeholders to key decision-makers and decision-making forums and processes, the transparency of those processes, and responsiveness to their input. Institutional frameworks, political factors and organizational culture and capacity were the major distinguishing factors between these provincial approaches to collaboration. Disparities in access to decisionmakers were reported, with business interests and certain civil society organizations experiencing easier access compared to other public interest groups.Conclusion Public health challenges are increasingly complex and intersectoral. Research on intersectoral collaboration must examine collaboration dynamics within and outside government holistically, rather than exploring these dynamics in siloes. Stakeholder engagement which combines institutional structures and inclusive stakeholder engagement within and outside government is crucial to managing complex policy processes during crisis and beyond. https://www.ijhpm.com/article_4914.html Conflict of interest (CoI) in health systems is commonly viewed as an individual ethical issue but may also become institutionalised when governance arrangements align policy-making authority with professional or financial self-interest. Using Iran as an illustrative case, this article examines how institutionalised CoI can gradually shape policy priorities and distort health system missions towards provider-centred rather than population-centred goals, often without deliberate intent. A comparative analysis of health ministers’ professional backgrounds suggests substantial variation across countries in governance arrangements and leadership models. The article discusses how institutionalised CoI may contribute to policy distortions including persistent reliance on fee-for-service (FFS) payment, weakened gatekeeping, dual practice, and inadequate transparency, ultimately affecting healthcare utilisation, financial protection, and health system performance. Addressing these challenges requires governance reforms that strengthen leadership, align provider incentives with population health, and improve transparency, accountability, and institutional independence. https://www.ijhpm.com/article_4923.html Background Universal health coverage (UHC) is a central target of the Sustainable Development Goals (SDGs), yet progress remains limited, particularly in fragile and conflict-affected states (FCAS). Despite commitments to leave no one behind, FCAS face complex circumstances that require better collaboration. Evidence on whether and how adherence to effective development cooperation (EDC) principles influences development outcomes remains scarce. This study examined which EDC principles have affected UHC attainment in FCAS.Methods Crisp-set qualitative comparative analysis (QCA) was applied to examine six EDC indicators as explanatory variables (conditions) which are EDC indicators: alignment with plans and budget priorities, partner coordination, national coordination mechanisms, use of national monitoring and evaluation (M&E) system, and provision of joint technical assistance (TA). The outcome was attainment of UHC service coverage index of at least 40. QCA assessed necessary conditions (for outcome to happen they must be present) and sufficient conditions (whenever they are present the outcome happens). We examined 17 FCAS; all were low and low. Seventeen low-income and lower-middle-income FCAS were included, using publicly available 2021 data on conditions and outcome.Results While none of the six conditions were found to be necessary for attaining UHC within our data, four appeared sufficient. The final solution indicated that either strong alignment with national plans or joint TA provided a pathway to UHC. The model had moderate coverage of 46%, explaining fewer than half of cases attaining the UHC threshold. Findings should be interpreted considering the small sample size, reliance on self-reported EDC ratings, and crosssectional data rather than assessment over time.Conclusion Better alignment among health partners is needed to minimise loss of already scarce and crucial resources in FCAS. Context-tailored TA may support attainment and sustainability of cooperation outcomes. Enhancement of frameworks and measures for tracking EDC and UHC with more frequent monitoring is needed. https://www.ijhpm.com/article_4853.html Background  The Kirkpatrick model is commonly used as a systematic approach to evaluate training programs, although its application to health sciences experiential learning programs is not well-established. To inform the use of the Kirkpatrick model in the evaluation of the Canadian Institutes of Health Research’s (CIHR’s) Health System Impact Fellowship National Cohort Training Program (HSIF NCTP), we examined its application in post-secondary health sciences programs. Methods  Using the Joanna Briggs Institute’s updated methodology for scoping reviews, we searched CINAHL, EMBASE, ERIC, MEDLINE, PsycINFO, and Web of Science for studies published from 2017 to 2023 that focused on health sciences experiential learning programs held at universities and reported on at least one level of the Kirkpatrick model (ie, reaction, learning, behavior, results). We extracted data on study characteristics and reported outcomes for each of the Kirkpatrick model levels. Results  After deduplication, we screened 755 titles and abstracts, we reviewed 97 full texts, and we included 34 studies in our scoping review. Many studies reported outcomes at the reaction or learning levels followed by the behaviour and results levels. Across levels, despite identifying several areas of improvement, learners typically reported favourable perceptions, increased confidence and knowledge, improved performance, and organizational improvements. Conclusion  The Kirkpatrick model is a widely used and highly adaptable evaluation model that has been successfully used to evaluate a range of post-secondary health sciences programs. Despite its wide use, evaluators using the Kirkpatrick model should use more robust methodologies to capture long-term behaviour and results associated with the programs. Future work should focus on evaluating a broader spectrum of programs such as doctoral- and postdoctoral-level experiential learning programs and underrepresented healthcare professions such as psychologists and dieticians. Integration of behaviour change and implementation science methodologies within the broader educational evaluation literature is also needed. https://www.ijhpm.com/article_4925.html Background The COVID-19 pandemic shaped childhood globally. The experiences of vulnerable children in Canada’s Maritime provinces reveal important lessons about equity, resilience, and the unintended consequences of public health directives. Public health restrictions were enacted in the early days of COVID-19. At-risk populations such as children with complex care needs (CCN) were among those most impacted by health system changes due to COVID-19. To better understand how COVID-19 public health measures impacted children with CCN who were highly susceptible to the virus and associated disruptions, we conducted an environmental scan to map changes in COVID-19 public health directives and services impacting children with CCN.Methods We systematically retrieved government news releases communicating new or changing COVID-19 public health directives published March 1, 2020-March 31, 2022. All directives and service changes in the health and education sectors were included. Directives were divided into 13 categories co-developed with parent and decision-maker partners, and we identified whether directives included support measures relevant to children with CCN.Results The environmental scan revealed that children with CCN were largely overlooked in COVID-19 directives across the Maritime provinces. We identified 699 public health directives and services changes. Fewer than 2.2% of COVID-19 directives explicitly referenced children with CCN, with most guidance focusing on general social restrictions, vaccinations, and education/daycare. Mental health and well-being were also rarely addressed (13 directives).Conclusion The Maritimes’ predominately rural and geographically dispersed population exacerbates the inequities experienced by children with CCN, offering insights relevant to other regions about the unintended consequences of broad public health policies delivered to heterogeneous populations. Examining this data through the lens of children with CCN and their families can inform recommendations to better support this vulnerable population in future public health emergencies. https://www.ijhpm.com/article_4855.html Background  South Korea faces significant healthcare challenges due to its rapidly aging population, necessitating alternative care models to hospital-based systems. In response, home healthcare has emerged as a promising strategy to support aging in place while maintaining care continuity and system sustainability. Methods  This literature review examines home healthcare in South Korea through the lens of healthcare access, quality, and cost, which are the three dimensions of the “Iron Triangle.” Online databases were used to identify papers published from 2010 to 2025, from which 39 documents were selected which examine the impact of home healthcare in South Korea, specifically in terms of access, quality, or cost. Results  Results indicate that home healthcare effectively addresses healthcare access disparities, especially for elderly and disabled populations, by overcoming geographic and mobility barriers through integrated care models and remote technologies. Quality of care is enhanced through patient-centered approaches, multidisciplinary collaboration, and proactive home visits, leading to improved clinical outcomes and higher patient satisfaction. Economically, home healthcare demonstrates potential cost savings by reducing hospitalizations and emergency care usage, particularly for patients with chronic conditions and high utilization patterns. Conclusion  Sustainability remains contingent upon effective reimbursement and resource allocation policies. Policy implications include expanding healthcare infrastructure, investing in caregiver training, adopting advanced technologies to maximize the effectiveness of home healthcare, and promoting a sustainable and equitable healthcare system in South Korea. Strategic integration of home healthcare within national insurance and long-term care frameworks will be essential to realizing its full system-level benefits. https://www.ijhpm.com/article_4926.html Background Smart healthy cities seek to integrate digital technologies with health-promoting environments to address urban health inequities. South Korea combines rapid urbanisation, population ageing, and advanced digital infrastructure, yet little is known about how local government health officials—key frontline implementers—prioritise health equity within smart healthy city agendas.Methods During the 2023 Korea Healthy Cities Conference, we conducted a real-time Mentimeter survey with local government health officials from 72 municipalities. Participants answered three sequential open-ended questions on (Q1) current healthy city challenges, (Q2) challenges better addressed through “smart” approaches, and (Q3) future priority values for Korean smart healthy cities. Free-text responses were coded into 43 indicators nested within 16 themes, mapped onto the six agendas of the World Health Organization (WHO) Copenhagen Consensus “6P” framework (People, Place, Participation, Prosperity, Peace, Planet). Aggregated counts were analysed using contingency tables, chisquare tests, correspondence analysis, and agenda-level (ie, across the six 6P categories) profile correlations.Results We analysed 482 coded mentions. For current challenges (Q1), responses centred on Planet (25.9%) and Participation (27.6%). For smart city–solvable challenges (Q2) and future priority values (Q3), distributions shifted markedly towards People: 23.0% (Q1), 41.4% (Q2), and 46.6% (Q3), while Planet and Participation declined. Agenda distributions differed significantly across the three questions (χ²[10] = 79.50, P < .001; Cramer’s V = 0.29), and Peoplecentred profiles for Q2 and Q3 were highly similar (r = 0.86, P = .028). Digital and health literacy, vulnerable populations, and service integration remained under-represented throughout.Conclusion Korean local government health officials increasingly frame smart healthy cities as vehicles for advancing health equity rather than as primarily environmental or technology-driven projects. However, persistent neglect of literacy, vulnerable groups, and service integration signals a gap between equity aspirations and implementation that equity-oriented digital governance and inclusive design must address. https://www.ijhpm.com/article_4861.html Background The uneven distribution of physicians between urban and rural areas remains a significant public health challenge. Rural clinical placements during medical training are increasingly viewed as a potential lever for enhancing the appeal of rural areas. The aim of this systematic review, supported by a meta-analysis, was to evaluate the real impact of rural placements on medical graduates’ decisions to practice in rural locations. Methods A systematic search was conducted across four databases (PubMed, Embase, Web of Science, and Cochrane Library) covering the data available up to June 2024. Included studies evaluated the impact of rural clinical placements on the professional practice location of medical students or early-career physicians. A random-effects meta-analysis was performed to estimate the relative risk (RR) of rural practice. Additional variables analyzed included practice duration, placement length, participants’ rural background, their satisfaction with the placement, and their stated intention to practice in a rural area. Results A total of 62 studies were selected, with 28 contributing to the meta-analysis, encompassing over 330 000 participants. The pooled analysis showed that students who completed a rural placement were more than twice as likely to establish practice in a rural area compared to their non-exposed peers (RR = 2.683; 95% CI [confidence interval]: 2.255–3.192). This effect was further amplified by factors such as rural background, extended placement duration, and a satisfactory placement experience. A key strength of this review is that it synthesizes actual workforce outcomes rather than relying solely on stated intentions. Conclusion Rural clinical placements have a significantly positive impact on the rural practice decisions of earlycareer physicians, particularly when these placements are of extended duration, well-structured, and accessible. Rural placements should be offered both to students from rural backgrounds, who consistently show the strongest effect, and to urban students who may develop an increased interest in rural practice when exposed to long, immersive placements. These findings support the integration of rural placements into a global policy aimed at achieving a more equitable geographic distribution of healthcare professionals. Although the effectiveness of rural placements is already recognized in international frameworks such as the World Health Organization (WHO) guidelines, their implementation remains uneven across countries. https://www.ijhpm.com/article_4928.html Background Out-of-pocket payments for medicines are the main driver of financial hardship for households in most countries in Europe, particularly in Central and Eastern Europe (CEE). The aim of this study was to analyze household spending on medicines in Poland and assess the effects of the Medicines 75+ program, implemented to improve access to medicines for older people.Methods We utilized 2013-2021 data from household budget surveys conducted on a representative sample of Poland’s population. A two-part model was employed to identify factors associated with paying for and amount spent on medicines. We evaluated the effect of the Medicines 75+ program using a difference-in-differences (DID) analysis for cross-sectional data covering the years 2013-2019 (pre-pandemic years). Our treatment group included households headed by people aged 75-85, which was compared to the control group, ie, households headed by individuals aged 65-74.Results The results show that out-of-pocket expenditure on medicines increased over the analyzed years and remains the primary driver of household health spending. Ability to pay and age are strong predictors of the likelihood of paying for medicines and expenditure levels, with their effects being cumulative. The average annual per capita spending in the treatment group decreased from PLN 1282 in the pre-intervention period (2013-2016) to PLN 1221 in the postintervention years (2017-2019), while the control group’s spending increased from PLN 930 to PLN 969. The DID analysis showed that the program of free medicines reduced the annual out-of-pocket spending by an average of PLN 71 (2019 US $18), which is relatively modest given the high expenditure in this age group. The decrease was also not observed across all consumption quintiles, with no significant improvement among the poorest households.Conclusion Poland should reconsider its policies for equitable access to medicines, placing greater emphasis on lowincome groups and addressing both prescription and over-the-counter (OTC) medicines. https://www.ijhpm.com/article_4894.html Background Employee green behavior (EGB) refers to environmentally responsible actions undertaken by employees in the workplace. Although interest in EGB is growing, hospitals represent a uniquely complex environment where clinical demands, operational constraints, and regulatory pressures may shape such behavior in distinct ways. To date, no review has synthesized literature on EGB within hospital settings. This scoping review synthesizes existing research to clarify how EGB has been conceptualized and studied in hospitals, identify factors associated with EGB, and inform future research and sustainability efforts in healthcare organizations.Methods This scoping review followed the Joanna Briggs Institute (JBI) methodology and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. Seven databases (PubMed, CINAHL, Embase, Web of Science, Scopus, APA PsycINFO, and Emerald) and grey literature were searched from inception to January 31, 2025. Studies examining EGB among hospital employees were included. Results Twenty-three studies met the inclusion criteria, with most published after 2021. The majority employed quantitative survey designs and focused on nurses, although some included multidisciplinary staff. Considerable variation was observed in how EGB was defined and measured across studies. Factors reported in relation to EGB were organized into four levels: individual, team, leadership, and organizational. Qualitative findings highlighted barriers such as time constraints, insufficient training, limited knowledge, and lack of leadership support, as well as facilitators including individual motivation, environmental awareness, shared responsibility, and access to sustainability resources and education.Conclusion EGB in hospital settings has been defined and examined inconsistently in the existing literature. This review proposes a working definition of EGB as employee actions in the workplace that minimize environmental harm and promote sustainability. The findings indicate that EGB in hospitals is influenced by multiple factors, and effective sustainability efforts in healthcare organizations require coordinated multilevel approaches. Registry Name and Number: The review protocol was registered with the Open Science Framework (osf.io/kd57r). https://www.ijhpm.com/article_4932.html Background Thalassaemia is a genetic blood disorder endemic in Thailand. Management of severe thalassaemia utilises significant resources posing a substantial socio-economic burden; thus, prevention has been identified as a more sustainable approach to address thalassaemia. This study evaluated the cost-effectiveness and budget impact of various thalassaemia screening strategies in Thailand, including both pre-conception and post-conception approaches.Methods A cost-effectiveness analysis (CEA), from the Thai healthcare payer’s perspective, was conducted using decision analytic modelling. Decision trees were used to estimate the incremental screening cost per severe thalassaemia birth averted for four main screening strategies compared to “no screening”: post-conception screening (Strategy 1), pre-conception screening with targeted deoxyribonucleic acid (DNA) analysis (Strategy 2), pre-conception screening with universal DNA analysis (Strategy 3), and a combination of pre-conception and post-conception screening (Strategy 4). The cost-effectiveness threshold (CET) used was the lifetime cost of managing severe thalassaemia in Thailand. The annual budget impact of the upfront costs of implementing these strategies was also estimated.Results Strategies 1, 2, and 4 were cost-saving compared to the threshold of the average lifetime cost of managing severe thalassaemia in Thailand, $21,017. Strategy 4 had the lowest screening cost of $6773 [$4522–$10 066] per severe thalassaemia birth averted. Strategy 2 cost $8977 [$5689–$13 956] per severe thalassaemia birth averted, and Strategy 1 cost $10 474 [$7121–$15 734] per severe thalassaemia birth averted. In contrast, Strategy 3 cost $57 692 [$33 240–$96 123] per severe thalassaemia birth averted and is not cost-saving. The annual budget impact of the upfront costs of implementing thalassaemia screening ranged from $1.30 million to $288.93 million, depending on the strategy adopted and uptake rates.Conclusion Post-conception thalassaemia screening is cost-saving in Thailand. Combining pre-conception and postconception screening strategies may offer even better value for money in the Thai context, but with a higher upfront cost of implementation. https://www.ijhpm.com/article_4907.html Background Power is routinely invoked to explain health inequities and governance failures in global health, yet existing work is conceptually fragmented, weakly connected to empirical analysis, and prone to what is referred to as the “power-as-resource fallacy”: the conflation of power bases (what actors possess) with power relationships (how actors influence one another). This narrative review examines how power is conceptualized and operationalized in global health discourse, identifies systematic analytical gaps, and proposes a relational framework to address them.Methods We conducted a narrative review of literature that explicitly engages with power in relation to global health, governance, or health systems. We synthesized the included texts thematically and, as a supplementary systems-thinking component, developed a causal loop diagram (CLD) based on a subset of quantitative studies to illustrate how different constellations of power interact with health outcomes over time.Results In global health, power is pervasively invoked but rarely operationalized. We organized the reviewed texts into six thematic domains: (1) power as a determinant of health; (2) structural power (class, race, gender, geopolitical hierarchies); (3) power asymmetry; (4) power and governance for health; (5) power and health securitization; and (6) power constellations and health outcomes. Across these domains, we find that discussions of power remain largely qualitative and often stop short of clear operationalization. The CLD translates these insights into interacting feedback loops, illustrating how specific power constellations are associated with particular patterns of policy response and health outcomes, highlighting potential leverage points for governance reform.Conclusion This review maps the existing knowledge on power in global health and provides an actionable framework for future research and governance design. It underscores that power is the fundamental thread connecting global political economy to local health inequities. https://www.ijhpm.com/article_4933.html Background While universal health coverage (UHC) is at the fore of contemporary international health system discourses, its introduction often necessitates far-reaching reforms and countries face a number of challenges to implementation. Ireland is one country that has introduced a national health reform policy, Sláintecare, which aims to achieve UHC. The purpose of this paper is to examine the case study of Ireland, utilising findings from our realist review on international reform implementation as a conceptual framework, thus deepening our understanding of the barriers and facilitators to implementation.Methods This paper examines the case study of health reform implementation in Ireland, drawing on qualitative data collected through semi-structured elite interviews with 16 senior Irish health system leaders, healthcare workers, political advisors, union representatives, and private sector stakeholders. Following ethical approval, interviews took place from July 2024-April 2025. With our realist review providing an analytic framework, NVivo 12 qualitative analysis software was used to conduct thematic analysis, deductively in the first instance using a predetermined coding tree and then inductively based on emerging themes.Results Participants highlighted a number of factors that acted as barriers or facilitators to implementation. Barriers included a lack of capacity and infrastructure, challenges around financing and a lack of clarity around universalism and universal healthcare. Additional barriers included a lack of public engagement with Sláintecare as well as challenges around priority setting. Meanwhile, political commitment, as well as a programmatic approach, facilitated reform implementation, while the COVID-19 pandemic both stymied and enabled reforms.Conclusion Through using this framework to test the Irish experience, the authors provide further evidence regarding the barriers and facilitators to implementation of UHC, adding to the international discourse and work being done on these important reforms. These learnings have implications for workforce capacity development, digital health infrastructure and health financing, amongst other policies. https://www.ijhpm.com/article_4917.html Background Artificial intelligence (AI) is increasingly used in research and scientific publishing, improving efficiency. However, it raises ethical concerns regarding scientific integrity, authorship, and originality. This study aimed to identify the main ethical challenges of AI use in research publishing and to explore factors influencing its responsible use.Methods This scoping review followed Arksey and O’Malley’s framework and PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) reporting guidelines. The review addressed two questions on the ethical challenges associated with AI use in research publishing and the factors influencing its ethical application. A comprehensive search was performed in PubMed, Web of Science, Scopus, and Embase, supplemented by additional searches. Studies eligible for inclusion were original research articles published up to January 2025 with accessible full texts. Two reviewers independently screened the records and charted the data; disagreements were resolved through consultation with a third reviewer. Extracted data included study characteristics, aims, design, and key findings.Results The search retrieved 20 952 records, of which 20 were included after screening. The analysis identified 10 key ethical challenges for the use of AI in research publishing, which broadly relate to three overarching concerns: threats to scientific integrity, challenges to transparency and accountability in AI-assisted research processes, and governance gaps in policy and regulatory frameworks. Furthermore, factors influencing ethical AI use were grouped into 10 dimensions across individual, institutional, and structural levels that shape researchers’ behavior and publishing practices.Conclusion The responsible use of AI in scientific publishing requires a shift from ad hoc approaches to an integrated ethical, technical, and legal governance system. Since health policies and clinical guidelines rely on published evidence, the ethical integration of AI in scientific publishing is essential to ensure the reliability and transparency of health research. This study highlights the necessity of developing policies, regulatory frameworks, and ethical standards in this area. https://www.ijhpm.com/article_4927.html The 2025–2026 withdrawal of the United States from the World Health Organization (WHO) represents one of the most consequential disruptions to global health governance in the postwar era. In the Americas, its effects are already visible: The Pan American Health Organization (PAHO) is facing delays and funding cuts; the Region lost its measles-free status in November 2025; and President’s Emergency Plan for AIDS Relief (PEPFAR)-supported HIV services have been reduced in Central America and the Caribbean. Additionally, the United States also benefits from multilateral cooperation through disease surveillance, vaccine strain selection, and the early detection of threats. Recent outbreaks outside the region demonstrate that weaknesses in international surveillance can become risks within its own borders. Therefore, we propose reforming WHO governance, diversifying its funding, strengthening regional institutions, and establishing clear frameworks for private-sector participation in global health. https://www.ijhpm.com/article_4842.html Pancreatic cancer remains one of the deadliest malignancies, with a persistently low five-year survival rate. The Recalcitrant Cancer Research Act (RCRA) of 2012 is one example of legislation aimed at accelerating research in highmortality cancers. This study examines long-term trends in federal funding and clinical trial sponsorship for pancreatic cancer over a 20-year period, spanning before and after the RCRA. We conducted a retrospective analysis of National Cancer Institute (NCI) funding data and pancreatic cancer clinical trials registered on ClinicalTrials.gov between 2003 and 2022. Linear regression with pre- and post-2013 comparisons evaluated changes over time. NCI support for pancreatic cancer increased 3.5-fold – from $78 million in 2003 to $250 million in 2022 (inflation-adjusted). The annual growth rate rose from $7.4 million per year before 2013 to $12.2 million per year after 2013. The share of the NCI’s budget allocated to pancreatic cancer also rose from 0.9% to 3.4%, with no significant shift in slope after 2013 (P = .98). Federally-funded clinical trials declined sharply before 2013, decreasing by 2.8% per year, and then stabilized after 2013, with a nonsignificant slope of –0.95% per year (interaction P = .06). Meanwhile, industry-sponsored trials grew substantially, increasing from 30% to nearly 75%, increasing by 2.0% per year after 2013. Findings were consistent in logistic regression models. These findings suggest that while federal investment in pancreatic cancer research has grown, the expansion of clinical trials has been driven largely by industry, suggesting that federal investment has likely been directed toward foundational and preclinical research. Strengthening public-private collaboration and maintaining federal engagement will be critical to ensuring that research advances align with patient-centered goals. https://www.ijhpm.com/article_4929.html This commentary presents a critical review of the paper proposed by Gartner and colleagues that describes a novel method and framework for implementing care pathways that incorporate key mechanisms from the learning health system (LHS) concept. The authors’ five-phased and 13-step method has several strengths, including the extent to which it is theory-informed, emphasizes patient involvement as a core design principle, and is oriented towards the creation of value in health systems. However, the paper also raises several critical questions related to the feasibility of the method’s faithful application in real-world settings and its consideration of issues related to health equity. In sum, the paper advances knowledge on care pathway implementation but the framework’s potential for real-world impact remains unclear. https://www.ijhpm.com/article_4863.html Organizational policies or protocols have been recommended as a potential means of improving sex trafficking services. Therefore, we examined the role of organizational policies or protocols on service providers’ perceptions of challenges in responding to sex trafficked persons. Data were collected using an online, anonymous, national survey between February and August 2023. The healthcare, social, and community service providers surveyed were asked to what extent they agreed or disagreed with the statements, “There are challenges that prevent me from providing the appropriate care, support, or services to sex trafficked persons” and “There are organizational policies or protocols in my place of work that provide guidance on how to respond to sex trafficked persons.” The analysis included 553 respondents, of whom almost three quarters (72.6%) perceived challenges and less than half (44.9%) reported the availability of organizational policies or protocols. Respondents who worked in an organization with policies or protocols were less likely than those who did not to report challenges in responding to sex trafficked persons (40.9% vs. 55.3%, unadjusted odds ratio = 0.56, P = .003; adjusted odds ratio = 0.64, 95% CI = 0.42, 0.96, P = .03). Our findings highlight the importance of implementing organizational policies or protocols that provide guidance on and facilitate the delivery of appropriate care, support, and services to sex trafficked persons. This may better position service providers to address the serious physical, sexual, and mental health sequalae sex trafficked persons experience. https://www.ijhpm.com/article_4930.html Cancer registries and clinical audits are increasingly used to compare healthcare performance across institutions. However, observed differences between hospitals are often interpreted as true differences in quality without considering whether the indicators can reliably distinguish between providers. This commentary discusses the framework applied by Verheul and colleagues to the Dutch Breast Cancer Audit. It distinguishes registry data quality from indicator performance and describes four complementary properties in sequence: feasibility, discriminative ability, validity, and reliability, with rankability as a measure of the latter. Reliability deserves particular attention when indicators guide public reporting, reimbursement, policy, or patient choice, because low rankability indicates that apparent differences may largely reflect random variation. International standards and the broader reliability literature support pre-use testing, transparent reporting of uncertainty and sample-size requirements, periodic re-evaluation, and restriction or retirement of unreliable indicators. Without adequate reliability, institutional differences should not be interpreted as true differences in quality of care. https://www.ijhpm.com/article_4828.html Background  Between 2010 and 2019 in Thailand, hospital admissions due to toxic effects of non-medicinal substances (International Classification of Diseases 10th Revision [ICD-10] codes: T51-T65) ranged from 59.78 to 87.47 per 100 000 population. The objective of this study was to estimate the costs of non-medicinal poisoning from healthcare provider perspective, and identify factors associated with the costs in Thailand for the year 2020. Methods  This was a prevalence-based cost-of-illness study conducted from healthcare provider perspective, analysing data from five hospitals (four regional and one provincial) across the Central, North, and Northeast regions of Thailand. We included all patients diagnosed with non-medicinal poisoning (ICD-10 codes: T51-T65) during the fiscal year 2020. Direct medical costs were calculated from hospital databases, estimating the cost per outpatient/emergency visit and the cost per hospital admission. Multiple regression analysis was used to determine the factors affecting these costs. All total costs were converted to international dollar (Int$) for 2020. Results  A total of 3260 patients were included (2472 outpatient visits and 788 admissions). The mean age was 39 years, with 51% being male. The mean cost per outpatient visit was Int$ 47, and the mean cost per admission was Int$ 896. Key factors significantly associated with higher costs included patient type (outpatient vs admission), length of stay (LOS), age, insurance scheme, diagnosis group, and the presence of comorbidities. Conclusion  This study provided critical, updated data that can inform health policy by emphasizing the economic burden of non-medicinal poisoning. These findings underscore the need for strengthening poisoning prevention and early intervention services and offer essential data for conducting future economic evaluation studies of relevant interventions in Thailand. https://www.ijhpm.com/article_4931.html Quality indicators (QIs) are central to benchmarking, accountability, and quality improvement, yet their ability to capture meaningful differences in healthcare quality cannot be assumed. Building on Verheul and colleagues’ evaluation of the Dutch NABON Breast Cancer Audit (NBCA), this commentary argues that methodological robustness is necessary but not sufficient for meaningful quality measurement. Breast cancer care involves preference-sensitive decisions for which guideline adherence, treatment rates, and clinical outcomes alone cannot define high-quality care. We propose broadening quality assessment across four complementary domains: clinical quality, patient-reported outcomes, patient experience, and decision quality, including shared decision-making (SDM) and preference concordance. Patient-centred measures used for provider comparison should undergo the same rigorous evaluation as conventional clinical indicators. The next generation of breast cancer QIs should assess clinical standards, outcomes that matter to patients, care experience, informed involvement, and concordance between care and informed preferences. https://www.ijhpm.com/article_4829.html Background  In October 2023, Bangladesh introduced a free, single-dose human papillomavirus (HPV) vaccine for girls aged 9–14 through its national vaccination program to prevent cervical cancer, the second most common cancer among Bangladeshi females, caused by the HPV. Although vaccine hesitancy was not a significant issue before the COVID-19 pandemic, experiences from that pandemic and global literature suggest that the population’s uptake of this vaccine may face barriers due to concerns related to reproductive health, fertility, and cultural and religious beliefs. This is particularly relevant in a country where Islam is the state religion, 91% of the population is Muslim, and religious leaders hold significant influence over public opinion. Methods  Building upon the recently developed Integrative Public Policy Acceptance (IPAC) framework, this qualitative study explores the factors shaping religious leaders’ support for the HPV vaccine informing their potential role in promoting it. Semi-structured interviews with leaders from Bangladesh’s five main Islamic traditions were thematically analysed using NVivo 14 with inductive and deductive coding. Results  Islamic religious leaders’ varying support for HPV vaccinations in Bangladesh was influenced by their limited awareness of cervical cancer, as well as their religious and social concerns about ingredients, side effects and a fear of promoting promiscuity. Political ideologies also played a significant role, as leaders were less supportive of the program when they perceived the government as ideologically opposed to the beliefs or practices of their specific religious tradition. Conclusion  The study’s contribution to the IPAC framework highlights the importance of political consensus in policy acceptance, explaining how partisanship and ideological differences impact public policy compliance. The findings underscore the need for health systems in Muslim majority countries to engage with religious authorities, build political inclusivity and consensus, and align health policies with religious and cultural values. https://www.ijhpm.com/article_4924.html https://www.ijhpm.com/article_4831.html Background  The alcohol industry builds engagement with United Nations (UN) organisations to enhance its corporate image and influence policy, supported by the UN’s endorsement of public-private partnerships (PPPs). However, the extent of the alcohol industry’s relationships with the UN remains unclear due to limited reporting. Methods  We searched the websites of 57 UN-affiliated entities and 18 transnational alcohol corporations (TNACs) for evidence of partnerships or relationships between the UN and the alcohol industry. We summarised the UN entities and TNACs involved in formal partnerships, membership of alliances or stakeholder networks, financial contributions, sponsorship of programmes or projects, sponsorship of events, event participation, and personal relationships with conflicts of interest. Results  We identified examples of all the above relationships between various UN entities and the world’s largest TNACs, including an alcohol industry donation towards the World Health Organization (WHO) Foundation, which was created to maximise private sector donations to WHO. The focus of these engagements aligned closely with the alcohol industry’s corporate social responsibility (CSR) initiatives, including drink-driving prevention, education, sustainability, and philanthropy. These activities frequently involved support for low- and middle-income countries (LMICs) and women, which are emerging markets for the TNACs. Sponsorship and participation in intergovernmental events allowed the TNACs privileged access to policy-makers. Limited disclosure by UN entities meant that our findings provided an incomplete picture of relationships with the alcohol industry. Conclusion  The UN’s wide-ranging relationships with the TNACs highlight the power of these large corporations in building political influence and the UN’s failure to acknowledge the alcohol industry’s conflicting interests with health. These relationships undermine WHO’s mandate to promote health, placing the integrity and impartiality of the UN system at risk. On top of adequate resources from member states and enhanced transparency measures, the UN requires effective safeguards against alcohol industry influence, in line with those for the tobacco industry. https://www.ijhpm.com/article_4935.html https://www.ijhpm.com/article_4837.html Background  Reimbursement decisions for new health interventions focus on maximizing health gains, with limited attention to who benefits from these gains or the impact on income related health inequalities. This study aimed to examine the preferences of Dutch citizens regarding the distribution of health gains of new interventions across income groups. Methods  A discrete choice experiment (DCE) was completed by 614 Dutch adults. Respondents were presented with 12 choice tasks. In each choice task, they were asked to choose between two health interventions that differed on the following attributes: total healthy life years gained, distribution of healthy life years gained across income groups, additional costs in terms of health insurance premium increases and whether the intervention was curative or preventive. Preferences were estimated using multinomial logit (MNL) models, relative attribute importance, willingness-to-pay, and willingness-to-trade total health gains. Preference heterogeneity was examined using latent class (LC) analyses. Results  Respondents found the distribution of health gains by income the most important attribute in their decision between health interventions (relative importance [RI] = 40.5%, 95% CI: 38.3%–42.7%). Overall, respondents preferred an equal distribution of healthy life years gained across income groups (βhigher income groups = -1.427, 95% CI: -1.547–-1.307; βlower-income groups = -0.315, 95% CI: -0.395–-0.235). A health intervention should yield 14 283 (95% CI: 10 463–18, 102) additional healthy life years or reduce the yearly health insurance premium by €39.96 (95% CI: €29.03–€50.89) if it mainly favors lower-income groups. Preventive interventions were generally preferred over equally effective or more effective curative interventions (βprevention = 0.270, 95% CI: 0.204–0.336). While preferences displayed a similar direction across LCs, the classes differed in the RI assigned to the attributes. Conclusion  Our findings suggest societal support for interventions that prioritize preventive programs over equally effective or more effective curative interventions and prioritize interventions that provide equal benefits across different income groups. https://www.ijhpm.com/article_4919.html https://www.ijhpm.com/article_4840.html Background  Delays in medical care can be especially critical for individuals with multiple chronic conditions (MCCs). The United States and Taiwan, with vastly different healthcare systems, offer contrasting contexts for access to care. This study aims to examine the relationship between MCCs, delayed medical care and hospitalization in the US and Taiwan. Methods  This analysis used data from the US National Health Interview Survey (NHIS) 2021 (n = 29 482) and the Taiwan Social Change Survey (TSCS) 2021 health module (n = 1604). We estimated multivariable logit regression models and calculated differential effects of MCCs status (no chronic conditions, one chronic condition, MCCs) on outcomes. Precision measures were estimated with delta method. All analyses for the US population incorporated applicable complex survey design and weighting, and for the Taiwan population incorporated weighting when appropriate. Results  Compared to those with no chronic conditions, individuals in the US with one chronic condition (2.0 percentagepoints, P < .001) or MCCs (3.6 percentage-points, P < .001) had a higher likelihood of delayed care due to costs. In Taiwan, delayed care was less likely among individuals with one chronic condition (5.6 percentage-points, P = .08) or MCCs (9.5 percentage-points, P = .02), compared to individuals with no chronic conditions. Furthermore, individuals with MCCs or one chronic condition are associated with higher hospitalization in both the US (6.1 percentage-point, P < .001; 1.6 percentage-point, P = .001, respectively) and Taiwan (15.7 percentage-point, P < .001, 3.8 percentage-point, P = .08, respectively), although the differential effect of one chronic condition in Taiwan did not reach statistical significance. Conclusion  Analyzing data from two national health systems, this analysis shows differing relationships between MCC status and delayed care, suggesting a possible bidirectional effect. As both regions undergo reforms—US efforts to improve coordination and Taiwan’s rising risk of fragmented care—these findings offer insights relevant to policymakers and health system leaders beyond each country’s context. https://www.ijhpm.com/article_4920.html https://www.ijhpm.com/article_4844.html Background  Unhealthy diets drive high rates of non-communicable diseases. Many food environments are dominated by foods high in fat, salt, and sugar (HFSS). Supermarkets are a predominant source of groceries, and the relationships between retailers and their suppliers determine the foods displayed on their shelves. The disproportionate display of less healthy foods suggests that existing regulatory frameworks are sub-optimal for public health. We aimed to investigate the nature of relationships between supermarkets and their suppliers in the UK, and their implications for dietary public health. Methods  We undertook secondary analysis of in-depth interviews with UK retailers and suppliers (n = 19), using inductive and deductive approaches to thematic analysis, underpinned by our quest to understand how food retailing drives less healthy diets. Codes and themes were generated and refined, then mapped diagrammatically and are presented in an explanatory narrative. Results  Large suppliers are critical to the supplier-retailer relationship, dominating category management and supermarket shelves. The relationship brings mutual benefits for supplier and retailer. Category managers from large suppliers engender indebtedness among retailers by building rapport and trust, and investing financially and materially in retailers. Reciprocity by retailers is enacted with preferential contracts and the award of leading roles in category management (“category captaincy”). Large suppliers thus gain competitive advantage, with preferential access to premium shelf space, driving greater sales. Important positive reinforcing feedback loops maintain the relationship, described as a “virtuous circle.” Yet, there are also countering forces, which act as negative feedback loops. Conclusion  Where the retailer-supplier relationship involves the largest manufacturers, it drives the product mix and volumes on supermarket shelves, resulting in a disproportionate dominance of the largest, processed food brands. The nature of this relationship is likely a key factor preventing movement towards an overall healthier food offer to consumers and remains a public health concern. https://www.ijhpm.com/article_4934.html https://www.ijhpm.com/article_4845.html Background  Since 2009, China has implemented a chronic disease management program within primary healthcare (PHC) institutions in response to challenges posed by an aging population. However, the effectiveness of the program has been reported as mixed, likely due to variations in PHC physicians’ efforts and the support they received from the health system and community. This multi-sector engagement was conceptualized as management intensity in this study, and its impact on the program’s effectiveness was evaluated. Methods  This study analyzed 60 885 patients under the chronic disease management program in Yuhuan, Zhejiang province, as of 2023. Management intensity, the primary predictor, was quantified by township-level residual measured based on patients’ length of follow-up after eliminating patient demographics. This approach removed the portion of follow-up length attributable to individual characteristics, leaving the residual serving as a purified exposure variable for management intensity. The outcome measures included outpatient visits, inpatient admissions, outpatient and inpatient expenses, and glycemic and blood pressure (BP) control status. Data sources included chronic disease management registration records, service records of follow-up, and electronic medical records. A two-level mixed-effects regression model was then used to examine how management intensity affected the outcomes. Results  Each unit increase in management intensity corresponded to 0.21 more PHC outpatient visits and 0.15 fewer hospital outpatient visits. Meanwhile, higher management intensity was also associated with increased utilization of PHC inpatient services (odds ratio [OR]: 0.98, 95% CI: 0.97-0.98) and decreased utilization of hospital inpatient services (OR: 1.24, 95% CI: 1.18-1.29). Conclusion  Greater management intensity correlated with better health outcomes and higher utilization of PHC services. Since multi-sector engagement strongly affected how intensively chronic diseases were managed, it was imperative for health systems and communities to actively participate in and strengthen the program by supporting physicians. https://www.ijhpm.com/article_4937.html https://www.ijhpm.com/article_4846.html Background  Public organizations in healthcare are progressively adopting digital tools to disseminate information regarding the benefits of screening. Nevertheless, no research has hitherto been conducted to investigate the link between the website-based health communications and cancer screening uptake. This study addresses this gap by assessing whether health communications conveyed via the websites of local health organizations improve adherence to breast and cervical cancer screening. Methods  We performed thematic content analysis of 97 websites belonging to Italian health organizations based on the OSEC-p model. This latter was developed to measure the compliance of prevention-oriented health communication with the effectiveness requirements indicated in the model. Next, correlation and regression analyses were performed to examine the relationship between the average regional OSEC-p scores and the regional breast and cervical cancer screening adherence rates reported by the National Centre for Screening Monitoring in 2022. Results  The findings show that the prevention-oriented health communication via health organizations’ websites can explain the 45% of the variance in female cancer (breast and cervical) screening uptake. Patient engagement tools and information on preventive cancer initiatives are key web-based communication elements that enhance cancer screening adherence. Conclusion  This exploratory study is one of the first to highlight the importance of digital health communications for improving cancer screening and public health. It offers insights both for national health policy-makers to optimize health economics through screening campaigns and health organizations managers to enhance the compliance of health communication on websites with the effectiveness requirements defined in the OSEC-p model. https://www.ijhpm.com/article_4918.html https://www.ijhpm.com/article_4847.html Background  The Shared Team Efforts Leading to Adherence Results (STELAR) program is a multifaceted quality improvement intervention directed at hospital clinicians to improve stroke care. In a stepped-wedge cluster trial (N = 9 hospitals, Australia), STELAR achieved a 17% improvement in adherence to prioritized clinical indicators (composite outcome). We report the critical success factors and challenges that influenced change in care delivery. Methods  STELAR included two externally facilitated workshops; (i) feedback of national registry data to identify practice gaps and prioritize indicators; (ii) barrier assessment and action plan development (2017-2018). Hospitals appointed a site coordinator, and identified local change champions. Two months of remote-support followed to implement action plans. The process evaluation included workshop observations (N = 18), document review, satisfaction surveys (N = 51), and semi-structured interviews (external facilitator, N = 9 clinician site coordinators). Qualitative data were mapped to an implementation framework before inductive thematic analysis. Quantitative data were analysed descriptively, with all data triangulated. Results  Critical success factors included delivery by knowledge translation experts, external facilitation support/nudging to maintain staff engagement at hospitals, and the use of evidence to self-select prioritized indicators. Involving multidisciplinary staff in action planning and supporting local change champions to lead the implementation fostered capacity building. Reported challenges related to insufficient time when focusing on several prioritized indicators simultaneously within a limited timeframe and having to address strategies that involved working with different clinicians or hospital departments. Staff workload and availability and lack of medical buy-in and management support during the process were wider organizational challenges reported. Conclusion  Despite the identified challenges imposed by the limited implementation period, STELAR’s multifaceted attributes underpinned the overall strong positive change in quality of stroke care. Implications for wider adoption include involvement of knowledge translation experts with ongoing support for capacity building, and allowing greater time to work through implementation strategies.  https://www.ijhpm.com/article_4936.html https://www.ijhpm.com/article_4849.html Background Drug shortages are a persistent global challenge. In South Korea, shortages occur within a distinct context characterized by high import dependence, inflexible pricing structures, and a hospital-centric distribution system. This study examined how frontline pharmacists and policy stakeholders perceive the structural causes of drug shortages across policy, supply-chain, and frontline pharmacy practice levels.Methods We employed a sequential mixed-methods design to triangulate institutional perspectives with frontline realities, comprising six focus group interviews (FGIs) (n = 35) with policy stakeholders and a national web-based survey of 223 licensed pharmacists. Qualitative data explored institutional perspectives on structural causes and policy responses, whereas survey data quantified recent shortage experiences, impacts on patient care, and perceived causes.Results Qualitative findings indicated that stakeholders attributed shortages to structural vulnerabilities, including unprofitable drug prices, dependence on imported raw materials, and distribution rigidities. These perceptions were supported by survey findings and aligned with frontline pharmacists’ reported experiences: 97.3% of pharmacists experienced shortages in the past three months, most frequently involving cold medicines and analgesics. Respondents identified raw material shortages (51.1%) and supply chain imbalances (17.5%) as primary drivers. Although pharmacists used coping strategies such as drug substitution, these adaptations were associated with substantial patient inconvenience (49.3%) and increased pharmacist workload (23%), indicating that individual-level responses are insufficient to address systemic failures.Conclusion Drug shortages in Korea reflect systemic vulnerabilities compounded by distribution constraints rather than temporary disruptions. To address these perceived barriers, we propose a graded policy approach: short-term measures should prioritize administrative flexibility and information sharing, medium-term measures should focus on reforming pricing incentives, and long-term measures should strengthen supply chain sovereignty. https://www.ijhpm.com/article_4852.html Background  Local councils in Australia, established by state governments, are responsible for delivering services, implementing policies, and enforcing regulations that impact community health and well-being. Partnerships between local governments and health agencies can provide a valuable opportunity to advance initiatives to improve health and well-being of communities. This paper explores findings from four case studies of such partnerships in south-west Sydney, Australia. Methods  Semi-structured qualitative interviews with 25 key stakeholders were conducted as part of a realist evaluation of these partnerships, focusing on factors at functional, organisational, individual, and external levels that influence their success. Results  The findings provide real-world insights into the enablers and barriers of effective intersectoral partnerships. While the interview data generally align with existing literature and the theory of change developed in earlier research phases, key context-specific differences emerged. The interviews reiterated the need for structural support of the partnerships (in the case studies, through a context specific, locally tailored memorandum of understanding [MoU]) however, structures alone were insufficient, partnerships required “actors” to enable implementation (the partnership officers). Beyond the MoU and partnership officers, wider supports provided by partner organisation through governance, management and workplans were also essential. Stakeholders expressed strong support for these partnerships, citing positive outcomes and the importance of their continuation. However, persistent challenges include sectoral interests and institutional silos that hinder collaboration. The findings underscore the complexity of expecting councils to adopt a health-focused mandate or vice versa. Conclusion  The study highlights that partnerships, facilitated through MoUs and joint officer appointments, are effective in driving impactful health initiatives. Nevertheless, overcoming organisational silos requires ongoing leadership support and mandates that emphasize the importance of these partnerships. This research emphasizes the critical role of structured collaborations in addressing health determinants and reducing potential inequities within communities. https://www.ijhpm.com/article_4856.html Background  Diabetic retinopathy (DR) is a major microvascular complication of diabetes. Given its growing global burden and research inequities, we examined how national DR burden and socioeconomic factors relate to research interest (RI) in DR across low- and middle-income countries (LMICs) and high-income countries (HICs). Methods  We retrieved peer-reviewed DR articles published between 2018 and 2022 from Scopus. Spearman’s correlation test and multivariable linear regression were used to assess the associations between the independent variables: (a) socioeconomic factors, including health expenditure per capita purchasing power parity (PPP), current health expenditure (% of gross domestic product [GDP]), research and development (R&D) index, and human development index (HDI); (b) age-standardized years lived with disability (YLDs) rates of DR-related moderate (moderate vision impairment, MVI) and severe vision impairment (SVI) and blindness; and (c) disability-adjusted life years (DALYs) rate for diabetes, with our outcome variable, DR RI, calculated as the ratio of the number of DR publications in the field of medicine and life sciences to the whole output in the same field and country. Sensitivity analyses (2020-2022 RI vs. 2018-2019 burden) were conducted to address temporality. Results  In HICs, after adjustment for socioeconomic factors and DR-specific burden (MVI, SVI, or blindness, modeled separately), the diabetes DALY rate was the only variable independently associated with RI: MVI (β = 0.56, 95% CI: 0.16 to 0.95), SVI (β = 0.57, 95% CI: 0.19 to 0.94), and blindness (β = 0.61, 95% CI: 0.21 to 1.02). In LMICs, no significant relationships were found between RI and MVI, SVI, blindness or diabetes DALY rates. These findings remained consistent in sensitivity analyses. Conclusion  Our research demonstrates that there is a lack of significant correlation between research efforts and the burden of DR, particularly among LMICs, which may highlight the need to strengthen research infrastructure and realign national health research priorities. https://www.ijhpm.com/article_4857.html Background Establishing research partnerships can help close the research-practice gap. The Integrated Knowledge Translation Guiding Principles were developed in a spinal cord injury research context as a resource to facilitate research partnerships. Research funders play a significant role in the spinal cord injury research system. However, how fundersdefine, require, evaluate, support research partnerships is rarely reported. This study identified spinal cord injury research funders in Canada and the United States, identified their approaches to supporting research partnerships, and explored organizational perspectives of principles of partnership. Methods An environmental scan was conducted through five steps: (1) identifying spinal cord injury research organizations that funded the greatest number of spinal cord injury research publications in Canada and the United States between 2017 and 2022; (2) identifying one funding program related to research partnerships of each funder; (3 extracting online information of the programs; (4) interviewing funder informants; and (5) descriptive and deductive content analysis. The five steps were completed between April 2022 and September 2024. An additional data collection was conducted in July 2025 on a relevant National Institutes of Health funding program.Results Sixteen organizations and seventeen partnership-supportive programs were identified. Six programs defined partnerships as researchers and research users engaging throughout the research process. Eleven programs required applicants to describe the partnership in applications and explicitly stated their peer review evaluation criteria. The programs supported research partnerships through remuneration for partners’ engagement (n = 6), facilitating connections between researchers and potential partners (n = 3), and helping applicants prepare applications (n = 4). The programs had few strategies to evaluate awarded partnerships post-grant. Three descriptive categories emerged from the interviews: (1) Varied support for research partnerships; (2) Minimal capacity for partnership evaluation postgrant; and (3) Need for tools and resources to further support research partnerships. Conclusion Differences existed in how spinal cord injury research funders in Canada and the United States defined, required, evaluated, and supported research partnerships. The results provided an initial landscape of funders’ role in the spinal cord injury research system and may inform strategic efforts to optimizing meaningful engagement in a broader health research context. https://www.ijhpm.com/article_4862.html Background Many countries are defining health benefits packages to progress toward universal health coverage (UHC). Cost estimates are required to ensure packages are affordable and implementable. However, a gap persists between global costing tools and recommendations informing package design and the way services are defined for country-level implementation. To address this, we developed the first health systems-wide costing tool and approach based on the World Health Organization (WHO) UHC Compendium database, which provides structured service definitions and data to facilitate country-level contextualisation and implementation. This paper presents our tool and approach through a proof-of-concept study in Kyrgyzstan. Methods We developed a tool in Microsoft Excel that estimates normative economic costs for over 500 UHC Compendium services using a combination of bottom-up and top-down approaches. Resource use was derived from UHC Compendium metadata, supplemented with publicly available and country-specific data sources to inform input prices and population in need estimates. In Kyrgyzstan, all secondary data were validated and contextualised with national experts. We produced high-level cost estimates for 424 services identified as relevant for Kyrgyzstan and refined estimates for 181 priority services selected by country stakeholders. Sensitivity analyses investigated variations in personnel, medicine and overhead costs and currency fluctuations. Results Delivering all 424 services at current utilisation levels, or low levels of utilisation for services not yet implemented, would cost an estimated US$ 186.97 per capita annually. Providing the 181 priority services would cost US$ 74.41 per capita at current utilisation levels and US$ 189.44 per capita if scaled to full (100%) utilisation. Costs were driven primarily by personnel and medicines. Sensitivity analyses showed costs ranging from US$ 58.76 to 90.05 per capita. Conclusion This study demonstrates the feasibility of using UHC Compendium data to generate country-specific, service-level cost estimates for benefits package design. Other countries can adapt our tool and approach to design affordable and implementable packages in support of UHC goals. https://www.ijhpm.com/article_4865.html Background  Chinese medical teams (CMTs) have long been a component of global health engagement in Africa, yet their effectiveness within national health systems remains under-examined. Methods  Drawing on Bardosh’s socio-anthropological framework of global health delivery, this qualitative study examines how CMTs function within Ghana’s public healthcare sector. Participants were purposively selected from key institutions in Ghana, including the Ministry of Health (MoH), two tertiary hospitals, and one district hospital hosting CMTs. Eighteen semi-structured interviews were conducted with Ghanaian clinicians, hospital administrators, national policy-makers, and Chinese medical staff. Policy-relevant documents from 2009 to 2024 were reviewed to supplement and triangulate the findings. Results  Based on Bardosh’s five domains, the analysis identifies several factors influencing programme effectiveness: the placement and facility-level integration of CMTs (terrain of intervention); cultural and linguistic disconnects affecting patient engagement (community agency); short-term rotations and fragmented collaboration with local staff (field staff strategies); limited adaptability and utilisation of donated medical technologies (socio-materiality); and weak institutional coordination and policy alignment (governance). Two additional themes—patient-centred care and continuity of healthcare delivery—emerged as important dimensions shaping the perceived value and limitations of the CMT model. The findings suggest that effectiveness is shaped not only by operational or resource-related factors but also by the extent to which foreign medical interventions are socially embedded, locally responsive, and institutionally aligned. Conclusion  These findings provide insights for the design of international health partnerships seeking to strengthen public health systems in low-resource settings through more participatory, coordinated, and locally embedded models of delivery. https://www.ijhpm.com/article_4868.html Background  Teleconsultation services grew significantly in France during the COVID-19 pandemic. Reimbursed teleconsultations increased by a hundredfold between 2019 and 2021, establishing it as an emerging healthcare delivery modality. However, medication dispensing patterns following teleconsultations remain largely unexplored. This study aimed to characterize post-teleconsultation medication dispensing patterns between 2021 and 2023. Methods  A retrospective cohort study was conducted using data from the French health database. The study included all teleconsultations conducted that resulted in at least one medication dispensing event (TLCs) between January 1, 2021, and June 30, 2023. We described patient demographics, prescriber characteristics, and dispensed medication. Results  During the study period, 11 202 364 TLCs (34.3%) out of 33 853 911 resulted in medication dispensing. Among these 11 202 364 TLCs, the patient population predominantly comprised females (64.4%), individuals without long-term medical conditions (86.4%), with a mean age of 42.2 years (SD ± 20.8). Teleconsultations were mainly conducted by liberals’ physicians (86.8%) and health centre-employed practitioners (12.1%). The use of teleconsultation platforms increased fivefold between the first semesters 2021 (4.2%) and 2023 (28.2%). Teleconsultations resulted in medications targeting the nervous system (53.1%), digestive system (28.3%), and respiratory system (21.8%). Two contexts of dispensing emerged: dispensing with chronic indication (42.8% of TLCs) characterized by a long median time and several dispensing, and dispensing with an acute indication (55.6%), characterized by single dispensing with a 0-1 day between teleconsultation and dispensing. Conclusion  One third of the teleconsultations resulted in medication dispensing, mainly for young, urban patients with good access to care, in contrast to the objective as described in the French Law. Dispensing patterns revealed two distinct modalities, acute symptomatic and chronic disease management. Certain classes of drugs dispensed (antibiotics, opioids, benzodiazepines) may raise questions about appropriate dispensing practices in teleconsultations. https://www.ijhpm.com/article_4870.html Background  Amidst growing pressures on primary care services in England, the Pharmacy First (PF) scheme was introduced in 2024 to enable community pharmacists (CPs) to manage seven common conditions, including supplying antibiotics, where appropriate, according to patient group directions (PGDs). PF aims to increase timely access to care, reduce general practitioner (GP) workloads, and address health inequalities in terms of access to primary healthcare. This paper, part of a wider evaluation of PF, aims to describe and explain the factors affecting its development and early implementation. Methods  Semi-structured (n = 31) qualitative interviews were conducted with policy-makers, representatives of national community pharmacy and general practice bodies and frontline CPs and GPs in England. Analysis was guided by a framework combining Walt and Gilson’s “Policy Triangle” and the Consolidated Framework for Implementation Research (CFIR). Results  The study identified a range of factors shaping PF development and implementation. These included policy design complexity, stakeholder engagement, political priorities, and contextual pressures such as funding constraints and workforce shortages. Pharmacists welcomed the clinical upskilling opportunity, while GPs voiced concerns about patient safety and duplication of work. A lack of public awareness, inadequate training access (particularly for independent pharmacies and locum CPs), and poor interoperability between community pharmacy and general practice information systems further hindered rollout. Policy “layering,” with limited consideration of the implications for existing community pharmacy clinical services and the absence of a phased implementation strategy caused confusion among GPs and patients. Conclusion  PF illustrates both the potential and challenges of expanding clinical roles in community pharmacy through national policy. Despite political backing and sector-wide engagement, its implementation faced structural, financial, and communication barriers. Realising its full potential requires workforce and integrated information infrastructure, sustainable funding, and clear inter-professional communication and information sharing between general practice and community pharmacy. https://www.ijhpm.com/article_4872.html Background Approximately 20% of the total healthcare expenditure in high-income countries is spent on low-value care, ie, care that is unnecessary, potentially harmful, or provides marginal health benefits to patients. Demand for lowvalue care is considered a multifactorial, complex problem, as a multitude of factors have been associated with low-value care use. However, there is limited knowledge on how these factors interrelate and lead to demand for low-value care. Therefore, the aim of this study was to explore and map the factors and their relations contributing to patients’ demand for low-value care using a complex systems approach. Methods Two group model building (GMB) sessions on the topic of low-value care were organised with experts from the Netherlands. Each session’s transcript was thematically analysed, resulting in one causal loop diagram (CLD) per session. These CLDs included determinants, relations between these determinants and feedback loops. Finally, the CLDs were synthesised into one CLD combining the insights from both sessions. Results The final CLD consisted of 42 factors influencing demand for low-value care. It includes biomedical factors, cognitive biases, socio-cultural factors, economic factors, emotions, knowledge-related factors, factors related to the interaction with the provider, and preferences and expectations. By mapping the relations between these factors, we identified 59 connections and nine reinforcing feedback loops potentially influencing demand for low-value care. Conclusion The CLD provides insight into factors, mechanisms and feedback loops influencing patients’ demand for low-value care. It highlights perceived insecurity as a central driver that influences multiple other factors and eventually affects patients’ demand for low-value care. These central factors influencing multiple other factors may be potential leverage points for policies aiming to reduce demand for low-value care. Further research is required to clarify the relative importance of the identified factors, relationships, and feedback loops to determine effective leverage points. https://www.ijhpm.com/article_4873.html Background Financial relationships between the medical device industry and healthcare providers have raised concerns about conflicts of interest (COIs). However, these relationships remain poorly characterized in Japan, despite the country’s large medical device market, which was valued at ¥4.41 trillion ($33.3 billion) as of 2021. This study examined the scale, composition, and temporal patterns of payments from the medical device industry and evaluated current transparency practices. Methods We analyzed publicly disclosed payment data from 117 medical device companies predominantly affiliated with the Japan Federation of Medical Devices Associations (JFMDA) from 2019 to 2022. Payment categories included research and development, academic research support, lecture and consulting fees, information-provision–related expenses, and other payments to healthcare professionals (HCPs) and healthcare organizations (HCOs). We assessed payment magnitude, category composition, company-level concentration, year-to-year changes, and disclosure transparency using an adapted proforma previously applied to European pharmaceutical payment data. Results Total payments amounted to $942.3 million over four years. Academic research support expenses constituted the largest share (33.0%, $310.7 million), followed by information provision–related expenses (25.2%, $237.5 million) and research and development expenses (21.7%, $204.8 million). Payments were highly concentrated, with the top 10 companies accounting for approximately 58% of total amounts. Using 2019 as the pre-pandemic baseline, total payments declined by 30.2% in 2020 and remained below pre-pandemic levels in 2021 (-24.0%), before partially recovering in 2022 (-11.6%). Category-specific trends diverged during the pandemic, with consulting, lecturing, and manuscript-related fees exceeding pre-pandemic levels by 2022, while information provision–related expenses remained substantially reduced. Transparency was limited: 78.6% of companies disclosed payment data with limited standardization, searchability, or data download functionality. Conclusion This multi-year analysis revealed substantial financial relationships between the medical device industry and healthcare stakeholders in Japan, alongside persistent shortcomings in transparency of disclosures. Introducing legally mandated disclosure would improve oversight and align Japan’s system with international best practices. https://www.ijhpm.com/article_4874.html Background Corporate political activity (CPA) refers to practices through which commercial actors seek to influence public policy and prioritise their commercial interests. While extensively documented internationally, little empirical evidence exists for Portugal. This study provides the first systematic analysis of the CPA of the food industry in Portugal.Methods We conducted a systematic document analysis, following a protocol developed by INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support), a network that monitors food environments. This was triangulated with semi-structured interviews and illustrated through two policy examples. Twenty-five food industry actors were selected based on market share, trade association membership, and relevance to policy debates. Publicly available materials (January 2022–December 2023) were collected and coded using Ulucanlar’s CPA framework, distinguishing framing and action strategies. Data were triangulated with 18 interviews conducted between July and December 2024 with informants from academia, government, industry, civil society, public health, and the media.Results We identified 534 examples of framing and 799 examples of action strategies. Framing was dominated by portrayals of corporations as “good actors” aligned with health, sustainability, and national development. Action strategies focused on reputational management, corporate social responsibility (CSR), and the displacement of public health roles. Legal obstruction and overtly adversarial tactics were absent. Large multinational manufacturers and major retailers accounted for the highest number of coded CPA examples, with trade associations also represented among actors engaging in policy-related activities. Interviewees confirmed these patterns and expressed concerns over informal access to policy-makers, weak state capacity, and reliance on corporate-led initiatives.Conclusions The food industry in Portugal primarily relies on reputational and co-regulatory strategies, with limited evidence of overtly confrontational tactics. These findings are consistent with a form of institutionalised influence in which corporate actors engage closely with public authorities and participate in governance processes in ways that may shape the direction and scope of public health policy. https://www.ijhpm.com/article_4876.html Background Unnecessary hospitalizations undermine the efficient use of healthcare resources and may expose patients to preventable safety risks. This study aimed to develop a computerized screening tool for identifying potentially inappropriate adult inpatient admissions using nationwide health insurance claims data in South Korea.Methods We conducted a retrospective cross-sectional study using the Health Insurance Review and Assessment Service-National Inpatient Sample (HIRA-NIS) (2017–2019) to develop and assess a claims-based hospitalization appropriateness screening tool (HAST) for adult admissions. Based on the adult hospitalization clinical service criteria from the Appropriateness Evaluation Protocol (AEP), we selected only those criteria directly observable in claims data and operationalized them using standardized electronic data interchange codes. The final tool included nine criteria and episodes meeting none of these criteria were classified as potentially inappropriate admissions (PIAs). HAST was assessed through a single-round of expert review for content validity, mortality-based known-groups comparison, andconvergent validity against selected SQLape diagnostic groups. Logistic regression models were applied to identify factors associated with PIA.Results The final tool comprised nine screening criteria: (1) receiving general anesthesia, (2) admission to intensive care unit (ICU), (3) receiving hospice care, (4) childbirth, (5) continuous monitoring of vital signs, (6) receiving arterial blood gas analysis (ABGA), (7) application of mechanical ventilator, (8) receiving intravenous injections, and (9) receiving intramuscular injections. Across analytic specifications, 17.5% to 19.2% of admissions were classified as PIAs. PIAs were more frequent among adults aged 20–39 years, females, National Health Insurance (NHI) beneficiaries, and patients admitted to small facilities with fewer than 100 beds.Conclusion HAST offers a feasible, reproducible, and scalable method for monitoring the appropriateness of hospital admissions using routinely collected administrative data. It can be used for large-scale surveillance to support health policy evaluation and system-level quality improvement. https://www.ijhpm.com/article_4877.html Background While the overall impact of pooled drug procurement on drug procurement has been evaluated, little is known about how healthcare institutions’ pre-policy procurement composition is associated with heterogeneous post-policy procurement responses. This study addresses this gap under China’s National Volume-Based Procurement (NVBP) policy.Methods We used monthly procurement data from January 2018 to December 2020 from four provinces in China, covering both pre- and post-policy periods, as the NVBP policy was implemented in January 2020. Outcomes were procurement volumes, measured as the number of defined daily doses (DDDs), of NVBP-covered drugs (bid-winning and non-winning products) and their clinically substitutable alternatives. All healthcare institutions in the selected provinces were included and stratified by (1) their pre-policy share of bid-winning products among NVBP drugs and (2) their pre-policy share of NVBP drugs among both NVBP and alternative drugs, to assess institutional heterogeneity. Interrupted time series (ITS) analysis was conducted to assess the immediate (level) and long-term (slope) post-policy changes.Results Procurement volumes of bid-winning products increased substantially following the policy (level change: 1275%, P < .01), with smaller increases observed among healthcare institutions with higher pre-policy bid-winning shares (eg, highest-share subgroup: 441%, P < .01), consistent with uniform procurement targets. Although overall procurement of alternative drugs remained stable, healthcare institutions with higher pre-policy NVBP shares experienced significant increases, with level changes of up to 1010.9%, suggesting substitution driven by financial losses. In contrast, healthcare institutions with lower NVBP shares saw notable declines (level change: −34.8% to −65.2%), possibly reflecting demand-side substitution toward lower-priced NVBP drugs.Conclusion Findings highlight that in pooled procurement, procurement behaviour is shaped more by regulatory enforcement and financial incentives than by price-driven demand. Strengthening guidance and oversight of supplier behaviour remains essential to realizing the full benefits of pooled procurement reforms. https://www.ijhpm.com/article_4879.html Background Although accountability interventions to strengthen adolescent sexual and reproductive health (ASRH) service delivery in marginalized urban neighbourhoods are on the rise, evidence on the underlying mechanisms and context conditions is scarce. We analysed the strategies of two grassroots organizations in India that support adolescent agency in sexual and reproductive health (SRHR) to identify the mechanisms and context conditions in which they work.Methods We used realist evaluation (RE) and a case study design with two sites in Delhi and Mumbai. We used Margaret Archer’s structure-agency-culture (SAC) framework to deepen the analysis of context and of the temporal dynamics of the intervention.Results We found that the organizations used five strategies: (1) mobilization of girls and young women, (2) raising critical consciousness, (3) supporting self-organization and emergent collective action, (4) documenting lived realities and engagement with local governance actors. Organizational and relational mechanisms triggered include trustbuilding in the community and with parents, which enables support, fosters a group identity, and provides a safe space for peer exchange. Enhancing reflexivity, self-efficacy and a sense of place among adolescent girls, the intervention stimulates emergent collective action within the neighbourhood, which in turn contributes to build consensus and enforce accountability with local and sub-national governance actors. We considered causal mechanisms to be historically grounded in practices preceding current ones, and we adopted a view on “context” that includes a longer-term temporal dimension.Conclusion The refined programme theory confirms that organizations will simultaneously engage in consensusoriented and agonistic strategies with state actors in their efforts to achieve social change. https://www.ijhpm.com/article_4881.html Background Performance measurement systems (PMSs) have become an essential component of health system reforms globally and are increasingly used to assess, reward and improve provider performance. While PMSs can be valuable tools for achieving desired health outcomes, their effectiveness depends on how they are designed, implemented, and used within complex multilevel governance structures. There is evidence that PMSs may also have unintended negative consequences. Drawing on new empirical evidence, the present study examines the consequences of PMSs implemented in multi-level governance systems through the analysis of the Italian National Healthcare Service (INHS), which exemplifies a decentralised health system with multiple levels of governance.Methods The study employed a mixed methods approach combining quantitative and qualitative methods to examine the functional and dysfunctional consequences of PMSs in the INHS across three governance levels: (i) State-Regions, (ii) Regions-healthcare organisations, and (iii) Healthcare organisations-healthcare professionals.Results We identified three key functional consequences. First, PMSs drive improvement by facilitating benchmarking, advocacy, and collaboration. Second, quantifying activities and services improves objectivity and transparency. Third, national PMSs provide a comprehensive view of performance across multiple dimensions and provide a more holistic understanding of how different aspects of the system interact. We confirmed previously reported dysfunctional consequences of PMSs found in other health systems and identified three new dysfunctional consequences in the INHS: Measurement Overload, Misconsideration, and Exploitation.Conclusion Based on our analysis and existing literature, we propose ten key factors for strengthening performance measurement in the INHS. While this study offers novel evidence on the functional and dysfunctional consequences of PMSs in the Italian system, our research is context-specific, and the applicability of these factors to other multi-level health systems remains an area for future empirical testing. https://www.ijhpm.com/article_4886.html Background The uneven distribution of nurses across Indonesia’s remote regions remains a major obstacle to achieving universal health coverage and Sustainable Development Goals. Recruitment and retention policies for remote areas are often based on assumptions about what nurses value, while empirical evidence remains limited. This study aimed to examine the job attributes influencing nurses’ preferences for working in remote and very remote areas in Indonesia.Methods A discrete choice experiment (DCE) was conducted among 243 nurses with at least one year of experience in remote healthcare facilities in East Nusa Tenggara, Papua, and West Papua. Job attributes and levels were identified through literature reviews and focus group discussions (FGDs). Six attributes were included: work location, employment status, supporting facilities, basic living facilities, student financial aid, and monthly net income. Preferences were estimated using a conditional logit model, with willingness-to-accept (WTA) estimates supporting policy interpretation.Results Basic living facilities were the most influential factor in shaping nurses’ job preferences. Positions offering reliable access to clean water, electricity, and internet services were significantly more likely to be chosen than those without such facilities (odds ratio [OR] = 2.06; 95% CI: 1.82–2.33). Jobs in very remote areas were also preferred over rural postings (OR = 1.76; 95% CI: 1.52–2.04). In contrast, civil servant employment was less preferred than contractbased positions (OR = 0.56; 95% CI: 0.49–0.64), and direct provision of housing and transportation did not significantly influence job choice (OR = 1.07; 95% CI: 0.94–1.22). A higher monthly income increased the likelihood of selecting a remote posting.Conclusion Nurses’ preferences for remote postings in Indonesia are driven mainly by living conditions, employment security, and location, rather than financial incentives alone. Policies should prioritize basic infrastructure improvements and stable employment arrangements. https://www.ijhpm.com/article_4887.html Background One Health decisions are challenging due to substantive and strategic uncertainty. This study aims to map and interpret strategic uncertainties surrounding a specific One Health issue (mosquito-borne disease [MBD] policy) in the Netherlands.Methods We used a game-theoretic framework to identify games from 26 interviews with key actors about strategic uncertainty. For each game we identified the context (where the game is played), the actors (who is playing), the content (what are the issues and outcomes), and the process (how the game has developed and what strategies were employed). Games with the same set of actors and overlapping content were clustered together.Results We identified 15 games, centered mostly around trade-offs between domains (human health, animal health, and the environment) and dilemma’s inherent to prevention policy. We identified three game clusters. Multi-level governance forms the context around MBD policy. It consists of a game involving issues around climate adaptation, infectious disease policy, and biodiversity. This game is played across time and hierarchical levels (local, regional, national), giving rise to cascade dynamics. In this governance context, actors deal with responsibilities around invasive mosquito control. This second cluster is characterized by a dilemma between acting (and bearing the cost) and waiting for someone else to act; and a game represented by a central notification hub. Finally, the zoonotic structure was developed to bridge domains and gives rise to a various games representing the tension between actors’ own and shared interests, power and information asymmetries, and acting versus not acting for their own benefit.Conclusion We argue for an actor-centered approach and more awareness of strategic uncertainties among involved actors in MBD policy to reduce strategic risks inherent in the identified game archetypes. We provide policy recommendations for anticipating, reducing or dealing with the associated strategic risks towards better MBD prevention. https://www.ijhpm.com/article_4888.html Background Intersectoral actions can improve population health and reduce health inequities by addressing social determinants of health. Priority setting methods are used by health ministries to rationalize resource allocation within the sector, but not for intersectoral actions.Methods We conducted a qualitative case study of an intersectoral priority setting exercise—a novel use of priority setting methods—undertaken by Pakistan’s Federal Ministry of Health between 2019–2022. Drawing on theories of agenda setting and priority setting, we examined the priority setting process through key informant interviews. We explored the perceived appropriateness of the priority setting approach and the challenges encountered during its implementation across sectors.Results Our findings reveal that the process of intersectoral priority setting is deeply influenced by its political and institutional context. According to respondents, existing institutional structures and norms in Pakistan are not optimally suited to support intersectoral actions for health, although there is growing recognition of their importance. Regardless of sector, all respondents view engaging in intersectoral actions as part of the health ministry’s responsibility for population health. Priority setting, thereby, is viewed as a way of clarifying the health ministry’s intersectoral agenda. However, intersectoral priority setting methods are seen as underdeveloped in terms of available evidence, standardized economic and policy evaluation, and deliberative mechanisms. Respondents suggest that to implement the prioritized intersectoral agenda, the health ministry must effectively navigate the political space outside the health sector, such as by highlighting shared benefits, grounding the intersectoral agenda in local needs, and leveraging the political dynamics of other sectors. Moreover, this political engagement must be complemented by competence in evidence generation and communication to influence cross-sectoral policy dialogues.Conclusion Using a priority setting approach, health ministries can systematically advance intersectoral health agendas by building political coalitions around shared priorities supported by rigorous evidence and analysis. https://www.ijhpm.com/article_4890.html Background This comparative study examines responsibilities for coordination of healthcare and long-term care (LTC) in Germany, the Netherlands, Sweden, and Switzerland. As populations age, frailty and multimorbidity are increasing, leading to greater care needs and coordination of care between sectors. We analyze how coordination responsibilities among healthcare professionals and organizations vary between different healthcare and LTC systems and what strategies are used for better coordination.Methods Fifty qualitative expert interviews were conducted with participants from local government agencies, social health insurances, various healthcare organizations, and professionals directly involved in healthcare and LTC provision. Data were analyzed with qualitative content analysis. The comparative research is based on existing healthcare and LTC typologies.Results This study shows the need for clear lines of responsibilities and financial allocation to minimize fragmentation of care coordination. Sweden and the Netherlands assign formal coordination roles to general practitioners (GPs), district nurses, and municipal services. Germany’s approach heavily relies on the family, and in Switzerland, public and private LTC providers are often responsible for coordination. Digital technologies are increasingly used for communication and coordination. In Germany and Switzerland, where GPs have no gatekeeping role and primary healthcare centers are less developed, older GPs are unwilling to invest in digitalization. In Sweden and the Netherlands, where GPs coordinate primary healthcare and referrals to specialists, there is a strong interest in digitalization to improve communication and coordination. Still, digital systems for healthcare and LTC are not fully harmonized.Conclusion The comparative study shows the need for clear responsibilities, systemic support, and financial recognition of care coordination to facilitate patient-centered care coordination. Digital technologies and in particularly integrated electronic records across sectors are reported as important tools that can facilitate care coordination across healthcare and LTC. https://www.ijhpm.com/article_4893.html Background Language barriers in primary care contribute to health inequalities, limiting access to services and affecting patient outcomes. Professional interpreting services are emphasised in UK guidance, but evidence on how policy-makers and commissioners deliver these services is lacking. This study aimed to explore the commissioning and implementation of interpreting services in UK primary care from the perspectives of commissioners, policy-makers, interpreters, and interpreting service providers.Methods Semi-structured interviews were conducted with 31 participants (12 national policy-makers, 6 commissioners, 7 interpreters, and 6 interpreting service providers). Thematic analysis was conducted to explore delivery and identify best practices and key challenges in delivery.Results The study found variation in commissioning models, with some areas favouring large national providers for widened scope and cost efficiency, while others prioritised local interpreting services for higher quality. The UK was seen as world-leading in interpreting provision, however fragmentation, lack of standardisation, accountability gaps, funding constraints within a publicly-funded healthcare system, and varied interpreter competencies and renumeration led to inconsistency in delivery. The healthcare sector was reported as having lower interpreting standards compared with other UK public sectors. Technological solutions were used in delivery and offered key advantages but sometimes failed to meet patient and provider needs.Conclusion Strengthening national regulation, funding allocation, and service integration is essential to addressing systemic issues and improving interpreting service delivery in UK primary care. Policy recommendations include promoting “what good looks like,” standardising interpreter qualifications and adopting approaches tailored to local population needs. https://www.ijhpm.com/article_4895.html Background Implementing diagnosis-related groups (DRGs) reform under the guidance of value-based healthcare (VBH) is of great significance for China to curb the rapid rise of medical costs and promote the allocation and utilization of medical resources. However, current research evaluating the effectiveness of China’s DRGs reform lacks a valuebased oriented approach to healthcare and has not yet explored whether different types of diseases and population characteristics will affect policy implementation.Methods A total of 16 564 acute myocardial infarction (AMI) and 74 356 cancer inpatients were included in this singlecenter study during 2018-2022. Interrupted time series models were used to estimate post-reform level and slope changes. Exploratory subgroup analyses were conducted by gender, age, and disease type. Hospital-level outcomes included riskadjusted success per cost (SPC), cost per success (CPS), and net monetary benefit (NMB). Individual-level outcomes included total hospitalization cost, length of stay, mortality, successful outcomes, and 30-day readmission.Results DRG reform was associated with changes in VBH indicators, with AMI mainly showing slope changes and cancer mainly showing level changes. However, individual-level analyses showed that some clinical outcomes did not improve consistently, which differed from the hospital-level results.Conclusion The findings suggest that DRG reform was associated with changes in selected hospital-level VBH indicators, while some individual-level clinical outcomes did not show consistent improvement. Future payment reform should combine disease-specific clinical pathways, stronger risk adjustment, and routine monitoring of patient-level quality outcomes, especially for acute and high-risk conditions. https://www.ijhpm.com/article_4896.html Background The right to adequate food (RtAF) is increasingly incorporated into domestic food and nutrition legal frameworks to inform policy-making. Mexico’s General Law on Adequate and Sustainable Food (LGAAS), enacted in April 2024, is the country’s first law to operationalize the RtAF, which has been recognized in Article 4 of the Mexican Constitution since 2011, within domestic food policy. We examined informant insights on the LGAAS, focusing on its policy formulation and informant perspectives on the RtAF in the law.Methods We conducted a review of legislative documents and semi-structured key informant interviews. The document review covered the period from the law’s introduction to parliament (2020) to its approval (2024). Interviews (13) were conducted with informants from the Mexican government, academia, international development partners, and civil society involved in or influencing the formulation of the LGAAS. The health policy triangle framework informed the interview guide development, while both deductive and inductive thematic approaches guided the analysis.Results Informants identified how the following key factors affected the formulation of the LGAAS: regional action influenced RtAF legislation, national intersectoral collaboration fostered accountability, coalition building sustained momentum, and an enabling policy environment supported prioritization of the LGAAS. Political contentions and perceived industry influence also impacted negotiations. Informants consistently framed the RtAF as a cross-cutting concept linked to food security and food sovereignty, but there were differing interpretations of the state’s role in the progressive realization of the RtAF to deliver food system transformation in Mexico.Conclusion The LGAAS positions Mexico among a small number of countries adopting a rights-based framework to address food system reform. Its formulation highlights the role of several key factors in supporting the operationalization of the RtAF into an actionable framework law, though implementation is yet to occur. https://www.ijhpm.com/article_4897.html Background In England, the National Institute for Health and Care Excellence (NICE) guidance recommends that women under 43 years old are offered 3 cycles of in vitro fertilisation (IVF) on the publicly funded healthcare system if they have not conceived after two years. However, regional commissioners decide the funding allocated for IVF. Our study aims to assess socioeconomic and regional factors associated with having a live birth after using IVF over time to determine if decreases in funding for IVF increase regional inequalities in live birth success rates.Methods We use Understanding Society Survey data from 2009-2022 employing a random effects probit model to estimate the determinants associated with a live birth via IVF among women having given birth in the previous year. Next, we estimate a random effects probit model to compare the determinants of live birth from IVF between 2009-2018 and 2019-2022 to assess the impact of unequal decreases in funding across different regions of England.Results Between 2009-2022, living in London, being older, in employment, degree level or higher education, and owning/mortgage home are positively and statistically significantly associated with a live birth using IVF. Comparing 2009-2018, to 2019-2022 with less generous funding we find that in Yorkshire and Humber, there is a decrease in women successfully conceiving using IVF. Married/cohabiting women are three percentage points more likely to have a live birth with IVF compared to single women in 2019-2022 compared to 2009-2018. Women living in a middle deprivation quintile area (3) are three percentage points more likely to have a live birth from IVF in 2019-2022 compared to 2009-2018.Conclusion Lack of individual resources in conjunction with regional difference in in IVF funding contribute to inequalities in reproductive autonomy by reducing opportunities to access IVF. https://www.ijhpm.com/article_4898.html Background An innovative payment method, the diagnosis-intervention packet (DIP), has been piloted in China since 2020 and was fully implemented in City A in November 2022. However, its specific impact on private hospitals remains inadequately explored. This study aimed to examine how the reform influenced inpatient care behaviours in private hospitals.Methods Using a dataset comprising 38 296 inpatient reimbursement records from 2021 to 2023 in a western city in China, 5 private hospitals included in the first batch of pilot institutions were selected as the treatment group, while 3 non-pilot private hospitals constituted the control group. Difference-in-differences (DID) analyses was conducted to estimate policy effects on providers’ inpatient care behaviours across four dimensions: cost control, service-volume adjustment, patient type, and quality risk.Results Following the reform, significant changes were observed across several outcome dimensions. Regarding servicevolume adjustment, the average length of stay decreased significantly (-1.94; 95% CI: -3.75 to -0.13), and average monthly admissions also declined (-30.36; 95% CI: -59.52 to -1.20). No statistically significant change was observed in patient type. For cost control, the average expenditure per admission decreased significantly by US $670.50 (95% CI: -1149.80 to -191.18). Out-of-pocket (OOP) expenditure per admission also declined by US $118.89 (95% CI: -188.88 to -48.90), although the share of OOP expenditure in total costs increased slightly (0.02; 95% CI: 0.05-4.64). As for quality risk, perihospitalisation outpatient visits increased significantly (1.473; 95% CI: 0.252-2.694).Conclusion The DIP payment reform in private hospitals contributed to cost containment and process optimisation. However, the structural tension between standardised payment mechanisms and market-oriented hospital operations may generate short-term adjustments that prioritise cost control over quality improvement. Under strict cost-control incentives, hospitals may adopt strategic responses such as shortening inpatient stays and adjusting patient composition, which could pose potential risks to healthcare quality. https://www.ijhpm.com/article_4903.html Background Strategic health purchasing is a critical lever for advancing universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). Across Southeast Asia, countries are reforming their purchasing functions to enhance the efficiency, equity, and quality of primary healthcare (PHC). This study assesses the extent and progress of strategic purchasing for PHC in four Association of Southeast Asian Nations (ASEAN) member states: Indonesia, the Philippines, Thailand, and Vietnam.Methods We applied the Strategic Health Purchasing Progress Tracking Framework to conduct a structured comparative assessment across five purchasing dimensions: financial management, benefits specification, contracting arrangements, provider payment, and performance monitoring. Data was collected through semi-structured interviews with national stakeholders, supplemented by grey literature and policy document reviews. The data was analysed, triangulated and validated through expert consultation and thematic analysis.Results All four countries have taken steps toward institutionalising strategic purchasing through national health insurance (NHI) schemes, though the depth and coherence of reforms vary. Thailand’s universal coverage scheme (UCS) demonstrates the most advanced implementation, characterised by performance-based payment mechanisms and relatively strong monitoring systems. Indonesia and the Philippines are implementing pilots to align payments with service delivery goals, though challenges persist in integrating PHC with broader health system functions. Vietnam maintains high insurance coverage but exhibits limited strategic purchasing practices, particularly for PHC. Across all countries, gaps in data systems and governance capacity constrain effective implementation.Conclusion Strategic purchasing reforms in Southeast Asia are progressing but remain uneven in scope and institutional maturity. Strengthening policy coherence, investing in health information systems and aligning public financing with PHC priorities will be critical to advancing these reforms. In particular, Thailand’s experience offers relevant lessons for broader regional efforts to operationalise strategic purchasing for more resilient and equitable PHC systems. https://www.ijhpm.com/article_4906.html Background The COVID-19 pandemic posed an unprecedented public health challenge, causing over one hundred thousand deaths in Germany alone. As elsewhere, policy-makers in Germany sought expert advice to navigate uncertainty and urgency, including through ad hoc advisory committees. We aimed to identify committees operating between 2021-2023, assess their composition, and analyse their work processes with a particular focus on structures, expert deliberations and evidence use.Methods We conducted a systematic document analysis of government documents and semi-structured interviews with committee members in April/May 2024. We identified documents (parliamentary inquiries and freedom of information requests) through systematic searches in digital government archives; and purposively sampled experts from identified committee member lists. Documents were analysed using abridged content analysis, and interview transcripts were analysed using codebook thematic analysis.Results We screened 984 documents, analysed 43 documents, and conducted 12 interviews. Ultimately, we identified six ad hoc advisory committees which met our inclusion criteria. These committees advised the German national government and the state governments of Bavaria, North Rhine-Westphalia, Rhineland-Palatinate, Schleswig-Holstein, and Thuringia. These were dominated by academic experts, especially from bio-medical disciplines. Structure of the advisory process: Consultations were direct (in person/online meeting) or indirect (written reports). Direct consultations typically included short presentations/input, followed by discussions to reach a consensus opinion. Expert deliberations drew on expert opinion, reports, pre-prints, and peer-reviewed studies. Multi-disciplinary exchange was valued but faced time constraints; opinions differed on whether a successful multi-disciplinary exchange was achieved. Reflections: Committee members were aware of the limits of their advisory role but occasionally struggled with the political nature of the work.Conclusion German policy-makers continued to involve ad hoc advisory committees after the first year of the pandemic. Where it was achieved and meaningful, multidisciplinary work was perceived as valuable. Political decisions deviating from expert advice required justification under certain circumstances. https://www.ijhpm.com/article_4909.html Background Reducing low-value care (LVC) remains a significant challenge in healthcare systems, despite efforts for de-implementation. To facilitate de-implementation payers may use provider Audit & Feedback (A&F). This study aims to examine trends in LVC following a payer-initiated A&F program, and to explore whether this association varies across hospital payment models.Methods Multilevel logistic regression was used to examine the trend in LVC in hospitals, its correlation with an A&F intervention, and whether this varied with payment models including fee-for-service (FFS), global budget (GB), cost ceiling (CC) and gradual tariff (GT). To assess this, we used hospital level claims data from a large nationwide Dutch health insurer on 70 hospitals in the period 2017-2022. The primary outcome was the yearly proportion of LVC per hospital. Independent variables were time, market share and payment models. We hypothesized that payer-initiated A&F had a stronger impact in hospitals were the payer had a larger market share, and that the effect would be stronger still for hospitals with financial incentives to reduce production.Results LVC showed a small, but significant decline over time (odds ratio [OR]: 0.98; 95% confidence level [CI]: 0.98-0.99). LVC tended to be higher in hospitals where the payer had a higher market share (OR: 1.03; 95% CI: 1.00-1.05). The CC model was associated with an increase in LVC (OR: 1.11; 95% CI: 0.99–1.03). The other payment models were associated with a decrease in LVC. The FFS model exhibited the smallest reduction in LVC (OR: 0.98; 95% CI: 0.98-0.99), and the GT model (OR: 1.01; 95% CI: 0.99-1.03) showed similar patterns in LVC. The GB model was associated with the largest reduction in LVC (OR: 0.94; 95% CI: 0.91-0.97).Conclusion By itself A&F did not clearly contribute to the decline of the proportion of LVC; combined with volumeconstraining financial incentives, it was associated with larger reductions. https://www.ijhpm.com/article_4911.html Background Rising demand for rheumatology care strains referral pathways between primary care and specialist services. We evaluated whether a virtual interconsultation (VIC) program, an asynchronous e-consult system integrated into the electronic health record (EHR), improved referral efficiency for new patients and generated net societal cost savings in a public health system.Methods We conducted a retrospective study of 12 213 VICs (10 181 patients) submitted from primary care to a tertiary rheumatology service between January 2021 and June 2022. Extracted EHR data included demographics, referral reason, delay time (submission to specialist response), resolution time (minutes per case), and outcomes (virtual resolution vs. in-person referral). Referral efficiency was assessed by the proportion of referrals resolved without an in-person visit and time to specialist response. Descriptive and comparative analyses used Mann–Whitney U, chi-square, and student’s t tests. The economic evaluation used a cost-avoidance micro costing approach from a societal perspective. Robustness of the economic evaluation was assessed through one-way sensitivity analyses, probabilistic Monte Carlo simulations (>100 000 iterations), and threshold analysis (ie, the minimum virtual resolution rate at which the program achieves breakeven).Results Patients were predominantly female (69%), mean age 54.8 years. Median specialist response time was 53.5 hours (interquartile range [IQR]: 20.6–122.3) and median resolution time 3.2 minutes (IQR: 1.6–8.6). Overall, 41.4% of referrals were resolved without an in-person visit. The program generated net societal savings of €206 280 over 18 months in the deterministic base case; the probabilistic analysis yielded a mean of €200 540 (95% credible interval: €142 289–€261 316) and a 100% probability of net savings. Absenteeism was the principal economic driver (highest Spearman correlation with net savings in Monte Carlo simulation, r = 0.92). The breakeven virtual resolution rate was 5.6%.Conclusion Integrating VICs into routine rheumatology referral pathways improved referral efficiency and produced substantial societal cost savings. These findings support scaling EHR-integrated VIC programs across publicly funded health systems to optimize specialist resources and enhance access to care. https://www.ijhpm.com/article_4910.html Background Childhood cancer poses significant public health challenges globally, with survival disparities between high-income countries (HICs) and low- and middle-income countries (LMICs). In response, the World Health Organization (WHO) launched the CureAll initiative to strengthen childhood cancer care. Despite being a HIC with a national oncology network, Chile faces fragmentation and unequal resource distribution similar to challenges in LMICs. The country recently introduced the role of gestores oncológicos, inspired by international health navigator models, to support patients and families through care coordination. This study describes the implementation of health navigators in paediatric and adolescent oncology in Chile from the perspective of healthcare professionals and health navigators, emphasising barriers and enablers to introduce this role in healthcare.Methods A qualitative multiple case study was conducted through 30 semi-structured interviews with health navigators and healthcare professionals from public hospitals across Chile. Participants were purposively selected to capture diverse experiences. Interviews were analysed using content analysis, supported by triangulation and reflexivity to ensure rigour.Results Barriers to implementation include structural issues, such as the lack of a national role definition and resource limitations, and team dynamics challenges linked to poor integration into clinical teams. Enablers included team openness to new roles and proactive strategies to introduce the navigator within the team, as well as individual qualities of navigators such as initiative, communication skills, and prior experience in paediatric oncology. Participants recommended that health navigators be full-time management roles focused exclusively on paediatrics. Key competencies include leadership, empathy, coordination, and organisational skills.Conclusion Implementing health navigators aligns with the CureAll strategy by improving care coordination and system responsiveness in paediatric oncology. This experience in Chile highlights how barriers, particularly at the team dynamics level, can be addressed through communication and role clarity, offering valuable insights for other Latin American countries pursuing similar models of care. https://www.ijhpm.com/article_4912.html Background Robotic-assisted radical prostatectomy (RARP) has become the dominant approach for prostate cancer surgery, replacing open and laparoscopic procedures. However, whether the introduction of robotic surgical systems has increased the overall number of radical prostatectomies (RPs) remains unclear, particularly within social health insurance systems.Methods We conducted a nationwide longitudinal observational study using hospital-level data from Japan between 2016 and 2023. Hospitals performing at least one RP annually and reporting complete data on robotic surgical system status and RP volume across the study period were included in the primary analysis. The primary outcome was the annual number of RPs per hospital. Using a staggered difference-in-differences (DID) design, we compared hospitals that adopted robotic surgical systems with hospitals that had not yet adopted them and estimated the association between adoption and annual hospital-level RP volume.Results A total of 288 hospitals were categorized as 189 previous adopters, 77 new adopters, and 22 non-adopters. New adopters demonstrated a sustained increase in RP volume, rising from 2608 procedures in 2016 to 4371 in 2023, whereas RP volumes among previous adopters and non-adopters remained stable. Compared with hospitals that had not yet adopted robotic surgical systems, adoption was associated with an increase of 17.4 RPs per hospital per year (95% CI, 10.7 to 24.1). No significant differences were observed between groups during the pre-adoption period, consistent with the parallel trends assumption.Conclusion In Japan’s social health insurance context, adoption of robotic surgical systems was associated with a significant and sustained rise in RP volume. These findings highlight the need for further research to determine whether the observed increase reflects changes in patient selection, referral patterns, clinical appropriateness, or other mechanisms, as well as the associated clinical and economic implications. https://www.ijhpm.com/article_4833.html Efforts to reduce the healthcare sector’s carbon footprint and greenhouse gas (GHG) emissions have brought increased attention to the adoption of the circular economy (CE) in recent years. These efforts aim to lower carbon-intensive products while improving efficiency, waste reduction, and healthcare resilience. Soares et al conducted a scoping review examining CE applicability in healthcare and identified strategies to enhance its implementation. In this commentary paper, a novel abstract text mining (ATM) approach is introduced as a complement to the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Using this approach, the search terms employed by Soares et al were expanded, article abstracts were extracted, and scope areas were mapped with the assistance of a well-established machine learning technique—latent Dirichlet allocation (LDA) topic modeling. Comparison of the ATM results with those reported by Soares et al revealed three additional scope areas: alternative treatment pathways, pharmaceutical footprint reduction, and the utilization of emerging technologies. https://www.ijhpm.com/article_4834.html This commentary draws on findings from Hoogervorst et al1 to underscore the urgent need for internationally coordinated medical device registries, addressing the fragmentation and inconsistency currently limiting their utility in Europe. It advocates for registries governed by academic specialty societies to ensure scientific integrity, transparency, and clinical relevance. Such registries can significantly enhance post-market surveillance, support regulatory compliance and accelerate real-world evidence (RWE) generation. The importance of standardized data collection, regular outcome reporting, and contributor recognition to foster engagement and improve data quality is highlighted. By complementing randomized controlled trials (RCTs), registries can detect rare adverse events, inform clinical guidelines and drive innovation. Actionable recommendations for governance, data harmonization and interoperability are given, emphasizing that now is the time for academic societies to lead this transformation for the benefit of patients and healthcare systems globally. https://www.ijhpm.com/article_4835.html In a world still grappling with exploring the underlying dynamics of challenges confronting human resources for health (HRH), how must the HRH research and planning ensue in conflict-affected settings (CAS)? Onvlee and colleagues undertake a scoping review to respond to this important question, using the World Health Organization’s (WHO’s) Health Labour Market (HLM) framework, to leverage upon available evidence. This commentary appraises the conceptual and methodological contributions of the review, while questioning the suitability of HLM to analyse HRH challenges in disrupted health systems. It argues that CAS-specific HRH planning exacts frameworks and approaches more attuned to political economy, contextual fragility, and structural inequalities, which shape healthcare workers’ vulnerabilities and responses in CAS. The commentary identifies five gap questions for future scholarship, calling for intersectionality-driven, politically informed and context-specific research approaches for HRH evidence, transcending supply and demand framing of HRH, to inform HRH policies in conflict-affected and fragile settings. https://www.ijhpm.com/article_4839.html The review stands out for its methodological rigour, clear results, and frank recognition of its limitations. However, the picture proposed by it is incomplete. Two aspects of great consequence are discussed in this commentary as a complement to the review. First, the political agency of human resources for health (HRHs) must always be considered. Among them, many take sides in a variety of roles, overt or not, as militants, activists, supporters, and researchers. Second, without including the informal practices adopted by HRH to survive and deliver in hostile environments, the health labour market cannot be understood. Arguably, these two key dimensions were not prominent in the review because the HRH literature prefers to focus on formal technical aspects easier to study and more likely to be published. Some of the reasons behind their neglect are suggested by this commentary, which concludes with a few remarks about how this drawback might be corrected. https://www.ijhpm.com/article_4850.html Attacks on healthcare are increasing globally, often with impunity and limited accountability with profound impacts on healthcare workers, the populations they serve and the wider health system, with effects that last well beyond the end of hostilities. Healthcare workers face impacts both on their personal and professional lives, with additional strains on their families which can lead them to emigrate, even where they may hold idealistic resolve to remain. This exodus (as well as the killing or detention) of their colleagues, places strains on the remaining healthcare workers and health system at a time when needs are at their highest. The cessation of such attacks, the naming of perpetrators and enforcing legal accountability are essential. To mitigate the long-term impacts on the health system, policies which build resilience into the production, distribution, retention, and demand components of health labour market (HLM) dynamics must be implemented in ways which are contextualised and dynamic. https://www.ijhpm.com/article_4858.html Hoogervorst et al systematically reviewed European cardiovascular and orthopaedic medical device registries to assess their preparedness for regulatory decision-making. The authors found high heterogeneity between data sources, limited transparency, and incomplete patient/procedure data, hindering cross-registry comparisons and regulatory reliability. Despite these limitations, registries remain essential for post-marketing surveillance, as exemplified by the case of “Metal on Metal” hip implants. In this commentary, we highlight emerging or ongoing initiatives focused on improving real-world evidence for medical devices, such as the UK’s Medical Devices Outcomes Registry (MDOR), which seeks to address current limitations by developing a centralised database with linkage to electronic health records (EHRs). Parallel initiatives, including Sentinel, Data Analytics and Real-World Interrogation Network (DARWIN EU®), National Evaluation System for Health Technology (NEST), and Guidance and Tools for Real-World Evidence Generation and Use for Decision-Making in Europe (GREG), seek to strengthen real-world evidence through common data models (CDMs) and federated analytics. Specifically, NEST and GREG focus on enhancing real-world data methods and guidelines for medical devices and drug-device combinations. Overall, all these initiatives represent major progress towards more robust and transparent systems for medical device surveillance. https://www.ijhpm.com/article_4859.html Karami and colleagues’ scoping review proposes a conceptual framework for age-friendly health systems based on Van Olmen’s 10-element model. The scoping review mapped existing literature on health service delivery for older adults using Arksey and O’Malley’s methodology. They generated a framework that prioritizes person- and family-centered care to reduce harm, improve satisfaction, and enhance value. Key components include strong governance, trained multidisciplinary teams, integrated service delivery across settings, and active involvement of older adults and caregivers in decision-making. The framework aligns with existing age-related models like PRISMA (Program of Research to Integrate the Services for the Maintenance of Autonomy) and the Universal Model of Family-Centered Care. Future research should focus on operationalizing and implementing core components of Karami’s framework. Co-design is an emerging methodological approach used to develop models of care. It can be used to formally engage older adults, families, and professionals to operationalize core components of Karami’s framework with the goal of improving health service delivery for our aging population. https://www.ijhpm.com/article_4867.html Global geopolitical conflicts, pandemics, the climate crisis or rising inequities within and between countries alongside other intersecting crises all impede the pursuit of healthier societies. This commentary highlights gaps in how framing and measurement approaches reflect narrower biomedical conceptualizations of health. These gaps also relate to whether and how power is analysed, and how interventions that contribute to the (re)building of healthier societies are designed, implemented and evaluated. Dominant measurement approaches in health that prioritize individual measurement of problems and solutions at the expense of whole-of-society intersectoral interventions, and their governance are among some of the reasons. More holistic and explicit measurement equity and well-being (as opposed of disease) are required. Theory-informed research that interrogates values, social norms and ideologies, power asymmetries and that centres the study of complex context-sensitive policy and program interventions should inform future inquiries. https://www.ijhpm.com/article_4902.html This commentary examines Agudelo-Hernández and Giraldo-Álvarez’s article as an important contribution to intercultural mental health policy in Colombia. The study illustrates how coproduction can move beyond consultation by translating community meanings of mental health into a territorial route with political relevance and administrative uptake. However, this achievement should be understood as an initial step rather than evidence of full epistemic transformation. Using Colombia’s Indigenous Intercultural Health System (Sistema Indígena de Salud Propia e Intercultural, SISPI) as a policy lens, we argue that intercultural implementation requires Indigenous decision-making authority, protection of ancestral knowledge, sustainable financing, and community-defined indicators of recovery, harmony, and collective well-being. Yet transformative effects cannot be assumed in advance. Current documentation on SISPI provides limited empirical evidence regarding operationalization, financing mechanisms, territorial coordination, and measurable outcomes, underscoring the need for ongoing evaluation as intercultural governance structures move into practice. https://www.ijhpm.com/article_4904.html This commentary builds on a policy-oriented understanding of recovery as a co-produced route of well-being, spiritual harmony, and community participation. It examines therapeutic hybridization: the negotiated articulation of biomedical care, ancestral practices, spiritual resources, family support, territorial meanings, and communitybased recovery. Rather than treating these arrangements as informal adaptations or cultural supplements, health systems must govern, finance, evaluate, and protect plural forms of care without subordinating Indigenous knowledge. Drawing primarily on Colombian cases and wider literature on community health systems, cultural safety, and intercultural policy, the commentary proposes six domains of preparedness: governance, care pathways, financing, workforce, clinical safety, and learning systems. The agenda is intended as an adaptable, non-exhaustive framework for settings where plural therapeutic systems already interact and where communities can share authority over design and evaluation. Therapeutic hybridization is therefore presented as a test of whether health systems can redistribute legitimacy, resources, and decision-making authority. https://www.ijhpm.com/article_4836.html https://www.ijhpm.com/article_4864.html https://www.ijhpm.com/article_4875.html https://www.ijhpm.com/article_4878.html https://www.ijhpm.com/article_4885.html https://www.ijhpm.com/article_4900.html https://www.ijhpm.com/article_4899.html https://www.ijhpm.com/article_4916.html https://www.ijhpm.com/article_4830.html https://www.ijhpm.com/article_4832.html https://www.ijhpm.com/article_4838.html https://www.ijhpm.com/article_4841.html https://www.ijhpm.com/article_4843.html https://www.ijhpm.com/article_4851.html https://www.ijhpm.com/article_4854.html https://www.ijhpm.com/article_4880.html https://www.ijhpm.com/article_4860.html https://www.ijhpm.com/article_4869.html https://www.ijhpm.com/article_4884.html https://www.ijhpm.com/article_4889.html https://www.ijhpm.com/article_4891.html https://www.ijhpm.com/article_4892.html https://www.ijhpm.com/article_4901.html https://www.ijhpm.com/article_4908.html https://www.ijhpm.com/article_4913.html https://www.ijhpm.com/article_4915.html https://www.ijhpm.com/article_4848.html https://www.ijhpm.com/article_4866.html https://www.ijhpm.com/article_4883.html https://www.ijhpm.com/article_4905.html