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State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.

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Persistent human papillomavirus (HPV) infections can cause cancer (e.g., cervical/vaginal/penile/anal/oropharyngeal). The HPV vaccine prevents cancer, yet U.S. vaccination rates remain low. We explored sociopolitical factors in the adoption of Puerto Rico's HPV vaccine school-entry requirement. Multiple streams framework explains how the intersection of problems, policy, and politics streams influence policy adoption. Policy entrepreneurs work on joining these streams. Interviews (n = 20) were conducted with stakeholders (e.g., physicians/researchers/nonprofit organizations' leaders). Data were analyzed using applied thematic analysis. High incidence of HPV and HPV-related cancers in Puerto Rico were indicators of problems. Focusing events included Rhaiza's case and the HPV-Advisory Panel Report. During summer 2017, a policy window opened; the Department of Health (DOH) adopted the requirement in summer 2018. Stakeholders discussed policy initiatives. Political turnover positively influenced the process. Policy entrepreneurs created an extended period of intersection resulting in the adoption of the requirement. Findings can inform policy initiatives to improve HPV vaccination rates and reduce HPV-related cancers.

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Abstract This article seeks to understand the circumstances that culminated in the formulation and implementation of the National Rural Water Supply and Sanitation Project (PNSR) in the 1980s, using the Multiple Streams Model as its theoretical reference. The results show that the theme's ascension to the government agenda stemmed from a conjuncture marked by intense transitions that contributed to opening a policy window. The struggle to guarantee social rights in the Brazilian re-democratization process; the activities of social movements like the grassroots public health movement; the large sanitary deficit and its consequences for public health; the joint involvement of institutions with considerable expertise like Economic and Social Planning Institute (IPEA), Public Health Special Service Foundation (FSESP) and Pan-American Health Organization (PAHO) and the availability of financial resources stemming from a partnership arrangement with the International Bank for Reconstruction and Development (IBRD) provided a favorable environment for the elaboration of the PNSR.

Resumen Este documento tiene como objetivo comprender las circunstancias que condujeron a la formulación e implementación, en la década de 1980, del Proyecto Nacional de Abastecimiento de Agua y Saneamiento Rural (PNSR), adoptando como marco teórico el modelo de flujos múltiples. Los resultados muestran que su ascenso a la agenda del gobierno se debe a una coyuntura marcada por intensas transiciones, que contribuyeron a la apertura de una ventana de oportunidad. La búsqueda de la garantía de los derechos sociales en el proceso de redemocratización brasileña; el desempeño de movimientos sociales, como el movimiento sanitario; el gran déficit de saneamiento y sus consecuencias en la salud pública; la participación conjunta de instituciones con experiencia, como el Instituto de Planificación Económica y Social (IPEA), la Fundación del Servicio Especial de Salud Pública (FSESP) y la Organización Panamericana de la Salud (OPS), y la disponibilidad de recursos financieros de una asociación con el Banco Internacional de Reconstrucción y Fomento (BIRF) proporcionó un entorno favorable para la elaboración del PNSR.

Resumo O presente artigo busca compreender as circunstâncias que culminaram na formulação e implementação, na década de 1980, do Projeto Nacional de Saneamento Rural (PNSR), adotando como marco teórico o Modelo de Múltiplos Fluxos. Os resultados evidenciam que sua ascensão à agenda governamental é decorrente de uma conjuntura marcada por intensas transições, que contribuíram para a abertura de uma janela de oportunidades. A busca pela garantia de direitos sociais no processo de redemocratização brasileiro; a atuação de movimentos sociais, como o movimento sanitarista; o grande déficit sanitário e suas consequências na saúde pública; o envolvimento conjunto de instituições com expertise, como o Instituto de Planejamento Econômico e Social (IPEA), a Fundação Serviço Especial de Saúde Pública (FSESP) e a Organização Pan-Americana de Saúde (OPAS) e a disponibilidade de recursos financeiros, provenientes de parceria com o Banco Internacional para Reconstrução e Desenvolvimento (BIRD), proporcionaram um ambiente favorável para a elaboração do PNSR.

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O estudo analisa a primeira edição dos Jogos Mundiais dos Povos Indígenas (JMPI), realizados em 2015, no Brasil, a partir de como procederam as discussões e as formulações das políticas voltadas a esse evento esportivo. De cunho qualitativo, o estudo utilizou do modelo de análise dos Múltiplos Fluxos que verifica os fatores que influenciam na formulação da agenda política, por meio da análise documental das leis e decretos nacionais que dispõem sobre o esporte voltado aos povos indígenas, bem como relatórios emitidos pelo Ministério do Esporte do Brasil, em parceria com a UNESCO. Os resultados apontam para a incorporação dos JMPI à agenda política a partir da convergência entre o fluxo de problemas, desenhado a partir da ausência de políticas públicas voltadas às demandas indígenas, da falta de valorização e de divulgação da cultura indigenista e do feedback dos Jogos dos Povos Indígenas Brasileiros; o fluxo das políticas, instaurado por meio de documentos internacionais publicados em defesa da cultura indígena e dos jogos tradicionais de diferentes povos; e, o fluxo da política, por meio das representações do Ministério do Esporte Brasileiro, do Comitê Intertribal e as lideranças estrangeiras, culminando na abertura da janela de oportunidade para a organização do evento esportivo.

The study examines the first edition of the World Indigenous Games, held in Brazil in 2015, based on how the discussions and formulations of the policies related to this sporting event proceeded. In a qualitative way, the study used the Multiple Streams framework, which verifies the factors that influence the formulation of the political agenda, through a documental analysis of national laws and decrees that regulate the sport focused on indigenous peoples, as well as reports issued by the Ministry of Sports (Brazil), in partnership with UNESCO. The results point to the incorporation of the World Indigenous Games into the political agenda based on the convergence between the problem stream, drawn from the absence of public policies focused on indigenous demands, lack of appreciation and dissemination of indigenous culture and feedback from the Brazilian Indigenous Games; the policy stream, established through international documents published in defense of indigenous culture and traditional games of different peoples; and the political stream, through the representations of the Brazilian Ministry of Sports, the Intertribal Committee and the foreign leadership, culminating in the opening of the "launch window" for the organization of the sporting event.

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Introdução: O uso e a prescrição inadequados de antimicrobianos e a pressão da indústria farmacêutica para a sua utilização transformaram a resistência bacteriana a esses medicamentos em um problema mundial de saúde pública. Objetivo: O objetivo do estudo foi analisar o processo de implantação da Resolução da Diretoria Colegiada (RDC) da Agência Nacional de Vigilância Sanitária (Anvisa) de nº 20/2011, que dispõe sobre o controle dos antimicrobianos. Método: Utilizou-se o Modelo de Múltiplos Fluxos de Kingdon para examinar a inserção do tema do controle dos antimicrobianos na agenda governamental e sua posterior conformação em política pública. Foram empregadas diversas estratégias metodológicas, como a revisão bibliográfica, a análise de documentos, a busca de notícias veiculadas na mídia e informações advindas de entrevistas com informantes-chave. Conclusão: Apesar da existência de legislações e regulamentações sobre o uso e a prescrição de antimicrobianos, além da ampliação do acesso da população aos profissionais de saúde para evitar a automedicação e promover o uso correto, esforços como a educação sanitária para profissionais e a população e o reforço da fiscalização sanitária devem ser efetivamente implementados, não apenas para alcançar o uso racional, mas também para diminuir a resistência aos antimicrobianos.(AU)

Introduction: Inappropriate use and prescription of antimicrobials and the pressure from the pharmaceutical industry for their use have turned bacterial resistance into a global public health problem. Objective: This study aimed to analyze the implementation process of ANVISA's Board of Directors Resolution (RDC) 20/2011 for antimicrobials control. Method: Kingdon's Multiple Streams Model was used to examine the inclusion of antimicrobial control into the government agenda and its subsequent shaping into public policy. Several methodological strategies were employed, such as bibliographic review, document analysis, the search for stories in the media and information from interviews with key informants. Conclusion: In addition to legislation and regulations of the use and prescription of antimicrobials, easier population's access to health professionals to avoid self-medication and promote correct use, it is necessary to implement efforts such as education of professionals and the general population, not only to achieve rational use, but also to reduce antimicrobial resistance.(AU)

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BACKGROUND: Government policy measures have a key role to play in the prevention and control of non-communicable diseases (NCDs). The Caribbean, a middle-income region, has the highest per capita burden of NCDs in the Americas. Our aim was to examine policy development and implementation between the years 2000 and 2013 on NCD prevention and control in Barbados, and to investigate factors promoting, and hindering, success. METHODS: A qualitative case study design was used involving a structured policy document review and semi-structured interviews with key informants, identified through stakeholder analysis and 'cascading.' Documents were abstracted into a standard form. Interviews were recorded, transcribed verbatim and underwent framework analysis, guided by the multiple streams framework (MSF). There were 25 key informants, from the Ministry of Health (MoH), other government Ministries, civil society organisations, and the private sector. RESULTS: A significant policy window opened between 2005 and 2007 in which new posts to address NCDs were created in the MoH, and a government supported multi-sectoral national NCD commission was established. Factors contributing to this government commitment and funding included a high level of awareness, throughout society, of the NCD burden, including media coverage of local research findings; the availability of policy recommendations by international bodies that could be adopted locally, notably the framework convention on tobacco control (FCTC); and the activities of local highly respected policy entrepreneurs with access to senior politicians, who were able to bring together political concern for the problem with potential policy solutions. However, factors were also identified that hindered multi-sectoral policy development in several areas, including around nutrition, physical activity, and alcohol. These included a lack of consensus (valence) on the nature of the problem, often framed as being predominantly one of individuals needing to take responsibility for their health rather than requiring government-led environmental changes; lack of appropriate detailed policy guidance for local adaptation; conflicts with other political priorities, such as production and export of alcohol, and political reluctance to use legislative and fiscal measures. CONCLUSION: The study's findings indicate mechanisms to promote and support NCD policy development in the Caribbean and similar settings.

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O presente trabalho teve como principal objetivo a análise do processo de formulação e implementação doPrograma Mais Médicos pautado nas reivindicações populares e no contexto da saúde no Brasil, por meio do Modelo de Múltiplos Fluxos de Kingdon. Realizou-se uma investigação de caráter aplicado por meio de uma pesquisa de cunho exploratório e descritivo. Analisandofatores antecedentes à implantação do programa, foi observado que o problema da distribuição dos médicos passou a constar na agenda decisória do governo por meio da insatisfação popular expressa nas manifestações ocorridas entre junho e julho de 2013. Esses eventos contribuíram para que o Governo Federal aprovasse a Medida Provisória referente a criação doPrograma Mais Médicos, mesmo com a forte oposição de entidades médicas e limitado respaldo da população, como apontaram as pesquisas de opiniãocontemporâneas a criação do programa. Ao longo de sua implantação, foi perceptível a existência da ambiguidade na tomada de decisão como uma dinâmicacaótica de acordo com Kingdon (2003). Atualmente,esta política continua gerando opiniões controversas.

This article has as main objective the analysis of the process of formulation and implementation of the More Doctors Program, guided by the popular claims and the context of health in Brazil. To perform the analysis, the Multiple Streams Model created by John Kingdon was used. The authors performed exploratory and descriptive research. Going through the precedents of the process of implementation, it’s possible to perceive that the problem of the concentration of doctors entered the government’s decisional agenda after themanifestations in June and July of 2013. Those events contributed to the approval of the Provisional Measure referent to the creation on the More Doctors Program. The program was not supported by the health institutions of Brazil and some opinion polls pointed tothe limited support of the population. Over the program’s implementation, it became perceptible the existence of ambiguity at the decisional process as part of the chaotic dynamic proposed by Kingdon (2003). Today, this politics still creates controversial opinions.

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