Table 3

Policy Categories, Sub-themes and Transferable Principles Found in Musculoskeletal Policy Documents

Policy Categories	Example Excerpts	Identified Sub-themes	Transferable Principles
Service Delivery
	“Define specific assistance paths with social integration, health and involvement of social services to support interventions for vulnerable people and/or those in difficult social contexts” (Italy 1). “Promote the early initiation of lifestyle modifications to reduce risk, injury, and pain by using effective nonpharmacological approaches and proven self-management education and physical activity programs” (United States of America 3). “Once screening is completed, a Healthy Lifestyle and Behaviours Plan will be implemented that is tailored to the individual’s needs. Health providers will advise which exercise is needed as part of this plan, as well as drug management/medication and nutrition management” (Republic of Korea 1). “The atlas shows great geographical variation in the treatment of musculoskeletal disease. The information in the atlas provides the professional community with knowledge that can help reduce unfounded variety and secure equivalent health services” (Norway 2). “In order to reach people in vulnerable situations more effectively, projects are to be tailored to the needs of the respective target groups and made easily accessible.” “The MoC should clearly define the target population and identify any specific priority groups” (International 1). “Develop best practice guidelines for rehabilitation in the health system” (Chile 1). “To promote an effective, evidence-based, and timely approach to managing musculoskeletal pain and disability that applies a biopsychosocial treatment model to restore workplace function and prevent or minimize work disability as early as possible” (United States of America 1). “Work collaboratively to influence commissioners and providers to deliver evidence-based interventions” (United Kingdom [England] 3). “Goal 1: Risk factors and Prevention Strategies. Goal 2: Early Diagnosis, Early Treatment and Follow up of Diseases” (Turkey 1). “Identify risk factors for severity or impact and use tools where they exist to analyse and stratify risk of progression to long term pain and disability” (United Kingdom [England] 2). “All relevant health professionals must be able to perform a valid, standardized, age appropriate musculoskeletal screening assessment” (Canada 2). “We have commissioned a research partner to answer which models of MSK and OH service provision are available, where the gaps exist in provision – both geographically and by service type” (United Kingdom [England]) 3). “Improved consumer experiences relating to services and pathways measured through: Satisfaction with both access to, and quality of, healthcare services; improved health literacy; consistency of service quality and access across sites” (New Zealand 1)	Sub-theme 1: Person-centred care	MSK requires care that is respectful of, and responsive to, the preferences needs and values of the individual.
		Sub-theme 2: Identifying and supporting vulnerable and priority populations	Discrimination (overt and institutional) impacts MSK healthcare. Equity should underpin strategy by identifying and targeting services for priority populations. Naming these populations and needs can help prevents such populations falling through the cracks.
		Sub-theme 3: Lifestyle interventions, prevention, early intervention	Complete service packages for MSK health include prevention, early intervention, active and passive treatment, management, recovery, rehabilitation and palliation.
		Sub-theme 4: Interdisciplinary and integrated services	MSK health service delivery is often multidisciplinary and needs to transition to fully integrated or interprofessional care.
		Sub-theme 5: Evidence-based care	Service models should align with best practice evidence and be reviewed regularly. Interventions should be aligned with evidence and reflect the needs of the individual. Low benefit, unnecessary and harmful interventions (low-value care) should be reduced in favour of high value care.
		Sub-theme 6: Access to specialist and rehabilitation services	Health services should be adequately resourced and structured to support rapid access to affordable specialist care for those who need it.
		Sub-theme 7: Risk screening and prioritisation	Prevention and early intervention requires the establishment of systems to identify modifiable risk factors and should target various settings (work and community).
		Sub-theme 8: Service mapping	Ensure access to care by maintaining data on service location and availability, and plan services geographically to enable access where it is needed most.
		Sub-theme 9: Quality of Care	Systems and processes must be in place to ensure high standards of evidence-based care are reached and maintained.
Workforce
	“The topic of musculoskeletal diseases is an integral part of the university and non-university training of all professionals involved” (Switzerland 2). “Develop a recommendation on minimum requirements for learning content for initial training programs for doctors, dentists, health psychologists, nurses and physiotherapists. Train teachers of inclusive education related to pain management. Develop common learning materials and new learning methods (video lectures, online courses). Compulsory elective courses on pain and its treatment will be created in medical faculties” (Finland 1). “Engage in effective inter-professional communication and collaboration with clear documentation to optimise the integrated management of conditions” (United Kingdom [England] 2). “The health professional should have access to regular sparring with another colleague who has knowledge of and experience with patient-oriented supervised individual physical training” (Denmark 1). “Create and disseminate guidelines, handbooks, and other tools targeting health care providers and insurers that support effective and efficient adoption, use, and maintenance of pr oven self-management strategies” (United States of America 3). “Building skills and capacity by providing a set of tools, training and learning events to support local awareness and good practice” (United Kingdom [England] 3). “Determine the training needs of the personnel involved (health and non-health) also in relation to the topic integrated management, teamwork, the use of new technologies” (Italy 1). “Goal 3: Health practitioners are well-informed and skilled on best practice evidence-based care and are supported to deliver this care” (Australia 3). “Strengthen the undergraduate/professional entry-level curricula related to arthritis as part of chronic disease prevention and management for all health care providers” (Canada 2). “The framework recognises that practitioners will acquire the capabilities through their pre-and post-registration education (at undergraduate and postgraduate levels) and as their learning and professional development progresses” (United Kingdom [England] 2).	Sub-theme 1: Workforce Networks	Develop and make use of communities of practice, for clinicians, public health officers, administrators, and policymakers. These should be multi-disciplinary. Digital technology can ease the establishment and maintenance of such networks.
		Sub-theme 2: Resources for workforce use in practice	Clinical guidelines; local service directories; decision-making tools and health workforce training and education materials should be developed and implemented in practice.
		Sub-theme 3: Continuous workforce education	Develop and deliver information, training and education for ongoing professional development and upskilling of the workforce in appropriate prevention, management and care.
		Sub-theme 4: Workforce Support Tools and Systems Support	Resources should be in place to support workforce capacity including specified workforce roles for MSK health and care coordination; resources to test application of new models of care; time and financing resources to undertake training.
		Sub-theme 5: Workforce capabilities	A framework of core workforce qualities and capabilities should be based on high levels of training, qualification and registration; and include recognition of specific skills required for MSK health including: multi-disciplinary skills, cultural competencies, system knowledge and team-based care.
		Sub-theme 6: Undergraduate and Post-Graduate Workforce Education	Include MSK competencies within curricula across formal health workforce education and tertiary training facilities.
		Sub-theme 7: Workforce planning	Project MSK workforce needs and determine suitable roles and qualifications.
		Sub-theme 8: Administrative Workforce	MSK policy, strategy and health system reform should be legitimised through the creation of dedicated administrative units and leadership roles and local, district and national levels.
Medicines and Technologies
	“In most primary-care settings, the range of available options for chronic pain management is limited, with the most common options being pharmacological management, specialist or surgical referrals, self-care instructions, or additional imaging and diagnostics” (United States of America 1). “Review and monitoring of technical guidelines and monitor opioid prescription” (Portugal 1). “Promote self-management in a variety of formats ( eg, group classes, home-based instruction, online options, self-directed guides, mobile health technologies using smart phones, and wearable tracking devices); and settings ( eg, the community, work sites, health care system, and home)” (United States of America 3). “Shared decision-making tools are available in all health boards providing information on which people living with persistent pain can make informed decisions about their care” (United Kingdom [Wales] 1). “Creation of a health education kit distributed to health professionals” (France 1).	Sub-theme 1: Pharmacologic and biologic interventions	Medicines should be used appropriately, guided by evidence and processes of health technology assessment and management such as evidence review, technology and data infrastructure supported monitoring and health economic evaluation.
		Sub-theme 2: Digital Technologies to support service delivery	Adopt technologies such as telehealth as a means of improving access.
		Sub-theme 3: Place of medicine in multi-disciplinary care	Pharmacologic treatments should be used, where appropriate, in conjunction with other treatments.
		Sub-theme 4: Safe Medicine use: education and knowledge for citizens	Maintain a strong process of education and awareness in the safe use of medications and have processes to monitor medicine use.
		Sub-theme 5: Biomechanical interventions/living aids	Where aligned to evidence, include adaptive devices and biomechanical interventions in the suite of tools and therapies.
		Sub-theme 6: Appropriate use of opioid medicines	A special focus on the use, safety and risks associated with opioid medication is warranted with resources to guide tapering, provide alternative medicines if indicated and reduce risks of overuse/addiction.
Financing
	“Through targeted strategic funding, CAN created collaborative multi-disciplinary teams to work on improving the care of Canadians living with arthritis and the Canadian economy” (Canada 2). “The contract for arranging special medical care must agree on eg, the division of labor and the coordination of the activities of the associations of municipalities in the hospital districts under special responsibility. The division of labor must ensure that, in accordance with the organization agreement, the operating unit providing care has sufficient financial and human resources as well as expertise” (Finland 1). “Work to provide public and private financing and reimbursement for participation in evidence-based, self-management education and physical activity programs among community” (United States of America 3). “To ensure the goals of the NCD strategy can be achieved, financial resources need to be deployed efficiently and in line with the strategic objectives” (Switzerland 1). “Research funding and capacity for arthritis and musculoskeletal conditions is commensurate with the burden and cost of these conditions” (Australia 1). “In addition to the internal partnerships with other CIHR Institutes, IMHA will work, nationally and internationally, with other funding agencies, and with charities, professional organizations and non-traditional partners in the public and private sector, to address its strategic priorities” (Canada 1).	Sub-theme 1: MSK targeted funding	Targeted funding for MSK conditions to increase quality and quantity of locally relevant community and health workforce knowledge to address the burden of MSK.
		Sub-theme 2: Funding beyond clinical services	MSK health has a particular connection to multifaceted, long-term and holistic care requiring self-management, community care, physical activity programs, social care and psychological care to be included in health financing and payment models.
		Sub-theme 3: Incentives for coordination, multi-disciplinary and holistic care	Include incentives to ensure citizens receive whole-of-person coordinated services.
		Sub-theme 4: Budget allocation in line with burden	The burden of MSK conditions, defined along multiple lines, should guide the allocation of budget and access to health financing models with a view to return on investment (addressing modifiable risk factors for other NCDs).
		Sub-theme 5: International financing mechanisms	Developing health systems should emphasise MSK health and leverage international partnerships to support reform agendas.
		Sub-theme 6: Affordable services	Essential components of MSK health should be identified and included in payment models and financing systems.
Data and information systems
	“Target: the creation of a national data system for Turkey Musculoskeletal System Diseases Prevention and Control Program Evaluation monitoring and reporting” (Turkey 1). “Updating of the Information Systems of the Occupational Risk Administrators and Health Promotion Entities, which facilitate the consultation, audit and migration of information, in a timely, efficient, truthful and complete manner” (Columbia 1). “Embed data collection into hospital and clinical management systems to capture and analyse treatment and outcomes data to inform clinical decisions and drive quality improvement” (Australia 1). “…build databases, in which administrative data converge clinical (health, social-health and social-assistance fields) for evaluation of clinical and organizational results and quality assistance” (Italy 1). “Monitor and evaluate their practice and its outcomes, including through data collection and analysis to assure and improve the quality of care, service delivery and address health inequalities” (Italy 1). “Increase information sharing, awareness, dissemination, and use of existing and new communication campaigns and tools to reduce OA symptoms and improve OA management” (United States of America 3). “Better use of linked data, such as linked primary and secondary care data, linked Census and secondary care data, could allow further investigation into the outcomes for people with MSK conditions” (United Kingdom [England] 3). “Justification for the target group should be informed by local data that demonstrate where services are needed the most” (International 1). “Coordinated and integrated surveillance systems at multiple levels of the health care systems can promote and enhance quality of care delivered for people living with arthritis” (Canada 2).	Sub-theme 1: Determining quality indicators	Quality health system performance measures should be developed with aligned with robust monitoring systems.
		Sub-theme 2: Mainstreaming monitoring and evaluation	Make full use of pilot monitoring and evaluation programs, rollout and scale up to build the evidence base for MSK health system improvement locally.
		Sub-theme 3: Data systems infrastructure	Systems of routine data collection should be implemented, data collected, collated and reported to support monitoring needs and progress against quality markers. Systems can be built on existing administrative processes or through the deployment of surveys. Local data should be collated in national systems.
		Sub-theme 4: Data reporting, dissemination and use	Build appropriate data collection, monitoring and evaluation and piloting systems to underpin decisions in 'learning health systems' (See also governance sub-theme 4).
		Sub-theme 5: Linking local data sources	Clinical digital health informatics platforms should enable connected care and monitoring across the health system in primary, secondary, tertiary, community, social care settings.
Leadership and governance
	“Establish and fund a National Arthritis Collaboration to engage with and align efforts across multiple stakeholders, sectors and levels of the health system to drive improvements in arthritis prevention and management” (Australia 1). “Working groups will be formed according to program objectives, in which the members of the general assembly take part in accordance with their job descriptions. Each working group prepares proposals for the planning, execution, evaluation and development of the work in its field specified in the action plans, submits it to the executive board, and carries out the approved activities” (Turkey 1). “Objective 1.2 Integrate workers' health protection measures into economic development policies and poverty reduction strategies” (Columbia 1). “The Arthritis Alliance of Canada, a coalition of arthritis organizations from across the country, has developed Joint Action on Arthritis: A Framework to Improve Arthritis Prevention and Care in Canada to facilitate collaboration on effective solutions and to secure the collective leadership commitments to make change happen” (Canada 2). “GPs also play an essential clinical leadership role in multi-professional teams, employing a growing range of clinicians in their services and commissioning MSK services for their local populations” (United Kingdom [England] 2). “Local clinical and administrative champions who are supported by their organisation to adopt a leadership position in the development, communication and implementation of the Model of Care” (Italy 1). “Strengthening political leadership to ensure a coordinated and intersectoral approach, and integration of health issues into all policies is of paramount importance” (International 1). “The Alliance and its members have taken a leadership role in developing this Framework and will be approaching governments and other arthritis stakeholder organizations with specific requests for support and participation in implementing its initial priorities and actions” (Canada 2). “It is recommended that a uniform registration takes place across the municipalities through reporting to national databases to the extent that they exist” (Denmark 1). “The champions tasked with spearheading the MoC should be up-skilled in implementation science or change leadership in order to act as effective change agents” (International 1).	Sub-theme 1: Championing MSK health.	The roles, knowledge and capacity of advocates should be acknowledged and harnessed for action.
		Sub-theme 2: Establishing systems for decision making	Establish responsible committee structures for decision-making in MSK health.
		Sub-theme 3: Delegating leadership	Knowledge, responsibility, and authority may be located across levels of government, in multiple parts of the health system and non-governmental organisations requiring delegation, multi-stakeholder governance and coordination.
		Sub-theme 4: Data for leadership	Build data collection, monitoring and evaluation and piloting systems to underpin decisions in 'learning health systems.'
		Sub-theme 5: Building local capacity and capability in leadership	The capacity and capability to undertake responsibilities and perform functions of leadership and governance should be supported across the system.
Citizens, consumers and communities
	“The focus is on people: The focus is on people. It does not matter whether it is a healthy person, a person with risk factors for a musculoskeletal disorder or a person who is affected by a musculoskeletal disorder” (Switzerland 2). “Every Canadian with arthritis must have access to accurate information and education on arthritis that meet a defined set of criteria and are appropriate to their age and stage of disease” (Canada 2). “State and professional organizations should increase consumers,’ primary care providers,’ and medical specialists’ awareness of, and access to, function- and work-oriented pain management services that use a biopsychosocial approach, especially patient education and counselling, emphasizing the health benefits of continued employment for most patients” (United States of America 1). “The programme provides education on pain and lifestyle, physical exercise training and a range of techniques to assist the individual's management of pain conditions” (Switzerland 1). “Goal 2: Consumers, their carers and the wider community are more empowered knowledgeable and supported to understand and manage pain” (Australia 3). “Identify and engage community organizations ( eg, faith-based and cultural or ethnic groups; neighborhood associations; senior centers; and parks, recreation, fitness, health, and wellness organizations) that may not be aware of or using the effective intervention strategies or offering evidence-based programs to help with OA” (United States of America 3). “Prepare material to raise awareness and sensitize, for managers, professionals and patients about the importance of adequate pain care” (European Union 1).	Sub-theme 1: Public education and awareness	Increase community awareness and understanding of the MSK conditions, their (modifiable) risk factors, prevention and management including role of self-management.
		Sub-theme 2: Working in partnership	Utilise partnerships with consumers and other organisations and associations to advance MSK health agendas.
		Sub-theme 3: Identifying and supporting vulnerable and priority populations (cross-over with service delivery sub-theme 2)	Equity should underpin strategy by identifying and including engagement of specific priority populations in inclusive and accessible ways to prevent discrimination and support culturally-appropriate care and care equity.
		Sub-theme 4: Citizen science and data	Technologies can provide opportunities to make use of citizen and consumer-level data capture to guide self-management, support shared decision making and promote population-level monitoring.
Research and innovation
	“In the “Research” area, the goal is to improve the data on musculoskeletal diseases. In addition to adapting or expanding existing health statistics and registers. Research funding also contributes to this. Innovative projects to care for people with musculoskeletal diseases should increasingly be scientifically supported” (Switzerland 2). “This entails building and sustaining research networks that aim to advance research, training and knowledge translation across multiple disciplines, with a focus on expediting knowledge uptake to mobilize and build IMHA’s research community” (Canada 1). “Facilitate the formation of multi-disciplinary research groups to address knowledge gaps in arthritis prevention, management and models of care” (Canada 1). “Provide dedicated funding for musculoskeletal research fellowships for clinician researchers and researchers at all career stages” (Australia 1).	Sub-theme 1: Investment in research	Invest in MSK health research across the spectrum including from early detection, prevention, diagnosis, management, treatment, rehabilitation and recovery.
		Sub-theme 2: Research dissemination, translation, and implementation	Translation and implementation strategies should be required to accompany application of new research to support whole-of-system reform.
		Sub-theme 3: Knowledge, skills and capacity to undertake research	Research and innovation should be approached in conjunction with and serve to benefit the MSK health workforce and expand research capacity in the MSK health workforce.
		Sub-theme 4: Research policy and funding systems	Develop high-level strategy and coordination of research for MSK health; with systematic identification of research priorities and allocated funding.

Abbreviations:
MSK = musculoskeletal;
NCDs = non-communicable diseases;
MoC = model of care;
A = osteoarthritis;
IMHA = Institute of Musculoskeletal Health and Arthritis.