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  • Spatial and temporal distribution of infectious disease epidemics, disasters and other potential public health emergencies in the World Health Organisation Africa region, 2016–2018
    Global. Health (IF 2.554) Pub Date : 2020-01-15
    Ambrose Otau TALISUNA; Emelda Aluoch OKIRO; Ali Ahmed YAHAYA; Mary STEPHEN; Boukare BONKOUNGOU; Emmanuel Onuche MUSA; Etienne Magloire MINKOULOU; Joseph OKEIBUNOR; Benido IMPOUMA; Haruna Mamoudou DJINGAREY; N’da Konan Michel YAO; Sakuya OKA; Zabulon YOTI; Ibrahima Socé FALL

    Emerging and re-emerging diseases with pandemic potential continue to challenge fragile health systems in Africa, creating enormous human and economic toll. To provide evidence for the investment case for public health emergency preparedness, we analysed the spatial and temporal distribution of epidemics, disasters and other potential public health emergencies in the WHO African region between 2016 and 2018. We abstracted data from several sources, including: the WHO African Region’s weekly bulletins on epidemics and emergencies, the WHO-Disease Outbreak News (DON) and the Emergency Events Database (EM-DAT) of the Centre for Research on the Epidemiology of Disasters (CRED). Other sources were: the Program for Monitoring Emerging Diseases (ProMED) and the Global Infectious Disease and Epidemiology Network (GIDEON). We included information on the time and location of the event, the number of cases and deaths and counter-checked the different data sources. We used bubble plots for temporal analysis and generated graphs and maps showing the frequency and distribution of each event. Based on the frequency of events, we categorised countries into three: Tier 1, 10 or more events, Tier 2, 5–9 events, and Tier 3, less than 5 or no event. Finally, we compared the event frequencies to a summary International Health Regulations (IHR) index generated from the IHR technical area scores of the 2018 annual reports. Over 260 events were identified between 2016 and 2018. Forty-one countries (87%) had at least one epidemic between 2016 and 2018, and 21 of them (45%) had at least one epidemic annually. Twenty-two countries (47%) had disasters/humanitarian crises. Seven countries (the epicentres) experienced over 10 events and all of them had limited or developing IHR capacities. The top five causes of epidemics were: Cholera, Measles, Viral Haemorrhagic Diseases, Malaria and Meningitis. The frequent and widespread occurrence of epidemics and disasters in Africa is a clarion call for investing in preparedness. While strengthening preparedness should be guided by global frameworks, it is the responsibility of each government to finance country specific needs. We call upon all African countries to establish governance and predictable financing mechanisms for IHR implementation and to build resilient health systems everywhere.

  • Physicians’ brain drain - a gravity model of migration flows
    Global. Health (IF 2.554) Pub Date : 2020-01-14
    Alina Botezat; Raul Ramos

    The past two decades have been marked by impressive growth in the migration of medical doctors. The medical profession is among the most mobile of highly skilled professions, particularly in Europe, and is also the sector that experiences the most serious labour shortages. However, surprisingly little is known about how medical doctors choose their destinations. In addition, the literature is scarce on the factors determining the sharp rise in the migration of doctors from Africa, Asia and Eastern and Southeastern Europe, and how the last economic crisis has shaped the migration flows of health professionals. We use the new module on health worker migration provided by the Organisation for Economic Co-operation and Development (OECD) for 2000–2016 in order to examine the channels through which OECD countries attract foreign physicians from abroad. We estimate a gravity model using the Pseudo-Poisson Maximum Likelihood estimator. Our results reveal that a lower unemployment rate, good remuneration of physicians, an aging population, and a high level of medical technology at the destination are among the main drivers of physicians’ brain drain. Furthermore, an analysis of the mobility of medical doctors from a number of regions worldwide shows that individuals react differently on a country-wise basis to various determinants present in the destination countries. Physicians from African countries are particularly attracted to destination countries offering higher wages, and to those where the density of medical doctors is relatively low. Concurrently, a higher demand for healthcare services and better medical technology in the receiving country drives the inflow of medical doctors from Central and Eastern Europe, while Asian doctors seem to preferentially migrate to countries with better school systems. This study contributes to a deeper understanding of the channels through which OECD countries attract foreign medical doctors from abroad. We find that, apart from dyadic factors, a lower unemployment rate, good remuneration of physicians, an aging population, and good medical infrastructure in the host country are among the main drivers of physicians’ brain drain. Furthermore, we find that utility from migration to specific countries may be explained by the heterogeneity of origin countries.

  • A survey of retail prices of antimicrobial products used in small-scale chicken farms in the Mekong Delta of Vietnam
    Global. Health (IF 2.554) Pub Date : 2020-01-14
    Nguyen T. T. Dung; Bao D. Truong; Nguyen V. Cuong; Nguyen T. B. Van; Doan H. Phu; Bach T. Kiet; Chalalai Rueanghiran; Vo B. Hien; Guy Thwaites; Jonathan Rushton; Juan Carrique-Mas

    In the Mekong Delta region of Vietnam, high quantities of products containing antimicrobial are used as prophylactic and curative treatments in small-scale chicken flocks. A large number of these contain antimicrobial active ingredients (AAIs) considered of ‘critical importance’ for human medicine according to the World Health Organization (WHO). However, little is known about the retail prices of these products and variables associated with the expense on antimicrobials at farm level. Therefore, the aims of the study were: (1) to investigate the retail price of antimicrobials with regards to WHO importance criteria; and (2) to quantify the antimicrobial expense incurred in raising chicken flocks. We investigated 102 randomly-selected small-scale farms raising meat chickens (100–2000 per flock cycle) in two districts in Dong Thap (Mekong Delta) over 203 flock production cycles raised in these farms. Farmers were asked to record the retail prices and amounts of antimicrobial used. A total of 214 different antimicrobial-containing products were identified. These contained 37 different AAIs belonging to 13 classes. Over half (60.3%) products contained 1 highest priority, critically important AAI, and 38.8% 1 high priority, critically important AAI. The average (farm-adjusted) retail price of a daily dose administered to a 1 kg bird across products was 0.40 cents of 1 US$ (₵) (SE ± 0.05). The most expensive products were those that included at least one high priority, critically important AAI, as well as those purchased in one of the two study districts. Farmers spent on average of ₵3.91 (SE ± 0.01) on antimicrobials per bird over the production cycle. The expense on antimicrobials in weeks with disease and low mortality was greater than on weeks with disease and high mortality, suggesting that antimicrobial use had a beneficial impact on disease outcomes (χ2 = 3.8; p = 0.052). Farmers generally used more expensive antimicrobials on older flocks. The retail prices of antimicrobial products used in chicken production in Mekong Delta small-scale chicken farms are very low, and not related to their relevance for human medicine. Farmers, however, demonstrated a degree of sensitivity to prices of antimicrobial products. Therefore, revising pricing policies of antimicrobial products remains a potential option to curb the use of antimicrobials of critical importance in animal production.

  • Methods to promote equity in health resource allocation in low- and middle-income countries: an overview
    Global. Health (IF 2.554) Pub Date : 2020-01-13
    James Love-Koh; Susan Griffin; Edward Kataika; Paul Revill; Sibusiso Sibandze; Simon Walker

    Unfair differences in healthcare access, utilisation, quality or health outcomes exist between and within countries around the world. Improving health equity is a stated objective for many governments and international organizations. We provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them. Methods are organised into four key policy questions facing decision-makers: (i) what is the current level of inequity in health; (ii) does government health expenditure benefit the worst-off; (iii) can government health expenditure more effectively promote equity; and (iv) which interventions provide the best value for money in reducing inequity. Benefit incidence analysis can be used to estimate the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify ‘best buy’ interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity. Methods from the economics literature can provide policymakers with a toolkit for addressing multiple aspects of health equity, from outcomes to financial protection, and can be adapted to accommodate data commonly available in low- and middle-income settings.

  • Understanding the implications of the Sustainable Development Goals for health policy and systems research: results of a research priority setting exercise
    Global. Health (IF 2.554) Pub Date : 2020-01-09
    Sara Bennett; Nasreen Jessani; Douglas Glandon; Mary Qiu; Kerry Scott; Ankita Meghani; Fadi El-Jardali; Daniel Maceira; Dena Javadi; Abdul Ghaffar

    Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals. To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals. We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30–36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings. Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures. To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

  • Determinants of enrollment decision in the community-based health insurance, North West Ethiopia: a case-control study
    Global. Health (IF 2.554) Pub Date : 2020-01-06
    Getasew Taddesse; Desta Debalkie Atnafu; Asmamaw Ketemaw; Yibeltal Alemu

    To identify the determinants for enrollment decision in the community-based health insurance program among informal economic sector-engaged societies, North West Ethiopia. Unmatched case-control study was conducted on 148 cases (member-to-insurance) and 148 controls (not-member-to-insurance program) from September 1 to October 30,2016. To select the villages and households, stratified then simple random sampling method was employed respectively. The data were entered in to Epi-info version 7 and exported to SPSS version 20 for analysis. Descriptive statistics, bi-variable, and multi-variable logistic regression analyses were computed to describe the study objectives and identify the determinants of enrolment decision for the insurance program. Odds ratio at 95% CI was used to describe the association between the independent and outcome variables. A total of 296 respondents (148 cases and 148 controls) were employed. The mean age for both cases and controls were 42 ± 11.73 and 40 ± 11.37 years respectively. Majority of respondents were males (87.2% for cases and 79% for controls). Family size between 4 and 6 (AOR = 2.26; 95% CI: 1.04, 4.89), history of illness by household (AOR = 3.24; 95% CI: 1.68, 6.24), perceived amount of membership contribution was medium (AOR = 2.3; 95% CI: 1.23, 4.26), being married (AOR = 6; 95% CI:1.43, 10.18) and trust on program (AOR = 4.79; 95% CI: 2.40, 9.55) were independent determinants for increased enrollment decision in the community-based health insurance. While, being merchant (AOR = 0.07; 95% CI: 0.09, 0.6) decreased the enrollment decision. Societies’ enrollment decision to community-based health insurance program was determined by demographic, social, economic and political factors. Households with large family sizes and farmers in the informal sector should be given maximal attention for intensifying enrollment decision in the insurance program.

  • Increasing the public health voice in global decision-making on nutrition labelling
    Global. Health (IF 2.554) Pub Date : 2020-01-03
    Anne Marie Thow; Alexandra Jones; Carmen Huckel Schneider; Ronald Labonté

    To respond to the global noncommunicable disease (NCD) crisis, the Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is developing global guidance for front of pack (FoP) nutrition labelling. Guidance from Codex regarding FoP nutrition labelling at the global level will almost certainly influence national policy making. This shift in Codex’s activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum; there is a potential commercial conflict of interest held by manufacturers of products whose consumption could be discouraged by such guidance. In this Commentary, we examine the implications of Codex processes for developing robust global guidance on FoP nutrition labelling and identify opportunities to increase consideration of public health objectives. To date, there has been significantly higher representation of food industry compared to public health actors in Codex discussions on FoP nutrition labelling. Without a strong public health voice in Codex, the industry voice could dominate discussions on FoP nutrition labelling, such that subsequent global guidance prioritises future trade and profits over potential risks to public health. There is currently a critical window of opportunity for public health interests to be prioritised in this multisectoral international forum. The key public health priority for global guidance on FoP nutrition labelling is to ensure protection of policy space for national governments to implement strong and effective regulation, and allow scope for innovation. Public health actors can engage directly with Codex processes, at both the national and global level, and also need to raise awareness among domestic policy makers – including with Ministries of Agriculture and Industry, which often represent countries at Codex – regarding the importance and effectiveness of FoP labelling in NCD prevention. Increased engagement with Codex processes represents a tangible new opportunity to strengthen global governance for public health, and move towards improved coherence between trade policy and health protection goals.

  • Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery
    Global. Health (IF 2.554) Pub Date : 2020-01-02
    Paul Truché; Haitham Shoman; Ché L. Reddy; Desmond T. Jumbam; Joanna Ashby; Adelina Mazhiqi; Taylor Wurdeman; Emmanuel A. Ameh; Martin Smith; Edwin Lugazia; Emmanuel Makasa; Kee B. Park; John G. Meara

    Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners – individuals and institutions – help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.

  • Social capital is associated with improved subjective well-being of older adults with chronic non-communicable disease in six low- and middle-income countries
    Global. Health (IF 2.554) Pub Date : 2020-01-02
    Aaron K. Christian; Olutobi Adekunle Sanuade; Michael Adu Okyere; Kafui Adjaye-Gbewonyo

    Non-communicable diseases (NCDs) are increasingly contributing to the morbidity and mortality burden of low and-middle income countries (LMIC). Social capital, particularly participation has been considered as a possible protective factor in the prevention and management of chronic conditions. It is also largely shown to have a negative effect on the well-being of patients. The current discourse on the well-being of individuals with NCDs is however focused more on a comparison with those with no NCDs without considering the difference between individuals with one chronic condition versus those with multiple chronic conditions (MCC). We employed a multinomial logit model to examine the effect of social capital, particularly social participation, on the subjective well-being (SWB) of older adults with single chronic condition and MCC in six LMIC. Social capital was associated with increased subjective well-being of adults in all the six countries. The positive association between social capital and subjective well-being was higher for those with a single chronic condition than those with multiple chronic conditions in India and South Africa. Conversely, an increase in the likelihood of having higher subjective well-being as social capital increased was greater for those with multiple chronic conditions compared to those with a single chronic condition in Ghana. The findings suggest that improving the social capital of older adults with chronic diseases could potentially improve their subjective well-being. This study, therefore, provides valuable insights into potential social determinants of subjective well-being of older adults with chronic diseases in six different countries undergoing transition. Additional research is needed to determine if these factors do in fact have causal effects on SWB in these populations.

  • Impacts of intellectual property provisions in trade treaties on access to medicine in low and middle income countries: a systematic review
    Global. Health (IF 2.554) Pub Date : 2019-12-30
    Md. Deen Islam; Warren A. Kaplan; Danielle Trachtenberg; Rachel Thrasher; Kevin P. Gallagher; Veronika J. Wirtz

    We present a systematic review describing ex-ante and ex-post evaluations of the impacts of intellectual property provisions in trade treaties on access to medicine in low and middle income countries. These evaluations focused on multilateral and bilateral trade agreements. We ascertained which IP provisions impacting access to medicines were the focus of these evaluations. We provide a further research agenda related to investigating the effect of trade agreement’s intellectual property provisions on access to medicines. We followed systematic review guidelines with 7 different databases to identify post-2000 ex ante and ex post evaluations of trade treaties on access to medicines in low and middle-income countries. We included only quantitative ex-ante studies that used structural modeling and simulations to derive quantitative predictions and ex-post studies that utilized empirical data and econometric techniques to quantify the effects of intellectual property provisions in free trade agreements on host country’s pharmaceutical industry. The search strategy identified 744 titles after removal of duplicates. We identified 14 studies that fulfilled all eligibility; 7 studies are ex-ante and 7 are ex-post. The studies looked at medicine price and cost, affordability, welfare effects and speed of medicine market launch. Changes in intellectual property policy due to the implementation of trade agreements affect price, medicines expenditure and sales, consumer welfare, and ultimately the affordability, of medicines. The direction and magnitude of the price effects differ between ex-ante and ex-post studies. Further, the reported impacts of policy changes due to trade agreements on medicine access seem clearly multifactorial. Both ex ante and ex post methods have advantages and limitations and, on balance, both types report, for the most part, an increase in price and a decrease in consumer welfare with imposition of intellectual property protection in trade agreements. The main differences between these studies are in the magnitude of the changes. There is a gap in our empirical understanding of the mechanisms through which such changes affect access to medicines and which outcomes relevant to access are most affected by which type of changes in intellectual property policy and law.

  • Urban health: an example of a “health in all policies” approach in the context of SDGs implementation
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Oriana Ramirez-Rubio; Carolyn Daher; Gonzalo Fanjul; Mireia Gascon; Natalie Mueller; Leire Pajín; Antoni Plasencia; David Rojas-Rueda; Meelan Thondoo; Mark J. Nieuwenhuijsen

    Cities are an important driving force to implement the Sustainable Development Goals (SDGs) and the New Urban Agenda. The SDGs provide an operational framework to consider urbanization globally, while providing local mechanisms for action and careful attention to closing the gaps in the distribution of health gains. While health and well-being are explicitly addressed in SDG 3, health is also present as a pre condition of SDG 11, that aims at inclusive, safe, resilient and sustainable cities. Health in All Policies (HiAP) is an approach to public policy across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP is key for local decision-making processes in the context of urban policies to promote public health interventions aimed at achieving SDG targets. HiAPs relies heavily on the use of scientific evidence and evaluation tools, such as health impact assessments (HIAs). HIAs may include city-level quantitative burden of disease, health economic assessments, and citizen and other stakeholders’ involvement to inform the integration of health recommendations in urban policies. The Barcelona Institute for Global Health (ISGlobal)‘s Urban Planning, Environment and Health Initiative provides an example of a successful model of translating scientific evidence into policy and practice with regards to sustainable and healthy urban development. The experiences collected through ISGlobal’s participation implementing HIAs in several cities worldwide as a way to promote HiAP are the basis for this analysis. The aim of this article is threefold: to understand the links between social determinants of health, environmental exposures, behaviour, health outcomes and urban policies within the SDGs, following a HiAP rationale; to review and analyze the key elements of a HiAP approach as an accelerator of the SDGs in the context of urban and transport planning; and to describe lessons learnt from practical implementation of HIAs in cities across Europe, Africa and Latin-America. We create a comprehensive, urban health related SDGs conceptual framework, by linking already described urban health dimensions to existing SDGs, targets and indicators. We discuss, taking into account the necessary conditions and steps to conduct HiAP, the main barriers and opportunities within the SDGs framework. We conclude by reviewing HIAs in a number of cities worldwide (based on the experiences collected by co-authors of this publication), including city-level quantitative burden of disease and health economic assessments, as practical tools to inform the integration of health recommendations in urban policies. A conceptual framework linking SDGs and urban and transportplanning, environmental exposures, behaviour and health outcomes, following a HiAP rationale, is designed. We found at least 38 SDG targets relevant to urban health, corresponding to 15 SDGs, while 4 important aspects contained in our proposed framework were not present in the SDGs (physical activity, noise, quality of life or social capital). Thus, a more comprehensive HiAP vision within the SDGs could be beneficial. Our analysis confirmed that the SDGs framework provides an opportunity to formulate and implement policies with a HiAP approach. Three important aspects are highlighted: 1) the importance of the intersectoral work and health equity as a cross-cutting issue in sustainable development endeavors; 2) policy coherence, health governance, and stakeholders’ participation as key issues; and 3) the need for high quality data. HIAs are a practical tool to implement HiAP. Opportunities and barriers related to the political, legal and health governance context, the capacity to inform policies in other sectors, the involvement of different stakeholders, and the availability of quality data are discussed based on our experience. Quantitative assessments can provide powerful data such as: estimates of annual preventable morbidity and disability-adjusted life-years (DALYs) under compliance with international exposure recommendations for physical activity, exposure to air pollution, noise, heat, and access to green spaces; the associated economic impacts in health care costs per year; and the number of preventable premature deaths when improvements in urban and transport planning are implemented. This information has been used to support the design of policies that promote cycling, walking, public, zero and low-emitting modes of transport, and the provision of urban greening or healthy public open spaces in Barcelona (e.g. Urban Mobility, Green Infrastructure and Biodiversity Plans, or the Superblocks’s model), the Bus Rapid Transit and Open Streets initiatives in several Latin American cities or targeted SDGs assessments in Morocco. By applying tools such as HIA, HiAP can be implemented to inform and improve transport and urban planning to achieve the 2030 SDG Agenda. Such a framework could be potentially used in cities worldwide, including those of less developed regions or countries. Data availability, taking into account equity issues, strenghtening the communication between experts, decision makers and citizens, and the involvement of all major stakeholders are crucial elements for the HiAP approach to translate knowledge into SDG implementation.

  • Financing intersectoral action for health: a systematic review of co-financing models
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Finn McGuire; Lavanya Vijayasingham; Anna Vassall; Roy Small; Douglas Webb; Teresa Guthrie; Michelle Remme

    Addressing the social and other non-biological determinants of health largely depends on policies and programmes implemented outside the health sector. While there is growing evidence on the effectiveness of interventions that tackle these upstream determinants, the health sector does not typically prioritise them. From a health perspective, they may not be cost-effective because their non-health outcomes tend to be ignored. Non-health sectors may, in turn, undervalue interventions with important co-benefits for population health, given their focus on their own sectoral objectives. The societal value of win-win interventions with impacts on multiple development goals may, therefore, be under-valued and under-resourced, as a result of siloed resource allocation mechanisms. Pooling budgets across sectors could ensure the total multi-sectoral value of these interventions is captured, and sectors’ shared goals are achieved more efficiently. Under such a co-financing approach, the cost of interventions with multi-sectoral outcomes would be shared by benefiting sectors, stimulating mutually beneficial cross-sectoral investments. Leveraging funding in other sectors could off-set flat-lining global development assistance for health and optimise public spending. Although there have been experiments with such cross-sectoral co-financing in several settings, there has been limited analysis to examine these models, their performance and their institutional feasibility. This study aimed to identify and characterise cross-sectoral co-financing models, their operational modalities, effectiveness, and institutional enablers and barriers. We conducted a systematic review of peer-reviewed and grey literature, following PRISMA guidelines. Studies were included if data was provided on interventions funded across two or more sectors, or multiple budgets. Extracted data were categorised and qualitatively coded. Of 2751 publications screened, 81 cases of co-financing were identified. Most were from high-income countries (93%), but six innovative models were found in Uganda, Brazil, El Salvador, Mozambique, Zambia, and Kenya that also included non-public and international payers. The highest number of cases involved the health (93%), social care (64%) and education (22%) sectors. Co-financing models were most often implemented with the intention of integrating services across sectors for defined target populations, although models were also found aimed at health promotion activities outside the health sector and cross-sectoral financial rewards. Interventions were either implemented and governed by a single sector or delivered in an integrated manner with cross-sectoral accountability. Resource constraints and political relevance emerged as key enablers of co-financing, while lack of clarity around the roles of different sectoral players and the objectives of the pooling were found to be barriers to success. Although rigorous impact or economic evaluations were scarce, positive process measures were frequently reported with some evidence suggesting co-financing contributed to improved outcomes. Co-financing remains in an exploratory phase, with diverse models having been implemented across sectors and settings. By incentivising intersectoral action on structural inequities and barriers to health interventions, such a novel financing mechanism could contribute to more effective engagement of non-health sectors; to efficiency gains in the financing of universal health coverage; and to simultaneously achieving health and other well-being related sustainable development goals.

  • Health for all by all-pursuing multi-sectoral action on health for SDGs in the WHO Eastern Mediterranean Region
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Ahmed Al-Mandhari; Maha El-Adawy; Wasiq Khan; Abdul Ghaffar

    The WHO Eastern Mediterranean Region is endowed with deep intellectual tradition, interesting cultural diversity, and a strong societal fabric; components of a vibrant platform for promoting health and wellbeing. Health has a central place in the Sustainable Development Goals (SDGs) for at least three reasons: Firstly, health is shaped by factors outside of the health sector. Secondly, health can be singled out among several SDGs as it provides a clear lens for examining the progress of the entire development process. Thirdly, in addition to being an outcome, health is also a contributor to achieving sustainable development. Realizing this central role of health in SDGs and the significance of collaboration among diverse sectors, the WHO is taking action. In its most recent General Program of Work 2019–2023 (GPW 13), the WHO has set a target of promoting the health of one billion more people by addressing social and other determinants of health through multi-sectoral collaboration. The WHO Regional Office for the Eastern Mediterranean Region, through Vision 2023, aims at addressing these determinants by adopting an equity-driven, leaving no one behind approach. Advocating for Health in All Policies, multi-sectoral action, community engagement, and strategic partnerships are the cornerstone for this approach. The focus areas include addressing the social and economic determinants of health across the life course, especially maternal and child health, communicable diseases, non-communicable diseases, and injuries. The aspirations are noteworthy – however, recent work in progress in countries has also highlighted some areas for improvement. Joint work among different ministries and departments at country level is essential to achieve the agenda of sustainable development. For collaboration, not only the ministries and departments need to be engaged, but the partnerships with other stakeholders such as civil society and private sector are a necessity and not a choice to effectively pursue achievement of SDGs.

  • Circular economy and environmental health in low- and middle-income countries
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Caradee Y. Wright; Linda Godfrey; Giovanna Armiento; Lorren K. Haywood; Roula Inglesi-Lotz; Katrina Lyne; Patricia Nayna Schwerdtle

    The circular economy framework for human production and consumption is an alternative to the traditional, linear concept of ‘take, make, and dispose’. Circular economy (CE) principles comprise of ‘design out waste and pollution’, ‘retain products and materials in use’, and ‘regenerate natural systems’. This commentary considers the risks and opportunities of the CE for low- and middle-income countries (LMICs) in the context of the Sustainable Development Goals (SDGs), acknowledging that LMICs must identify their own opportunities, while recognising the potential positive and negative environmental health impacts. The implementation of the CE in LMICs is mostly undertaken informally, driven by poverty and unemployment. Activities being employed towards extracting value from waste in LMICs are imposing environmental health risks including exposure to hazardous and toxic working environments, emissions and materials, and infectious diseases. The CE has the potential to aid towards the achievement of the SDGs, in particular SDG 12 (Responsible Consumption and Production) and SDG 11 (Sustainable Cities and Communities). However, since SDG 3 (Good Health and Well-Being) is critical in the pursuit of all SDGs, the negative implications of the CE should be well understood and addressed. We call on policy makers, industry, the health sector, and health-determining sectors to address these issues by defining mechanisms to protect vulnerable populations from the negative health impacts that may arise in LMICs as these countries domesticate the CE. Striving towards a better understanding of risks should not undermine support for the CE, which requires the full agency of the public and policy communities to realise the potential to accelerate LMICs towards sustainable production and consumption, with positive synergies for several SDGs.

  • Health equity monitoring is essential in public health: lessons from Mozambique
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Alba Llop-Gironés; Lucinda Cash-Gibson; Sergio Chicumbe; Francesc Alvarez; Ivan Zahinos; Elisio Mazive; Joan Benach

    Countries must be able to describe and monitor their populations health and well-being needs in an attempt to understand and address them. The Sustainable Development Goals (SDGs) have re-emphasized the need to invest in comprehensive health information systems to monitor progress towards health equity; however, knowledge on the capacity of health information systems to be able do this, particularly in low-income countries, remains very limited. As a case study, we aimed to evaluate the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with SDG 3 (Good Health and Well Being for All at All Ages). A data source mapping of the health information system in Mozambique was conducted. We followed the World Health Organization’s methodology of assessing data sources to evaluate the information available for every equity stratifier using a three-point scale: 1 - information is available, 2 - need for more information, and 3 - an information gap. Also, for each indicator we estimated the national average inequality score. Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 SDG3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with SDG3 can be fully disaggregated by equity stratifiers; they either lack some information (15 indicators) or do not have information at all (nine indicators). The indicators that contain more information are related to maternal and child health. There are important information gaps in Mozambique’s current national health information system which prevents it from being able to comprehensively measure and monitor health equity. Comprehensive national health information systems are an essential public health need. Significant policy and political challenges must also be addressed to ensure effective interventions and action towards health equity in the country.

  • Australian policies on water management and climate change: are they supporting the sustainable development goals and improved health and well-being?
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Toni Delany-Crowe; Dora Marinova; Matt Fisher; Michael McGreevy; Fran Baum

    Sustainable management of the natural environment is essential. Continued environmental degradation will lead to worsened health outcomes in countries and across generations. The Sustainable Development Goals (SDGs) provide a framework for viewing the preservation of natural environments and the promotion of health, well-being and health equity as interconnected pursuits. Within the SDG framework the goals of promoting environmental sustainability and human health are unified through attention to the social determinants of health and health equity (SDH/HE). This paper presents findings from a document analysis of all Australian environment sector policies and selected legislation to examine whether and how current approaches support progress toward achieving SDG goals on water, climate change, and marine ecosystems (Goals 6, 13 and 14), and to consider implications for health and health equity. Consideration of a broad range of SDH/HE was evident in the analysed documents. Related collaborations between environment and health sectors were identified, but the bulk of proposed actions on SDH/HE were initiated by the environment sector as part of its core business. Strengths of Australian policy in regard to SDGs 6, 13 and 14 are reflected in recognition of the effects of climate change, a strong cohesive approach to marine park protection, and recognition of the need to protect existing water and sanitation systems from future threats. However, climate change strategies focus predominately on resilience, adaptation and heat related health effects, rather than on more comprehensive mitigation policies. The findings emphasise the importance of strengthened cross-sectoral action to address both the drivers and effects of environmental degradation. A lack of policy coherence between jurisdictions was also evident in several areas, compounded by inadequate national guidance, where vague strategies and non-specific devolution of responsibilities are likely to compromise coordination and accountability. Evidence on planetary health recognises the interconnectedness of environmental and human health and, as such, suggests that ineffective management of climate change and water pose serious risks to both the natural environment and human well-being. To address these risks more effectively, and to achieve the SDGs, our findings indicate that cross-jurisdiction policy coherence and national coordination must be improved. In addition, more action to address global inequities is required, along with more comprehensive approaches to climate change mitigation.

  • Court as a health intervention to advance Canada’s achievement of the sustainable development goals : a multi-pronged analysis of Vancouver’s Downtown Community Court
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Regiane A. Garcia; Kristi Heather Kenyon; Claire E. Brolan; Juliana Coughlin; Daniel D. Guedes

    The increase in problematic substance use is a major problem in Canada and elsewhere, placing a heavy burden on health and justice system resources given a spike in drug-related offences. Thus, achievement of Sustainable Development Goal (SDG) Target 3.5 to ‘Strengthen the prevention and treatment of substance abuse’ is important for Canada’s overall realization of the SDGs, including SDG 3 (Good Health and Wellbeing). Since 2008, Vancouver’s Downtown Community Court (DCC) has pioneered an innovative partnership among the justice, health and social service systems to address individuals’ needs and circumstances leading to criminal behaviour. While researchers have examined the DCC’s impact on reducing recidivism, with Canada’s SDG health commitments in mind, we set out to examine the ways health and the social determinants of health (SDH) are engaged and framed externally with regard to DCC functioning, as well as internally by DCC actors. We employed a multi-pronged approach analyzing (1) publicly available DCC documents, (2) print media coverage, and (3) health-related discourse and references in DCC hearings. The documentary analysis showed that health and the SDH are framed by the DCC as instrumental for reducing drug-related offences and improving public safety. The observation data indicate that judges use health and SDH in providing context, understanding triggers for offences and offering rationale for sentencing and management plans that connect individuals to healthcare, social and cultural services. Our study contributes new insights on the effectiveness of the DCC as a means to integrate justice, health and social services for improved health and community safety. The development of such community court interventions, and their impact on health and the SDH, should be reported on by Canada and other countries as a key contribution to SDG 3 achievement, as well as the fulfillment of other targets under the SDG framework that contain the SDH. Consideration should be given by Canada as to how to capture and integrate the important data generated by the DCC and other problem-solving courts into SDG reporting metrics. Certainly, the DCC advances the SDGs’ underlying Leave No One Behind principle in a high-income country context.

  • Contradictions within the SDGs: are sin taxes for health improvement at odds with employment and economic growth in Zambia
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    Peter Hangoma; Gavin Surgey

    A recurring discussion in the literature relates to the possible contradictions among the Sustainable Development Goals (SDGs). The focus has been on economic goals, such as economic growth and goals related to climate change. We explore the possible contradictions that may arise between economic goals and health goals, specifically, the goal on Non-Communicable Diseases (NCDs) — SDG3.4. As a way to achieve SDG3.4, countries have been urged to introduce sin taxes, such as those on sugar. Yet others have argued that such taxes may affect employment (SDG 8.5), economic growth (SDG 8.1), and increase poverty (SDG1). However, there is limited or no reliable evidence, using actual experience, on the effect of sugar tax on health and economic outcomes. This makes it hard to assess the possible contradictions in SDGs that sugar taxes may generate. Using a conceptual framework on SDGs that views relationships among SDGs as either contradictory, reinforcing, or neutral, we carefully consider whether there are contradictions between SDG 3.4 on one hand and SDG 1, SDG 8.1, and SDG 8.5 on the other hand. We illustrate this using Zambia which recently introduced an equivalent 3% tax on non-alcoholic beverages, implicitly targeted at sugar-sweetened beverages (SSBs), given the stated goal of reducing NCDs. Concerns are that such a tax would be detrimental to the Zambia sugar value chain which contributes about 6% to GDP, in which case the achievement of SDG 3.4 (health) would be at odds with, or contradict, SDG 1, SDG 8.1, and SDG 8.5 (poverty eradication, economic growth, and creation of employment). We discuss that the existence of contradictions depend on a number of contextual factors, which allows us to make two conclusions about sugar taxation in Zambia. First, the current tax rate of 3% is likely neutral (no contradictions or reinforcing relationships) because it is too low to have any health or employment effects. However, the revenue raised can be reinvested to improve livelihoods. Secondly, the tax rate should be increased but care has to be exercised to ensure that the rate is not too high to generate contradictions. There will be need to carefully assess important parameters such as elasticities and explore alternative economic livelihoods. Without paying due consideration to important contextual factors, Zambia and many LMIC risk experiencing contradictions among SDGs.

  • Systems approaches for localising the SDGs: co-production of place-based case studies
    Global. Health (IF 2.554) Pub Date : 2019-12-18
    David T. Tan; José Gabriel Siri; Yi Gong; Benjamin Ong; Shiang Cheng Lim; Brian H. MacGillivray; Terry Marsden

    Localisation is a pervasive challenge in achieving sustainable development. Contextual particularities may render generalized strategies to achieve the Sustainable Development Goals (SDGs) unfeasible, impractical, or ineffective. Furthermore, many localities are resource- and data-poor, limiting applicability of the global SDG indicator framework. Tools to enable local actors to make sense of complex problems, communicate this understanding, and act accordingly hold promise in their ability to improve results. Systems approaches can help characterise local causal systems, identify useful leverage points, and foster participation needed to localise and catalyse development action. Critically, such efforts must be deeply rooted in place, involving local actors in mapping decision-processes and causation within local physical, social and policy environments. Given that each place has a unique geographical or spatial extent and therein lies its unique characters and problems, we term these activities “placially explicit.” We describe and reflect on a process used to develop placially explicit, systems-based (PESB) case studies on issues that intersect with and impact urban health and wellbeing, addressing the perspectives of various actors to produce place-based models and insights that are useful for SDG localisation. Seven case studies were co-produced by one or more Partners with place-based knowledge of the case study issue and a Systems Thinker. In each case, joint delineation of an appropriate framing was followed by iterative dialogue cycles to uncover key contextual factors, with attention to institutional and societal structures and paradigms and the motivations and constraints of other actors. Casual loop diagrams (CLDs) were iteratively developed to capture complex narratives in a simple visual way. Case study development facilitated transfer of local knowledge and development of systems thinking capacity. Partners reported new insights, including a shifting of problem frames and corresponding solution spaces to higher systems levels. Such changes led partners to re-evaluate their roles and goals, and thence to new actions and strategies. CLD-based narratives also proved useful in ongoing communications. Co-production of PESB case studies are a useful component of transdisciplinary toolsets for local SDG implementation, building the capacity of local actors to explore complex problems, identify new solutions and indicators, and understand the systemic linkages inherent in SDG actions across sectors and scales.

  • How healthy is a ‘healthy economy’? Incompatibility between current pathways towards SDG3 and SDG8
    Global. Health (IF 2.554) Pub Date : 2019-12-02
    Mariska Meurs; Lisa Seidelmann; Myria Koutsoumpa

    The interconnections between health and the economy are well known and well documented. The funding gap for realizing SDG3 for good health and well-being, however, remains vast. Simultaneously, economic growth, as expressed and measured in SDG8, continues to leave many people behind. In addition, international financial institutions, notably the International Monetary Fund (IMF), continue to influence the economic and social policies that countries adopt in ways that could undermine achievement of the SDGs. We examine the incoherence between the economic growth and health goals of the SDGs with reference to three East African countries, Malawi, Uganda, and Tanzania, where our organization has been working with partner organizations on SDG related policy analysis and advocacy work. In all three study countries, some health indicators, notably infant and child mortality, show improvement, but other indicators are lagging behind. Underfunding of the health sector is a major cause for poor health of the population and inequities in access to health care. GDP increases (as a measure of economic growth) do not automatically translate to increases in the countries’ health spending. Health expenditure from domestic public resources remains much lower than the internationally recommended minimum of USD 86 per capita. To achieve this level of health spending from domestic resources only, GDP in these countries would require an unrealistic manifold increase. External aid is proving insufficient to close the funding gap. IMF policy advice and loan conditionality that focus on GDP growth and tight monetary and fiscal targets impair growth in health and social sector spending, while recommended taxation measures are generally regressive. The existence of the GDP-focused SDG8 can delay efforts towards the achievement of the SDG3 for health and well-being if governments choose to focus on GDP growth without taking sufficient measures to equally distribute wealth and invest in the social sectors, often under the influence of policies advised or conditions put in place by the IMF. Although the IMF has started to acknowledge the importance of social development, its policy advice still adheres to austerity and pro-cyclical economic development harming a country’s population health. To realize the SDGs everywhere, governments should abandon GDP growth as a policy objective and place more emphasis on SDG17 on global co-operation.

  • A conceptual framework for capacity strengthening of health research in conflict: the case of the Middle East and North Africa region
    Global. Health (IF 2.554) Pub Date : 2019-11-28
    Nassim El Achi; Andreas Papamichail; Anthony Rizk; Helen Lindsay; Marilyne Menassa; Rima A. Abdul-Khalek; Abdulkarim Ekzayez; Omar Dewachi; Preeti Patel

    In conflict settings, research capacities have often been de-prioritized as resources are diverted to emergency needs, such as addressing elevated morbidity, mortality and health system challenges directly and/or indirectly associated to war. This has had an adverse long-term impact in such protracted conflicts such as those found in the Middle East and North Africa region (MENA), where research knowledge and skills have often been compromised. In this paper, we propose a conceptual framework for health research capacity strengthening that adapts existing models and frameworks in low- and middle-income countries and uses our knowledge of the MENA context to contextualise them for conflict settings. The framework was synthesized using “best fit” framework synthesis methodology. Relevant literature, available in English and Arabic, was collected through PubMed, Google Scholar and Google using the keywords: capacity building; capacity strengthening; health research; framework and conflict. Grey literature was also assessed. The framework is composed of eight principal themes: “structural levels”, “the influence of the external environment”, “funding, community needs and policy environment”, “assessing existing capacity and needs”, “infrastructure and communication”, “training, leadership and partnership”, “adaptability and sustainability”, and “monitoring and evaluation”; with each theme being supported by examples from the MENA region. Our proposed framework takes into consideration safety, infrastructure, communication and adaptability as key factors that affect research capacity strengthening in conflict. As it is the case more generally, funding, permissible political environments and sustainability are major determinants of success for capacity strengthening for health research programmes, though these are significantly more challenging in conflict settings. Nonetheless, health research capacity strengthening should remain a priority. The model presented is the first framework that focuses on strengthening health research capacity in conflict with a focus on the MENA region. It should be viewed as a non-prescriptive reference tool for health researchers and practitioners, from various disciplines, involved in research capacity strengthening to evaluate, use, adapt and improve. It can be further extended to include representative indicators and can be later evaluated by assessing its efficacy for interventions in conflict settings.

  • Correction to: Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis
    Global. Health (IF 2.554) Pub Date : 2019-04-10
    Kafui Adjaye-Gbewonyo; Sebastian Vollmer; Mauricio Avendano; Kenneth Harttgen


  • Public health law coverage in support of the health-related sustainable development goals (SDGs) among 33 Western Pacific countries
    Global. Health (IF 2.554) Pub Date : 2019-04-11
    Yuri Lee; So Yoon Kim

    A resilient health system is inevitable in attaining the health-related Sustainable Development Goals (SDGs). One way of strengthening health systems is improving the coverage of public health laws for better health governance. The aim of this study is to describe the public health law situation in the Western Pacific Region and analyse the association of public health law coverage with health-related SDGs statistics. A total of 33 Western Pacific countries were selected and analysed using a multi-group ecological study design. Public health law coverage was measured from April 2013 to October 2016 based on the public health law coverage module in the ‘Tool to Assess Health Law’ developed by the WHO Western Pacific Regional Office and Asian Institute for Bioethics and Health Law of Yonsei University. The health-related SDGs status were examined using health statistics data from World Health Statistics 2017 and 2018 by WHO and SDGs index scores of previous research. Countries with high public health law coverage were Vietnam, Republic of Korea, Hong Kong, and Singapore. Low coverage countries were mainly Pacific Island countries. High public health law coverage issues were health care organisation, communicable diseases, and substance abuse, whereas those of low coverage were human reproduction, family health, and oral health. Public health law coverage was associated with health-related SDGs statistics such as life expectancy at birth (r = 0.47, p = 0.03), health life expectancy at birth (r = 0.47, p = 0.04), health-related SDGs index (r = 0.43, p = 0.05). Among the SDG 3 indicators, maternal mortality ratio (r = − 0.53, p = 0.01), neonatal mortality rate (r = − 0.44, p = 0.02), new HIV infections (r = 0.78, p = 0.04), total alcohol consumption (r = 0.45, p = 0.02), adolescent birth rate (r = − 0.40, p = 0.04), UHC service coverage index (r = 0.50, p = 0.02), and IHR average core capacity score (r = 0.54, p = 0.004) were statistically meaningful. However, there was no association of public health law coverage with health statistics in other SDGs. This study proved the importance of public health law in supporting the attainment of health-related SDGs. These results should be used as the basis for review and action at country level in improving public health law for better health systems, consequently achieving health-related SDGs.

  • Sugar-sweetened beverage affordability and the prevalence of overweight and obesity in a cross section of countries
    Global. Health (IF 2.554) Pub Date : 2019-04-18
    Fabrizio Ferretti; Michele Mariani

    A key component of ‘obesogenic environments’ is the ready availability of convenient, calorie-dense foods, in the form of hyper-palatable and relatively inexpensive ultra-processed products. Compelling evidence indicates that the regular consumption of soft drinks, specifically carbonated and non-carbonated sugar-sweetened beverages (SSBs), has a significant impact on the prevalence of overweight and obesity. However, to implement country-level effective prevention programmes we need to supplement this evidence with quantitative knowledge of the relationships between overweight/obesity and the main determinants of SSB consumption, notably SSB prices and consumers’ disposable income. Affordability considers the simultaneous effects of both price and disposable income on the buying decision. The purpose of this study was to investigate the effect of SSB affordability on the consumers’ purchasing behaviour and weight-related health outcomes. Our study was divided into three parts. First, we computed SSB consumption and affordability for approximately 150 countries worldwide. Second, we estimated a demand function for SSBs to assess the impact of affordability on consumption at the country level. Third, we used a multivariate regression model and country data on the prevalence of overweight and obesity to test the role of SSB affordability in the current obesity epidemic. The analysis reveals that SSB affordability: 1) showed both a large variability across countries and a clear tendency to increase substantially with the level of economic development; 2) played a key role in determining cross-country differences in the amount of soft drink consumed per capita; and 3) was significantly associated with the prevalence rates of both overweight and obesity. Specifically, we show that a 10 % increase in SSB affordability was associated, on average, with approximately 0.4 more overweight/obese adults per 100 inhabitants. By controlling for the main possible confounding factors, our results clearly indicate that affordability is a major driver of purchasing behaviours and is significantly associated with the prevalence rates of both overweight and obesity. We thus suggest a fiscal approach to curb SSB consumption based on the effectiveness of ‘soda taxes’ to affect the long-term dynamic of SSB affordability.

  • The value of international volunteers experience to the NHS
    Global. Health (IF 2.554) Pub Date : 2019-04-23
    B. Zamora; M. Gurupira; M. Rodes Sanchez; Y. Feng; K. Hernandez-Villafuerte; J. Brown; K. Shah

    Global Engagement works with health partnerships to establish workforce and educational translation on a global scale to support the National Health Service (NHS). There is growing evidence on how international experiences (through volunteering, exchanges and placements) benefit the NHS through an innovative workforce that develops international best practice and promotes lifelong learning. Most of this evidence has been captured though surveys to returned international volunteers. However, there is limited evidence about how to quantify the value that returned international healthcare volunteers bring back to their country of residence. This paper identifies the various benefits to the NHS from returned international healthcare volunteers. The outcomes from returned international volunteers, which have been identified as relevant form a NHS perspective, are linked to three key areas in a multisector analytical framework used by the World Bank to evaluate labour market programmes: (1) Investment climate and Infrastructure, (2) Labor market regulations and institutions, and (3) Education and skills development. The monetary value of these outcomes is quantified through productivity indices which capture the economic value that the achievement of these outcomes have on the quality of the NHS labor force. This model is applied to a dataset of international volunteers provided by the Global Engagement health partnerships. The results suggest that international volunteering generates average productivity gains of up to 37% for doctors and up to 62% for nurses. Average productivity gains estimated from health partnerships data vary depending on duration of volunteering periods and occupational category mix. Our analysis offers a value for money rationale for international volunteering programmes purely from a domestic and NHS perspective. The valuation method considers only one of the aims of international volunteering programmes: the development of the existing and future NHS workforce. Broader benefits for health system strengthening at a global level are acknowledged but not accounted for. Overall, we conclude that if the acquisition of volunteering outcomes is realised, the NHS can accrue a productivity increase of between 24 and 41% per volunteer, with a value ranging from £13,215 to £25,934 per volunteer.

  • What is driving global obesity trends? Globalization or “modernization”?
    Global. Health (IF 2.554) Pub Date : 2019-04-27
    Ashley Fox; Wenhui Feng; Victor Asal

    Worldwide obesity has more than doubled since 1980. Researchers have attributed rising obesity rates to factors related to globalization processes, which are believed to contribute to obesity by flooding low-income country markets with inexpensive but obesogenic foods and diffusing Western-style fast food outlets (dependency/world systems theory). However, alternative explanations include domestic factors such as increases in unhealthy food consumption in response to rising income and higher women’s labor force participation as countries develop economically (“modernization” theory). To what extent are processes of globalization driving rising global overweight/obesity rates versus domestic economic and social development processes? This study evaluates the influence of economic globalization versus economic development and associated processes on global weight gain. Using two-way fixed-effects OLS regression with a panel dataset of mean body weight for 190-countries over a 30-year period (1980–2008), we find that domestic factors associated with “modernization” including increasing GDP per capita, urbanization and women’s empowerment were associated with increases in mean BMI over time. There was also evidence of a curvilinear relationship between GDP per capita and BMI: among low income countries, economic growth predicted increases in BMI whereas among high-income countries, higher GDP predicted lower BMI. By contrast, economic globalization (dependency/world systems theory) did not significantly predict increases in mean BMI and cultural globalization had mixed effects. These results were robust to different model specifications, imputation approaches and variable transformations. Global increases in overweight/obesity appear to be driven more by domestic processes including economic development, urbanization and women’s empowerment, and are less clearly negatively impacted by external globalization processes suggesting that the harms to health from global trade regimes may be overstated.

  • Cardio-metabolic disease risk factors among South Asian labour migrants to the Middle East: a scoping review and policy analysis
    Global. Health (IF 2.554) Pub Date : 2019-05-02
    Shiva Raj Mishra; Saruna Ghimire; Chandni Joshi; Bishal Gyawali; Archana Shrestha; Dinesh Neupane; Sudesh Raj Sharma; Yashashwi Pokharel; Salim S. Virani

    This paper aims to explore the burgeoning burden of cardiovascular and metabolic disease (CMD) risk factors among South Asian labor migrants to the Middle East. We conducted a qualitative synthesis of literature using PubMed/Medline and grey literature searches, supplemented by a policy review of policies from the South Asian countries. We found a high burden of cardio-metabolic risk factors among the migrants as well as among the populations in the home and the host countries. For example, two studies reported the prevalence of diabetes mellitus (DM) ranging between 9 and 17% among South Asian migrants. Overweight and obesity were highly prevalent amongst South Asian male migrants; prevalence ranged from 30 to 66% (overweight) and 17–80% (obesity) respectively. The home country population had a significant CMD risk factor burden. Nearly 14 to 40% have three or more risk factors: such as hypertension (17 to 37%), diabetes (3 to 7%), overweight (18 to 41%), and obesity (2 to 15%). The host country also exhibited similar burden of risk factors: hypertension (13 to 38%), diabetes (8 to 17%), overweight (33 to 77%) and obesity (35 to 41%). Only Nepal, Bangladesh and Sri Lanka have some provisions related to screening of CMDs before labor migration. Further, analysis of policy papers showed that none of the reviewed documents had requirements for screening of any specific CMDs, but chronic diseases were used generically, failing to specify specific screening target. Given the high burden of risk factors, migrants’ health should become an urgent priority. The lack of specific focus on screening during different stages of labor migration should receive attention. The International Labour Organization and the International Office for Migration, through their country coordination teams should engage local stakeholders to create policies and plans to address this concern. Similarly, there is a need for the host country to become an equal partner in these efforts, as migrant’s better cardiometabolic health is in the benefit of both host and home countries.

  • Inclusive engagement for health and development or ‘political theatre’: results from case studies examining mechanisms for country ownership in Global Fund processes in Malawi, Tanzania and Zimbabwe
    Global. Health (IF 2.554) Pub Date : 2019-05-07
    Russell Armstrong; Arlette Campbell White; Patrick Chinyamuchiko; Steven Chizimbi; Sarah Hamm Rush; Nana K. Poku

    For many countries, including Malawi, Tanzania and Zimbabwe, 2017 was a transition year for support from the Global Fund to Fight AIDS, Tuberculosis and Malaria as one funding cycle closed and another would begin in 2018. Since its inception in 2001, the Global Fund has required that countries demonstrate ownership and transparency in the development of their funding requests through specific processes for inclusive, deliberative engagement led by Country Coordinating Mechanisms (CCMs). In reporting results from case study research, the article explores whether, in the context of the three countries, such requirements continue to be fit-for-purpose given difficult choices to be made for financing and sustaining their HIV programmes. The findings show how complex, competing priorities for limited resources increasingly strain processes for inclusive deliberation, a core feature of the Global Fund model. Each country has chosen expansion of HIV treatment programmes as its main strategy for epidemic control relying almost exclusively on external funding sources for support. This step has, in effect, pre-committed HIV funding, whether available or not, well into the future. It has also largely pre-empted the results of inclusive dialogue on how to allocate Global Fund resources. As a result, such processes may be entering the realm of ‘political theatre,’ or processes for processes’ sake alone, rather than being important opportunities where critical decisions regarding priorities for national HIV programmes and how they are funded could or should be made. To address this, the Global Fund has begun an initiative to shore-up the capabilities of CCMs, with specialised technical and financial support, so that they can both grasp and influence the overall financing and sustainability of HIV programmes, rather than focussing on Global Fund programmes alone. What stronger CCMs could achieve, given the growing HIV-treatment-related commitments in these three countries, remains to be seen. Starting in 2020, the three countries will discover what resources the Global Fund will have for them for the 2021–2023 period. The resource needs for expanding HIV treatment programmes for this period are already foreseeable leaving few if any options for future deliberation should funding from the Global Fund and others not grow at a similar pace.

  • USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health
    Global. Health (IF 2.554) Pub Date : 2019-05-14
    Ronald Labonté; Eric Crosbie; Deborah Gleeson; Courtney McNamara

    In late 2018 the United States, Canada, and Mexico signed a new trade agreement (most commonly referred to by its US-centric acronym, the United States-Mexico-Canada Agreement, or USMCA) to replace the 1994 North American Free Trade Agreement (NAFTA). The new agreement is the first major trade treaty negotiated under the shadow of the Trump Administration’s unilateral imposition of tariffs to pressure other countries to accept provisions more favourable to protectionist US economic interests. Although not yet ratified, the agreement is widely seen as indicative of how the US will engage in future international trade negotiations. Drawing from methods used in earlier health impact assessments of the Trans-Pacific Partnership agreement, we undertook a detailed analysis of USMCA chapters that have direct or indirect implications for health. We began with an initial reading of the entire agreement, followed by multiple line-by-line readings of key chapters. Secondary sources and inter-rater (comparative) analyses by the four authors were used to ensure rigour in our assessments. The USMCA expands intellectual property rights and regulatory constraints that will lead to increased drug costs, particularly in Canada and Mexico. It opens up markets in both Canada and Mexico for US food exports without reducing the subsidies the US provides to its own producers, and introduces a number of new regulatory reforms that weaken public health oversight of food safety. It reduces regulatory policy space through new provisions on ‘technical barriers to trade’ and requirements for greater regulatory coherence and harmonization across the three countries. It puts some limitations on contentious investor-state dispute provisions between the US and Mexico, provisions often used to challenge or chill health and environmental measures, and eliminates them completely in disputes between the US and Canada; but it allows for new ‘legacy claims’ for 3 years after the agreement enters into force. Its labour and environmental chapters contain a few improvements but overall do little to ensure either workers’ rights or environmental protection. Rather than enhancing public health protection the USMCA places new, extended, and enforceable obligations on public regulators that increase the power (voice) of corporate (investor) interests during the development of new regulations. It is not a health-enhancing template for future trade agreements that governments should emulate.

  • Are industry-funded charities promoting “advocacy-led studies” or “evidence-based science”?: a case study of the International Life Sciences Institute
    Global. Health (IF 2.554) Pub Date : 2019-06-03
    Sarah Steele; Gary Ruskin; Lejla Sarcevic; Martin McKee; David Stuckler

    Industry sponsorship of public health research has received increasing scrutiny, and, as a result, many multinational corporations (MNCs), such as The Coca-Cola Company and Mars Inc., have committed to transparency with regard to what they fund, and the findings of funded research. However, these MNCs often fund charities, both national and international, which then support research and promote industry-favourable policy positions to leaders. We explore whether one industry funded charity, the International Life Sciences Institute (‘ILSI’), is the scientifically objective, non-lobby, internationally-credible body that it suggests it is, so as to aid the international health and scientific communities to judge ILSI’s outputs. Between June 2015 and February 2018, U.S. Right to Know), a non-profit consumer and public health group, submitted five U.S. state Freedom of Information requests (FOIs) to explore ILSI engagement with industry, policy makers, and/or researchers, which garnered a total of 17,163 pages for analysis. Two researchers explored these documents to assess the activities and conduct of ILSI against its purported objectives. Within the received documents we identified instances of ILSI seeking to influence research, conferences, public messages, and policy, including instances of punishments for ILSI bodies failing to promote industry-favourable messaging. We identified ILSI promoting its agenda with national and international bodies to influence policy and law, causing the World Health Organization to withdraw from official relations with what it now considers a private sector entity. ILSI seeks to influence individuals, positions, and policy, both nationally and internationally, and its corporate members deploy it as a tool to promote their interests globally. Our analysis of ILSI serves as a caution to those involved in global health governance to be wary of putatively independent research groups, and to practice due diligence before relying upon their funded studies and/or engaging in relationship with such groups.

  • The international partner universities of East African health professional programmes: why do they do it and what do they value?
    Global. Health (IF 2.554) Pub Date : 2019-06-07
    Aaron N. Yarmoshuk; Donald C. Cole; Anastasia Nkatha Guantai; Mughwira Mwangu; Christina Zarowsky

    Globalization and funding imperatives drive many universities to internationalize through global health programmes. University-based global health researchers, advocates and programmes often stress the importance of addressing health inequity through partnerships. However, empirical exploration of perspectives on why universities engage in these partnerships and the benefits of them is limited. To analyse who in international partner universities initiated the partnerships with four East African universities, why the partnerships were initiated, and what the international partners value about the partnerships. Fifty-nine key informants from 26 international universities partnering with four East African universities in medicine, nursing and/or public health participated in individual in-depth interviews. Transcripts were analysed thematically. We then applied Burton Clark’s framework of “entrepreneurial” universities characterized by an “academic heartland”, “expanded development periphery”, “managerial core” and “expanded funding base”, developed to examine how European universities respond to the forces of globalization, to interpret the data through a global health lens. Partnerships that were of interest to universities’ “academic heartland” - research and education - were of greatest interest to many international partners, especially research intensive universities. Some universities established and placed coordination of their global health activities within units consistent with an expanded development periphery. These units were sometimes useful for helping to establish and support global health partnerships. Success in developing and sustaining the global health partnerships required some degree of support from a strengthened steering or managerial core. Diversified funding in the form of third-stream funding, was found to be essential to sustain partnerships. Social responsibility was also identified as a key ethos required to unite the multiple elements in some universities and sustain global health partnerships. Universities are complex entities. Various elements determine why a specific university entered a specific international partnership and what benefits it accrues. Ultimately, integration of the various elements is required to grow and sustain partnerships potentially through embracing social responsibility as a common value.

  • Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda
    Global. Health (IF 2.554) Pub Date : 2019-06-13
    Ligia Paina; Gertrude Namazzi; Moses Tetui; Chrispus Mayora; Rornald Muhumuza Kananura; Suzanne N. Kiwanuka; Peter Waiswa; Aloysius Mutebi; Elizabeth Ekirapa-Kiracho

    In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care – through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh’s Model of Diffusion to reflect on these projects’ approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.

  • The development of a globally acceptable national model for occupational hygiene in Turkey: a modified Delphi study
    Global. Health (IF 2.554) Pub Date : 2019-06-13
    Sibel Kiran; Alp Ergor; Ceyda Sahan; Esra Emerce; Sergio Luzzi; Yucel Demiral

    Although various organizations working in developed countries established the standards and approaches used in occupational hygiene, occupational hygiene professional interests and needs continue to develop in a global context. There is thus an urgent need for expanded occupational hygiene models. For successful field implementation, these models should be based on several sets of criteria, including those related to international standards, various national requirements, and multidisciplinary approaches. This is particularly important for countries in which no occupational hygiene model has been developed. This study thus examined the consensus on occupational hygiene standards among stakeholders in Turkey regarding the development of a national model. A modified Delphi study was conducted among key occupational health experts in Turkey who could aid in the relevant implementation, policy-making, and educational processes for such a model. Participants were selected from various governmental institutions, non-governmental organizations, trade unions, universities, and occupational health practices. The first-round findings were obtained from open-ended questions. The results revealed several requirements, including the adoption of an international hygiene definition, the official recognition of professional and practical areas in Turkish occupational hygiene, hygienist training methods, priorities, and competent institutions. Second-round findings indicated a consensus rate of over 80% regarding the need for implementation standards, training and education standards, requirements and priorities, and competent institutions for professionals working in the field of occupational hygiene. A third-round and SWOT analysis was also conducted among the group to confirm the consensus issues. The search for solutions and developmental expectations increases when awareness of internationalization and the need for common global standards increase. This developmental process may provide the basis for an appropriate model in developing countries.

  • Applying an environmental public health lens to the industrialization of food animal production in ten low- and middle-income countries
    Global. Health (IF 2.554) Pub Date : 2019-06-13
    Yukyan Lam; Jillian P. Fry; Keeve E. Nachman

    Industrial food animal production (IFAP) is characterized by dense animal housing, high throughput, specialization, vertical integration, and corporate consolidation. Research in high-income countries has documented impacts on public health, the environment, and animal welfare. IFAP is proliferating in some low- and middle-income countries (LMICs), where increased consumption of animal-source foods has occurred alongside rising incomes and efforts to address undernutrition. However, in these countries IFAP’s negative externalities could be amplified by inadequate infrastructure and resources to document issues and implement controls. Using UN FAOSTAT data, we selected ten LMICs where food animal production is expanding and assessed patterns of IFAP growth. We conducted a mixed methods review to explore factors affecting growth, evidence of impacts, and information gaps; we searched several databases for sources in English, Spanish, and Portuguese. Data were extracted from 450+ sources, comprising peer-reviewed literature, government documents, NGO reports, and news articles. In the selected LMICs, not only has livestock production increased, but the nature of expansion appears to have involved industrialized methods, to varying extents based on species and location. Expansion was promoted in some countries by explicit government policies. Animal densities, corporate structure, and pharmaceutical reliance in some areas mirrored conditions found in high-income countries. There were many reported weaknesses in regulation and capacity for enforcement surrounding production and animal welfare. Global trade increasingly influences movement of and access to inputs such as feed. There was a nascent, compelling body of scientific literature documenting IFAP’s negative environmental and public health externalities in some countries. LMICs may be attracted to IFAP for economic development and food security, as well as the potential for increasing access to animal-source foods and the role these foods can play in alleviating undernutrition. IFAP, however, is resource intensive. Industrialized production methods likely result in serious negative public health, environmental, and animal welfare impacts in LMICs. To our knowledge, this is the first systematic effort to assess IFAP trends through an environmental public health lens for a relatively large group of LMICs. It contributes to the literature by outlining urgent research priorities aimed at informing national and international decisions about the future of food animal production and efforts to tackle global undernutrition.

  • The integration of the global HIV/AIDS response into universal health coverage: desirable, perhaps possible, but far from easy
    Global. Health (IF 2.554) Pub Date : 2019-06-18
    Gorik Ooms; Krista Kruja

    The international community’s health focus is shifting from achieving disease-specific targets towards aiming for universal health coverage. Integrating the global HIV/AIDS response into universal health coverage may be inevitable to secure its achievements in the long run, and for expanding these achievements beyond addressing a single disease. However, this integration comes at a time when international financial support for the global HIV/AIDS response is declining, while political support for universal health coverage is not translated into financial support. To assess the risks, challenges and opportunities of the integration of the global HIV/AIDS response into national universal health coverage plans, we carried out assessments in Indonesia, Kenya, Uganda and Ukraine, based on key informant interviews with civil society, policy-makers and development partners, as well as on a review of grey and academic literature. In the absence of international financial support, governments are turning towards national health insurance schemes to finance universal health coverage, making access to healthcare contingent on regular financial contributions. It is not clear how AIDS treatment will be fit in. While the global HIV/AIDS response accords special attention to exclusion due to sexual orientation and gender identity, sex work or drug use, efforts to achieve universal health coverage focus on exclusion due to poverty, gender and geographical inequalities. Policies aiming for universal health coverage try to include private healthcare providers in the health system, which could create a sustainable framework for civil society organisations providing HIV/AIDS-related services. While the global HIV/AIDS response insisted on the inclusion of civil society in decision-making policies, that is not (yet) the case for policies aiming for universal health coverage. While there are many obstacles to successful integration of the global HIV/AIDS response into universal health coverage policies, integration seems inevitable and is happening. Successful integration will require expanding the principle of ‘shared responsibility’ which emerged with the global HIV/AIDS response to universal health coverage, rather than relying solely on domestic efforts for universal health coverage. The preference for national health insurance as the best way to achieve universal health coverage should be reconsidered. An alliance between HIV/AIDS advocates and proponents of universal health coverage requires mutual condemnation of discrimination based on sexual orientation and gender identity, sex work or drug use, as well as addressing of exclusion based on poverty and other factors. The fulfilment of the promise to include civil society in decision-making processes about universal health coverage is long overdue.

  • Importance of the intellectual property system in attempting compulsory licensing of pharmaceuticals: a cross-sectional analysis
    Global. Health (IF 2.554) Pub Date : 2019-06-27
    Kyung-Bok Son

    Recently, interest in compulsory licensing of pharmaceuticals has been growing regardless of a country’s income- level. We aim to investigate the use of compulsory licensing as a legitimate part of the patent system and tool for the government to utilize by demonstrating that countries with a mature patent system were more likely to utilize compulsory licensing of pharmaceuticals. We used a multivariate logistic model to regress attempts to issue compulsory licensing on the characteristics of the intellectual property system, controlling for macro context variables and other explanatory variables at a country level. A total 139 countries, selected from members of the World Trade Organization, were divided into a CL-attempted group (N = 24) and a non-CL-attempted group (N = 115). An attempt to issue compulsory licensing was associated with population (+) and a dummy variable for other regions, including Europe and North America (−). After controlling for macro context variables, mature intellectual property system was positively associated with attempting compulsory licensing. Our study provided evidence of an association between attempting compulsory licensing and matured patent systems. This finding contradicts our current understanding of compulsory licensing, such as compulsory licensing as a measure to usurp traditional patent systems and sometimes diametrically opposed to the patent system. The findings also suggest a new role of compulsory licensing in current patent systems: compulsory licensing could be a potential alternative or complement to achieve access to medicines in health systems through manufacturing and exporting patented pharmaceuticals.

  • Telecoupled impacts of livestock trade on non-communicable diseases
    Global. Health (IF 2.554) Pub Date : 2019-07-01
    Min Gon Chung; Jianguo Liu

    Non-communicable diseases (NCDs)—chronic human health problems such as cardiovascular diseases linked to poor diets—are significant challenges for sustainable development and human health. The international livestock trade increases accessibility to cheap animal products that may expand diet-related NCDs worldwide. However, it is not well understood how the complex interconnections among livestock production, trade, and consumption affect NCD risks around the world. Our global dataset included 33 livestock products (meat, offal, and animal fats) in 156 countries from 1992 to 2011. We employed path analysis to uncover how livestock trade contributes to diet-related NCDs and identify underlying environmental and socioeconomic factors of livestock trade. Then we performed trend analyses to investigate long-term changes in livestock production and trade at a country level. We found that livestock consumption through livestock import increased diet-related NCD risks. This was especially true in developing countries, which in general were not well prepared in terms of policies for NCD risk reduction, and where there was a lack of funding to implement the policies. Population size and income level were the main factors affecting global livestock import activities. Our results suggest that new governance structures to incorporate separate international efforts, improved national policies, and bolstering individual efforts are needed to decrease NCD risks, particularly in developing countries.

  • Correction to: USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health
    Global. Health (IF 2.554) Pub Date : 2019-07-01
    Ronald Labonté; Eric Crosbie; Deborah Gleeson; Courtney McNamara

    Following publication of the original article [1], the authors flagged an error concerning two missing article references, which were unfortunately not provided prior to publication of the article.

  • The development and reform of public health in China from 1949 to 2019
    Global. Health (IF 2.554) Pub Date : 2019-07-02
    Li Wang; Zhihao Wang; Qinglian Ma; Guixia Fang; Jinxia Yang

    Public health system plays a vital role in the development of health sector in China and protects the health of Chinese people. However, there are few comprehensive reviews and studies focusing on its evolution and reform. It is worthwhile to pay attention to the public health development in China, given that the history and structure of public health system have their own characteristics in China. The study is a retrospective review of the development public health over seven decades in China. It presents the findings from some national or provincial survey data, interviews with key informants, reviews of relevant published papers and policy contents. This study identified four key stages that public health experienced in China: the initial stage centering on prevention, the stage of deviation with more attention to treatment but little to prevention, the recovery stage after SARS(Severe Acute Respiratory Syndromes) Crisis, and the new stage to an equitable and people-centered system. In the latest stage, the National Basic Public Health Service Program (NBPHSP) is implemented to respond the threat of noncommunicable diseases (NCDs) and has achieved some initial results, while there are still many challenges including service quality, poor integration among service items and IT system, lack of quality professionals and insufficient intersectoral endeavor. There are unique Chinese wisdom and remarkable achievements as well as twists and turns on the development of China’s public health. Prevention-first, flexible structure of the system, multi-agency collaboration and mass mobilization and society participation are the main experience of public health in early stage. Despite twists and turns since 1980s, public health system in China shows substantial resilience which may be from the government’s continuous commitment to social development and people’s livelihoods and its flexible governance. In 2010s, in order to achieve the well-off society, Chinese government pays unprecedented attention to health sector, which bring a new wave of opportunities to public health such as remaining the NBPHSP for priority. The evolution and reform of China’s public health is based on its national condition, accumulates rich experience but also faces many common worldwide challenges. Getting this development and reform right is important to China’s social and economic development in future, and China’s experience in public health may provide many lessons for other countries. Public health in China needs to focus on prevention, strengthen multi-agency coordination mechanism, improve the quality of public health services in the future.

  • The global fight against trans-fat: the potential role of international trade and law
    Global. Health (IF 2.554) Pub Date : 2019-07-11
    Andrea Parziale; Gorik Ooms

    Non-communicable diseases in general and cardiovascular diseases in particular are a leading cause of death globally. Trans-fat consumption is a significant risk factor for cardiovascular diseases. The World Health Organization’s ‘REPLACE’ action package of 2018 aims to eliminate it completely in the global food supply by 2023. Legislative and other regulatory actions (i.e., banning trans-fat) are considered as effective means to achieve such a goal. Both wealthier and poorer countries are taking or considering action, as shown by the United States food regulations and Cambodian draft food legislation discussed in this paper. This paper reviews these actions and examines public and private stakeholders’ incentives to increase health-protecting or health-promoting standards and regulations at home and abroad, setting the ground for further research on the topic. It focuses on the potential of trade incentives as a potential driver of a ‘race to the top’. While it has been documented that powerful countries use international trade instruments to weaken other countries’ national regulations, at times these powerful countries may also be interested in more stringent regulations abroad to protect their exports from competition from third countries with less stringent regulations. This article explores practical and principled considerations on how such a dynamic may spread trans-fat restrictions globally. It argues that trade dynamics and public health considerations within powerful countries may help to promote anti-trans-fat regulation globally but will not be sufficient and is ethically questionable. True international regulatory cooperation is needed and could be facilitated by the World Health Organization. Nevertheless, the paper highlights that international trade and investment law offers opportunities for anti-trans-fat policy diffusion globally.

  • How environmental treaties contribute to global health governance
    Global. Health (IF 2.554) Pub Date : 2019-07-19
    Jean-Frédéric Morin; Chantal Blouin

    Recent work in international relations theory argues that international regimes do not develop in isolation, as previously assumed, but evolve as open systems that interact with other regimes. The implications of this insight’s for sustainable development remains underexplored. Even thought environmental protection and health promotion are clearly interconnected at the impact level, it remains unclear how global environmental governance interacts with global health governance at the institutional level. In order to fill this gap, this article aims to assess how environmental treaties contribute to global health governance. To assess how environmental treaties contribute to global health governance, we conducted a content analysis of 2280 international environmental treaties. For each of these treaties, we measure the type and number of health-related provisions in these treaties. The result is the Health and Environment Interplay Database (HEIDI), which we make public with the publication of this article. This new database reveals that more than 300 environmental treaties have health-related provisions. We conclude that the global environmental regime contributes significantly to the institutionalization of the global health regime, considering that the health regime includes itself very few treaties focusing primarily on health. When reflecting on how global governance can improve population health, decision makers should not only consider the instruments available to them within the realm of global health institutions. They should broaden their perspectives to integrate the contribution of other global regimes, such as the global environmental regime.

  • Book review: Human Rights in Global Health: Rights-Based Governance for a Globalizing World
    Global. Health (IF 2.554) Pub Date : 2019-07-23
    Unni Gopinathan

    This is a review of the book “Human Rights in Global Health: Rights-Based Governance for a Globalizing World” edited by Benjamin Mason Meier and Lawrence O. Gostin.

  • Zika, abortion and health emergencies: a review of contemporary debates
    Global. Health (IF 2.554) Pub Date : 2019-07-24
    Clare Wenham; Amaral Arevalo; Ernestina Coast; Sonia Corrêa; Katherine Cuellar; Tiziana Leone; Sandra Valongueiro

    The Zika outbreak provides pertinent case study for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates. This paper provides a baseline of contemporary debates taking place in the intersection of two key health policy areas, and seeks to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our paper suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, epitomised by Zika, and 3) the need for rights based approaches to health. Global health security planning and response should specifically include programmatic activity for SRH provision during health emergencies.

  • Strengthening national health research systems in the WHO African Region – progress towards universal health coverage
    Global. Health (IF 2.554) Pub Date : 2019-07-26
    Simbarashe Rusakaniko; Michael Makanga; Martin O. Ota; Moses Bockarie; Geoffrey Banda; Joseph Okeibunor; Francisca Mutapi; Prosper Tumusiime; Thomas Nyirenda; Joses Muthuri Kirigia; Juliet Nabyonga-Orem

    Health challenges and health systems set-ups differ, warranting contextualised healthcare interventions to move towards universal health coverage. As such, there is emphasis on generation of contextualized evidence to solve local challenges. However, weak research capacity and inadequate resources remain an impendiment to quality research in the African region. WHO African Region (WHO AFR) facilitated the adoption of a regional strategy for strengthening national health research systems (NHRS) in 2015. We assessed the progress in strengthening NHRS among the 47 member states of the WHO AFR. We employed a cross sectional survey design using a semi structured questionnaire. All the 47member states of WHO AFR were surveyed. We assessed performance against indicators of the regional research strategy, explored facilitating factors and barriers to strengthening NHRS. Using the research barometer, which is a metric developed for the WHO AFR we assessed the strength of NHRS of member states. Data were analysed in Excel Software to calculate barometer scores for NHRS function and sub-function. Thematic content was employed in analysing the qualitative data. Data for 2014 were compared to 2018 to assess progress. WHO AFR member states have made significant progress in strengthening their NHRS. Some of the indicators have either attained or exceeded the 2025 targets. The average regional barometer score improved from 43% in 2014 to 61% in 2018. Significant improvements were registered in the governance of research for health (R4H); developing and sustaining research resources and producing and using research. Financing R4H improved only modestly. Among the constraints are the lengthy ethical clearance processes, weak research coordination mechanisms, weak enforcement of research laws and regulation, inadequate research infrastructure, limited resource mobilisation skills and donor dependence. There has been significant improvement in the NHRS of member states of the WHO AFRO since the last assessment in 2014. Improvement across the different objectives of the regional research strategy is however varied which compromises overall performance. The survey highlighted the areas with slow improvement that require a concerted effort. Furthermore, the study provides an opportunity for countries to share best practice in areas of excellence.

  • What is the meaning of urban liveability for a city in a low-to-middle-income country? Contextualising liveability for Bangkok, Thailand
    Global. Health (IF 2.554) Pub Date : 2019-07-30
    Amanda Alderton; Melanie Davern; Kornsupha Nitvimol; Iain Butterworth; Carl Higgs; Elizabeth Ryan; Hannah Badland

    Creating ‘liveable’ cities has become a priority for various sectors, including those tasked with improving population health and reducing inequities. Two-thirds of the world’s population will live in cities by 2050, with the most rapid urbanisation in low- and middle-income countries (LMIC). However, there is limited guidance about what constitutes a liveable city from a LMIC perspective, with most of the evidence relating to high-income countries, such as Australia. Existing liveability frameworks include features such as public transport, affordable housing, and public open space; however, these frameworks may not capture all of the liveability considerations for cities in LMIC contexts. This case study formed a multi-sectoral partnership between academics, policymakers (Bangkok Metropolitan Administration, Victorian (Australia) Department of Health and Human Services), and a non-government organisation (UN Global Compact – Cities Programme). This study aimed to: 1) conceptualise and prioritise components of urban liveability within the Bangkok, Thailand context; 2) identify alignment to or divergence from other existing liveability tools; and 3) identify potential indicators and data sources for use within a Pilot Bangkok Liveability Framework. The Urban Liveability Workshop involving technical leaders from the Bangkok Metropolitan Administration and a rapid review of liveability literature informed the conceptualisation of liveability for Bangkok. The Bangkok Metropolitan Administration Working Group and key informants in Bangkok provided input into the liveability framework. Indicators identified for Bangkok were mapped onto existing liveability tools, including the UN Global Compact CityScan. Findings revealed commonalities with the Australian liveability definition, as well as new potential indicators for Bangkok. The resulting Pilot Bangkok Liveability Framework provides a structure for measuring liveability in Bangkok that can be implemented by the Bangkok Metropolitan Administration immediately, pending appropriate data acquisition and licensing. The Bangkok Metropolitan Administration Working Group and key informants identified core issues for implementation, including limited spatial data available at the district-level or lower. This study conceptualised urban liveability for Bangkok, a city in a LMIC context, with potential for adjustment to other cities. Future work should leverage opportunities for using open source data, building local capacity in spatial data expertise, and knowledge sharing between cities.

  • Lessons learned on teaching a global audience with massive open online courses (MOOCs) on health impacts of climate change: a commentary
    Global. Health (IF 2.554) Pub Date : 2019-08-22
    Sandra Barteit; Ali Sié; Maurice Yé; Anneliese Depoux; Valérie R. Louis; Rainer Sauerborn

    The adverse health impacts of climate change are increasing on a global level. However, knowledge about climate change and health is still unavailable to many global citizens, in particular on adaptation measures and co-benefits of health mitigation. Educational technologies, such as massive open online courses (MOOCs), may have a high potential for providing access to information about climate change links to health for a global audience. We developed three MOOCs addressing the link between climate change and health to take advantage of the methodology’s broad reach and accelerate knowledge dissemination on the nexus of climate change and health. The primary objective was to translate an existing face-to-face short course that only reached a few participants on climate change and health into globally accessible learning opportunities. In the following, we share and comment on our lessons learned with the three MOOCs, with a focus on global teaching in the realm of climate change and health. Overall, the three MOOCs attracted a global audience with diverse educational backgrounds, and a large number of participants from low-income countries. Our experience highlights that MOOCs may play a part in global capacity building, potentially for other health-related topics as well, as we have found that our MOOCs have attracted participants within low-resource contexts. MOOCs may be an effective method for teaching and training global students on health topics, in this case on the complex links and dynamics between climate change and health and may further act as an enabler for equitable access to quality education.

  • Preparedness and management of global public health threats at points of entry in Ireland and the EU in the context of a potential Brexit
    Global. Health (IF 2.554) Pub Date : 2019-09-03
    Máirín Boland; Mary O’Riordan

    Health security in the European Union (EU) aims to protect citizens from serious threats to health such as biological agents and infectious disease outbreaks- whether natural, intentional or accidental. Threats may include established infections, emerging diseases or chemical and radiological agents. Co-ordinated international efforts attempt to minimize risks and mitigate the spread of infectious disease across borders. We review the current situation (March 2019) with respect to detection and management of serious human health threats across Irish borders- and what may change for Ireland if/when the United Kingdom (UK) withdraws from the EU (Brexit). Specifically, this paper reviews international legislation covering health threats, and its national transposition; and EU legislation and processes, especially the relevant European Decision No. 1082/2013/EU of the European Parliament and of the Council on serious cross border threats to health with repeal of Decision No 2119/98/EC. We enumerate European surveillance systems and agencies which relate to port health security; we consider consortia and academic arrangements within the EU framework and established collaboration with the World Health Organization. We describe current Health Services Executive port health structures in Ireland which address preparedness and management of human health threats at points of entry. We appraise risks which Brexit could bring, reviewing literature on shared concerns about these risks, and we evaluate post-Brexit challenges for the EU, and potential opportunities to remain within current structures in shared health threat preparedness and response. It is imperative that the UK, Ireland and the EU work together to mitigate these risks using some agreed joint coordination mechanisms for a robust, harmonised approach to global public health threats at points of entry.

  • The glocalization of antimicrobial stewardship
    Global. Health (IF 2.554) Pub Date : 2019-09-09
    Olivier Rubin

    This brief commentary argues that glocal governance introduces a fruitful new perspective to the global governance debate of AMR, and cautions against too strict a focus on establishing globally binding governance regimes for curbing AMR.

  • A multidisciplinary review of the policy, intellectual property rights, and international trade environment for access and affordability to essential cancer medications
    Global. Health (IF 2.554) Pub Date : 2019-09-18
    Sangita M. Baxi; Reed Beall; Joshua Yang; Tim K. Mackey

    In 2015, the World Health Organization (WHO) Expert Committee approved the addition of 16 cancer medicines to the WHO Model List of Essential Medicines (EML), bringing the total number of cancer medicines on the list to 46. This change represented the first major revision to the EML oncology section in recent history and reinforces international recognition of the need to ensure access and affordability for cancer treatments. Importantly, many low and middle-income countries rely on the EML, as well as the children’s EML, as a guide to establish national formularies, and moreover use these lists as tools to negotiate medicine pricing. However, EML inclusion is only one component that impacts cancer treatment access. More specifically, factors such as intellectual property rights and international trade agreements can interact with EML inclusion, drug pricing, and accessibility. To better understand this dynamic, we conducted an interdisciplinary review of the patent status of EML cancer medicines compared to other EML noncommunicable disease medicines using the 17th, 18th, 19th, 20th, and 21st editions of the list. We also explored the interaction of intellectual property rights with the international trade regime and how trade agreements can and do impact cancer treatment access and affordability. Based on this analysis, we conclude that patent status is simply one factor in the complex international environment of health systems, IPR policies, and trade regimes and that aligning these oftentimes disparate interests will require shared global governance across the cancer care continuum.

  • Corporations’ use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation
    Global. Health (IF 2.554) Pub Date : 2019-09-25
    Gary Jonas Fooks; Simon Williams; Graham Box; Gary Sacks

    Sugar sweetened beverages (SSB) are a major source of sugar in the diet. Although trends in consumption vary across regions, in many countries, particularly LMICs, their consumption continues to increase. In response, a growing number of governments have introduced a tax on SSBs. SSB manufacturers have opposed such taxes, disputing the role that SSBs play in diet-related diseases and the effectiveness of SSB taxation, and alleging major economic impacts. Given the importance of evidence to effective regulation of products harmful to human health, we scrutinised industry submissions to the South African government’s consultation on a proposed SSB tax and examined their use of evidence. Corporate submissions were underpinned by several strategies involving the misrepresentation of evidence. First, references were used in a misleading way, providing false support for key claims. Second, raw data, which represented a pliable, alternative evidence base to peer reviewed studies, was misused to dispute both the premise of targeting sugar for special attention and the impact of SSB taxes on SSB consumption. Third, purposively selected evidence was used in conjunction with other techniques, such as selective quoting from studies and omitting important qualifying information, to promote an alternative evidential narrative to that supported by the weight of peer-reviewed research. Fourth, a range of mutually enforcing techniques that inflated the effects of SSB taxation on jobs, public revenue generation, and gross domestic product, was used to exaggerate the economic impact of the tax. This “hyperbolic accounting” included rounding up figures in original sources, double counting, and skipping steps in economic modelling. Our research raises fundamental questions concerning the bona fides of industry information in the context of government efforts to combat diet-related diseases. The beverage industry’s claims against SSB taxation rest on a complex interplay of techniques, that appear to be grounded in evidence, but which do not observe widely accepted approaches to the use of either scientific or economic evidence. These techniques are similar, but not identical, to those used by tobacco companies and highlight the problems of introducing evidence-based policies aimed at managing the market environment for unhealthful commodities.

  • Getting the most from after action reviews to improve global health security
    Global. Health (IF 2.554) Pub Date : 2019-10-10
    Michael A. Stoto; Christopher Nelson; Rachael Piltch-Loeb; Landry Ndriko Mayigane; Frederik Copper; Stella Chungong

    After Action Reviews (AARs) provide a means to observe how well preparedness systems perform in real world conditions and can help to identify – and address – gaps in national and global public health emergency preparedness (PHEP) systems. WHO has recently published guidance for voluntary AARs. This analysis builds on this guidance by reviewing evidence on the effectiveness of AARs as tools for system improvement and by summarizing some key lessons about ensuring that AARs result in meaningful learning from experience. Empirical evidence from a variety of fields suggests that AARs hold considerable promise as tools of system improvement for PHEP. Our review of the literature and practical experience demonstrates that AARs are most likely to result in meaningful learning if they focus on incidents that are selected for their learning value, involve an appropriately broad range of perspectives, are conducted with appropriate time for reflection, employ systems frameworks and rigorous tools such as facilitated lookbacks and root cause analysis, and strike a balance between attention to incident specifics vs. generalizable capacities and capabilities. Employing these practices requires a PHEP system that facilitates the preparation of insightful AARs, and more generally rewards learning. The barriers to AARs fall into two categories: concerns about the cultural sensitivity and context, liability, the political response, and national security; and constraints on staff time and the lack of experience and the requisite analytical skills. Ensuring that AARs fulfill their promise as tools of system improvement will require ongoing investment and a change in mindset. The first step should be to clarify that the goal of AARs is organizational learning, not placing blame or punishing poor performance. Based on experience in other fields, the buy-in of agency and political leadership is critical in this regard. National public health systems also need support in the form of toolkits, guides, and training, as well as research on AAR methods. An AAR registry could support organizational improvement through careful post-event analysis of systems’ own events, facilitate identification and sharing of best practices across jurisdictions, and enable cross-case analyses.

  • Experiences of care in the context of payment for performance (P4P) in Tanzania
    Global. Health (IF 2.554) Pub Date : 2019-10-16
    Victor Chimhutu; Marit Tjomsland; Mwifadhi Mrisho

    Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.

  • Extent, nature and consequences of performing outside scope of training in global health
    Global. Health (IF 2.554) Pub Date : 2019-11-01
    Ashti Doobay-Persaud; Jessica Evert; Matthew DeCamp; Charlesnika T. Evans; Kathryn H. Jacobsen; Natalie E. Sheneman; Joshua L. Goldstein; Brett D. Nelson

    Globalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one’s scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified. The authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years. A total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time. Given that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.

  • Pension and state funds dominating biomedical R&D investment: fiduciary duty and public health
    Global. Health (IF 2.554) Pub Date : 2019-11-06
    Slavek Roller

    Who benefits from the commercial biomedical research and development (R&D)? Patients-consumers and investors-shareholders have traditionally been viewed as two distinct groups with conflicting interests: shareholders seek maximum profits, patients - maximum clinical benefit. However, what happens when patients are the shareholders? With billions of dollars of public risk capital channeled into the drug development industry, analysing the complex financial architecture and the market for corporate control is essential for understanding industry’s characteristics, such as pricing strategies or R&D priorities. Adding investments by governmentally-mandated retirement schemes, central and promotional banks, and sovereign wealth funds to tax-derived governmental financing shows that the majority of biomedical R&D funding is public in origin. Despite this, even in the high-income countries patients can be denied access to effective treatments due to their high cost. Since these costs are set by the drug development firms that are owned in substantial part by the retirement accounts of said patients, the complex financial architecture of biomedical R&D may be inconsistent with the objectives of the ultimate beneficiaries. The divergence in economic and public health performance of the drug development industry is resultant from its financial underwriting by enormously expanded pension schemes, governmentally mandated to represent the interests of “captive” beneficiaries, as well as similar policymaker-designed funding flows, whose standards of transparency, accountability and representation are substantially lower than that of governments themselves. Strengthening those elements of institutional design and thus ensuring active responsible shareholding in the interest of the patients-savers is an under-utilised, but potentially high-impact opportunity for advancing public health.

  • Correction to: Are industry-funded charities promoting “advocacy-led studies” or “evidence-based science”?: a case study of the International Life Sciences Institute
    Global. Health (IF 2.554) Pub Date : 2019-11-06
    Sarah Steele; Gary Ruskin; Lejla Sarcevic; Martin McKee; David Stuckler

    Since the publication of this article [1], the journal and the authors have received further context about the position of ILSI on the issue with the ILSI Mexico branch.

  • Determinants of nutritional status among children under age 5 in Ethiopia: further analysis of the 2016 Ethiopia demographic and health survey
    Global. Health (IF 2.554) Pub Date : 2019-11-06
    Zerihun Yohannes Amare; Mossa Endris Ahmed; Adey Belete Mehari

    The aim of this study was to examine the determinants of nutritional status among children under age 5 (0–59 months) in Ethiopia. Child malnutrition is an underlying cause of almost half (45%) of child deaths, particularly in low socioeconomic communities of developing countries. In Ethiopia, the prevalence of stunting decreased from 47% in 2005 to 39% in 2016, but the prevalence of wasting changed little over the same time period (from 11 to 10%). Despite improvements in reducing the prevalence of malnutrition, the current rate of progress is not fast enough to reach the World Health Organization global target for reducing malnutrition 40% by 2025. This study used data from the 2016 Ethiopia Demographic and Heath Survey (EDHS). The analysis used stunting and wasting as dependent variables, while the independent variables were characteristics of children, mothers, and households. Logistic regression was used to analyze the determinants of nutritional status among children. Bivariate analysis was also used to analyze the association between the dependent and independent variables. Study results show that child’s age, sex, and perceived birth weight, mother’s educational status, body mass index (BMI), and maternal stature, region, wealth quintile, type of toilet facility, and type of cooking fuel had significant associations with stunting. Child’s age, sex, and perceived birth weight, mother’s BMI, and residence and region showed significant associations with wasting. The study found that child, maternal, and household characteristics were significantly associated with stunting and wasting among children under age 5. These findings imply that a multi-sectorial and multidimensional approach is important to address malnutrition in Ethiopia. The education sector should promote reduction of cultural and gender barriers that contribute to childhood malnutrition. The health sector should encourage positive behaviors toward childcare and infant feeding practices. More should be done to help households adopt improved types of toilet facilities and modern types of cooking fuels.

  • The use of stunting as a nutrition indicator in Yemen civil war
    Global. Health (IF 2.554) Pub Date : 2019-11-08
    Nima Yaghmaei; Debarati Guha-Sapir

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  • Australia’s overseas development aid commitment to health through the sustainable development goals: a multi-stakeholder perspective
    Global. Health (IF 2.554) Pub Date : 2019-11-21
    Claire E. Brolan; Christopher A. McEwan; Peter S. Hill

    In 2018, the Australian Government, through a Senate-led Parliamentary Inquiry, sought the views of diverse stakeholders on Sustainable Development Goal (SDG) implementation both domestically and as part of Australia’s Overseas Development Assistance (ODA) program. One hundred and sixty-four written submissions were received. The submissions offered perspective and guidance from a rich cross-section of those involved, and with keen interest in, Australia’s ODA-SDG commitment. This article identifies and explores the submissions to that Inquiry which placed impetus on Australia’s ODA-SDG and health and development nexus. It then compares how the synthesized views, concerns and priorities of selected Inquiry stakeholders align with and reflect the Australian Government’s treatment of SDG 3 in its SDG Voluntary National Review (VNR), as well as with the final Inquiry report summarizing submission content. Four key themes were synthesized and drawn from the thirty-one stakeholder submissions included in our analysis. Disconnect was then found to exist between the selected stakeholder views and the Australian Government’s SDG-VNR’s treatment of SDG 3, as well as with the content of the Parliamentary Inquiry’s final report with respect to the ODA-SDG and health and development nexus. We situate the findings of our analysis within the wider strategic context of the Australian Government’s policy commitment to “step up” in the Pacific region. This research provides an insight into both multi-stakeholder and Federal Government views on ODA in the Indo-Pacific region, especially at a time when Australia’s Pacific engagement has come to the forefront of both foreign and security policy. We conclude that the SDG agenda, including the SDG health and development agenda, could offer a unique vehicle for enabling a paradigm shift in the Australian Government’s development approach toward the Pacific region and its diverse peoples. This potential is strongly reflected in stakeholder perspectives included in our analysis. However, study findings remind that the political determinants of health, and overlapping political determinants of SDG achievement, will be instrumental in the coming decade, and that stakeholders from different sectors need to be genuinely engaged in SDG-ODA policy-related decision-making and planning by governments in both developed and developing countries alike.

  • Building the capacity of users and producers of evidence in health policy and systems research for better control of endemic diseases in Nigeria: a situational analysis
    Global. Health (IF 2.554) Pub Date : 2019-11-21
    Obinna Onwujekwe; Enyi Etiaba; Chinyere Mbachu; Uchenna Ezenwaka; Ifeanyi Chikezie; Ifeyinwa Arize; Chikezie Nwankwor; Benjamin Uzochukwu

    There is a current need to build the capacity of Health Policy and Systems Research + Analysis (HPSR+A) in low and middle-income countries (LMICs) as this enhances the processes of decision-making at all levels of the health system. This paper provides information on the HPSR+A knowledge and practice among producers and users of evidence in priority setting for HPSR+A regarding control of endemic diseases in two states in Nigeria. It also highlights the HPSR+A capacity building needs and interventions that will lead to increased HPSR+A and use for actual policy and decision making by the government and other policy actors. Data was collected from 96 purposively selected respondents who are either researchers/ academia (producers of evidence) and policy/decision-makers, programme/project managers (users of evidence) in Enugu and Anambra states, southeast Nigeria. A pre-tested questionnaire was the data collection tool. Analysis was by univariate and bivariate analyses. The knowledge on HPSR+A was moderate and many respondents understood the importance of evidence-based decision making. Majority of researcher stated their preferred channel of dissemination of research finding to be journal publication. The mean percentage of using HPSR evidence for programme design & implementation of endemic disease among users of evidence was poor (18.8%) in both states. There is a high level of awareness of the use of evidence to inform policy across the two states and some of the respondents have used some evidence in their work. The high level of awareness of the use of HPSR+A evidence for decision making did not translate to the significant actual use of evidence for policy making. The major reasons bordered on lack of autonomy in decision making. Hence, the existing yawning gap in use of evidence has to be bridged for a strengthening of the health system with evidence.

  • Sweden’s engagement in global health: a historical review
    Global. Health (IF 2.554) Pub Date : 2019-11-26
    Rachel Irwin

    Sweden is a long-standing and significant contributor to overseas development aid. This commitment to global health and development is part of Sverigebilden, or the view of Sweden in the world that is formally promoted by the Swedish government. Sweden is seen by many in the global health community as leader on human rights and health and has traditionally been one of the most engaged countries in multilateral affairs more broadly. This article places Sweden’s engagement in global health within the wider context of domestic changes, as well as transitions within the broader global health landscape in the post-World War Two (WWII)- era. In doing so, it reviews the globalization of health from a Swedish perspective. It also addresses broader questions about what it means for a country to be ‘active’ or ‘engaged’ in global health and responds to recent suggestions that Swedish influence in health has waned. The article finds that in Sweden there is wide political consensus that international development and global health engagement are important, and both are part of the maintenance of Sverigebilen. While there is a not one single Swedish approach to global health, there are norms and values that underpin global health engagement such as human rights, solidarity, equity and gender equality. A sustained focus on key issues, such as sexual and reproductive rights and health (SRHR), creates a tradition which feeds back into Sverigebilden. The Swedish experience demonstrates the linkages between foreign and domestic policies with regard to international health and development, and to the globalization of public health practice and diplomacy. In global health Sverigebilden is tied to credibility. Sweden is able to exercise influence because of a successful welfare model and strong research traditions; conversely, long-standing and new threats to this credibility and to Sverigebilden pose challenges to Sweden’s future engagement in global health.

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上海纽约大学William Glover