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Wu D, Low N, Hawkes SJ. Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis. BMJ Glob Health 2024; 9:e014237. [PMID: 38262682 PMCID: PMC10823925 DOI: 10.1136/bmjgh-2023-014237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/01/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation. METHODS Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts. RESULTS A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control. CONCLUSION Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts' views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.
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Affiliation(s)
- Dadong Wu
- Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, China
- Center for World Health Organization Studies, Southern Medical University, Guangzhou, China
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sarah J Hawkes
- Institute for Global Health, University College London, London, UK
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2
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Kurowski C, Evans DB, Ottersen T, Gopinathan U, Dale E, Norheim OF. New strides towards fair processes for financing universal health coverage. Health Policy Plan 2023; 38:i5-i8. [PMID: 37963075 PMCID: PMC10645048 DOI: 10.1093/heapol/czad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Christoph Kurowski
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, United States
| | - David B Evans
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, United States
| | - Trygve Ottersen
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Unni Gopinathan
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Elina Dale
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting, University of Bergen (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway
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3
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Abstract
The relationship of health to rights or human rights is complex. Although many find no right of any kind to health or health care, and others view health care as a right or human right, the American College of Physicians (ACP) instead sees health as a human right. The College, in the ACP Ethics Manual, has long noted the interrelated nature of health and human rights. Health as a human right also has implications for the social and structural determinants of health, including health care. Any rights framework is imperfect, and rights, human rights, and ethical obligations are not synonymous. Individual physicians and the profession have ethical obligations to patients, and these obligations can go beyond matters of rights. Society, too, has responsibilities-the equitable and universal access to appropriate health care is an ethical obligation of a just society. By recognizing health as a human right based in the intrinsic dignity and equality of all patients and supporting the patient-physician relationship and health systems that promote equitable access to appropriate health care, the United States can move closer to respecting, protecting, and fulfilling for all the opportunity for health.
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Affiliation(s)
- Matthew DeCamp
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado (M.D.)
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4
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Elnaiem A, Mohamed-Ahmed O, Zumla A, Mecaskey J, Charron N, Abakar MF, Raji T, Bahalim A, Manikam L, Risk O, Okereke E, Squires N, Nkengasong J, Rüegg SR, Abdel Hamid MM, Osman AY, Kapata N, Alders R, Heymann DL, Kock R, Dar O. Global and regional governance of One Health and implications for global health security. Lancet 2023; 401:688-704. [PMID: 36682375 DOI: 10.1016/s0140-6736(22)01597-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/21/2023]
Abstract
The apparent failure of global health security to prevent or prepare for the COVID-19 pandemic has highlighted the need for closer cooperation between human, animal (domestic and wildlife), and environmental health sectors. However, the many institutions, processes, regulatory frameworks, and legal instruments with direct and indirect roles in the global governance of One Health have led to a fragmented, global, multilateral health security architecture. We explore four challenges: first, the sectoral, professional, and institutional silos and tensions existing between human, animal, and environmental health; second, the challenge that the international legal system, state sovereignty, and existing legal instruments pose for the governance of One Health; third, the power dynamics and asymmetry in power between countries represented in multilateral institutions and their impact on priority setting; and finally, the current financing mechanisms that predominantly focus on response to crises, and the chronic underinvestment for epidemic and emergency prevention, mitigation, and preparedness activities. We illustrate the global and regional dimensions to these four challenges and how they relate to national needs and priorities through three case studies on compulsory licensing, the governance of water resources in the Lake Chad Basin, and the desert locust infestation in east Africa. Finally, we propose 12 recommendations for the global community to address these challenges. Despite its broad and holistic agenda, One Health continues to be dominated by human and domestic animal health experts. Substantial efforts should be made to address the social-ecological drivers of health emergencies including outbreaks of emerging, re-emerging, and endemic infectious diseases. These drivers include climate change, biodiversity loss, and land-use change, and therefore require effective and enforceable legislation, investment, capacity building, and integration of other sectors and professionals beyond health.
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Affiliation(s)
- Azza Elnaiem
- Royal Free London NHS Foundation Trust, London, UK
| | - Olaa Mohamed-Ahmed
- UK Health Security Agency, London, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London, London, UK; National Institute for Health and Care Research Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Tajudeen Raji
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Ammad Bahalim
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Logan Manikam
- Global Health Programme, Royal Institute of International Affairs, London, UK
| | - Omar Risk
- Department of Population, Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | | | - John Nkengasong
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Simon R Rüegg
- Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | | | - Nathan Kapata
- Zambia National Public Health Institute, Ministry of Health, Lusaka, Zambia
| | - Robyn Alders
- Global Health Programme, Royal Institute of International Affairs, London, UK; Development Policy Centre, Australian National University, Canberra, ACT, Australia
| | - David L Heymann
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Kock
- Royal Veterinary College, University of London, London, UK
| | - Osman Dar
- Global Operations, London, UK; Global Health Programme, Royal Institute of International Affairs, London, UK
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5
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Wale JL, Sehmi K, Kamoga R, Ssekubugu R. Civil society and medical product access in Africa: Lessons from COVID-19. Front Med Technol 2023; 5:1091425. [PMID: 36824260 PMCID: PMC9941705 DOI: 10.3389/fmedt.2023.1091425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/16/2023] [Indexed: 02/10/2023] Open
Abstract
Understanding health as a human right creates a legal obligation on countries to ensure access to timely, acceptable, and affordable health care. We highlight the importance of a meaningful role for civil society in improving access to well-regulated quality medical products in Africa; to support and be part of a regional social contract approach following the access issues that have been particularly evident during the COVID-19 pandemic. We argue that African communities have a clear participatory role as important stakeholders in the regulatory lifecycle. Solidarity is important for a cohesive approach as formal government healthcare infrastructure may be minimal for some countries, with little training of communities available for disease management and insufficient money to fund people to organise and deliver health care. Some of the issues for civil society engagement with multi-stakeholders, and possible mitigating strategies, are tabulated to initiate discussion on facilitators and concerns of governments and other stakeholders for meaningful participation by patients, communities and civil society within a regional regulatory lifecycle approach. Solidarity is called for to address issues of equity, ethics and morality, stigmatisation and mutual empowerment - to sustainably support the region and national governments to develop greater self-sufficiency throughout the regulatory lifecycle. By creating a participatory space, patients, communities and civil society can be invited in with clear missions and supported by well-defined guidance to create a true sense of solidarity and social cohesion. Strong leadership coupled with the political will to share responsibilities in all aspects of this work is key.
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Affiliation(s)
- Janet L. Wale
- Independent Researcher, Brunswick, VIC, Australia,Correspondence: Janet L. Wale
| | - Kawaldip Sehmi
- International Alliance of Patients' Organisations, London, United Kingdom
| | - Regina Kamoga
- Uganda Alliance of Patients Organizations (UAPO), World Patient Alliance (WPA), CHAIN, Kampala, Uganda
| | - Robert Ssekubugu
- Rakai Health Sciences Program Research Institute in Kalisizo, Kalisizo, Uganda
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6
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Uberoi D, Ojo T, Sriharan A, Lau L. What can implementation science offer civil society in their efforts to drive rights-based health reform? Glob Health Res Policy 2023; 8:1. [PMID: 36650592 PMCID: PMC9843858 DOI: 10.1186/s41256-023-00284-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
Over the years, civil society organizations (CSOs) have made tremendous efforts to ensure that state policies, programmes, and actions facilitate equitable access to healthcare. While CSOs are key actors in the realization of the right to health, a systematic understanding of how CSOs achieve policy change is lacking. Implementation science, a discipline focused on the methods and strategies facilitating the uptake of evidence-based practice and research can bring relevant, untapped methodologies to understand how CSOs drive health reforms. This article argues for the use of evidence-based strategies to enhance civil society action. We hold that implementation science can offer an actionable frame to aid CSOs in deciphering the mechanisms and conditions in which to pursue rights-based actions most effectively. More empirical studies are needed to generate evidence and CSOs have already indicated the need for more data-driven solutions to empower activists to hold policymakers to account. Although implementation science may not resolve all the challenges CSOs face, its frameworks and approaches can provide an innovative way for organizations to chart out a course for reform.
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Affiliation(s)
- Diya Uberoi
- Faculty of Law, McGill University, 3644 Peel St, Montreal, QC, H3A 1W9, Canada.
| | - Tolulope Ojo
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
| | - Abi Sriharan
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
| | - Lincoln Lau
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
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7
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Ashu JT, Mwangi J, Subramani S, Kaseje D, Ashuntantang G, Luyckx VA. Challenges to the right to health in sub-Saharan Africa: reflections on inequities in access to dialysis for patients with end-stage kidney failure. Int J Equity Health 2022; 21:126. [PMID: 36064532 PMCID: PMC9444088 DOI: 10.1186/s12939-022-01715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/10/2022] [Indexed: 11/12/2022] Open
Abstract
Realization of the individual’s right to health in settings such as sub-Saharan Africa, where health care adequate resources are lacking, is challenging. This paper demonstrates this challenge by illustrating the example of dialysis, which is an expensive but life-saving treatment for people with kidney failure. Dialysis resources, if available in sub-Saharan Africa, are generally limited but in high demand, and clinicians at the bedside are faced with deciding who lives and who dies. When resource limitations exist, transparent and objective priority setting regarding access to such expensive care is required to improve equity across all health needs in a population. This process however, which weighs individual and population health needs, denies some the right to health by limiting access to health care. This paper unpacks what it means to recognize the right to health in sub-Saharan Africa, acknowledging the current resource availability and scarcity, and the larger socio-economic context. We argue, the first order of the right to health, which should always be realized, includes protection of health, i.e. prevention of disease through public health and health-in-all policy approaches. The second order right to health care would include provision of universal health coverage to all, such that risk factors and diseases can be effectively and equitably detected and treated early, to prevent disease progression or development of complications, and ultimately reduce the demand for expensive care. The third order right to health care would include equitable access to expensive care. In this paper, we argue that recognition of the inequities in realization of the right to health between individuals with “expensive” needs versus those with more affordable needs, countries must determine if, how, and when they will begin to provide such expensive care, so as to minimize these inequities as rapidly as possible. Such a process requires good governance, multi-stakeholder engagement, transparency, communication and a commitment to progress. We conclude the paper by emphasizing that striving towards the progressive realization of the right to health for all people living in SSA is key to achieving equity in access to quality health care and equitable opportunities for each individual to maximize their own state of health.
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Affiliation(s)
- James Tataw Ashu
- Internal Medicine and Nephrology, Jura Bernois Hospital, Berne, Moutier, Switzerland.,Nephrology and Hypertension Service, Geneva University Hospitals, Geneva, Switzerland
| | - Jackline Mwangi
- Department of Law Science and Technology at the School of Law, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Supriya Subramani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | | | - Gloria Ashuntantang
- Yaounde General Hospital Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon.,Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon
| | - Valerie A Luyckx
- Department of Nephrology, University Children's Hospital, Zurich, Switzerland. .,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. .,Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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8
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Sehmi K, Wale JL. Where National Medicines Policies Have Taken Us With Patient Involvement and Health Technology Assessment in Africa. Front Med Technol 2022; 4:810456. [PMID: 35281672 PMCID: PMC8915114 DOI: 10.3389/fmedt.2022.810456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
The Covid-19 pandemic has highlighted global knowledge about, but lack of equitable access to, life-changing medicines, and other innovative medical products by populations in African low and middle income countries. The World Health Organization (WHO) and other international non-profit foundations and organizations are constantly striving to address inequity. In the 1970s, WHO initiated a regularly updated essential medicines list, together with the concept of national medicines policies (NMPs) to ensure access and availability, affordability, rational, and effective use of medicines which are considered essential in addressing predominant population health issues and disease burden. We studied the NMPs of Ghana, South Africa, Uganda and Zimbabwe to highlight some of the important issues that these countries experience in the safe and effective use of medical products. Thailand is an example of how health technology assessment (HTA) can provide a country with an internationally supported, clearly defined and transparent process to broaden access to medicines and services. These medical services can add considerable value in accordance with local values and priorities. Involvement of civil society adds democratic legitimacy to such processes. Community health workers and patient advocacy groups are important in raising awareness and knowledge of safety issues and the effective use of quality medicines. They can apply pressure for increased funding to improve access to healthcare. Medicines and services that contribute to supported self-care are of benefit in any setting. Joint efforts across African countries such as with the African Medicines Agency are important in addressing some of the major health issues.
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Affiliation(s)
- Kawaldip Sehmi
- International Alliance of Patients' Organizations, London, United Kingdom
| | - Janet L. Wale
- HTAi Patient and Citizen Involvement Interest Group (PCIG), Brunswick, VIC, Australia
- *Correspondence: Janet L. Wale
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9
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White JA, Rispel LC. Policy exclusion or confusion? Perspectives on universal health coverage for migrants and refugees in South Africa. Health Policy Plan 2021; 36:1292-1306. [PMID: 33848339 PMCID: PMC8428584 DOI: 10.1093/heapol/czab038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/22/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022] Open
Abstract
Notwithstanding the promise of the inclusivity of universal health coverage (UHC), the integration of migrants and refugees into host countries' health systems remains elusive and contested. In South Africa, there is insufficient scholarly attention on UHC, migrants and refugees, given the country's strategic importance in Africa and the envisaged implementation of the National Health Insurance (NHI) system. In this paper, a social exclusion conceptual framework is used to explore whether South African legislation, health policies and perspectives or actions of health policy actors facilitate UHC for migrants and refugees or exacerbate their exclusion. We combined a review of legislation and policies since 1994, with semi-structured interviews with 18 key informants from government, academia, civil society organizations and a United Nations organization. We used thematic analysis to identify themes and sub-themes from the qualitative data. The South African Constitution and the National Health Act facilitate UHC, while the Immigration Act and the 2019 NHI Bill make the legal status of migrants the most significant determinant of healthcare access. This legislative disjuncture is exacerbated by variations in content, interpretation and/or implementation of policies at the provincial level. Resource constraints in the public health sector contribute to the perceived dysfunctionality of the public healthcare system, which affects the financial classification, quality of care and access for all public sector patients. However, migrants and refugees bear the brunt of the reported dysfunctionality, in addition to experiences of medical xenophobia. These issues need to be addressed to ensure that South Africa's quest for UHC expressed through the NHI system is realized.
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Affiliation(s)
- Janine A White
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew’s Road, Parktown, Johannesburg 2193, South Africa
| | - Laetitia C Rispel
- Centre for Health Policy & South African Research Chair, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew’s Road, Parktown, Johannesburg 2193, South Africa
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10
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Bastani P, Hakimzadeh SM, Teymourzadeh E, Nouhi M. Universal health coverage under the Joint Comprehensive Plan of Action's sanctions: strategic purchasing approach in the Iranian health system. Health Promot Int 2021; 36:693-702. [PMID: 33006610 DOI: 10.1093/heapro/daaa070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Due to the sanctions imposed by the USA government upon the Iranian health system, achieving the UHC might face some financial problems. This study aimed to make the best solution for the Iran health care system to overcome not only the temporary sanctions but also a program to reach the UHC goals through the strategic purchasing approach. This was a qualitative study carried out from 2015 to 2017 containing two phases: a comparative analysis and a three-step Delphi technique. In the first phase, the Garden model was applied to select the countries. In the second phase, 20 experts who specialised in health management, health economics, and health insurance science were asked. Data were analyzed with SPSS (version 20.0) and STATA (version 15.0) In the threat of trade and economic sanctions imposed on the Iranian health care system, the experts identified and emphasized that the vulnerable groups to receive financial assistance can be the retired, fecund women, teenagers and people with lower wages. The experts thought that, in the context of resource constraints, different payment systems are proposed for cities and villages based on the different needs of local population. Considering the difficult situation, this study focused on how Iran can cope well in a dangerous situation and economies the health expenditure applying strategic purchasing as one of the key tools in controlling costs to achieve universal health coverage. Economic evaluation, payment system, and priority population are the linchpins of the UHC. Universal health coverage, if it is to be considered, not only is applicable, but it could also be a solution for future generations. Therefore, the proposed policy proposals can provide both a short-term and long-term basis for the health care system of countries that are facing budget constraints or are basically low-income.
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Affiliation(s)
- Peivand Bastani
- Department of Health Service Management and Health Economics, Health Human Resources Research Center, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Ghasrodasht Street, Shiraz , Iran
| | - Seyyed Mostafa Hakimzadeh
- Health Economics, Iran University of Medical Sciences, School of Public Health and Management, Kargar Street, Enqelab Square, Tehran 1541444456, Iran
| | - Ehsan Teymourzadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Sheikhbahaei Street, Tehran 1444445454, Iran
| | - Mojtaba Nouhi
- Health Economics, Health Equity Research Center, Tehran University of Medical Sciences, 2th floor. Sciences and Research Building, Kargar Street, Enqelab Square, Tehran 6446473199, Iran
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11
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Abstract
Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized.
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Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Child Health and Pediatrics, University of Cape Town, Cape Town, South Africa.
| | - M Rafique Moosa
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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12
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Abstract
Kidney disease, whether acute or chronic, is an important health concern for more than 750 million people worldwide. Although its magnitude has been better studied within developed countries, evidence increasingly suggests similar scales of impact in developing and underdeveloped countries. On a shared planet where limited resources and high costs keep life-saving care out of reach for the poor and other structurally disadvantaged populations, addressing health concerns on such a large scale requires a governing basis in the recognition of the universal right to health. As designed under international human rights law, the right to health is meant to be legally enforceable on par with other human rights, and so provides a firm guiding framework for advancing health equity. This article traces the evolution of the right to health in international human rights law while assessing the framework's potential contributions to equitable access to treatment in forums including domestic litigation and rights-based advocacy tools. This article ultimately outlines and clarifies the right to health as a viable, justiciable means for advancing equitable access to kidney treatment and care.
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Affiliation(s)
- Diya Uberoi
- Social and Behavioural Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Lisa Forman
- Social and Behavioural Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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13
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Verguet S, Hailu A, Eregata GT, Memirie ST, Johansson KA, Norheim OF. Toward universal health coverage in the post-COVID-19 era. Nat Med 2021; 27:380-387. [PMID: 33723458 DOI: 10.1038/s41591-021-01268-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/27/2021] [Indexed: 01/29/2023]
Abstract
All countries worldwide have signed up to the United Nations Sustainable Development Goals and have committed to the objective of achieving 'universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all'. During the COVID-19 pandemic and beyond, advancement toward universal health coverage (UHC) will become more difficult for many countries, demonstrating that locally led priority setting is urgently needed to provide health services with appropriate financial protection to all. Because resources are limited and no national constituency can provide an unlimited number of services to their whole population in a sustainable manner, rationing and setting priorities for the selection of interventions to be included in a defined package of services is critical. In this Perspective, we discuss how packages of essential health services can be developed in resource-constrained settings, and detail how experts and the public can decide on principles and criteria, use a comprehensive array of analytical methods and choose which services to be provided free of charge. We illustrate these main steps while drawing on a recently conducted exercise of revising the national essential health services package in Ethiopia, which we compare with examples from other countries that have defined their essential benefits packages. This Perspective also provides recommendations for other low- and middle-income countries on their pathway to UHC.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Alemayehu Hailu
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Getachew Teshome Eregata
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Solomon Tessema Memirie
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole Frithjof Norheim
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
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Villar Uribe M, Escobar ML, Ruano AL, Iunes RF. Realizing the right to health in Latin America, equitably. Int J Equity Health 2021; 20:34. [PMID: 33441143 PMCID: PMC7804898 DOI: 10.1186/s12939-020-01332-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022] Open
Abstract
This special issue “Realizing the Right to Health in Latin America and the Caribbean” provides an overview of one of the most challenging objectives of health systems: equity and the realization of the right to health. In particular, it concentrates on the issues associated with such a challenge in countries suffering of deep inequity. The experience in Latin America and the Caribbean demonstrates that the efforts of health systems to achieve Universal Health Coverage are necessary but not sufficient to achieve an equitable realization of the right to health for all. The inequitable realization of all other human rights also determines the realization of the right to health.
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Affiliation(s)
| | | | - Ana Lorena Ruano
- Center for International Health, Department of Global Public Health at University of Bergen, Bergen, Norway.,Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala City, Guatemala
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15
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Arredondo A, Recamán AL, Suarez-Herrera JC, Cuadra SM. Recent trends for the management of hypertension in older adults in Latin America in the context of universal coverage: Evidence from Mexico. Int J Health Plann Manage 2020; 36:579-586. [PMID: 33368667 DOI: 10.1002/hpm.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/23/2020] [Accepted: 12/09/2020] [Indexed: 11/08/2022] Open
Abstract
Taking the Mexican case as a tracer of what is happening in Latin America on public health, we estimate the recent changes and challenges for the management of hypertension in older adults in the context of universal health coverage. The population base was 200, and 308 reported cases of older adults with hypertension. The cost-evaluation method used was based on the instrumentation and consensus technique. Regarding epidemiological changes for 2016 versus 2018, there is an increase of 21% (CI: 95%, p < 0.001). Comparing the economic impact in 2016 versus 2018 (CI: 95%, p < 0.001), the increase is 33%. The total amount estimated for hypertension in 2018 (in US dollars) was $ 1,896,520,273. It includes $ 898,064,979 as direct costs and $ 998,455,294 as indirect costs. The recent trends show that the financial requirements for the coming years do not guarantee the effectiveness of the coverage rates required for the elderly. In terms of catastrophic expenditure, the challenge is not minor, the greatest economic burden is for the pocket of patients and their families.
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Affiliation(s)
- Armando Arredondo
- Center for Health System Research, National Institute of Public Health, Cuernavaca, México
| | | | - José Carlos Suarez-Herrera
- Department of Strategy, Entrepreneurship and Sustainable Development, KEDGE Business School, Marseille, France
| | - Silvia Magali Cuadra
- Center for Health System Research-National Institute of Public Health, Cuernavaca, México
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16
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Samuel J, Flores W, Frisancho A. Social exclusion and universal health coverage: health care rights and citizen-led accountability in Guatemala and Peru. Int J Equity Health 2020; 19:216. [PMID: 33298093 PMCID: PMC7724714 DOI: 10.1186/s12939-020-01308-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While equity is a central concern in promoting Universal Health Coverage (UHC), the impact of social exclusion on equity in UHC remains underexplored. This paper examines challenges faced by socially excluded populations, with an emphasis on Indigenous peoples, to receive UHC in Latin America. We argue that social exclusion can have negative effects on health systems and can undermine progress towards UHC. We examine two case studies, one in Guatemala and one in Peru, involving citizen-led accountability initiatives that aim to identify and address problems with health care services for socially excluded groups. The case studies reveal how social exclusion can affect equity in UHC. METHODS In-depth analysis was conducted of all peer reviewed articles published between 2015 and 2019 on the two cases (11 in total), and two non-peer reviewed reports published over the same period. In addition, two of the three authors contributed their first-hand knowledge gathered through practitioner involvement with the citizen-led initiatives examined in the two cases. The analysis sought to identify and compare challenges faced by socially excluded Indigenous populations to receive UHC in the two cases. RESULTS Citizen-led accountability initiatives in Guatemala and Peru reveal very similar patterns of serious deficiencies that undermine efforts towards the realization of Universal Health Coverage in both countries. In each case, the socially excluded populations are served by a dysfunctional publicly provided health system marked by gaps and often invisible barriers. The cases suggest that, while funding and social rights to coverage have expanded, marginalized populations in Guatemala and Peru still do not receive either the health care services or the protection against financial hardship promised by health systems in each country. In both cases, the dysfunctional character of the system remains in place, undermining progress towards UHC. CONCLUSIONS We conclude that efforts to promote UHC cannot stop at increasing health systems financing. In addition, these efforts need to contend with the deeper challenges of democratizing state institutions, including health systems, involved in marginalizing and excluding certain population groups. This includes stronger accountability systems within public institutions. More inclusive accountability mechanisms are an important step in promoting equitable progress towards UHC.
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Affiliation(s)
- Jeannie Samuel
- Health and Society Program, York University, Toronto, Canada.
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala
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17
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Wang D, Vasconcelos NPD, Poirier MJ, Chieffi A, Mônaco C, Sritharan L, Van Katwyk SR, Hoffman SJ. Health technology assessment and judicial deference to priority-setting decisions in healthcare: Quasi-experimental analysis of right-to-health litigation in Brazil. Soc Sci Med 2020; 265:113401. [PMID: 33250316 PMCID: PMC7769796 DOI: 10.1016/j.socscimed.2020.113401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 12/02/2022]
Abstract
The constitutional right to health in Brazil has entitled patients to litigate against the government-funded national health system (SUS), claiming access to various health treatments including those excluded from the health system's benefits package. Courts have tended to rely on a single medical prescription to judge these cases in favor of individual patients and against the health system. The large volume of cases has had a substantial financial impact on the government's health budget and has created unfairness in accessing healthcare. To change courts' behavior, a new health technology assessment (HTA) body - CONITEC - was created in 2011. Its creation was accompanied by an administrative procedure that made decisions about the health system's benefits package more transparent, accountable, participative and evidence-informed. It was expected that this HTA system would bring more legitimacy to the government's priority-setting decisions and promote deference from the courts. This study tests whether Brazil's new HTA system succeeded in encouraging judicial deference by analyzing a stratified random sample of 13,263 court decisions for whether the existence of a CONITEC report resulted in less frequent court orders to provide treatment for individual litigants. The results show that the creation of CONITEC did not change courts' behavior; courts still decide in favor of patients in most cases. Indeed, even when there was a CONITEC report recommending against government funding for a particular healthcare treatment, the vast majority of the relatively few patients who were unsuccessful in obtaining a health benefit at their first court hearing later obtained a favorable decision after appealing to a higher court. This finding was confirmed through an interrupted time-series analysis that did not find an impact of having a CONITEC report on courts' willingness to override a government priority-setting decision. In fact, CONITEC was rarely cited in court decisions, even when litigants mentioned the existence of a CONITEC report.
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Affiliation(s)
- Daniel Wang
- Fundação Getulio Vargas (FGV), Law School in São Paulo, Brazil.
| | | | - Mathieu Jp Poirier
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health & Osgoode Hall Law School, York University, Toronto, Canada; School of Global Health, York University, Toronto, Canada
| | - Ana Chieffi
- Deapartment of Health of the State of São Paulo, São Paulo, Brazil
| | - Cauê Mônaco
- Centro Universitário São Camilo, School of Medicine, São Paulo, Brazil
| | - Lathika Sritharan
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health & Osgoode Hall Law School, York University, Toronto, Canada
| | - Susan Rogers Van Katwyk
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health & Osgoode Hall Law School, York University, Toronto, Canada
| | - Steven J Hoffman
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health & Osgoode Hall Law School, York University, Toronto, Canada; School of Global Health, York University, Toronto, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster Health Forum, McMaster University, Hamilton, Canada
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18
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Tichenor M. Essential universal health coverage needs local capacity development. Lancet Glob Health 2020; 8:e748-e749. [PMID: 32446339 DOI: 10.1016/s2214-109x(20)30224-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Marlee Tichenor
- School of Social and Political Science, Chrystal Macmillan Building, The University of Edinburgh, Edinburgh EH8 9LD, UK.
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19
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Sundler AJ, Darcy L, Råberus A, Holmström IK. Unmet health-care needs and human rights-A qualitative analysis of patients' complaints in light of the right to health and health care. Health Expect 2020; 23:614-621. [PMID: 32069375 PMCID: PMC7321718 DOI: 10.1111/hex.13038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/23/2020] [Accepted: 01/31/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This study focuses on patient complaints from a human rights perspective. Despite the UN Convention on Human Rights being widely recognized, it has not previously been examined in relation to patients' complaints on health care. A human rights perspective and the right to the highest attainable standard of health are a major sustainability challenge in health care today. Previous research points to patients' complaints as a growing concern for health-care organizations, and the handling of this concern can lead to improvement in health-care services. OBJECTIVE The aim was to analyse patients' complaints on health-care services and to examine expressed needs for health care from a human rights perspective. METHODS In this descriptive study, a random sample of 170 patient complaints about Swedish health-care services were qualitatively analysed from a human rights perspective. RESULTS The complaints are described in three themes: the right to available and accessible health-care services, the right to good quality health-care services and the right to dignity and equality in health care. Questions of availability, accessibility, acceptability and quality are highlighted by patients and/or relatives making complaints on health-care services. DISCUSSION AND CONCLUSION This study emphasizes the human right to health in relation to patient complaints. Findings indicate that this right has been breached in relation to availability, accessibility, acceptability and quality in health-care services. Further debate, education and investigations are necessary to ensure that patients' rights to health and health care not be taken for granted.
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Affiliation(s)
- Annelie J. Sundler
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Laura Darcy
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Anna Råberus
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Inger K. Holmström
- School of Health, Care and Social WelfareMälardalen UniversityVästeråsSweden
- Department of Public Health and Caring SciencesUppsala UniversityUppsalaSweden
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20
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Isaranuwatchai W, Teerawattananon Y, Archer RA, Luz A, Sharma M, Rattanavipapong W, Anothaisintawee T, Bacon RL, Bhatia T, Bump J, Chalkidou K, Elshaug AG, Kim DD, Reddiar SK, Nakamura R, Neumann PJ, Shichijo A, Smith PC, Culyer AJ. Prevention of non-communicable disease: best buys, wasted buys, and contestable buys. BMJ 2020; 368:m141. [PMID: 31992592 PMCID: PMC7190374 DOI: 10.1136/bmj.m141] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Wanrudee Isaranuwatchai and colleagues highlight the importance of local context in making decisions about implementing interventions for preventing non-communicable diseases
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Affiliation(s)
- Wanrudee Isaranuwatchai
- Health Intervention and Technology Assessment Programme, Bangkok, Thailand
- University of Toronto, Toronto, Canada
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Programme, Bangkok, Thailand
- National University of Singapore, Singapore
- National Health Foundation, Bangkok, Thailand
| | - Rachel A Archer
- Health Intervention and Technology Assessment Programme, Bangkok, Thailand
| | - Alia Luz
- Health Intervention and Technology Assessment Programme, Bangkok, Thailand
| | - Manushi Sharma
- Health Intervention and Technology Assessment Programme, Bangkok, Thailand
| | | | | | - Rachel L Bacon
- Tufts Medical Center, Boston, USA
- Boston University, Boston, USA
| | | | - Jesse Bump
- Harvard TH Chan School of Public Health, Boston, USA
| | - Kalipso Chalkidou
- Centre for Global Development, London, UK
- Imperial College London, London, UK
| | - Adam G Elshaug
- University of Sydney, Sydney, Australia
- Brookings Institution, Washington DC, USA
| | | | | | | | - Peter J Neumann
- Tufts Medical Center, Boston, USA
- Tufts University School of Medicine, Boston, USA
| | | | - Peter C Smith
- University of York, York, UK
- Imperial College Business School, London, UK
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21
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Luciano A, Voorhoeve A. Have Reforms Reconciled Health Rights Litigation and Priority Setting in Costa Rica? Health Hum Rights 2019; 21:283-293. [PMID: 31885457 PMCID: PMC6927383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The experience of Costa Rica highlights the potential for conflicts between the right to health and fair priority setting. For example, one study found that most favorable rulings by the Costa Rican constitutional court concerning claims for medications under the right to health were either for experimental treatments or for medicines that should have low priority based on health gain per unit of expenditure and severity of disease.32 In order to better align rulings with priority setting criteria, in 2014, the court initiated a reform in its assessment of claims for medicine. This paper assesses this reform's impact on the fairness of resource allocation. It finds three apparent effects: (1) a reduction in successful claims for experimental medication, which is beneficial; (2) an increase in the success rate of medication lawsuits, which is detrimental because most claims are for extremely cost-ineffective medications; and (3) a decline in the number of claims for medicine, which is beneficial because it forestalls such low-priority spending. This paper estimates that, taking all three effects into account, the reform has had a modest net positive impact on overall resource allocation. However, it also argues that there is a need for further reforms to lower the number of claims to low-priority medicines that are granted.
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Affiliation(s)
- Alessandro Luciano
- Recent alumnus of the Philosophy, Politics and Economics program at the London School of Economics, London, UK
| | - Alex Voorhoeve
- Professor in the Department of Philosophy, Logic, and Scientific Method, London School of Economics, London, UK
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22
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Oliveira GM, Vidal DG, Ferraz MP, Cabeda JM, Pontes M, Maia RL, Calheiros JM, Barreira E. Measuring Health Vulnerability: An Interdisciplinary Indicator Applied to Mainland Portugal. Int J Environ Res Public Health 2019; 16:E4121. [PMID: 31731572 PMCID: PMC6862183 DOI: 10.3390/ijerph16214121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/28/2023]
Abstract
Health promotion and inequality reduction are specific goals of the United Nations 2030 Agenda, which are interconnected with several dimensions of life. This work proposes a composite index SEHVI-socioeconomic health vulnerability index-to address Portuguese population socioeconomic determinants that affect health outcomes. Variables composing SEHVI are aligned with the sustainable development goals considering data and times series availability to enable progress monitoring, and variables adequacy to translate populations' life conditions affecting health outcomes. Data for 35 variables and three periods were collected from official national databases. All variables are part of one of the groups: Health determinants (social, economic, cultural, and environmental factors) and health outcomes (mortality indicators). Variables were standardized and normalized by "Distance to a reference" method and then aggregated into the SEHVI formula. Several statistical procedures for validation of SEHVI revealed the internal consistency of the index. For all municipalities, SEHVI was calculated and cartographically represented. Results were analyzed by statistical tests and compared for three years and territory typologies. SEHVI differences were found as a function of population density, suggesting inequalities of communities' life conditions and in vulnerability to health.
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Affiliation(s)
- Gisela M. Oliveira
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
| | - Diogo Guedes Vidal
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
| | - Maria Pia Ferraz
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
- Health Sciences Faculty, University Fernando Pessoa, 4200-150 Porto, Portugal
| | - José Manuel Cabeda
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
- Health Sciences Faculty, University Fernando Pessoa, 4200-150 Porto, Portugal
| | - Manuela Pontes
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
| | - Rui Leandro Maia
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
| | - José Manuel Calheiros
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
- Health Sciences Faculty, University Fernando Pessoa, 4200-150 Porto, Portugal
| | - Esmeralda Barreira
- UFP Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa, 4249-004 Porto, Portugal; (G.M.O.); (D.G.V.); (M.P.F.); (J.M.C.); (M.P.); (R.L.M.); (J.M.C.)
- Health Sciences Faculty, University Fernando Pessoa, 4200-150 Porto, Portugal
- Lung Clinic—Portuguese Oncology Institute Francisco Gentil, EPE (IPO-Porto), 4200-072 Porto, Portugal
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Yamin AE, Pichon-Riviere A, Bergallo P. Unique challenges for health equity in Latin America: situating the roles of priority-setting and judicial enforcement. Int J Equity Health 2019; 18:106. [PMID: 31272460 PMCID: PMC6610856 DOI: 10.1186/s12939-019-1005-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 11/23/2022] Open
Abstract
Overcoming continuing polarization regarding judicial enforcement of health rights in Latin America requires clarifying divergent normative and political premises, addressing the lack of reliable empirical data, and establishing the conditions for fruitful inter-sectoral, inter-disciplinary dialogue.
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Affiliation(s)
- Alicia Ely Yamin
- Global Health Education and Learning Incubator at Harvard University, Harvard University, 104 Mt. Auburn St, 3rd floor, Cambridge, MA, 02138, USA.
| | - Andrés Pichon-Riviere
- Institute for Clinical Effectiveness and Health Policy (IECS), University of Buenos Aires, Dr. Emilio Ravignani 2024, C1414 CPV, Buenos Aires, Argentina
| | - Paola Bergallo
- Universidad Torcuato di Tella, Av. Pres. Figueroa Alcorta 7350, C1428 CABA, Buenos Aires, Argentina
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24
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Cardiel MH, Carrillo S, Pérez M, Andrade L, Pacheco Tena C, Silveira LH, Limón L, Cerpa S, Gutiérrez Ureña S, Durán S, Irazoque Palazuelos F, Muñoz López S, Sicsik Ayala SA, Barile L, Ramos Sánchez MA, Grajeda Portes D, Portela M, Hernández Bedolla A, García-Figueroa JL, Montero M, Abud-Mendoza C, Martínez Martínez MU, Herrera van Ostdam D, Pascual-Ramos V, Merayo-Chalico J, Guzmán-Sánchez I, Pérez-Bastidas ME, Aguilar Arreola JE, López Rodríguez A, Reyes-Cordero G, Ricardez HA, Hernández Cabrera MF, Olvera-Soto G, Xibillé Friedmann D. Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. ACTA ACUST UNITED AC 2021; 17:215-28. [PMID: 31103432 DOI: 10.1016/j.reuma.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/28/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.
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25
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Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, Kim SC, Alwan A, Binagwaho A, Burci GL, Cabal L, DeLand K, Evans TG, Goosby E, Hossain S, Koh H, Ooms G, Roses Periago M, Uprimny R, Yamin AE. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet 2019; 393:1857-1910. [PMID: 31053306 PMCID: PMC7159296 DOI: 10.1016/s0140-6736(19)30233-8] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 01/25/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Lawrence O Gostin
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA.
| | - John T Monahan
- Office of the President, Georgetown University, Washington, DC, USA
| | - Jenny Kaldor
- School of Law, University of Tasmania, Hobart, TAS, Australia
| | | | - Eric A Friedman
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Katie Gottschalk
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Susan C Kim
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA
| | - Ala Alwan
- Health and Environment, Government of Iraq, Baghdad, Iraq
| | | | - Gian Luca Burci
- Global Health Centre, Graduate Institute of International and Development Studies, Geneva, Switzerland
| | | | | | - Timothy Grant Evans
- Health, Nutrition and Population Global Practice, World Bank Group, Washington, DC, USA
| | - Eric Goosby
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Howard Koh
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Gorik Ooms
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Alicia Ely Yamin
- Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School, Cambridge, MA, USA; Harvard T H Chan School of Public Health, Boston, MA, USA
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26
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Littlejohns P, Kieslich K, Weale A, Tumilty E, Richardson G, Stokes T, Gauld R, Scuffham P. Creating sustainable health care systems. J Health Organ Manag 2019; 33:18-34. [PMID: 30859907 PMCID: PMC7068726 DOI: 10.1108/jhom-02-2018-0065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/28/2018] [Accepted: 10/02/2018] [Indexed: 12/02/2022]
Abstract
PURPOSE In order to create sustainable health systems, many countries are introducing ways to prioritise health services underpinned by a process of health technology assessment. While this approach requires technical judgements of clinical effectiveness and cost effectiveness, these are embedded in a wider set of social (societal) value judgements, including fairness, responsiveness to need, non-discrimination and obligations of accountability and transparency. Implementing controversial decisions faces legal, political and public challenge. To help generate acceptance for the need for health prioritisation and the resulting decisions, the purpose of this paper is to develop a novel way of encouraging key stakeholders, especially patients and the public, to become involved in the prioritisation process. DESIGN/METHODOLOGY/APPROACH Through a multidisciplinary collaboration involving a series of international workshops, ethical and political theory (including accountability for reasonableness) have been applied to develop a practical way forward through the creation of a values framework. The authors have tested this framework in England and in New Zealand using a mixed-methods approach. FINDINGS A social values framework that consists of content and process values has been developed and converted into an online decision-making audit tool. RESEARCH LIMITATIONS/IMPLICATIONS The authors have developed an easy to use method to help stakeholders (including the public) to understand the need for prioritisation of health services and to encourage their involvement. It provides a pragmatic way of harmonising different perspectives aimed at maximising health experience. PRACTICAL IMPLICATIONS All health care systems are facing increasing demands within finite resources. Although many countries are introducing ways to prioritise health services, the decisions often face legal, political, commercial and ethical challenge. The research will help health systems to respond to these challenges. SOCIAL IMPLICATIONS This study helps in increasing public involvement in complex health challenges. ORIGINALITY/VALUE No other groups have used this combination of approaches to address this issue.
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Affiliation(s)
- Peter Littlejohns
- Department of Primary Care and Public Health Sciences, King’s College London, London, UK
| | | | - Albert Weale
- School of Public Policy, University College London, London, UK
| | - Emma Tumilty
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Georgina Richardson
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- School of Business, University of Otago, Dunedin, New Zealand
| | - Paul Scuffham
- Centre for Applied Health Economics, Griffith University, Southport, Australia
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Gallagher S, Little M. Procedural justice and the individual participant in priority setting: Doctors' experiences. Soc Sci Med 2019; 228:75-84. [PMID: 30889515 DOI: 10.1016/j.socscimed.2019.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 11/30/2018] [Accepted: 03/08/2019] [Indexed: 11/23/2022]
Abstract
In this study we describe, synthesise, and discuss the experiences and views of doctors who participate as technical experts in health care priority setting, reflect on the ethical significance of the challenges to procedural and distributive justice they encounter, and propose an empirically derived practical approach to improving the fairness of the process. Between August 2015 and July 2016 we conducted semi-structured face-to-face interviews with 20 doctors in NSW, Australia, purposively selected on the basis of their participation in macroallocation. Participant selection, data collection, and analysis were carried out according to the principles of grounded moral analysis, an empirical bioethics methodology closely based on grounded theory. The doctors we interviewed attached ethical significance to a broad range of procedural concerns that militated both against the prospect of distributive justice and against their own wellbeing: unfair access to opportunities to participate in macroallocation, sexist behaviours and structures, rewards for rule-breakers, cynical and insincere practices, waste, duplication, and inefficiency, and being taken for granted. On the basis of our data, we hypothesise that the institutional conditions for macroallocation do not support the care of medical participants in deliberations. Evaluating our findings against the 'accountability for reasonableness' framework of Daniels and Sabin, we expose as incompatible with the conditions for procedural justice processes that treat participants in macroallocation unfairly or cause them to have moral unease about the justice of the enterprise. We suggest a supplementary procedure that positions commitment to the care and just treatment of participants as a foundation of any macroallocation procedure.
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28
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Duffy RM, Kelly BD. India's Mental Healthcare Act, 2017: Content, context, controversy. Int J Law Psychiatry 2019; 62:169-178. [PMID: 30122262 DOI: 10.1016/j.ijlp.2018.08.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/30/2018] [Accepted: 08/06/2018] [Indexed: 05/13/2023]
Abstract
India's new mental health legislation, the Mental Healthcare Act, 2017, was commenced on 29 May 2018 and seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities. It grants a legally binding right to mental healthcare to over 1.3 billion people, one sixth of the planet's population. Key measures include (a) new definitions of 'mental illness' and 'mental health establishment'; (b) revised consideration of 'capacity' in relation to mental healthcare (c) 'advance directives' to permit persons with mental illness to direct future care; (d) 'nominated representatives', who need not be family members; (e) the right to mental healthcare and broad social rights for the mentally ill; (f) establishment of governmental authorities to oversee services; (g) Mental Health Review Boards to review admissions and other matters; (h) revised procedures for 'independent admission' (voluntary admission), 'supported admission' (admission and treatment without patient consent), and 'admission of minor'; (i) revised rules governing treatment, restraint and research; and (j) de facto decriminalization of suicide. Key challenges relate to resourcing both mental health services and the new structures proposed in the legislation, the appropriateness of apparently increasingly legalized approaches to care (especially the implications of potentially lengthy judicial proceedings), and possible paradoxical effects resulting in barriers to care (e.g. revised licensing requirements for general hospital psychiatry units). There is ongoing controversy about specific measures (e.g. the ban on electro-convulsive therapy without muscle relaxants and anaesthesia), reflecting a need for continued engagement with stakeholders including patients, families, the Indian Psychiatric Society and non-governmental organisations. Despite these challenges, the new legislation offers substantial potential benefits not only to India but, by example, to other countries that seek to align their laws with the United Nations' Convention on the Rights of Persons with Disabilities and improve the position of the mentally ill.
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Affiliation(s)
- Richard M Duffy
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
| | - Brendan D Kelly
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
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McCollum R, Theobald S, Otiso L, Martineau T, Karuga R, Barasa E, Molyneux S, Taegtmeyer M. Priority setting for health in the context of devolution in Kenya: implications for health equity and community-based primary care. Health Policy Plan 2018; 33:729-742. [PMID: 29846599 PMCID: PMC6005116 DOI: 10.1093/heapol/czy043] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2018] [Indexed: 11/14/2022] Open
Abstract
Devolution changes the locus of power within a country from central to sub-national levels. In 2013, Kenya devolved health and other services from central government to 47 new sub-national governments (known as counties). This transition seeks to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. With changing responsibilities and power following devolution reforms, comes the need for priority-setting at the new county level. Priority-setting arises as a consequence of the needs and demand for healthcare resources exceeding the resources available, resulting in the need for some means of choosing between competing demands. We sought to explore the impact of devolution on priority-setting for health equity and community health services. We conducted key informant and in-depth interviews with health policymakers, health providers and politicians from 10 counties (n = 269 individuals) and 14 focus group discussions with community members based in 2 counties (n = 146 individuals). Qualitative data were analysed using the framework approach. We found Kenya’s devolution reforms were driven by the need to demonstrate responsiveness to county contexts, with positive ramifications for health equity in previously neglected counties. The rapidity of the process, however, combined with limited technical capacity and guidance has meant that decision-making and prioritization have been captured and distorted for political and power interests. Less visible community health services that focus on health promotion, disease prevention and referral have been neglected within the prioritization process in favour of more tangible curative health services. The rapid transition in power carries a degree of risk of not meeting stated objectives. As Kenya moves forward, decision-makers need to address the community health gap and lay down institutional structures, processes and norms which promote health equity for all Kenyans.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sassy Molyneux
- KEMRI Centre for Geographic Medicine Research-Coast, and Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Onarheim KH, Melberg A, Meier BM, Miljeteig I. Towards universal health coverage: including undocumented migrants. BMJ Glob Health 2018; 3:e001031. [PMID: 30364297 PMCID: PMC6195153 DOI: 10.1136/bmjgh-2018-001031] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022] Open
Abstract
As countries throughout the world move towards universal health coverage, the obligation to realise the right to health for undocumented migrants has often been overlooked. With unprecedented millions on the move - including refugees, asylum seekers, internally displaced persons, and returnees - undocumented migrants represent a uniquely vulnerable subgroup, experiencing particular barriers to health related to their background as well as insecure living and working conditions. Their legal status under national law often restricts access to, and affordability of, healthcare services. While striving to ensure health for all, national governments face challenging priority setting dilemmas in deciding: who to include, which services to provide, and how to cover out-of-pocket expenses. Building on comparative experiences in Norway, Thailand and the United States - which reflect varied approaches to achieving universal health coverage - we assess whether these national approaches provide rights-based access to affordable essential healthcare services for undocumented migrants. To meet the shared Sustainable Development Goal on universal health coverage, the right to health must be realised for all persons - including undocumented migrants. To ensure universal health coverage in accordance with the right to health, governments must evaluate laws, regulations, policies and practices to evaluate: whether undocumented migrants are included, to which services they have access, and if these services are affordable. Achieving universal health coverage for everyone will require rights-based support for undocumented migrants.
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Affiliation(s)
| | - Andrea Melberg
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Benjamin Mason Meier
- Department of Public Policy, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Ingrid Miljeteig
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Norheim OF. Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy. Int J Health Policy Manag 2018; 7:771-777. [PMID: 30316224 PMCID: PMC6186484 DOI: 10.15171/ijhpm.2018.60] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/17/2018] [Indexed: 11/24/2022] Open
Abstract
How can evidence from economic evaluations of the type the Disease Control Priorities project have synthesized be translated to better priority setting? This evidence provides insights into how investing in health, particularly though priority interventions and expanded access to health insurance and prepaid care, can not only save lives but also help alleviate poverty and provide financial risk protection. The article discusses some of the relevant factors needed to develop a Theory of Change for translating economic evidence to better priority setting within countries, and proposes some key strategic choices that are necessary to achieve the desired outputs and outcomes.
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Affiliation(s)
- Ole F. Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Arredondo A, Azar A, Recaman AL. Challenges and dilemmas on universal coverage for non-communicable diseases in middle-income countries: evidence and lessons from Mexico. Global Health 2018; 14:89. [PMID: 30143010 PMCID: PMC6109335 DOI: 10.1186/s12992-018-0404-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite more than 20 years of reform projects in health systems, the universal coverage strategy has not reached the expected results in most middle-income countries (MICs). Using evidence from the Mexican case on diabetes and hypertension as tracers of non-communicable diseases, the effective coverage rate barely surpasses half of the expected goals necessary to meet the challenges that these two diseases represent at the population level. Prevalence and incidence rates do not diminish either; they even grow. In terms of the economic burden, this means that lack of financial protection and catastrophic expense rates have increased, contrary to what could have been expected. DISCUSSION As any complex system, health systems present challenges and dilemmas that are difficult to solve. In terms of universal coverage, when contrasting normative coverage versus effective coverage, the epidemiological, cultural, organizational and economic challenges and barriers become evident. Such challenges have not allowed a greater effectiveness of the contributions of state of the art medicine in the resolution of health problems, particularly in relation to diabetes and hypertension. CONCLUSIONS Despite of the existence of many universal coverage projects, strategies and programs implemented in MICs, challenges remain and, far from disappearing, unresolved problems are still present, even with increasing trends. The model of care based on a curative biomedical approach was enough to respond to the health needs of the last century, but is no longer adapted to the needs of the present century. The dilemmas of continuity vs. rupture require to review and discuss the background and structure of health systems and their underlying models of care. These two elements have not allowed the different coverage schemes to guarantee greater effectiveness in the application of state of the art medicine, nor a greater health care financial protection for patients and their families. We thus can either accept the fragmented health systems and bio-medical-curative models of care approach or, instead, we can move towards integrated health systems that would be based on a socio-medical-preventive approach to health care.
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Affiliation(s)
- Armando Arredondo
- National Institute of Public Health-Mexico, Av Universidad 655, Col., Sta Maria Ahuacatitlan, CP 62508 Cuernavaca, Mexico
| | - Alejandra Azar
- National Institute of Public Health-Mexico, Av Universidad 655, Col., Sta Maria Ahuacatitlan, CP 62508 Cuernavaca, Mexico
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Gallagher S, Little M, Hooker C. The values and ethical commitments of doctors engaging in macroallocation: a qualitative and evaluative analysis. BMC Med Ethics 2018; 19:75. [PMID: 30041650 PMCID: PMC6056994 DOI: 10.1186/s12910-018-0314-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 07/17/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In most socialised health systems there are formal processes that manage resource scarcity and determine the allocation of funds to health services in accordance with their priority. In this analysis, part of a larger qualitative study examining the ethical issues entailed in doctors' participation as technical experts in priority setting, we describe the values and ethical commitments of doctors who engage in priority setting and make an empirically derived contribution towards the identification of an ethical framework for doctors' macroallocation work. METHOD We conducted semi-structured interviews with 20 doctors, each of whom participated in macroallocation at one or more levels of the Australian health system. Our sampling, data-collection, and analysis strategies were closely modelled on grounded moral analysis, an iterative empirical bioethics methodology that employs contemporaneous interchange between the ethical and empirical to support normative claims grounded in practice. RESULTS The values held in common by the doctors in our sample related to the domains of personal ethics ('taking responsibility' and 'persistence, patience, and loyalty to a cause'), justice ('engaging in distributive justice', 'equity', and 'confidence in institutions'), and practices of argumentation ('moderation' and 'data and evidence'). Applying the principles of grounded moral analysis, we identified that our participants' ideas of the good in macroallocation and their normative insights into the practice were strongly aligned with the three levels of Paul Ricoeur's 'little ethics': 'aiming at the "good life" lived with and for others in just institutions'. CONCLUSIONS Our findings suggest new ways of understanding how doctors' values might have procedural and substantive impacts on macroallocation, and challenge the prevailing assumption that doctors in this milieu are motivated primarily by deontological considerations. Our empirical bioethics approach enabled us to identify an ethical framework for medical work in macroallocation that was grounded in the values and ethical intuitions of doctors engaged in actions of distributive justice. The concordance between Ricoeur's 'little ethics' and macroallocation practitioners' experiences, and its embrace of mutuality, suggest that it has the potential to guide practice, support ethical reflection, and harmonise deliberative practices amongst actors in macroallocation generally.
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Affiliation(s)
- Siun Gallagher
- Faculty of Medicine and Health, Sydney Health Ethics, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006 Australia
| | - Miles Little
- Faculty of Medicine and Health, Sydney Health Ethics, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006 Australia
| | - Claire Hooker
- Faculty of Medicine and Health, Health and Medical Humanities, Sydney Health Ethics, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006 Australia
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Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, Coll-Seck AM, Grover A, Laski L, Roa M, Sathar ZA, Say L, Serour GI, Singh S, Stenberg K, Temmerman M, Biddlecom A, Popinchalk A, Summers C, Ashford LS. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet 2018; 391:2642-2692. [PMID: 29753597 DOI: 10.1016/s0140-6736(18)30293-9] [Citation(s) in RCA: 427] [Impact Index Per Article: 71.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/02/2018] [Accepted: 02/08/2018] [Indexed: 01/10/2023]
Affiliation(s)
| | - Alex C Ezeh
- African Population and Health Research Center, Nairobi, Kenya; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Center for Global Development, Washington, DC, USA
| | | | - Alaka Basu
- Department of Development Sociology, Cornell University, Ithaca, NY, USA
| | - Jane T Bertrand
- Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Robert Blum
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Monica Roa
- Independent Consultant, Islamabad, Pakistan
| | | | - Lale Say
- World Health Organization, Geneva, Switzerland
| | - Gamal I Serour
- International Islamic Center For Population Studies And Research, Al Azhar University, Cairo, Egypt
| | | | | | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
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Charvel S, Cobo F, Larrea S, Baglietto J. Challenges in Priority Setting from a Legal Perspective in Brazil, Costa Rica, Chile, and Mexico. Health Hum Rights 2018; 20:173-184. [PMID: 30008561 PMCID: PMC6039745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Priority setting is the process through which a country's health system establishes the drugs, interventions, and treatments it will provide to its population. Our study evaluated the priority-setting legal instruments of Brazil, Costa Rica, Chile, and Mexico to determine the extent to which each reflected the following elements: transparency, relevance, review and revision, and oversight and supervision, according to Norman Daniels's accountability for reasonableness framework and Sarah Clark and Albert Wale's social values framework. The elements were analyzed to determine whether priority setting, as established in each country's legal instruments, is fair and justifiable. While all four countries fulfilled these elements to some degree, there was important variability in how they did so. This paper aims to help these countries analyze their priority-setting legal frameworks to determine which elements need to be improved to make priority setting fair and justifiable.
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Affiliation(s)
- Sofía Charvel
- An assistant professor of law in the Academic Department of Law at the Autonomous Technological Institute, Río Hondo 1, Mexico City 01080, Mexico
| | - Fernanda Cobo
- Coordinator of the Public Health Law Program of the Academic Department of Law at the Autonomous Technological Institute, Río Hondo 1, Mexico City 01080, Mexico
| | - Silvana Larrea
- Postgraduate student at the National Institute of Public Health, Mexico
| | - Juliana Baglietto
- Postgraduate student at the National Institute of Public Health, Mexico
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Adam MB, Muma S, Modi JA, Steere M, Cook N, Ellis W, Chen CT, Shirk A, Muma Nyagetuba JK, Hansen EN. Paediatric and obstetric outcomes at a faith-based hospital during the 100-day public sector physician strike in Kenya. BMJ Glob Health 2018; 3:e000665. [PMID: 29662693 PMCID: PMC5898292 DOI: 10.1136/bmjgh-2017-000665] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 11/04/2022] Open
Abstract
Published reviews of national physician strikes have shown a reduction in patient mortality. From 5 December 2016 until 14 March 2017, Kenyan physicians in the public sector went on strike leaving only private (not-for-profit and for-profit) hospitals able to offer physician care. We report on our experience at AIC-Kijabe Hospital, a not-for-profit, faith-based Kenyan hospital, before, during and after the 100-day strike was completed by examining patient admissions and deaths in the time periods before, during and after the strike. The volume of patients increased and exceeded the hospital's ability to respond to needs. There were substantial increases in sick newborn admissions during this time frame and an additional ward was opened to respond to this need. Increased need occurred across all services but staffing and space limited ability to respond to increased demand. There were increases in deaths during the strike period across the paediatric medical, newborn, paediatric surgical and obstetric units with an OR (95% CI) of death of 3.9 (95% CI 2.3 to 6.4), 4.1 (95% CI 2.4 to 7.1), 7.9 (95% CI 3.2 to 20) and 3.2 (95% CI 0.39 to 27), respectively. Increased mortality across paediatric and obstetrical services at AIC-Kijabe Hospital correlated with the crippling of healthcare delivery in the public sector during the national physicians' strike in Kenya.
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Affiliation(s)
- Mary Beth Adam
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | - Sarah Muma
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | | | - Mardi Steere
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | - Nate Cook
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | - Wayne Ellis
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya.,Pediatrics, Howard Hughes Medical Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Catherine T Chen
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | - Arianna Shirk
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
| | | | - Erik N Hansen
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kiambu, Kenya
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Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O, Anand S, Atun R, Bertozzi S, Bhutta Z, Binagwaho A, Black R, Blecher M, Bloom BR, Brouwer E, Bundy DAP, Chisholm D, Cieza A, Cullen M, Danforth K, de Silva N, Debas HT, Donkor P, Dua T, Fleming KA, Gallivan M, Garcia PJ, Gawande A, Gaziano T, Gelband H, Glass R, Glassman A, Gray G, Habte D, Holmes KK, Horton S, Hutton G, Jha P, Knaul FM, Kobusingye O, Krakauer EL, Kruk ME, Lachmann P, Laxminarayan R, Levin C, Looi LM, Madhav N, Mahmoud A, Mbanya JC, Measham A, Medina-Mora ME, Medlin C, Mills A, Mills JA, Montoya J, Norheim O, Olson Z, Omokhodion F, Oppenheim B, Ord T, Patel V, Patton GC, Peabody J, Prabhakaran D, Qi J, Reynolds T, Ruacan S, Sankaranarayanan R, Sepúlveda J, Skolnik R, Smith KR, Temmerman M, Tollman S, Verguet S, Walker DG, Walker N, Wu Y, Zhao K. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet 2018; 391:1108-1120. [PMID: 29179954 PMCID: PMC5996988 DOI: 10.1016/s0140-6736(17)32906-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 12/23/2022]
Abstract
The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.
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Affiliation(s)
- Dean T Jamison
- University of California, San Francisco, San Francisco, CA, USA.
| | - Ala Alwan
- University of Washington, Seattle, WA, USA
| | | | | | | | | | | | - Rifat Atun
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Robert Black
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark Blecher
- National Treasury of South Africa, Cape Town, South Africa
| | - Barry R Bloom
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Dan Chisholm
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | | | | | | | - Haile T Debas
- University of California, San Francisco, San Francisco, CA, USA
| | - Peter Donkor
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Tarun Dua
- World Health Organization, Geneva, Switzerland
| | - Kenneth A Fleming
- Center for Global Health, National Cancer Institute, Bethesda, MD, USA; University of Oxford, Oxford, UK
| | | | | | - Atul Gawande
- Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas Gaziano
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | | | - Roger Glass
- Fogarty International Center, US National Institutes of Health, Bethesda, MD, USA
| | | | - Glenda Gray
- University of the Witwatersrand, Johannesburg, South Africa
| | - Demissie Habte
- International Clinical Epidemiology Network, New Delhi, India
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carol Medlin
- Praxis Social Impact Consulting, Washington, DC, USA
| | - Anne Mills
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Zachary Olson
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | - Toby Ord
- University of Oxford, Oxford, UK
| | | | - George C Patton
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | - John Peabody
- University of California, San Francisco, San Francisco, CA, USA
| | - Dorairaj Prabhakaran
- London School of Hygiene & Tropical Medicine, London, UK; Public Health Foundation of India, New Delhi, India
| | - Jinyuan Qi
- Princeton, University, Princeton, NJ, USA
| | | | | | | | - Jaime Sepúlveda
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Kirk R Smith
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | | | | | - Neff Walker
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Kun Zhao
- China National Health Development Research Center, Beijing, China
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Goldhagen JL, Kadir A, Fouad FM, Spencer NJ, Raman S. The Budapest declaration for children and youth on the move. Lancet Child Adolesc Health 2018; 2:164-165. [PMID: 30169251 DOI: 10.1016/s2352-4642(18)30030-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Jeffrey L Goldhagen
- Division of Community and Societal Pediatrics, University of Florida, Jacksonville, FL 32207, USA.
| | - Ayesha Kadir
- Center for Social Paediatrics, Herlev Hospital, Copenhagen, Denmark
| | - Fouad M Fouad
- Faculty of Health Sciences, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Nicholas J Spencer
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shanti Raman
- Community Paediatrics, South Western Sydney Local Health District, Liverpool NSW, Australia
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Baltussen R, Jansen MP, Bijlmakers L, Tromp N, Yamin AE, Norheim OF. Progressive realisation of universal health coverage: what are the required processes and evidence? BMJ Glob Health 2017; 2:e000342. [PMID: 29082012 PMCID: PMC5656135 DOI: 10.1136/bmjgh-2017-000342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/08/2023] Open
Abstract
Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.
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Affiliation(s)
- R Baltussen
- Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - M P Jansen
- Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - L Bijlmakers
- Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - N Tromp
- Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
- Royal Tropical Institute, Amsterdam, Noord-Holland, The Netherlands
| | - A E Yamin
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Georgetown University Law Center, Washington, District of Columbia, USA
| | - O F Norheim
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- University of Bergen, Bergen, Norway
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40
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Li R, Ruiz F, Culyer AJ, Chalkidou K, Hofman KJ. Evidence-informed capacity building for setting health priorities in low- and middle-income countries: A framework and recommendations for further research. F1000Res 2017; 6:231. [PMID: 28721199 PMCID: PMC5497935 DOI: 10.12688/f1000research.10966.1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 02/02/2023] Open
Abstract
Priority-setting in health is risky and challenging, particularly in resource-constrained settings. It is not simply a narrow technical exercise, and involves the mobilisation of a wide range of capacities among stakeholders - not only the technical capacity to "do" research in economic evaluations. Using the Individuals, Nodes, Networks and Environment (INNE) framework, we identify those stakeholders, whose capacity needs will vary along the evidence-to-policy continuum. Policymakers and healthcare managers require the capacity to commission and use relevant evidence (including evidence of clinical and cost-effectiveness, and of social values); academics need to understand and respond to decision-makers' needs to produce relevant research. The health system at all levels will need institutional capacity building to incentivise routine generation and use of evidence. Knowledge brokers, including priority-setting agencies (such as England's National Institute for Health and Care Excellence, and Health Interventions and Technology Assessment Program, Thailand) and the media can play an important role in facilitating engagement and knowledge transfer between the various actors. Especially at the outset but at every step, it is critical that patients and the public understand that trade-offs are inherent in priority-setting, and careful efforts should be made to engage them, and to hear their views throughout the process. There is thus no single approach to capacity building; rather a spectrum of activities that recognises the roles and skills of all stakeholders. A range of methods, including formal and informal training, networking and engagement, and support through collaboration on projects, should be flexibly employed (and tailored to specific needs of each country) to support institutionalisation of evidence-informed priority-setting. Finally, capacity building should be a two-way process; those who build capacity should also attend to their own capacity development in order to sustain and improve impact.
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Affiliation(s)
- Ryan Li
- Global Health and Development Group, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Francis Ruiz
- Global Health and Development Group, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Anthony J Culyer
- University of York, York, UK
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kalipso Chalkidou
- Global Health and Development Group, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Karen J Hofman
- Priority Cost Effective Lessons for System Strengthening South Africa (PRICELESS SA), MRC/Wits Rural Public Health and Health Transitions Research Unit, Wits University School of Public Health, Johannesburg, South Africa
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Voorhoeve A, Edejer TT, Kapiriri L, Norheim OF, Snowden J, Basenya O, Bayarsaikhan D, Chentaf I, Eyal N, Folsom A, Tun Hussein RH, Morales C, Ostmann F, Ottersen T, Prakongsai P, Saenz C, Saleh K, Sommanustweechai A, Wikler D, Zakariah A. Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage. Health Hum Rights 2016; 18:11-22. [PMID: 28559673 PMCID: PMC5395011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.
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Affiliation(s)
- Alex Voorhoeve
- Department of Philosophy, Logic, and Scientific Method, London School of Economics, London, UK and Visiting Scholar in the Department of Bioethics at the National Institutes of Health, Bethesda, US
| | - Tessa T.T. Edejer
- Coordinator of Costs, Effectiveness, Expenditure and Priority Setting, Health Systems Governance and Financing, and Health Systems and Innovation, World Health Organization, Geneva, Switzerland
| | - Lydia Kapiriri
- Associate Professor in the Department of Health, Aging, and Society, McMaster University, Hamilton, Ontario, Canada
| | - Ole F. Norheim
- Director of Global Health Priorities in the Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway
| | - James Snowden
- Research Analyst at Giving What We Can, Centre for Effective Altruism, Oxford, UK
| | - Olivier Basenya
- Performance-Based Financing Expert in the Ministry of Health, Bujumbura, Burundi
| | - Dorjsuren Bayarsaikhan
- Health Economist in the Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Ikram Chentaf
- International and Intergovernmental Cooperation Program Manager in the Cooperation Division at the Ministry of Health, Rabat, Morocco
| | - Nir Eyal
- Associate Professor, Department of Global Health and Population, TH Chan School of Public Health, Harvard University, Boston, US
| | - Amanda Folsom
- Program Director at the Results for Development Institute, Washington, DC, US
| | - Rozita Halina Tun Hussein
- Deputy Director, Unit for National Health Financing, Planning and Development Division, Ministry of Health, Putrajaya, Malaysia
| | | | - Florian Ostmann
- School of Public Policy, University College London, London, UK
| | - Trygve Ottersen
- Research Fellow, Department of Global Public Health and Primary Care, University of Bergen and Associate Professor, Oslo Group on Global Health Policy, Centre for Global Health, University of Oslo, Bergen, Norway
| | - Phusit Prakongsai
- Director, Bureau of International Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Carla Saenz
- Bioethics Regional Advisor, Pan American Health Organization, Washington, DC, US
| | - Karima Saleh
- Senior Economist in Health at the World Bank, Washington, DC, US
| | | | - Daniel Wikler
- Saltonstall Professor of Ethics and Population Health, Department of Global Health and Population, TH Chan School of Public Health, Harvard University, Boston, US
| | - Afisah Zakariah
- Director, Policy, Planning, Monitoring and Evaluation, Ministry of Health, Accra, Ghana
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