Although research misconduct is responsible for most retractions in health and life sciences from authors affiliated with Brazilian institutions, there are few studies evaluating retraction notices and research misconduct in the country. Understanding the form of research misconduct may share light on the weaknesses and strengths of individual, organizational, and structural factors toward the implementation of a research integrity culture. This review on policies and practices aims to access the available information from research integrity offices and the guidelines from Brazilian funding institutions and universities who were involved in retractions in health and life science publications based on a previously published systematic review. Additionally, we summarize the available guidelines and policies for research integrity in the country. Additionally, we searched publicly available guidelines and offices for research integrity. In total, 15 institutions were analyzed: five funding agencies and 10 universities. Approximately 40% of the funding agencies promoted local research, and 60% promoted national research. Considering national funding agencies, 66% had the commission on research integrity. Approximately 30% of the universities do not have the official office for research integrity or any publicly available guidelines. Most institutions involved in retractions due to some form of research misconduct. Brazilian institutions involved in publication retractions lack instruments to prevent, supervise, and sanction research misconduct. Institutions of the country have insufficiently developed a system to promote and sustain research integrity practices. Nevertheless, there is a positive movement of researchers who are engaged in the investigation of research integrity, policy creation and training. This study emphasizes increased influence of Brazilian scientific collaboration and production globally as well as the impact of retractions in medical sciences. In contrast, it addresses the need for clear research integrity policies to foster high-quality and trustworthy research. In 2018, the National Science Foundation  classified countries according to their number of international publications and ranked Brazil at the 11th position, reaching the number 60,147.96 published articles FAPESP, . The couTo foster the quality and reliability of research, academic leaders and institutions started to disseminate research integrity standards. A systematic review was conducted to gather all scientific articles published by Brazilian authors on research integrity , which fosters scientific and technological research and dissemination. Apart from the SRP acting locally, there are national agencies to foment science, such as the Coordination of Improvement of Higher Education Personnel known as CAPES and the Brazilian National Council for Scientific and Technological Development known as CNPq.We analyzed publicly available information of five funding agencies. Of these, 40% promoted local research locally and 60% promoted national research. Considering national funding agencies, 66% had the commission on research integrity and all published some guidelines related to research integrity practices. Still, some documents fail to contemplate principles, research misconduct, regulations, and punitive actions. For instance, CAPES published a declaration anti-plagiarism without mentioning the other aspects of research integrity. However, the institution does not have the original document at its official website. The most active and transparent institution that promotes research integrity and responsible research is the São Paulo SRP (FAPESP). In 2011, the first guideline for research integrity in the country was published by FAPESP, giving this institution a leading position in addressing the topic. In addition, FAPESP advocates for a research integrity culture by requiring support from institutions that benefit from it to regulate the prevention, investigation, and punishment of research misconduct  took place. The event was the result of a postdoctoral research project on research integrity at UFRJ .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Variation in public investments to health, health outcomes, and progress toward universal health coverage across countries is vast and neither economic status nor the knowledge on solutions have borne out to be binding constraints to health improvements. The drivers for universal health coverage go beyond the macro-economic context of a nation, and as pointed out by scholars, are deeply linked with the extent of political prioritization of healthcare. Low public investments to health in India and slow movement toward universal health coverage underline the need for more attention to the political priority accorded to health in the country. While the role of politics in policy reforms has been established by several scholars, this paper seeks to identify the intrinsic motivations or incentives that drive political priority. Drawing on the experience of nine countries, the paper attempts to inform the analysis for countries such as India , on the political incentives for prioritization of healthcare, and how these may be shaped or strengthened. The analysis finds that health care reforms happen in (at least) two stages: the existence and recognition of a national context and a problem, followed by political opportunities and motivations which lead political leaders to address the identified problem. The paper separates motivation as a distinct factor for analysis because, in the absence of strong incentives, not every political opportunity may lead to attention to an issue, and finds that reforms were motivated by a need to gain political legitimacy by an incoming regime, or by its political ideology, or a combination of both. Importantly, political motivation does not always take root in itself, but often driven by external factors and stakeholders who contribute to creating or strengthening incentives for political attention. A greater role from citizens and other actors such as elected representatives, questioning status quo and highlighting the schisms in the social contract between a political regime and citizens may contribute to shifting the source of legitimacy for leaders. The world has made significant strides in health, in eliminating disease and improving health indicators and in committing itself to the Sustainable Development Goals, with several countries aspiring to universal health coverage. However, approximately half of the world's population is still unable to obtain essential health care services, and every year about 100 million people are pushed into extreme poverty globally, because of healthcare-related expenditures  political leaders actively pay attention to health and prioritize interventions needed for progress on health, and (2) political decisions lead to system reforms and programs that address the problem. All of the countries selected had undertaken health reforms and initiated programs to address health related challenges at a specific time.Turkey faced inequities in health outcomes across regions and segments of the population, shortage and inequitable distribution of infrastructure and human resources, and inequitable financing of the health system. These were addressed through the Health Transformation Plan which introduced a single purchaser model to address these inequities;Thailand had an uninsured population of 30 percent, with significant private expenditure on health, leading to the introduction of a tax financed program (the 30 Baht scheme) providing health care at the point of service for a co-payment of 30 Bahts;In Argentina, the economic crises led unemployment resulted in a large proportion of the population losing health insurance cover, and consequently deteriorating health outcomes. This was addressed through Plan Nacer, aimed at increasing coverage of basic services among the uninsured population;A large proportion of Mexico's population, specially the poorest, lacked health insurance, leading to high out of pocket expenditures and catastrophic financial events. Reforms in the form of Seguro Popular were introduced to address the unequal distribution of the financial, physical and human resources in health services;Brazil had different health rights for workers and poor populations working outside the formal economy, which was addressed through a Unified Health System enshrined in the constitution to ensure equal access to health services for all citizens;In Vietnam, out of pocket expenditure on health increased significantly with a shift to a market economy. A state financed health insurance was introduced along with citizens being provided a legal right to health protection;The Philippines healthcare program was not successful in addressing the healthcare needs of its poor due to poor governance and accountability. The PhilHealth sponsored program was extended to focus on the poorest population, with premiums paid for by the government;Indonesia experienced an increased cost of healthcare input and diminishing purchasing power after the financial crisis. A constitutional amendment made the state responsible for ensuring health service provision for all citizens, leading to the national government paying for inpatient services for all poor people;China witnessed a shift to a market based system, resulting in inequalities in health access and increased private health expenditure. A basic health insurance scheme was introduced in response.Second, the country selection was aimed at obtaining a representative sample of diverse economic, political and geographic contexts. On the economic front, countries were chosen from amongst low income, lower middle income, and upper middle income to gauge the interaction of the economic circumstance with the motivation to reform domestic healthcare sectors. The rationale for different economic contexts stems from the need to explore hypotheses pointing to stronger economic contexts being more amenable to the introduction of reforms. The countries chosen represent significantly different economic contexts with per capita GDP ranging from $430.05 to $7,484.49 at the time of initiating health reforms  to examine if and how the political system influences the motivation for and priority to health issues.Geographic regions have experienced economic and/or political transitions: structural shifts emerging from the Washington Consensus, the transition from authoritarian rule in much of Latin America and the Asian financial crisis in South-East Asia, to name a few. These processes shaped the autonomy and priorities of countries in the region. This analysis therefore includes countries across regions, in Latin America, Middle East, and Asia, to examine how the regional contexts influenced the rationale and motivation for attention to health.The study has followed a mixed methodology of extensive secondary literature analysis and a limited set of stakeholder interviews. The secondary analysis focused on specific reforms introduced in the country in the last few decades . It examined contexts pre and post reforms, and combined historical, political, economic and social aspects to trace the trajectory of the processes that led to reforms. Stakeholders interviewedThis paper rests on the basic premise that health care reforms happen in (at least) two stages. This is followed by political opportunities and motivations which lead policy makers and political leaders to address the national context/problem. This paper separates motivation as a distinct factor for analysis because not every political opportunity may lead to sectoral attention, in the absence of strong incentives. Elections, as a political window, underlines this fact, as not every change in political leadership leads to a shift in a sector's priority.The experience across the nine countries analyzed also underlines the influence of other factors and stakeholders, such as civil society organizations, social workers, and activists; social movements; citizen demand; and international organizations, in influencing agenda setting; a role identified by many political economy scholars –14. MuchThe study sought to understand the factors that drive political prioritization of policy reforms, with an emphasis on healthcare. The paper explores motivations to address specific economic and socio-political contexts, and the nature of incentives that move leaders from recognizing a situation to taking action on it. Despite similarities in economic contexts, we examined if, and the manner in which, incentives varied for different leaders.The goals of reducing poverty and inequality or seeking national development or increased growth are seen across several countries. The pathways to these, however, vary and are often built around the perceived incentives by leaders. Incentives could be viewed in different forms; it is precisely this interrogation that led to identifying the foundational motivation for leaders.Buchanan  points tA different pathway is based on ideology, as defined by several political theorists –18, builIn order to understand how these and possibly other pathways influenced the political prioritization of health in these countries, it is important to understand the national and political context in each.At the time of reforms, all nine countries were experiencing high rates of poverty or inequality or both, along with high levels of out-of-pocket expenditures on health. In large part, healthcare reforms were introduced by them to address systemic inequities constraining Universal Health Coverage.At the time reforms were undertaken, Turkey had a Gini coefficient at 0.43, with only 66.3% of the population covered by insurance. The 1990's were characterized by a series of weak and indecisive coalition governments, resulting in unstable and unsustainable economic development, with the country witnessing economic cycles of boom and bust. As a result, Turkey witnessed a contraction in its real GDP during this period, rampant inflation and high rates of unemployment. Inequality increased in the country with the Gini coefficient rising to 0.43 in the early 2000's. Marred by political instability, economic shocks, runaway inflation, rising unemployment, and social discord, successive governments in the 1990's failed to prioritize the health sector, which faced three major issues - inadequate and inequitable financing of the health system, absolute shortage and inequitable distribution of physical infrastructure and health human resources, and inequities in health outcomes, between the deprived eastern areas and the more developed western regions of the country, among the richer and poorer segments of the population, and across rural and urban areas . Inequalities persisted, of which one was access to quality healthcare, reflected through high out-of-pocket health expenditures, one of the major factors that led to the impoverishment of poor households , 26. TheBrazil had a Gini coefficient of 0.61 when it underwent the democratization process in 1988 . At the In Indonesia democratization was ushered in after the Asian Financial Crisis, when the percentage of people living under the $1.90 poverty line (2011 PPP) was as high as 63.2% with out-of-pocket health expenditures comprising 43.86% of total health expenditure. The Asian Financial Crisis of 1997, citizen's protests and political instability acted as a catalyst for the reform in Indonesia's healthcare system. Prior to the crisis (1970–1996), Indonesia's health outcomes were relatively better than other peer countries . Post thLike in other countries in the region, Argentina's health sector agenda was developed in the 1990s at the same time as the country was experiencing “profound economic and social restructuring, along neoliberal lines” , and it Vietnam, being a Communist one-party led state, had an inherent mandate of providing access to healthcare to all its citizens as part of its socialist agenda. Despite this, 37% of the population lived under the $1.90 poverty line in 2002, a year before the reforms were carried out (2011 PPP) . This leIn China, out-of-pocket expenditure was at 64.19% of total health expenditure while 31.7% of the population lived under the $1.90 poverty line, as of 2002, just before the health reforms were implemented (2011 PPP) .As with the economic context, similarities in political context across the nine countries were evident from the political transitions they went through, although the nature and extent of political change was quite different. Some countries witnessed the initiation of a democratic process (such as Brazil and Indonesia), while others merely witnessed a change of political leadership .In Indonesia, the aftermath of the economic crisis led to widespread social unrest and citizen's protests. This unrest was instrumental in forcing the then autocratic ruler, President Suharto, to step down in 1998. While his successor, B.J. Habibie, tried to mitigate the effects of the crisis and increase acceptability to the ruling party by strengthening education, nutrition, and health services for the poorest, these did not prove effective in saving Suharto's party , 35–37.In order to counter Suharto's autocratic policies, multiple student movements had been unified into a political party known as the Indonesian Democratic Party of Struggle (PDI-P party); a party formed by Megawati Sukarnoputri (daughter of former President Suharto) as a government dissent faction in 1998. Although this party did not have an inherent welfarist agenda, they capitalized on citizens' protests against President Suharto. As demands for democratization increased, they highlighted the social ills brought about by the Suharto regime, campaigning on a platform for increased equity, leading to their election to power in 1999. They leveraged focus on social welfare and equity as a political tool to gain legitimacy amongst a public who were already protesting against Suharto's policies. After the electoral success of the party, the Megawati administration amended the Constitution in 2000 to include “the right to receive medical services,” highlighting the state's responsibility in ensuring health service provisions and sought to develop a social security system for all citizens , 38.In Brazil, it was the process of democratization and the promulgation of the constitution, which led to the prioritization of healthcare and priority to the social sector more broadly. Brazil experienced a period of military dictatorship from 1964 to 1989. The last phase of the military dictatorship (1985–1990) marked the process of re-democratization in the country wherein a regime opposed to the dictatorship (Brazilian Democratic Movement Party) came into power (1986), a new constitution was promulgated (1988) and the popular presidential elections were carried out (1989) .sanitarista  movement (discussed in detail in the next section), that Brazil witnessed attention to the health sector. Amidst the economic crisis and democratization in the 1980's, the country witnessed the emergence of healthcare reforms which culminated in the recognition of health care as a right of citizenship and the creation of the public, universal Unified Health System (SUS) enshrined in the Constitution of 1988  implemented well, resulted in electoral success for the AK party over the years; in turn continuing the priority to healthcare, through which the party was able to leverage greater political legitimacy. Over a ten-year period, the percentage of the population satisfied with the healthcare system in Turkey increased from 39.5% in 2003 to 74.7% in 2013 . Public Patton  argues tMexico witnessed the Vincente Fox led National Action Party (NAP) coming into power in the early 2000's after breaking the Institutional Revolutionary Party's (PRI) hold on presidential power for over 70 years. A new party and the political ideology of the health minister, Dr. Julio Frenk, when the party came into power, led to the initiation of health reforms in Mexico, largely termed as a minister driven reform . The minArgentina witnessed one of the greatest economic and unemployment crises in the country's history in 2001, leading to disappointment with the political and economic situation in the country and citizens re-evaluating the presidency of Carlos Menem of the Peronist party in the 2003 general elections .In the run up to the elections, Nestor Kirchner (who won the elections) ran on a center left platform and focused on production and work to battle the legacy of social exclusion bequeathed by the menemista mode' . Upon coIn Thailand, the push for reforms came from the newly elected political party, Thai Rak Thai,—a populist reform-oriented party led by Thaksin Shinawatra—who campaigned on a pro-poor agenda in the lead-up to the January 2001 elections . ThaksinSimilar to Brazil, healthcare professionals came to occupy important positions in the government in Thailand, playing a significant role in pushing UHC on the agenda and ensuring its implementation. Two senior members of the party, including the future Deputy Prime Minister, were members of the Rural Doctor's Society (RDS)—a society formed in 1978 and instrumental in driving healthcare reforms in Thailand (explained in detail in the next session) and strong supporters of universal health coverage. Mor  argues tIn the Philippines, the Benigno Aquino III presidency (2010–2016) followed the Gloria Macapagal Arroyo regime (2001–2010). The latter saw high inequalities in healthcare, reflected through high out-of-pocket health expenditures and impoverishment of poor households. Despite healthcare being free for poor households during the Arroyo regime, poor implementation led to inefficiency and corruption in the public healthcare systems , 26. TheThe conditions during the Arroyo regime changed significantly with the Beningo Aquino III administration undertaking several health reforms to strengthen the roadmap toward Universal Health Care, and the commitment of the Aquino III Presidency was instrumental in establishing a strong social contract with the Filipino people , 55.Healthcare prioritization in China saw a shift in the mid-1970's when it moved from a government led socialist economy to a market economy brought about by the privatization policies of the Deng Xiaoping administration (1978–1991). The shift to the market-based system started in 1978, when the policies of the centrally planned socialist system led to severe underemployment, low productivity, poverty, and famines. The shift to market economy was envisioned as a means to produce rapid economic growth, which also saw its effect on the health sector with greater push toward individual self-reliance. This change resulted in a significant reduction in government regulations within the healthcare sector which led to increased mark-up on drugs, and re-orientation of public hospitals into for-profit entities. These health practices led to health inequalities between rural and urban residents, poor quality of healthcare and increasing private health expenditure. The high healthcare costs and lack of insurance coverage prompted high public discontent and protests, picked up through media coverage .At the same time, two other policy windows contributed to the change—the SARS outbreak and a transitional political leadership . The tumWhile healthcare is one of the core agendas of China's communist party ideology as part of its social welfare system, the healthcare reforms that took place in 2003 were influenced in large part by a need for the Chinese Communist Party to demonstrate good governance, as also a means to control the citizens' protests and reduce focus on the state's failure to provide access to quality healthcare. Thus, external pressures, citizen demand as well as the ill-effects of the SARS pandemic prompted the Hu-Wen government to provide basic insurance programs as well catalyzed the change for the 2009 reforms, which led to the establishment of universal healthcare for all Chinese residents , 56.Our analysis of select countries suggests that while political transitions have been a common factor in shifting priority to social policy, it is not a necessary condition. The experience of Vietnam points to the initiation of healthcare reforms even in the absence of political transitions.Vietnam, being a one-party led communist state, had an inherent mandate of providing access to healthcare to all its citizens as part of its socialist agenda , though,The social context, in terms of citizen demand, social movements and the influence of policy actors constitutes the third pillar, which not only brings visibility to the issue but establishes it as a key national agenda. Agenda setting and political prioritization are influenced by various factors. Policy actors—including NGOs, civil society organizations, social workers and activists—can be key in influencing agenda setting and policy choice . Similarsanitarista  movement had long advocated for more equitable health reforms and played a critical role in institutionalizing principles of universalism in the 1988 constitution, following the transition to democracy in 1985, and for the 1990 Unified Health System Law”  law which mandated social security protection for all Indonesians, saw several organizations such as labor unions and NGOs coming together to form the Social Security Action Committee (KAJS) to ensure that the BPJS funds were directed into health insurance for all . CitizenPolitical attention to health in Thailand can be traced back to the times of King Rama VI (1910-25) which saw early investments in health system infrastructure . By the An analysis of the nine countries reveals that healthcare reforms happened in the backdrop of an economic system marred by high rates of poverty and/or inequality, leading to high out of pocket expenditures on healthcare. At the time of reforms, most countries witnessed growth contraction, unemployment, inequality and citizen dissatisfaction with healthcare access, high rising costs of healthcare emerging from privatization of healthcare in some cases. Regional contexts were contributing factors: the Asian financial crisis for Thailand and Indonesia, the collapse of Soviet Union for Vietnam, and the transition from autocratic regimes in Brazil and Philippines.Elections and the formation of a new government proved to be the catalyst and the momentum for reform in most countries. Turkey, Thailand, Mexico, Argentina, Philippines, China, Indonesia and Brazil, all witnessed the start of reforms when new governments came into power. Whether political transitions were a result of a democratization process or a change in leadership resulting from elections, our analysis found that healthcare reforms were invariably motivated by a need to gain political legitimacy by the incoming regime, or motivated by the political ideology of the new regime, or a combination of both.Where a new regime was yet to establish its legitimacy with the voter base and form a social compact with citizens, the motivation was borne out of seeking political legitimacy through addressing a key and felt need amongst citizens; reaping electoral benefits from political capital formed. Seeking political legitimacy was a driving motivation for reforms in Turkey, Philippines, Indonesia, Brazil and China, all of which witnessed new political regimes in power. The A K Party in Turkey prioritised healthcare to differentiate itself from the previous Political Islamist movement and to gain credibility as a new party. Aquino III sought legitimacy when he came to power in Philippines, through countering the corruption ridden regime of his predecessor and simultaneously building on his mother's legacy  by focusing on social policy. The PDI-P party in Indonesia, that replaced the Suharto rule, sought political legitimacy through responding to citizen protests against Suharto and focused on social policy and equity, areas where the Suharto regime had failed. In the case of Argentina, Nestor focussed on a centre left campaign to distinguish himself from Menem and implemented social equity programs including healthcare reform upon coming into power. China, despite being an authoritarian regime, felt the need for political legitimacy for the new leadership, given large citizen protests against rising healthcare costs; leading to the prioritization of healthcare. Reforms in China were influenced by both: a need to seek political legitimacy, as also a response to an ideology of social welfare and equity.On the other hand, certain new political regimes came into power with a foundational ideology of social welfare and equity, which formed the motivation and base for health reforms, as revealed by the experience of Brazil and Argentina. The motivation in Thailand was driven by a combination of the ideology of the network of bureaucrats who had for long engaged with healthcare, and the new political regime's need to seek political legitimacy through improved healthcare. In the case of Mexico, the ideology of the Health Minister played a key role in the prioritization of health. Vietnam was the outlier, where the introduction of reforms did not align with a new political regime. However, even then, it was the political ideology of social equity which was the driving force for the existing regime, leading to the prioritization of healthcare in the country.The achievement of tangible improvement in benefits offered legitimacy to political regimes in two ways. One, it contributed to the legitimacy needed to sustain the government itself and second, it provided the legitimacy to undertake further reforms. This was then a reinforcing cycle, where key reforms, well implemented and effective in addressing critical needs, sustained governments, which in turn contributed to sustaining reforms. The experience of Turkey illustrates this well. Well implemented reforms fuelled expectations from citizens , which led to increased citizen demand, creating the space for further reform.While the countries examined in this paper point to ideology and/or the need to establish legitimacy as a driving force for attention to health and the initiation of reforms, the obvious question that emerges is what happens in contexts where neither of these can be a driving factor? It is possible that in some country contexts, neither political ideology nor political legitimacy is centred around issues of social equity. Would that then suggest the absence of political motivation for attention to social sectors in such cases? It does not have to, as our analysis of select countries reveals that the political motivation outlined above does not necessarily take root in itself. On the contrary, it is often driven by other factors and stakeholders such as varied policy entrepreneurs and advocates, who contribute to creating or strengthening incentives for political attention. The experience of some of the countries studied shows that internal and external advocacy played a key role in ensuring that key issues got highlighted and identified as those needing attention.Sanitarista movement and Rural Doctor's Society) played an important role in the prioritization of healthcare, by bringing visibility to a felt need and positioning health as a high-level priority. The voice of citizens and the role played by bureaucrats combined to create the context where health was viewed as a potential means to political legitimacy. In countries such as China, despite the ideological position on social welfare, citizen protests contributed significantly to the political regime viewing health as a pathway to strengthening legitimacy. Similar citizen protests were seen in Indonesia.In the case of Brazil and Thailand, social movements and long-standing networks of doctors and public health professionals  was introduced in 2005, soon after a new government, the Congress led UPA (United progressive Alliance) government came to power in 2004. The coalition government forged a Common Minimum Program, focusing on the needs of India's poor. The UPA government's focus on addressing not only basic unfulfilled needs of India's citizens but also their rights to human development, translated into a social equity oriented politics, in contrast to the prior regime's politics, which promoted an “India shining” narrative.The National Rural Health Mission, a key reform in the health sector, was introduced soon after the formation of the UPA government, as did a health insurance scheme for the poor, Rashtriya Swasthya Bima Yojana (RSBY). These, combined with other social policy measures introduced during the UPA regime, such as employment, food and education guarantees, all of which were, could be seen to emerge at the confluence of the UPA's rights based ideology and their need for differentiating themselves from the previous regime and seeking political legitimacy through addressing structural needs; specially in the context of the criticism targeted at the previous ruling regime for ignoring social welfare and equity issues.A second significant reform in India took the form of a tax funded health insurance for 40 percent of India's population, in the form of what is now called PM-JAY, introduced by the BJP government during its 2014–2019 term. While this could be viewed as a mere expansion of the previous insurance program (RSBY), the context for the new program was one where several states had already launched state specific insurance programs, and the national government did not have a health program that conveyed its commitment to social policy. It could be arguedImportantly, neither of these reforms took place in themselves. Other stakeholders played a key role: civil society in the case of the UPA regime and bureaucrats in the BJP case. The need to build an identity distinct from the previous government, prompted UPA leaders to engage extensively with civil society leaders , which contributed to the setting of a social equity agendaIn conclusion, for contexts where neither political ideology nor the social contract with citizens centres on notions of social equity with health as a key element, a greater role from citizens and other actors, questioning the political legitimacy of the regime in power and highlighting the schisms in the social contract between the two may contribute to shifting the source of legitimacy for leaders. Voices, through electoral and other platforms, combined with clear pathways to addressing felt challenges, have a role to play in building a deeper social contract and accordingly shifting the incentives of political leaders.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.SV led the study, conceptualized the study, directed it, reviewed multiple versions, provided edits and changes, and write sections of it. SS and SM conducted desk research and prepared drafts. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems.Redistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains.Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs’ self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries.Countries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs’ working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation. Primary care practices adapted to the changed patterns of morbidity and patients’ increasingly complex health care needs by, for example, expanding the services offered and the skill-mix of health care workers involved  strongly differ between countries , prescribing drugs and referring patients, more technical procedures , and health promotion activities   European countries, conducted in 2012. We will first describe the extent of task shifting in these countries. Next, to understand potential barriers and facilitators to task shifting, we will analyse the associations between the extent of task shifting and a number of characteristics of the GPs and their practices and the health care systems in which they operate.et al., individual GPs and other professionals involved ;level 1: the practices they work in ;level 2: the country or health system .level 3: the Based on theories on readiness for change in general Weiner,  and on sInfluences at different levels may independently increase or decrease the readiness for task shifting, but they are also expected to influence each other. Commitment of care providers, for instance, may be impacted by the experienced urgency of change, and their ability to bring about change depends on the resources available in the primary care practice .individual GPs and practice assistants/nurses ;level 1: practice environment ;level 2: the country and health system context .level 3: the Likewise, potential barriers and facilitators for task shifting can be identified at these three levels:To identify the barriers at patient, GP and practice level, multilevel data are needed at the professional and practice level. For level 3 barriers, data are needed at the health system or country-level influencing policies and policy options. As described below, the QUALICOPC study provides the required multilevel data to analyse the impact of these barriers in an integrative manner.We will test the following hypotheses:At the level of GPs:More innovative GPs have shifted more tasks to practice assistants/nurses.et al., Task shifting can be considered an innovation in the work organisation of general practices. We assume that younger GPs are more willing and capable to adopt innovations in their practices, as shown in the literature about the uptake of electronic health records (EHRs)  and three non-European countries . In each country, a sample of around 220 GPs completed a questionnaire, except for small countries  where this was around 75. In most countries, a random sample of GPs was invited to participate. In countries without a national sampling frame, alternatives were sought as close as possible to a random sample. Only one GP per practice participated in the study. The participation rates varied from less than 10% in Austria and Belgium to over 70% in Malta and Spain, with an average of 30% , and ‘no’ or ‘not applicable (no nurse in my practice)’ (counted as 0). Therefore, the composite score ranges between 0 and 4. We combined the categories ‘no’ and ‘not applicable’ .As a first indicator for innovativeness, we used the number of EHRs applications used by GPs ; and other professionals .Information on the practice location was derived from the answer on the question: How would you characterise the place where you are currently practising? (possible answers: big (inner)city, suburbs,  town, mixed urban–rural and rural). The practice composition was measured as the estimated proportion of elderly people; people from ethnic minorities; and deprived people .In the absence of direct information to operationalise barriers or facilitators in the institutional environment of primary care practices, we assume that the institutional environment is more facilitating when it is more usual to have support staff in the practice. We therefore aggregated the number of practices without receptionist/assistant, practice nurse, home care nurse or nurse practitioner to country level.http://databank.worldbank.org/data/home.-aspx-For demand and supply of primary care, we used the following three indicators. Firstly, population ageing, that is, the increase in the percentage of the population over 65 years old between 1993 and 2012 retrieved from World Bank data .et al. Is there professional training specifically for PC/GP practice nurses? (Yes/no)Do national associations or organisations of PC nurses exist in this country?(Yes/no)Is a professional journal on PC nursing being published in this country? (Yes/no).A scale consisting of the following indicators derived from the PHAMEU database  at GP and country level to describe the clustering of task shifting by GPs. The country-level variances were used to construct a caterpillar plot to show the differences between countries on the task shifting scale. The GP, practice and country variables were included in a multilevel linear regression analysis with the scale value as dependent variable.P < 0.05 as the boundary value for statistical significance.For the GP and practice characteristics, we used list-wise deletion of missing values. As the number of countries is relatively small for statistical analysis, we included country-level variables one at a time. We use empty model to calculate the clustering of the dependent variable within GP practices and countries;adding GP and practice variables and average number of working hours per country;average number of working hours dropped and country variables (one-by-one) added.The modelling strategy consists of the following steps:Analyses were performed in MLwiN, version 2.30.Ethical approval for the QUALICOPC study was acquired in accordance with the legal requirements in each country  which is 44% .Regarding the country variables, the percentage of practices without support staff is negatively related to task shifting, while nurse prescribing is positively related to task shifting by GPs. The first shows the strongest relationship and explains 73% of the country variation in task shifting by GPs .In 2012, task shifting in primary care to nurses/assistants was very common in the 34 countries included in our study. The extent of task shifting by GPs differs between countries with England on the high end of the distribution and Luxemburg on the low end. We tested a number of hypotheses related to GP, practice and country characteristics. The following hypotheses were (partly) confirmed. First, GPs that use more EHR applications in their practice more often shifted tasks to nurses or assistants. We used computer use as an indicator for innovativeness (hypothesis 1). GPs who work less hours (while controlling for the average number of working hours per country) as an indicator for part-time working had more often shifted tasks (hypothesis 2). Hypothesis 4 about patient populations with higher demands for care and more complex care needs was only partly confirmed – only in practices with above average deprived persons task shifting was higher; however, the results for practice location varied and there was rather less task shifting in inner city practices. Hence, it appears that increasing (complexity of) demand for care and (expected future) shortage of GPs are not systematically related to task shifting. Remarkable is the fact that older GPs, contrary to hypothesis 1, have shifted task to a larger extent than younger GPs.Two of our hypotheses at country level were confirmed. In countries where it is less common to have practice support, task shifting occurs less in the practices that have support staff to shift tasks to. We have used this variable as an indicator for an institutional factor in the absence of direct information on barriers or facilitators in the institutional environment (hypothesis 5). Second, in countries where nurses have prescribing rights, GPs have shifted tasks to nurses/assistants to a greater extent. We have used this as an indicator for less strict professional boundaries (hypothesis 7).et al., Our first confirmed hypothesis related to innovativeness  demand for care and (expected future) shortages of GPs on task shifting were not systematically confirmed. Yet, these developments have further progressed in many countries, with a strong impact on the workload and availability of GPs for which task shifting can be among the solutions. This makes insight into barriers and facilitators to task shifting important to pave the way for new initiatives to unfold. Task shifting from GPs to nursing and support staff can be considered as one of the first emerging forms of task shifting. However, also other professionals play increasingly important roles in the strengthening of primary care organisation. Several countries invested in task shifting from GPs to pharmacists. In Canada, New Zealand, the US and the UK, pharmacists have prescribing rights with varying levels of responsibilities. In the Netherlands, experiments with pharmacists as clinical care provider in primary health care teams and employee within a GP practice show promising results in terms of improved safety and effectiveness of pharmacotherapy in primary care, including a reduced risk of medication-related hospitalisations compared to usual care . This is particularly relevant for the descriptive value of the study, but our hypothesis testing is less sensitive to this. If our data collection could be repeated as of now, we expect to see effects of different changes over time. For example, there is increased acceptance of task shifting by the population, for example, in Germany (Jedro Finally, it should be emphasised that the associations we found cannot be considered as causal associations. Interprofessional relations have a system character and complex feedbacks Abbott, . An implet al., Task shifting by GPs to practice assistants/nurses can be an answer to current challenges in primary care. The extent of task shifting in a country strongly depends on a facilitating institutional environment, as indicated by how common it is to have support staff in GP practices and by prescription rights for nurses. Within countries, task shifting is more prevalent in practices with an innovating attitude, with more support staff and among GPs who work less hours and older GPs. Given the importance of task shifting and its potential for innovation (Van Tuyl


In recent years, there has been an increasing demand for engineering materials that possess good mechanical and thermal properties and are cheap an d environmentally friendly. From an industrial and academic point of view, there is a need to study the heat conductivity of newly developed polymer composites and the influence of porosity on the insulation performance of polymer composites. Experimental and theoretical studies were conducted on mainly sisal/glass fibre gypsum composites with different fibre volumes . The outcomes from the theoretical model in ANSYS have shown that there is a high possibility to simulate the experimental work and high accuracy for reflecting the experimental findings. Moreover, the results show that natural fibre polymer composites with a high-volume fraction of natural fibres have higher insulation performance than synthetic polymer composites with the same volume fraction of synthetic fibres. Furthermore, the results suggest and support that the improved performance of natural fibre-based composites was due at least in part to the internal porosity of the fibres. This literature reviews the basic science of heat conductivity in fibre polymer composites and natural fibres. Composites are manufactured by combining raw materials in two phases: resin and a reinforcing material. The resin material can be either ceramic, metal, or polymer in which fibres are embedded to reinforce; in the case of polymers, the resins are normally thermosetting polymers. On the other hand, the reinforcing material can be fibrous or in any other form. It is normally synthesised material such as carbon, glass, or aramid fibres. Natural fibres based on wood or cellulose can also be incorporated into a biodegradable polymer matrix producing a new class of composites, termed green composites. The reinforcing fibres provide structural integrity and improved mechanical properties to the composite. Combining the two different phases produces a superior material called advanced fibre reinforced composite.Among the synthetic composites, fiberglass composites hold the maximum market share because of their wide-scale applications. Advanced natural fibre reinforced composites are also investigated to make them competitive in manufacturing cost, performance, and long-term stability ,2,3. TheResearchers have investigated the amount of natural fibre needed to reinforce polymer mortar composites to improve their fracture resistance. However, natural fibre composites are not exposed to tough mechanical impacts such as synthetic fibre composites, which are, to a larger degree, used in high-tech engineering applications such as in the automotive and aerospace industries ,6. In thThe primary objective of incorporating fibrous material into a brittle polymeric matrix is to improve its mechanical properties. Generally, fibre is defined as an elongated discrete piece or a bundle of threads composed of continuous filaments. Fibres which are thin and possess a longer surface-to-volume ratio usually adhere better to the polymer matrix. The arrangement of fibres in a polymer matrix can be conducted in two orientations, quasi-isotropic or orthotropic: in the quasi-isotropic orientation, all fibres are oriented in either single or multiple directions. In the orthotropic orientation, the fibres are oriented in multiple directions . Mechanical properties of the fibre reinforced composite also depend on the orientation. The type and orientation of the fibres depend upon the intended application ,12. The Synthetic fibres  are made from various organic or inorganic materials. Examples of organic fibres include fibres made from ultra-high density polyethene and aramid . Fibres made from carbon and glass are the most widely used inorganic fibres. Their synthesis can be either through mechanical extrusion or by any chemical method. Incorporating such fibres imparts improved mechanical properties to the composite such as high strength and stiffness, but they also add cost when compared to conventional engineering materials. They also pose environmental problems . CompareNatural fibres are those found in nature and can be obtained from mineral, plant, or animal sources. The building blocks of plant fibres are mainly composite of cellulose microfibrils which are bound together by lignin and hemicellulose. The amount of cellulose depends on the type of fibre, and is usually 60 to 80% by weight. The percentage of lignin is around 5 to 20% by weight, and the moisture contents can range up to 20% by weight. Plant-based fibres such as cotton, jute, and flax have cellulose as the primary building block, and as a result, their fibres are highly polar. This polarity is caused by the hydroxyl groups present on the surface, and when such fibres are embedded in a polymer to form a composite material, these hydroxyl groups form hydrogen bonding with the matrix. Animal fibres such as wool, silk, and hair, on the other hand, consist of proteins. Mineral fibres are rarely used and investigated because of their carcinogenic nature ,15,16.Porosity is commonly referred to as empty spaces or cavities that develop in a continuous material during processing or due to the air that becomes trapped during the processing of the material. In composites, such cavities are developed during different processing steps such as mixing or consolidation of fibres and the polymer resin. In the case of composites based on synthetic fibres, significant knowledge is present on how to control the porosity during the processing stage. In addition, the effect of this porosity on the mechanical and thermal properties is also well known ,18,19. IIt is well known that polymers have many applications in several industrial sectors. Many academic researchers have studied the electrical conductivity of polymers. Composites have a sensitive feature of electrical conductivity in polymer-based composites; most of the applications in electronics and electrical requires electronically conductive polymer composites, numerous trading devices such as bipolar plates and gas flow layers in Proton Exchange Membrane (PEM) fuel cells, conductive pastes comprising the conductive stuffing and polymer resins. Therefore, according to the increase in the mechanical stronger polymers need to have higher electrical conductivity. The best way to study the electrical conductivity is to simulate and model the behaviour of the polymer because of the effectiveness and the low cost that these methods provide. Moreover, investigation of the properties of the polymer matrix, it is reinforcement, and the interface between their naturals can be studied by this modelling. Several ways can be used to model the electrical conductivity in polymer-based composites. Investigators used numerical simulation ,23,24,253 and a thermal conductivity value from 0.046 to 0.068 W/mK, which is comparable to cellulose fibres and mineral wool. Actually, there are current trends that can be characterised as trends of increasing quality requirements for structures connected to growing awareness towards using materials with less environmental impact such as larch bark  is the conductivity matrix, which is given as follows [Here, [ follows ,49,(22)xxk, yyk, and zzk are the conductivity elements in the x, y, and z dimensions, respectively. The equations could be combined to form a compound equation as follows [In the above matrix, the  follows ,49,(23)The above equation can be expanded to a more familiar form as follows ,49,(25)T = T* Specified temperatures acting over the surface S1, Here, it has been assumed that all of the effects are in the global Cartesian system. There are three boundary conditions considered for this system, and it has been presumed that these conditions cover the entire element. These are given as follows, T* in above is the specified temperature.Specified heat flows acting over the surface S2 as shown in The n} = Unit outward normal vector; {Q* = Specified heat flow.Here,The preliminary shapes of models and fibres were made by providing information about the elements and related material. The thermal properties of the three materials of composite cylinders are also given in All composites’ materials have been inserted in the engineering data of ANSYS, and all their mechanical properties will be shown from Meshing is the most important tool in computer simulation as it can make the results more accurate, irrespective of whether the simulation is structural, static, or thermal analysis. In addition, meshing is a very useful tool for generating a specific area in the model which needs a focused analysis. This makes the users more comfortable in using it in some specific cases. For example, in the project model, the temperature has been applied to one area in which the finest mesh is required as compared with the rest surfaces where a coarser mesh is sufficient. The different meshes created for each composite cylinder are shown in The meshed models were divided into five sections for analysing the heat flow across the composite cylinders. The total length of the cylinder was taken as 10 cm, and each section’s length into 2 cm. The temperature of the beginning of the cylinder was taken as 120 °C, and this model is shown in The boundary conditions are given in The model was then solved, and the solution of the simultaneous equations was obtained by the software to give images of the models in The numerical results of the thermal characteristics of different fibre/matrix composites are presented in this section. The numerical test was evaluated on mainly sisal fibre and glass fibre which they combined with gypsum, as shown in The results for gypsum with 20% glass fibre are presented in The error was calculated usingSimilarly, the ANSYS results for sisal fibre reinforced gypsum composite were exported from the software and are shown in From However, the experimental study showed slightly higher heat conduction than theoretical values at different lengths for all composite samples. Even though both studies showed a uniform decrease in the temperature values along the composite lengths, at some point, the experimental temperature was higher. One exception was the point at a length of 0.02 m for the 25% composite, at which the numerical temperature was nearly 3 °C higher than the experimental temperature. When such a case is compared with other samples of sisal mixed with gypsum, the experimental temperature might involve any inaccuracy because of the affection of any operating conditions.The composites experienced a major temperature drop at the length of 0.02 m, and further, a limited temperature variation existed. An approximate average decrease of 67 °C in the temperature was obtained from 0 to 0.02 m. The temperature values along the length of the composites are inconsistent with the results obtained in previous studies . In the Similar to the sisal fibre composites, the difference in the experimental and numerical values was found for the different glass fibre composite samples. The results for the glass fibre composites are shown in the figure, ranging from Overall, a uniform decrease in the results was also obtained along the length of the composite samples. As before, these composites also experienced a major temperature drop at a length of 0.02 m. Further along the length, the temperature variation was very much limited, and a smooth decrease in temperature was observed. The approximate average decrease in temperature from 0 to 0.02 m length was around 68 °C, and further along the length, this decrease ranged from 2 to 9 °C. Recently, a study developed a mathematical model and analysed the thermal conductivity patterns of glass fibre boards. The fibre board samples had different percentages of glass fibres, and it was found that increasing percentages of fibres provide better insulation. However, it was suggested that the percentage should be in a limiting range for obtaining the maximum insulation properties ,54. In oHere, the high percentage of error can be found in the middle section of the sample. This can be due to the fact that the middle sections are far from the boundaries. The long-time of running and finding meshing can be used to reduce that amount of error. This point has been given in the recommendations section.A comparison of both sisal and glass fibres in terms of their insulation capabilities in gypsum is shown in Such a trend was also observed in another study by Patnaik et al. He modelled and experimentally studied the thermal characteristics of glass fibre reinforced epoxy composites having different percentages of glass fibres. He found an increase in the insulation capability of composites with increasing glass fibre contents. However, he found that the insulation capability of the composite was dependent on the glass fibre contents. The insulation capability was increased with the increase in fibre loading, starting from 15%, and, on the other hand, it was decreased slightly beyond 45% loading . Almost These results have shown that it was possible to construct a theoretical model in ANSYS that produced results that reflected the experimental findings. This analysed used to evaluate the thermal performance of a range of synthetic and natural fibres comparison. First, this evaluation concludes the effect of fibre volume fraction on the composites’ thermal conductivity, which could introduce a new potential to fabricate polymer composites with different volume fractions using sisal fibres and determine the level of porosity in each sample of composites. The second objective was the measurement of heat conductivity of each sample and the development of a mathematical model to correlate the porosity with heat conductivity. A higher volume fraction of natural fibres produced composites with higher insulation performance. Whereas, a higher volume fraction of synthetic fibre produced composites with a lower insulation performance. Overall, the results suggest that the improved performance of natural fibre-based composites was due at least in part to the internal porosity of the fibres. Moreover, this investigation has shown the wide range of thermal performance of synthetic and natural fibre composites. They are affected by many parameters in their manufacture. Moreover, these results highlight the advanced bio-composites and provide a foundation for further research on the molecular basis of resistance heat transfer within the composites.


GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart’s seminal ‘inverse care law’ paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need.To use scoping methodology to map out the process of creating a Deep End GP group.A scoping review using Arksey and O’Malley’s framework.MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria.From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo.Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement. The Deep End GP network, originating in Scotland in 2009, pools the experience and ideas of GPs in the most deprived areas. This enables advocacy, mitigates burnout, and provides practical, grassroots interventions to improve patient care in areas with the highest patient need. This scoping review mapped the process of establishing a new Deep End GP group, based on the success of existing Deep End GP groups across the world, providing a framework for other colleagues to do the same. and an increased association with mental health morbidity. GPs working in areas of deprivation experience increased demand for GP appointments and are under increased stress, with more patients registered per GP. This is not a new problem, as explained in 1971 by the late Julian Tudor Hart, in his seminal ‘inverse care law’ article, which posits that those in most need of good health care are least likely to be able to access it. Despite significant efforts to address health inequities and inequalities within general practice, progress has been slow.Compared to the most affluent populations, deprived populations in the UK have increased levels of multimorbidity, with disease onset 10–15 years earlier, significantly higher mortality rate, Each subsequent project serves the most deprived populations, facilitating advocacy and engagement with the public and patients to influence health policy and practice. There are currently 11 Deep End GP groups across five countries, with growing interest in the establishment of new groups. The positive impacts have been numerous, for example, the recruitment and training of younger GPs through Deep End training schemes, as well as the introduction of projects supporting GPs with protected time to integrate and align with social workers and other members of the multidisciplinary team.The Scottish Deep End Project was established in 2009. It brought together GPs working within areas of high deprivation. demonstrated by COVID-19 mortality rates, which, like all-cause mortality rates, are higher in more deprived areas. The Build Back Fairer report called for multisectoral action; the formation and development of Deep End GP groups is one example of how general practice can mobilise its collective voice and resources to make a difference in shaping health and social care systems.The COVID-19 pandemic continues to expose existing health inequities, Scoping reviews focus on breadth, and are regarded as the favourable methodology to systematically map the available literature and summarise the research findings. The process was strengthened by the use of reference scanning and grey literature searches as part of the stepwise methodology.The rationale for this scoping review was to map the processes and themes involved in starting a Deep End GP group, based on the successes of existing Deep End GP groups across the world. Using this process as an evidence base, the authors plan to establish their own Deep End GP group, in their locality, as well as providing a framework for other colleagues to do the same. A scoping review was chosen over a systematic review, as the appropriate tool of data synthesis in determining the scope and coverage of literature in this area, particularly given that not all articles were empirical. and was informed by more recent publications around scoping review methodology.The scoping review followed the processes and steps set by Arksey and O’Malley,This article aimed to answer what the literature tells us about how to establish a Deep End GP group.In scoping methodology, inclusion and exclusion criteria see  were iteMEDLINE, Embase, Web of Science, and CINAHL databases were selected to locate articles on the scoping review topic. A search strategy combining key terms was developed and used in the database searches with the aid of a librarian. See Supplementary Appendix S1 for the MEDLINE search strategy. was used to manage the study selections.Titles and abstracts of all studies and articles were screened by two independent reviewers based on relevance to the scoping review question, initially by title screening, then second level screening of abstracts, and finally full-text screening. Where differences in selection occurred, this was resolved through discussion. A third reviewer was available to resolve any disputes. Rayyan softwareReference lists were searched for additional relevant publications. A grey literature search followed. Each available Deep End GP group website was reviewed and if an appropriate published report was found (including online repositories) it was included. These then underwent abstract and full-text screening. was used for data collection and coding. Key findings related to the research question were characterised, summarised, and subsequently assigned coding (see Supplementary Box S1).A modified data extraction table, as set out by the Joanna Briggs Institute, Data have been presented in a descriptive format that aligned with the objective of establishing future Deep End GP groups, built off the evidence and success of previous Deep End initiatives.Descriptive thematic analysis was performed, alongside extraction of demographic data, and charted according to Arksey and O’Malley’s framework.A total of 16 articles were included in the review.The final selection comprised nine peer reviewed journal articles, one book publication, and six reports published outside of peer review journals.Ten results were authored or co-authored by Graham Watt of the University of Glasgow, who was central to the instigation of the initial Scottish Deep End Project and the subsequent international Deep End GP groups. All, except one article, were published in UK journals, with the BJGP publishing seven of nine articles.The results were published over 11 years since the first Deep End Project commenced in 2009. Peaks were seen in 2012 and 2019 coinciding with increased publication around the first Deep End work in 2011–2012 and the subsequent International Deep End bulletins.Seven overarching themes emerged when establishing a Deep End GP group, listed below.n = 8) used quantitative methods to identify those GPs and patient groups in areas of deprivation, mapping the Deep End. The most common modality used was that of the initial Scottish Deep End Project, where the Indices of Multiple Deprivation were used to rank practices with the highest proportion of patients living in 15% most deprived data zones.Quantifying areas of deprivation and the general practices that serve them was the initial step identified. Most groups (n = 2) used an alternative self-identifying approach, whereby GPs self-identified as working in an area of socioeconomic deprivation. This was seen outside of the UK, in Australia and Ireland, due to the difficulty of accessing similar data to that used within the UK NHS. Thus, in these areas it was not possible to follow the example of the Scottish Deep End Project in quantifying practices in areas of deprivation.Other groups  of the groups were facilitated by academic GP colleagues based in universities.A strong collaboration between academic and ‘frontline’ general practice emerged. The initial Scottish Deep End Project sought to bring together GPs serving the most deprived areas, enabling the practitioners’ voices to be united.The connection with academic general practice supports evidence gathering, inspired by issues and experiences raised by frontline Deep End colleagues, as well as academically rigorous evaluations of interventions and pilots that have been undertaken. Ireland, North and West London, and Canberra. This, however, has evolved to include other allied primary care colleagues within primary care and general practice teams, including frontline GPs, nurses, practice managers, researchers, educators, medical students, and public health colleagues.The results showed a mixed approach to those recruited and included within the different Deep End GP groups, with all groups being initially established and led by GPs. Most groups started exclusively with GPs, as seen in Scotland, It demonstrates, in pictorial form, the realities of life and work at the Deep End, with it being harder for patients and practitioners to keep their metaphorical heads above water as deprivation and associated need deepens. It is a uniting aspect of all the individual groups as they merge to become a collective voice of the international network for general practice at the Deep End of deprivation.Deep End GP groups have adopted a similar logo initially inspired by the Scottish Deep End Project see .11,26,3The scoping methodology on how to establish a Deep End GP group mapped the first step of quantifying and defining the Deep End of general practice for a geographical area. Ideally, this method used a quantitative approach, then invited representatives of practices in the most deprived areas. However, where this was not possible, GPs successfully established groups by inviting self-identified Deep End colleagues.Early participant co-design and objective setting, led by the practitioners who work in high need, high deprivation areas, was key to establishing a successful Deep End GP group. This not only gathered momentum but ultimately helped to achieve the aims it specifically set out. Deep End GP groups built with an academic general practice partnership have benefited in developing a strong evidence base of the issues faced and in reviewing the successes of piloted solutions. In turn, this has strengthened the advocacy and voice of practitioners working at the Deep End. Funding and allied health care involvement are beneficial, but not a prerequisite to a successful and impactful group.For colleagues interested in embarking on this journey, visiting the Scottish Deep End Project website is essential reading. In particular, reviewing the work of the different groups within the International Deep End reports. Colleagues wanting to express their interest in starting a Deep End GP group are encouraged to use the contact details found on the Scottish Deep End Project website. and as healthcare systems begin to reflect on the impact of the COVID-19 pandemic on society, especially the high mortality rate among people living in the most socioeconomically deprived areas. As measures to address health inequalities and inequities are considered, the initiative and impact of Deep End GP groups uniting general practice will be increasingly important.This scoping review was timely in the shadow of 50 years of the ‘inverse care law’The low number of articles in this search limited the extent and impact outside of a Deep End framework or initiative. It may be that other initiatives or projects that bring GPs in the most deprived areas together have not been included. The review also focused on formation and establishment of a Deep End GP group rather than the impact and successes of individual groups.Scoping methodology is different from systemic review methodology. In focusing on breadth, it allows a map of existing literature to be created and gaps identified. It also allows for the inclusion of multiple types of data without a quality assessment. While no formal synthesis akin to meta-analysis is part of a scoping review, some degree of synthesis was undertaken in descriptive thematic analysis. A systemic review may sometimes be an appropriate follow-up to a scoping study, but the authors felt this was less valuable given the high number of non-empirical articles. these groups are modelled on previous well-established groups. This review brought together and synthesised the approaches taken in establishing a Deep End GP group, aiming to provide a framework for other interested colleagues across the UK and further afield looking for a pragmatic approach to address the health inequalities they see in daily practice.There has been a plethora of innovation and practice changing interventions published by Deep End GP groups since 2009. As of December 2021, 11 Deep End GP groups have been established,This study set out to establish how to create a GP network based on the Deep End model, as a tool for colleagues to improve general practice and the health outcomes in areas of high need. The key steps identified start with quantifying patients and practices in areas of deprivation; establishing locally specific, GP-inspired objectives at an initial meeting; introducing regular steering groups meetings, with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and finally adopting a local Deep End logo.


A growing literature emphasizes that the output effect of fiscal consolidation hinges on its composition, as the choice of increasing revenues vs cutting expenditure is not neutral. Existing studies, however, underscore the role of local governments in a federal setting. Indeed, transfer cuts at the central level might translate into higher local taxes, changing the effective composition of the fiscal adjustment. We evaluate this transmission mechanism in Italy, where municipalities below the threshold of 5,000 inhabitants were exempted from (large) transfer cuts in 2012. This allows us to implement a difference-in-discontinuities design in order to estimate the causal impact of transfer cuts on the composition of fiscal adjustment, also because tight fiscal rules impose a balanced budget on Italian municipalities. We find a pass-through mechanism by which local governments react to the contraction of intergovernmental grants by mainly increasing taxes rather than reducing spending. From a political economy perspective, this revenue based fiscal consolidation is driven by local governments with low electoral competition and low party fragmentation. Recent works in both macroeconomics and political economics show that the output effect of fiscal consolidation depends on its composition, as the choice of increasing revenues vs cutting expenditure is not neutral from both an economic and a political perspective . As the current public spending of Italian municipalities amounted to 39.6 billions in 2010 , this transfer reduction had a sizable impact on the local governments’ fiscal position, and forced them to either increase local taxes or reduce spending, also because a tight balanced-budget constraint is in place and no deficit is allowed at the local level. This environment—which is common to many other countries with a certain degree of decentralization—allows us to investigate the transmission mechanism from a reduction in federal transfers to the composition of fiscal adjustment at lower layers of government. Moreover, as municipalities below the threshold of 5000 inhabitants were exempted from most of the transfer cuts, we can implement a difference-in-discontinuities design to causally evaluate the quantity and quality of the fiscal adjustment effort. Our identification strategy also benefits from the high level of Italian municipalities fragmentation: considering that 75% of them has less than 5000 inhabitants, even a narrow window around this population threshold provides a good sample size.In particular, local governments in municipalities below the threshold of 5000 inhabitants were exempted from (large) transfer cuts in 2012. This allows us to implement a difference-in-discontinuities design  political competition by politicians that have an incentive to emphasize the tax increase in the public discussion and campaign against the government.Our study contributes to different strands of the literature in both macroeconomics and political economics. Moreover, we also provide a small contribution to the growing literature, recently surveyed by Agrawal et al. , on how The analysis of fiscal adjustments has mainly been conducted at the national level, mostly in the attempt to quantify the output effects of revenue based as opposed to expenditure based fiscal consolidation plans , with The representative agent’s discounted utility (twice differentiable and under Inada conditions) is given by:The representative agent chooses consumption and next-period capital stock in order to maximize  under usiThe local government—see Eq. —reduces iiU(g)) and the income tax rate (this is consistent with the previous result). The derivative of : (1) low fiscal effort ; (2) high tax base ; (3) high marginal utility of expenditure.Solving the system in steady state and assuming that It is interesting to notice that most of the studies in the literature Volden  are in lMoreover, our theoretical framework indicates in what direction we could structure part of the empirical analysis, identifying three primary sources of heterogeneity that can cause a response to the transfers cuts. First, the level of fiscal effort can foster a pass-through from federal cuts to lower local spending when tax rates are already high before the cuts. Second, the local tax base level that, instead, can support a pass-through from transfers cuts to higher local taxes in wealthier municipalities. Finally, the political environment and the electoral salience of local taxes can mitigate the increase of local revenues in response to the reduction in central government’s transfers when the level of political competition and the incumbent mayor’s electoral concerns are high. In Sect. In this section, we provide background information on the Italian system of sub-national governments. This will allow us to show why Italy is a perfect testing ground to estimate the impact of federal cuts on the composition of the fiscal adjustment realized by lower layers of government in a federal system. Italy is a unitary Republic with three layers of sub-national governments. The territory is divided in 20 Regions , managed by elected regional governments that account for 19% of total current public expenditure (143 billion euros). The main responsibilities of regional governments are in the following sectors: healthcare; public transportation; complementary social welfare; higher education; and vocational training.The second layer of the institutional system is represented by 93 Provinces  and 14 Metropolitan districts , managed by local administrators appointed among the members of the municipal councils elected within the boundaries of each province or metropolitan district. At this level of government is allocated the 0.8% of total current public expenditure (6 billion euros) in order to provide services related to the maintenance of provincial road network, the management of public high school buildings, environmental protection and, depending on the regions, other delegated functions by regional governments in local public transportation or vocational training.Comuni), which have a long and important historical tradition in Italy. Municipal governments are ruled by a city council and an executive committee appointed by the elected mayor (Sindaco). The council and the mayor are directly elected for a five-year term and are subject to a two-term limit.The third and most important layer of the institutional system is represented by municipalities  equalization grants allocated with a system based on historical expenditure up to 2014; after that year a new equalization system based on the difference between standard expenditure needs and fiscal capacity has been gradually introduced with the goal of completely replacing the previous method in 2021. Specific grants are exceptional and earmarked; they are a residual source of funding provided by the central or the regional government, in favor of municipalities with specific investment needs.Municipalities’ own fiscal revenues come from two main sources: (1) local taxes, among which the most relevant are the Property Tax , the tax on waste disposal , and the local income tax surcharge; (2) local fees related to road and traffic, libraries, theaters and culture, burial services, and other services such as the occupation of public spaces, public billboards, certificates.According to the Italian Constitution, all local governments are subject to a balanced-budget constraint and fiscal deficit is allowed only to finance capital expenditure. Moreover, as an additional and fundamental fiscal discipline mechanism, all municipalities (with the exception of those below 5000 inhabitants until 2013), provinces, and metropolitan districts must comply with the rules of the “Domestic Stability Pact” (DSP). The DSP was introduced in Italy, as in other European countries, in 1999 after the European Union adopted its Stability and Growth Pact in 1997. According to the rules of the DSP, local governments have to keep their fiscal gap below a specific target fixed by the central government. Since 1999, the definition of the fiscal gap has changed multiple times.13In the aftermath of the financial crisis, starting in 2010, the Italian government has implemented an intense program of spending cuts.Figure Note that there are other municipal policies that also jump at 5000 inhabitants: in particular, the wage of the mayor sharply increases above this threshold . Moreover, we restrict the time span to the four-year period between 2009 and 2012, as the rules of the DSP are stable over this period . Table The “treatment” dummy takes value one for municipalities above 5000 inhabitants, which represent 27% of all observations. The “post treatment” dummy takes value one for the year 2012 only for municipalities above 5000 inhabitants, that is, 7% of the total observations and 25% of the municipalities above the 5000 population threshold. The source of the financial information included in the dataset is the municipal budget accounts published yearly by the Italian Ministry of Internal Affairs, and the full list of financial variables includes: transfer cuts, current expenses, capital expenses, local tax revenues, fees, grants, and the DSP target. The Italian Ministry of Finance, upon a specific request, provided information on the distribution of the legal tax rates for the property taxTables Regarding electoral variables we can also notice the absence of sharp differences between the two groups: both municipalities below and above 5000 exhibit an average turnout, an average margin of victory, and the probability of facing an election that are close to the national mean ; 38% of the mayors in municipalities above 5000 show a term limit compared to 13% in smaller municipalities.In order to identify the causal impact of the 2012 transfer cuts, imposed to municipalities above 5000 inhabitants but not to those below, we need to control for a series of potential confounding factors, which prevent the use of a simple  regression discontinuity design. The 5000 threshold is in fact associated to a compound treatment, as other municipal policies use the same population cutoff. First, municipalities below 5000 were exempted from the DSP until 2013. Second, the wage of mayors and executive committee members sharply increases at 5000. As discussed above, we restrict our sample to observations before 2013 so that both confounding policies are time-invariant in our analysis. This allows us to control for them by exploiting the time variation before/after 2012. One additional confounding factor is the implementation of the 2012 property tax reform, which increased local tax autonomy. The reform, however, was implemented for all municipalities and this allows us to control for it by exploiting the discontinuity at 5000. In particular, the 2012 cadastral revaluation, which represents the bulk of the reform, consisted of a simple sixty per cent increase of the tax base, uniform across all municipalities and nation-wide. Further specific revaluations of cadastral values are national decisions out of mayors’ exclusive decision power. However, to control any influence produced by the change in the tax base, we have included the average cadastral value computed at municipal level among the control variables. Moreover, another potential confounding source would come from the distribution of the share of owner-occupied main residence across municipalities since they entered the tax base composition in 2012. Although we did not have any discontinuity evidence at 5000 in the percentage of the owner-occupied main residence, we have included this variable in the controls set. In other words, to control for all of these confounding factors, it is enough to combine the before/after and the discontinuous policy variation so as to implement a difference-in-discontinuities design  outcome is equal to the potential (budget) outcome associated with the set of treatments actually received by municipality C alone. In fact:C that we may want to estimate, and the second is the bias introduced by the mayor’s wage and the DSP exemption.In this setting, a simple  RDD estimator cannot identify any causal effect of the transfer cuts C alone, we can exploit the time variation discussed above, that is, the fact that transfer cuts were implemented at local parallel trends  with optimal bandwidth .The point estimates are stable across all difference-in-discontinuities estimation methods, supporting the robustness of the findings. The increase in tax revenues is mainly due to an increase in revenues from the property tax (between 27 and 32 euros per capita), followed by a smaller increase in municipal fees (between 14 and 18 euros per capita) and municipal local income tax (between 8 and 11 euros per capita). In other words, we disclose a pass-through mechanism by which local governments react to the contraction of intergovernmental grants by increasing local taxes. As the fiscal policy variables we evaluate capture the sudden response of local governments to the fiscal shock, we identify a partial-equilibrium effect, which speaks directly to the theoretical hypotheses of the macro literature on fiscal consolidations. In other words, we can rule out general-equilibrium feedbacks that would make our results more difficult to interpret.19Figure To study the potential redistribution implications of the higher tax burden, we investigate the magnitude of the treatment effect on four additional outcome variables: the statutory municipal income tax rate; a dummy that takes value one when we observe a progressive structure for the municipal income tax; and finally the two statutory tax rates of the property tax respectively on the residents main dwelling and the second properties owned, mainly, by non-residents. For each variable, we report the point estimates of DID, LLR and LPR estimators in Table As reported in Table To shed more light on the mechanism of the transmission from transfer cuts to higher local taxes, we go back to the implications of our theoretical framework and investigate if they are met in our data. Specifically, we perform heterogeneity analysis with respect to both pre-treatment fiscal variables and political variables. The empirical strategy is to interact the diff-in-disc specifications reported in Eqs.  and 13)13) with high vs low fiscal effort, namely those local authorities that set the property tax rate or the local income tax rate above the 75th percentile of the distribution of the tax rates computed separately for each year and for each group of municipalities belonging to the same population brackethigh vs low tax base, namely those local authorities with a fiscal capacity above the 75th percentile of the distribution computed separately for each year and each municipality group belonging to the same population bracket. The fiscal capacity is the best proxy for the comprehensive tax base of each municipality. Our analysis is based on the Italian Ministry of Finance’s official values for the pre-treatment period considering the tax bases’ standard values and the standard tax rates.In Table Table High vs low political competition, measured by the margin of victory of the elected mayor;Political fragmentation, measured by the fact that the mayoral coalition is formed by a single party or by more parties ;Binding term limit for the incumbent, when the mayor is in her or his second mandate  and can not run again in the next electoral competition.The results reported in Table 24Table In this section, we evaluate the robustness of our main findings. First, we perform a set of permutation-based placebo tests to evaluate the possibility that our results arise from random chance rather than a causal relationship. Figure Within-the-Group estimator controlling for the municipal fixed effect clustering the standard errors at the municipal level. Figures As discussed by Eggers et al. , the difIn Fig. Figure Finally, Table Our results show that Italian municipalities reacted to the contraction of intergovernmental grants by mainly increasing local taxes rather than reducing expenditure. Thanks to the peculiarity of Italian institutions, we can claim that this effect is causal  and can be extended to many other government settings with a certain degree of decentralization . The implications of the evidence we provide on this transmission mechanism are twofold. First, the macro literature on the output effect of fiscal consolidations should be extended to the analysis of local public finance. Second, the emergence of revenue vs expenditure based fiscal consolidations crucially rests on the forces at play in the underlying political environment, as we also find that the increase in local taxation is mainly driven by local governments with low electoral competition and low party fragmentation. Macro predictions on the policy responses to fiscal shocks should therefore incorporate both institutional and political factors.Our results, moreover, can stimulate further research. In particular, in future research, we can expand the empirical analysis to investigate the impact of different fiscal adjustment behaviours on efficiency. It is not clear whether the pass-through mechanism based on the increase of local revenues may bust or deteriorate efficiency in providing local services, compared to the alternative pass-through mechanism that may stimulate local spending cuts. Evidence of different impact on efficiency may provide, in the end, normative implications in support of one of the two pass-through mechanisms.