Background
A global threat requiring a re-look at governance approaches
Conceptual framework of analysis: The health policy system and the AMR issue
The traditional approach: Top down power through hierarchy
Democratisation and collaboration as an emergent governance model.
Governance approaches within and across countries
England
Overall health system governance
England | France | Germany | ||
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Governance model
| • National Health Services (NHS): centrally planned health system • AMR: Hierarchical with authoritative pressure of DH | • Central-level governance model based on central government leading and setting directions for the health care system. • AMR: Hierarchical organization with authoritative pressure of the ministry of health and the Regional agency of health | • Federal government with corporate governance and the help of agencies • Wage-related contributions • 16 federal states (Länders) with their own administration • AMR: national and federal | |
How priorities are set for improving actions and standards?
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Who is involved & what is the role?
| • The DH & Care Quality Commission sets targets and puts in place the Outcomes Framework; Providing support, guidance, legislation, and Code of Practice. • NICE: provide clinical guidance. | • Ministry of Health via national agencies: Technical committee (High council of public health), policy group (Cosu Propias), the interministerial committee for health dedicated to AMR • Regional agency of Health: spell out criteria and targets for the provision of care. | • Bundesministerium für Gesundheit (BMG; Federal Ministry of Health) • The Commission of Hospital hygiene and Infection prevention (KRINKO) at the Robert Koch-Institute (RKI) • Possibility of local priority setting by federal states |
What is the evidence base for decision-making?
| • Health technology assessment (rational arguments) | • Health technology assessment (rational arguments) | • Health technology assessment (rational arguments) | |
What are the main strengths
| • Transparency of information to public | • Performance management approach: Emphasis on structural and infrastructural aspects. | • Relatively strong degree of delegated and autonomous decision making. | |
What are the main weaknesses?
| • Difficulties to convert national goals into local practices • National targets led to local anomalies and unsustainable • Patient role not well defined. • Cost-effectiveness analysis studies not available | • Poor cost-effectiveness analysis | • Weak governmental powers. Decisions possibly blocked by nongovernmental and could delay the implementation of priorities • Risk of somewhat arbitrary goals by agencies. | |
How is performance monitored?
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By whom?
| • DH and PHE (NINSS): National surveillance. • NHS Improvement (formerly the Monitor): Intervene if concerns about performance of NHS foundation trusts. • Care Quality Commission: Inspections and assessments of NHS (foundation) trusts regarding national objectives. | • Ministry of Health: mandatory indicators with public reporting. • High Authority of Health (HAS): hospital certification. • Public Health of France and 5 interregional coordinating centres: Voluntary surveillance (RAISIN) for benchmarking. | • IQTIQ: Federal institute for quality management, quality report each year on federal level (formerly AQUA institute). • National Reference Centre for Surveillancce (Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen, NRZ). Funded by the BMG, Its activities led to the creation of a national nosocomial infection surveillance system entitled Krankenhaus-Infektions-Surveillance System (KISS). |
How and what are the main strengths and weaknesses?
| • Performance management approach: mandatory indicators with public reporting. Penalties and fines. • Empower patients. • Creation a culture of fearfulness and open up the possibilities of gaming. • Tunnel vision. | • Performance management approach: mandatory indicators with public reporting. • Tunnel vision. | • Mandatory for hospitals to survey nosocomial infections in high-risk areas (neonatal ICUs) and to record emerging multi-resistant nosocomial pathogens. • Nationwide surveillance of nosocomial infections, multi-resistant nosocomial pathogens and alcoholic hands rub consumption in Germany. | |
How is accountability for performance ensured?
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How are the accountability mechanisms in place linked to the health system’s broader governance structures?
| • Direct incentives through managerial control. • Financial pressure on contracts. • Public release of performance data, informed by goals and priorities, and serving a meaningful accountability process. | • Direct incentives through managerial control. • Public release of performance data, informed by goals and priorities, and serving a meaningful accountability process. • Financial penalties for not reporting data | • Statutory and voluntary accreditation schemes, at the organizational and practitioner level, and the freedom of patients to choose provider. • Confidential reporting of surveillance data |
Are the mechanisms effective?
| • Increasing pressure for hospitals to produce and file plans for control activities with health authorities. • Increasing tendency for hospital and boards to be subject to audit. • Strong accountability structure in hospital trusts. | • No strong accountability structure. | • Weak governmental accountability. | |
To what extent are the three components aligned? | • Broad national goals must translate into achievable local targets. • Possible conflict between national and local priorities. | • Broad national goals must translate into achievable local targets. • Possible conflict between national and local priorities. | • Lack of capacity and coordination, technical difficulties. • Capture by powerful vested interests. |
Governance for prevention of AMR in healthcare settings
France
Overall health system governance
Governance for prevention of AMR in healthcare settings
Germany
Overall health system governance
Governance for prevention of AMR in healthcare settings
Convergence and divergence of approaches across the countries
Network governance
Drivers for governance changes for AMR prevention | Mechanism for change | New perspective on AMR prevention governance | Objective | Suggested actions towards the new perspective governance for AMR prevention |
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Complexitya | Diffusiond | Network governance | Create a new academic/industrial/biotech skills mix based on systems thinking and complexity science. | Build inter-sectoral training in cooperation with schools of infectious disease, microbiology/hygiene, public health, business schools and policy. |
Increased accountability across healthcare and non-healthcare organizations. | Include HCPs, users, citizens and mass media in the governance approach and decision-making via independent agencies or organizations to implement new assessments and accountability frameworks. | |||
Diffusion and shared valuee | Include AMR as a goal at governmental and societal level, as a key component of sustainable development | Engage organizations far beyond those involved in AMR sectors or even health (other ministers such as finance minister, business leaders, users) [2] | ||
Inter-dependenceb | Diffusion | Multi-level governance | Control interactions and promote coherence between sectors by an alignment of priorities | Cooperation among the various levels, e.g. geographical (regions and countries), clinical (primary and secondary care), species (antibiotics in humans/animals/agriculture/wider environment) following the “One Health” concept [61]. |
Sharing information and experience | Pool reports of best and failed innovative practices in working with other organizations, groups, sectors via regular meetings for shared goals at the regional, national level and beyond. | |||
Mixing regulation and persuasion | Promote growing interest in nudge policiesf | Monitoring progress through a mixture of hard and soft governance mechanisms to engage for AMR. | ||
Co-productionc | Diffusion | Adaptive governance | Transparency | Users, public and private organizations must work together to define new indicators for monitoring change and progress in AMR with new measures, shared for all parties and accessible to the public. |
Flexible and adaptable systems approaches with self-organization and decentralized decision | Create a dedicated structure to assess and monitor governance at the local, national, and international level, to adapt governance mechanisms to innovations (i.e. new mode of communication). Cybernetic approachg utilizing communications and information for guidance and control. | |||
Democracy | Participatory governance, e-governance | Empower and involve users; public accountability; and strengthen health literacy | Dialogue with HCPs, users and citizens on AMR through new information and communication technologies (e.g. social media); open-data initiatives, tracking systems, digital and mobile approaches to strengthen health literacy. | |
Preparedness | Anticipatory governance | Finding solutions for a better future adaptation | Development of simulation models including feedback loops. Creation of new forecasting tools for anticipatory governance, shared for all actors and fields to deal with emergent events. |