Showing papers in "Globalization and Health in 2011"

Masculinity as a barrier to men's use of HIV services in Zimbabwe.

Abstract: Background: A growing number of studies highlight men’s disinclination to make use of HIV services. This suggests there are factors that prevent men from engaging with health services and an urgent need to unpack the forms of sociality that determine men’s acceptance or rejection of HIV services. Methods: Drawing on the perspectives of 53 antiretroviral drug users and 25 healthcare providers, we examine qualitatively how local constructions of masculinity in rural Zimbabwe impact on men’s use of HIV services. Results: Informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the ‘good patient’ persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of ‘a good patient’ can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. However, once men had been counselled and had the opportunity to reflect upon the impact of ART on their productivity and social value, it was possible for some to construct new and more ART-friendly versions of masculinity. Conclusion: We urge HIV service providers to consider the obstacles that prevent many men from accessing their services and argue for community-based and driven initiatives that facilitate safe and supportive social spaces for men to openly discuss social constructions of masculinity as well as renegotiate more health-enabling masculinities.

Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia

Abstract: Medical tourism is a growing phenomenon with policy implications for health systems, particularly of destination countries. Private actors and governments in Southeast Asia are promoting the medical tourist industry, but the potential impact on health systems, particularly in terms of equity in access and availability for local consumers, is unclear. This article presents a conceptual framework that outlines the policy implications of medical tourism's growth for health systems, drawing on the cases of Thailand, Singapore and Malaysia, three regional hubs for medical tourism, via an extensive review of academic and grey literature. Variables for further analysis of the potential impact of medical tourism on health systems are also identified. The framework can provide a basis for empirical, in country studies weighing the benefits and disadvantages of medical tourism for health systems. The policy implications described are of particular relevance for policymakers and industry practitioners in other Southeast Asian countries with similar health systems where governments have expressed interest in facilitating the growth of the medical tourist industry. This article calls for a universal definition of medical tourism and medical tourists to be enunciated, as well as concerted data collection efforts, to be undertaken prior to any meaningful empirical analysis of medical tourism's impact on health systems.

Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

Abstract: Objective Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.

India-EU relations in health services: prospects and challenges

Abstract: India and the EU are currently negotiating a Trade and Investment Agreement which also covers services. This paper examines the opportunities for and constraints to India-EU relations in health services in the context of this agreement, focusing on the EU as a market for India's health services exports and collaboration. The paper provides an overview of key features of health services in the EU and India and their bearing on bilateral relations in this sector. Twenty six semi-structured, in-person, and telephonic interviews were conducted in 2007-2008 in four Indian cities. The respondents included management and practitioners in a variety of healthcare establishments, health sector representatives in Indian industry associations, health sector officials in the Indian government, and official representatives of selected EU countries and the European Commission based in New Delhi. Secondary sources were used to supplement and corroborate these findings. The interviews revealed that India-EU relations in health services are currently very limited. However, several opportunity segments exist, namely: (i) Telemedicine; (ii) Clinical trials and research in India for EU-based pharmaceutical companies; (iii) Medical transcriptions and back office support; (iv) Medical value travel; and (v) Collaborative ventures in medical education, research, training, staff deployment, and product development. However, various factors constrain India's exports to the EU. These include data protection regulations; recognition requirements; insurance portability restrictions; discriminatory conditions; and cultural, social, and perception-related barriers. The interviews also revealed several constraints in the Indian health care sector, including disparity in domestic standards and training, absence of clear guidelines and procedures, and inadequate infrastructure. The paper concludes that although there are several promising areas for India-EU relations in health services, it will be difficult to realize these opportunities given the pre-dominance of public healthcare delivery in the EU and sensitivities associated with commercializing healthcare. Hence, a gradual approach based on pilot initiatives and selective collaboration would be advisable initially, which could be expanded once there is demonstrated evidence on outcomes. Overall, the paper makes a contribution to the social science and health literature by adding to the limited primary evidence base on globalization and health, especially from a developing-developed country and regional perspective.

A win-win solution?: A critical analysis of tiered pricing to improve access to medicines in developing countries

Abstract: Tiered pricing - the concept of selling drugs and vaccines in developing countries at prices systematically lower than in industrialized countries - has received widespread support from industry, policymakers, civil society, and academics as a way to improve access to medicines for the poor. We carried out case studies based on a review of international drug price developments for antiretrovirals, artemisinin combination therapies, drug-resistant tuberculosis medicines, liposomal amphotericin B (for visceral leishmaniasis), and pneumococcal vaccines. We found several critical shortcomings to tiered pricing: it is inferior to competition for achieving the lowest sustainable prices; it often involves arbitrary divisions between markets and/or countries, which can lead to very high prices for middle-income markets; and it leaves a disproportionate amount of decision-making power in the hands of sellers vis-a-vis consumers. In many developing countries, resources are often stretched so tight that affordability can only be approached by selling medicines at or near the cost of production. Policies that "de-link" the financing of R&D from the price of medicines merit further attention, since they can reward innovation while exploiting robust competition in production to generate the lowest sustainable prices. However, in special cases - such as when market volumes are very small or multi-source production capacity is lacking - tiered pricing may offer the only practical option to meet short-term needs for access to a product. In such cases, steps should be taken to ensure affordability and availability in the longer-term. To ensure access to medicines for populations in need, alternate strategies should be explored that harness the power of competition, avoid arbitrary market segmentation, and/or recognize government responsibilities. Competition should generally be the default option for achieving affordability, as it has proven superior to tiered pricing for reliably achieving the lowest sustainable prices.

Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists

Abstract: Medical tourism is a global health practice where patients travel abroad to receive health care. Voluntourism is a practice where physicians travel abroad to deliver health care. Both of these practices often entail travel from high income to low and middle income countries and both have been associated with possible negative impacts. In this paper, we explore the social responsibilities of medical tourists and voluntourists to identify commonalities and distinctions that can be used to develop a wider understanding of social responsibility in global health care practices. Social responsibility is a responsibility to promote the welfare of the communities to which one belongs or with which one interacts. Physicians stress their social responsibility to care for the welfare of their patients and their domestic communities. When physicians choose to travel to another county to provide medical care, this social responsibility is expanded to this new community. Patients too have a social responsibility to use their community's health resources efficiently and to promote the health of their community. When these patients choose to go abroad to receive medical care, this social responsibility applies to the new community as well. While voluntourists and medical tourists both see the scope of their social responsibilities expand by engaging in these global practices, the social responsibilities of physician voluntourists are much better defined than those of medical tourists. Guidelines for engaging in ethical voluntourism and training for voluntourists still need better development, but medical tourism as a practice should follow the lead of voluntourism by developing clearer norms for ethical medical tourism. Much can be learned by examining the social responsibilities of medical tourists and voluntourists when they engage in global health practices. While each group needs better guidance for engaging in responsible forms of these practices, patients are at a disadvantage in understanding the effects of medical tourism and organizing responses to these impacts. Members of the medical professions and the medical tourism industry must take responsibility for providing better guidance for medical tourists.

More than just talk: the framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa

Abstract: Background: ’Transactional sex’ was regarded by the mid-1990s as an important determinant of HIV transmission, particularly in sub-Saharan Africa. Little attention has been paid to what the terms used to denote transactional sex suggest about how it is understood. This study provides a nuanced set of descriptions of the meaning of transactional sex in three settings. Furthermore, we discuss how discourses around transactional sex suggest linkages to processes of globalization and hold implications for vulnerability to HIV. Methods: The analysis in this article is based on three case studies conducted as part of a multi-country research project that investigated linkages between economic globalization and HIV. In this analysis, we contextualize and contrast the ‘talk’ about transactional sex through the following research methods in three study sites: descriptions revealed through semi-structured interviews with garment workers in Lesotho; focus groups with young women and men in Antananarivo, Madagascar; and focus groups and in-depth interviews with young women and men in Mbekweni, South Africa. Results: Participants’ talk about transactional sex reveals two themes: (1) ‘The politics of differentiation’ reflects how participants used language to demarcate identities, and distance themselves from contextually-based marginalized identities; and (2) ‘Gender, agency and power’ describes how participants frame gendered-power within the context of transactional sex practices, and reflects on the limitations to women’s power as sexual agents in these exchanges. Talk about transactional sex in our study settings supports the assertion that emerging transactional sexual practices are linked with processes of globalization tied to consumerism. Conclusions: By focusing on ‘talk’ about transactional sex, we locate definitions of transactional sex, and how terms used to describe transactional sex are morally framed for people within their local context. We take advantage of an opportunity to comparatively explore such talk across three different study sites, and contribute to a better understanding of both emerging sexual practices and their implications for HIV vulnerability. Our work underlines that transactional sex needs to be reflected as it is perceived: something very different from, but of at least equal concern to, formal sex work in the efforts to curb HIV transmission.

The first decade of antiretroviral therapy in Africa

Abstract: The past decade has seen remarkable progress in increasing access to antiretroviral therapy in resource-limited settings. Early concerns about the cost and complexity of treatment were overcome thanks to the efforts of a global coalition of health providers, activists, academics, and people living with HIV/AIDS, who argued that every effort must be made to ensure access to essential care when millions of lives depended on it. The high cost of treatment was reduced through advocacy to promote access to generic drugs; care provision was simplified through a public health approach to treatment provision; the lack of human resources was overcome through task-shifting to support the provision of care by non-physicians; and access was expanded through the development of models of care that could work at the primary care level. The challenge for the next decade is to further increase access to treatment and support sustained care for those on treatment, while at the same time ensuring that the package of care is continuously improved such that all patients can benefit from the latest improvements in drug development, clinical science, and public health.

Social participation and healthy ageing: a neglected, significant protective factor for chronic non communicable conditions

Abstract: Background Low and middle income countries are ageing at a much faster rate than richer countries, especially in Asia. This is happening at a time of globalisation, migration, urbanisation, and smaller families. Older people make significant contributions to their families and communities, but this is often undermined by chronic disease and preventable disability. Social participation can help to protect against morbidity and mortality. We argue that social participation deserves much greater attention as a protective factor, and that older people can play a useful role in the prevention and management of chronic conditions. We present, as an example, a low-cost, sustainable strategy that has increased social participation among elders in Sri Lanka.

Framing international trade and chronic disease

Abstract: There is an emerging evidence base that global trade is linked with the rise of chronic disease in many low and middle-income countries (LMICs). This linkage is associated, in part, with the global diffusion of unhealthy lifestyles and health damaging products posing a particular challenge to countries still facing high burdens of communicable disease. We developed a generic framework which depicts the determinants and pathways connecting global trade with chronic disease. We then applied this framework to three key risk factors for chronic disease: unhealthy diets, alcohol, and tobacco. This led to specific 'product pathways', which can be further refined and used by health policy-makers to engage with their country's trade policy-makers around health impacts of ongoing trade treaty negotiations, and by researchers to continue refining an evidence base on how global trade is affecting patterns of chronic disease. The prevention and treatment of chronic diseases is now rising on global policy agendas, highlighted by the UN Summit on Noncommunicable Diseases (September 2011). Briefs and declarations leading up to this Summit reference the role of globalization and trade in the spread of risk factors for these diseases, but emphasis is placed on interventions to change health behaviours and on voluntary corporate responsibility. The findings summarized in this article imply the need for a more concerted approach to regulate trade-related risk factors and thus more engagement between health and trade policy sectors within and between nations. An explicit recognition of the role of trade policies in the spread of noncommunicable disease risk factors should be a minimum outcome of the September 2011 Summit, with a commitment to ensure that future trade treaties do not increase such risks.

Multi-Country analysis of palm oil consumption and cardiovascular disease mortality for countries at different stages of economic development: 1980-1997

Abstract: Background: Cardiovascular diseases represent an increasing share of the global disease burden There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat Methods: The study analyzed country-level data from 1980-1997 derived from the World Health Organization’s Mortality Database, US Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries) Outcomes included mortality from IHD and stroke for adults aged 50 and older Predictors included per-capita consumption of palm oil and cigarettes and per-capita Gross Domestic Product as well as time trends and an interaction between palm oil consumption and country economic development level Analyses examined changes in country-level outcomes over time employing linear panel regressions with countrylevel fixed effects, population weighting, and robust standard errors clustered by country Sensitivity analyses included further adjustment for other major dietary sources of saturated fat Results: In developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000 (95% CI [21-115]), whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 (95% CI [-12-49]) but were not significant For historically high-income countries, changes in IHD and stroke mortality rates from palm oil consumption were smaller (IHD: 17 deaths per 100,000 (95% CI [53-29]); stroke: 51 deaths per 100,000 (95% CI [-12-110])) Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries Conclusions: Increased palm oil consumption is related to higher IHD mortality rates in developing countries Palm oil consumption represents a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens

HIV/AIDS, chronic diseases and globalisation.

Abstract: HIV/AIDS has always been one of the most thoroughly global of diseases. In the era of widely available anti-retroviral therapy (ART), it is also commonly recognised as a chronic disease that can be successfully managed on a long-term basis. This article examines the chronic character of the HIV/AIDS pandemic and highlights some of the changes we might expect to see at the global level as HIV is increasingly normalised as "just another chronic disease". The article also addresses the use of this language of chronicity to interpret the HIV/AIDS pandemic and calls into question some of the consequences of an uncritical acceptance of concepts of chronicity.

The increasing chronicity of HIV in sub-Saharan Africa: Re-thinking "HIV as a long-wave event" in the era of widespread access to ART

Abstract: HIV was first described as a "long-wave event" in 1990, well before the advent of antiretroviral therapy (ART). The pandemic was then seen as involving three curves: an HIV curve, an AIDS curve and a curve representing societal impact. Since the mid-2000's, free public delivery of life-saving ART has begun shifting HIV from a terminal disease to a chronic illness for those who can access and tolerate the medications. This increasing chronicity prompts revisiting HIV as a long-wave event. First, with widespread availability of ART, the HIV curve will be higher and last longer. Moreover, if patterns in sub-Saharan Africa mirror experiences in the North, people on ART will live far longer lives but with new experiences of disability. Disability, broadly defined, can result from HIV, its related conditions, and from side effects of medications. Individual experiences of disability will vary. At a population level, however, we anticipate that experiences of disability will become a common part of living with HIV and, furthermore, may be understood as a variation of the second curve. In the original conceptualization, the second curve represented the transition to AIDS; in the era of treatment, we can expect a transition from HIV infection to HIV-related disability for people on ART. Many such individuals may eventually develop AIDS as well, but after a potentially long life that includes fluctuating episodes of illness, wellness and disability. This shift toward chronicity has implications for health and social service delivery, and requires a parallel shift in thinking regarding HIV-related disability. A model providing guidance on such a broader understanding of disability is the World Health Organization's International Classification of Functioning, Disability and Health (ICF). In contrast to a biomedical approach concerned primarily with diagnoses, the ICF includes attention to the impact of these diagnoses on people's lives and livelihoods. The ICF also focuses on personal and environmental contextual factors. Locating disability as a new form of the second curve in the long-wave event calls attention to the new spectrum of needs that will face many people living with HIV in the years and decades ahead.

Chronic non-communicable diseases in Cameroon - burden, determinants and current policies

Abstract: Cameroon is experiencing an increase in the burden of chronic non-communicable diseases (NCDs), which accounted for 43% of all deaths in 2002. This article reviews the published literature to critically evaluate the evidence on the frequency, determinants and consequences of NCDs in Cameroon, and to identify research, intervention and policy gaps. The rising trends in NCDs have been documented for hypertension and diabetes, with a 2-5 and a 10-fold increase in their respective prevalence between 1994 and 2003. Magnitudes are much higher in urban settings, where increasing prevalence of overweight/obesity (by 54-82%) was observed over the same period. These changes largely result from the adoption of unfavorable eating habits, physical inactivity, and a probable increasing tobacco use. These behavioral changes are driven by the economic development and social mobility, which are part of the epidemiologic transition. There is still a dearth of information on chronic respiratory diseases and cancers, as well as on all NDCs and related risk factors in children and adolescents. More nationally representative data is needed to tract risk factors and consequences of NCDs. These conditions are increasingly been recognized as a priority, mainly through locally generated evidence. Thus, national-level prevention and control programs for chronic diseases (mainly diabetes and hypertension) have been established. However, the monitoring and evaluation of these programs is necessary. Budgetary allocations data by the ministry of health would be helpful, to evaluate the investment in NCDs prevention and control. Establishing more effective national-level tobacco control measures and food policies, as well as campaigns to promote healthy diets, physical activity and tobacco cessation would probably contribute to reducing the burden of NCDs.

The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries

Abstract: Background The growing caseload caused by patients with chronic life-long conditions leads to increased needs for health care providers and rising costs of health services, resulting in a heavy burden on health systems, populations and individuals. The professionalised health care for chronic patients common in high income countries is very labour-intensive and expensive. Moreover, the outcomes are often poor. In low-income countries, the scarce resources and the lack of quality and continuity of health care result in high health care expenditure and very poor health outcomes. The current proposals to improve care for chronic patients in low-income countries are still very much provider-centred. The aim of this paper is to show that present provider-centred models of chronic care are not adequate and to propose 'full self-management' as an alternative for low-income countries, facilitated by expert patient networks and smart phone technology.

Major multinational food and beverage companies and informal sector contributions to global food consumption: implications for nutrition policy.

Abstract: Background In recent years, 10 major multinational food and beverage companies have worked together within the International Food and Beverage Alliance (IFBA) to increase their commitments to public health. Current IFBA commitments include initiatives to improve the nutrition quality of products and how these products are advertised to children. The impact and magnitude of IFBA member contributions to the total market share of packaged foods and beverages consumed remain incompletely understood, however.

Globalisation of birth markets: a case study of assisted reproductive technologies in India

Abstract: The escalation of Assisted Reproductive Technologies (ARTs) in India into a veritable fertility industry is the result of a multitude of reasons. This paper places the bio-genetic industry within the larger political economy framework of globalisation and privatisation, thus employing a framework that is often omitted from discussions on ARTs, but has direct and significant bearings on the ART industry in India. As markets for human organs, tissues and reproductive body parts experience unprecedented growth, the limits of what can or should be bought and sold continue to be pushed. As such, bodies have emerged as sale-worthy economic capital. Commercial flows of reproductive material create and deploy the division of the body into parts over which ownership is claimed, in the process following 'modern routes of capital' and raising issues of structural inequality.

A review of health system infection control measures in developing countries : what can be learned to reduce maternal mortality

Abstract: A functional health system is a necessary part of efforts to achieve maternal mortality reduction in developing countries. Puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Infections can be contracted during childbirth either in the community or in health facilities. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. This article reviews health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low resource settings. A health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.

The private sector, international development and NCDs

Abstract: This article addresses an area that has been largely underserved by the development community, and one in which there is a particularly good opportunity for the private sector to take a lead in making a difference to employees, customers and local communities: chronic, non-communicable diseases (NCDs). It highlights the extent of the epidemic of NCDs in developing countries, sets out the 'business case' for the private sector to act on NCDs, and gives examples of initiatives by business to ensure that the healthy choice really is an easier choice for employees, consumers and local communities. It makes the case that, to be genuinely sustainable, businesses should be addressing health as a core part of what they do and, by working in partnership - as called for by the Millennium Development Goals - they can make a real difference and become part of the solution. Identifying ways in which this can be done should form a key part both of planning for, and action after, the UN High-level Meeting on NCDs, to be held in September 2011.

Scaling up antiretroviral therapy in Uganda: using supply chain management to appraise health systems strengthening

Abstract: Strengthened national health systems are necessary for effective and sustained expansion of antiretroviral therapy (ART). ART and its supply chain management in Uganda are largely based on parallel and externally supported efforts. The question arises whether systems are being strengthened to sustain access to ART. This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems. This study uses the WHO health systems framework and examines the issues of governance, financing, information, human resources and service delivery in relation to supply chain management of medicines and the technologies. It looks at links and causal chains between supply chain management for ART and the national supply system for essential drugs. It combines data from the literature and key informant interviews with observations at health service delivery level in a study district. Current drug supply chain management in Uganda is characterized by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches. The opportunity and need to use ART investments for an essential supply chain management and strengthened health system has not been exploited. By applying a systems perspective this work indicates the seriousness of missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and program-specific nature of external assistance.

The creation of the health consumer: challenges on health sector regulation after managed care era

Abstract: Background We utilized our previous studies analyzing the reforms affecting the health sector developed in the 1990s by financial groups to frame the strategies implemented by the pharmaceutical industry to regain market positions and to understand the challenges that regulatory agencies are confronting.

'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan

Abstract: Despite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs). Semi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors. Stigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included: criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers. Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.

Healthy lifestyle behaviour among Ghanaian adults in the phase of a health policy change.

Abstract: Many countries have adopted health policies that are targeted at reducing the risk factors for chronic non-communicable diseases. These policies promote a healthy population by encouraging people to adopt healthy lifestyle behaviours. This paper examines healthy lifestyle behaviour among Ghanaian adults by comparing behaviours before and after the introduction of a national health policy. The paper also explores the socio-economic and demographic factors associated with healthy lifestyle behaviour. Descriptive, bivariate and multivariate regression techniques were employed on two nationally representative surveys (2003 World Health Survey (Ghana) and 2008 Ghana Demographic and Health Survey) to arrive at the results. While the prevalence of some negative lifestyle behaviours like smoking has reduced others like alcohol consumption has increased. Relatively fewer people adhered to consuming the recommended amount of fruit and vegetable servings per day in 2008 compared to 2003. While more females (7.0%) exhibited healthier lifestyles, more males (9.0%) exhibited risky lifestyle behaviours after the introduction of the policy. The improvement in healthy lifestyle behaviours among female adult Ghanaians will help promote healthy living and potentially lead to a reduction in the prevalence of obesity among Ghanaian women. The increase in risky lifestyle behaviour among adult male Ghanaians even after the introduction of the health policy could lead to an increase in the risk of non-communicable diseases among men and the resultant burden of disease on them and their families will push more people into poverty.

Canadian medical tourism companies that have exited the marketplace: Content analysis of websites used to market transnational medical travel

Abstract: Background Medical tourism companies play an important role in promoting transnational medical travel for elective, out-of-pocket medical procedures. Though researchers are paying increasing attention to the global phenomenon of medical tourism, to date websites of medical tourism companies have received limited scrutiny. This article analyzes websites of Canadian medical tourism companies that advertised international healthcare but ultimately exited the marketplace. Using content analysis of company websites as an investigative tool, the article provides a detailed account of medical tourism companies that were based in Canada but no longer send clients to international health care facilities.

The potential for bi-lateral agreements in medical tourism: A qualitative study of stakeholder perspectives from the UK and India

Abstract: Background: Globalisation has prompted countries to evaluate their position on trade in health services. However, this is often done from a multi-lateral, rather than a regional or bi-lateral perspective. In a previous review, we concluded that most of the issues raised could be better addressed from a bi-lateral relationship. We report here the results of a qualitative exercise to assess stakeholders’ perceptions on the prospects for such a bi-lateral system, and its ability to address concerns associated with medical tourism. Methods: 30 semi-structured interviews were carried out with stakeholders, 20 in India and 10 in the UK, to assess their views on the potential offered by a bi-lateral relationship on medical tourism between both countries. Issues discussed include data availability, origin of medical tourists, quality and continuity of care, regulation and litigation, barriers to medical tourism, policy changes needed, and prospects for such a bi-lateral relationship. Results: The majority of stakeholders were concerned about the quality of health services patients would receive abroad, regulation and litigation procedures, lack of continuity of care, and the effect of such trade on the healthcare available to the local population in India. However, when considering trade from a bi-lateral point of view, there was disagreement on how these issues would apply. There was further disagreement on the importance of the Diaspora and the validity of the UK’s ‘rule’ that patients should not fly more than three hours to obtain care. Although the opinion on the prospects for an India-UK bi-lateral relationship was varied, there was no consensus on what policy changes would be needed for such a relationship to take place. Conclusions: Whilst the literature review previously carried out suggested that a bi-lateral relationship would be best-placed to address the concerns regarding medical tourism, there was scepticism from the analysis provided in this paper based on the over-riding feeling that the political ‘cost’ involved was likely to be the major impediment. This makes the need for better evidence even more acute, as much of the current policy process could well be based on entrenched ideological positions, rather than secure evidence of impact.

The 'global health' education framework: a conceptual guide for monitoring, evaluation and practice

Abstract: In the past decades, the increasing importance of and rapid changes in the global health arena have provoked discussions on the implications for the education of health professionals. In the case of Germany, it remains yet unclear whether international or global aspects are sufficiently addressed within medical education. Evaluation challenges exist in Germany and elsewhere due to a lack of conceptual guides to develop, evaluate or assess education in this field. To propose a framework conceptualising 'global health' education (GHE) in practice, to guide the evaluation and monitoring of educational interventions and reforms through a set of key indicators that characterise GHE. Literature review; deduction. Currently, 'new' health challenges and educational needs as a result of the globalisation process are discussed and linked to the evolving term 'global health'. The lack of a common definition of this term complicates attempts to analyse global health in the field of education. The proposed GHE framework addresses these problems and presents a set of key characteristics of education in this field. The framework builds on the models of 'social determinants of health' and 'globalisation and health' and is oriented towards 'health for all' and 'health equity'. It provides an action-oriented construct for a bottom-up engagement with global health by the health workforce. Ten indicators are deduced for use in monitoring and evaluation.

Trust and the regulation of pharmaceuticals: South Asia in a globalised world

Abstract: Background: Building appropriate levels of trust in pharmaceuticals is a painstaking and challenging task, involving participants from different spheres of life, including producers, distributors, retailers, prescribers, patients and the mass media. Increasingly, however, trust is not just a national matter, but involves cross-border flows of knowledge, threats and promises. Methods: Data for this paper comes from the project ‘Tracing Pharmaceuticals in South Asia’, which used ethnographic fieldwork and qualitative interviews to compared the trajectories of three pharmaceuticals (Rifampicin, Oxytocin and Fluoxetine) from producer to patient in three sites (north India, West Bengal and Nepal) between 2005-08. Results: We argue that issues of trust are crucial in reducing the likelihood of appropriate use of medicines. Unlike earlier discussions of trust, we suggest that trust contexts beyond the patient-practitioner relationship are important. We illustrate these arguments through three case studies: (i) a conflict over ethics in Nepal, involving a suggested revised ethical code for retailers, medical representatives, producers and prescribers; (ii) disputes over counterfeit, fake, substandard and spurious medicines, and quality standards in Indian generic companies, looking particularly at the role played by the US FDA; and (iii) the implications of lack of trust in the DOTS programmes in India and Nepal for the relationships among patients, government and the private sector. Conclusions: We conclude that the building of trust is a necessary but always vulnerable and contingent process. While it might be desirable to outline steps that can be taken to build trust, the range of conflicting interests in the pharmaceutical field make feasible solutions hard to implement. Background In conducting our research tracing three pharmaceuticals (Rifampicin, Fluoxetine and Oxytocin) from production to consumption in South Asia we became increasingly interested in participants’ concern with ‘trust’ as a key feature of how different stakeholders related to the pharmaceuticals industry. We turned our attention to how a lack of trust was a key problem in ensuring that these drugs were appropriately produced, stored, distributed, prescribed and consumed. We understand trust ‘in rational or calculative terms, as a form of confidence based on incentives, rules, or institutional features that gives one person reason to believe

The Health Systems Funding Platform: Is this where we thought we were going?

Abstract: In March 2009, the Task Force for Innovative International Financing for Health Systems recommended "a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies." Momentum to establish the Health Systems Funding Platform was swift, with the World Bank convening a Technical Workshop on Health Systems Strengthening (HSS), and serial meetings organized to progress the agenda. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information. This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform. The findings show a fluid and volatile process, with debate over whether ongoing engagement in HSS by Global Fund and GAVI represents a dilution of organizational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. Uncertainty in the development of the Platform reflects the flexibility of the recently formed global health initiatives, and the instability of donor commitments, particularly in the current financial climate. But implicit in the conflict is tension between key global stakeholders over defining and ownership of the health systems agenda. The tensions appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems, that has not been previously possible.

Understanding chronic non-communicable diseases in Latin America: towards an equity-based research agenda

Abstract: Although chronic non-communicable diseases are traditionally depicted as diseases of affluence, growing evidence suggests they strike along the fault lines of social inequality. The challenge of understanding how these conditions shape patterns of population health in Latin America requires an inter-disciplinary lens. This paper reviews the burden of chronic non-communicable diseases in the region and examines key myths surrounding their prevalence and distribution. It argues that a social justice approach rooted in the idea of health inequity needs to be at the core of research in this area, and concludes with discussion of a new approach to guide empirical research, the 'average/deprivation/inequality' framework.

An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries

Abstract: Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases. We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia. Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system. The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.