Showing papers on "International health published in 2017"

Advancing Social Connection as a Public Health Priority in the United States

Abstract: A robust body of scientific evidence has indicated that being embedded in high-quality close relationships and feeling socially connected to the people in one's life is associated with decreased risk for all-cause mortality as well as a range of disease morbidities. Despite mounting evidence that the magnitude of these associations is comparable to that of many leading health determinants (that receive significant public health resources), government agencies, health care providers and associations, and public or private health care funders have been slow to recognize human social relationships as either a health determinant or health risk marker in a manner that is comparable to that of other public health priorities. This article evaluates current evidence (on social relationships and health) according to criteria commonly used in determining public health priorities. The article discusses challenges for reducing risk in this area and outlines an agenda for integrating social relationships into current public health priorities. (PsycINFO Database Record

The co-production of what? Knowledge, values, and social relations in health care.

Abstract: "Co-production" is becoming an increasingly popular term in policymaking, governance, and research. While the shift from engagement and involvement to co-production in health care holds the promise of revolutionising health services and research, it is not always evident what counts as co-production: what is being produced, under what circumstances, and with what implications for participants. We discuss these questions and propose that co-production can be understood as an exploratory space and a generative process that leads to different, and sometimes unexpected, forms of knowledge, values, and social relations. By opening up this discussion, we hope to stimulate future debates on co-production as well as draw out ways of thinking differently about collaboration and participation in health care and research. Part of the title of this article is inspired by the book "The Social Construction of What?" by Ian Hacking (Cambridge, MA: Harvard University Press; 2000).

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

Abstract: Health is created largely outside the health sector. Engagement in health governance, policy, and intervention development and implementation by sectors other than health is therefore important. Recent calls for building and implementing Health in All Policies, and continued arguments for intersectoral action, may strengthen the potential that other sectors have for health. This review clarifies the conceptual foundations for integral health governance, policy, and action, delineates the different sectors and their possible engagement, and provides an overview of a continuum of methods of engagement with other sectors to secure integration. This continuum ranges from institutional (re)design to value-based narratives. Depending on the lens applied, different elements can be identified within the continuum. This review is built on insights from political science, leadership studies, public health, empirical Health in All Policy research, knowledge and evidence nexus approaches, and community perspectives. ...

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions.

Abstract: Equity is one of the major goals of China’s recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions. Data of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates. The Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions. Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

Readiness for delivering digital health at scale: lessons from a longitudinal qualitative evaluation of a national digital health innovation program in the United Kingdom

Abstract: Background: Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. Objective: The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale” (dallas) from 2012-2015. Methods: The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. Results: We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. Conclusions: Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale. [J Med Internet Res 2017;19(2):e42]

The World Health Organization "Rehabilitation 2030: a call for action".

Abstract: February 6th-7th, 2017 might become a memorable date in the future of rehabilitation. On these two days, the World Health Organization (WHO) has summoned over 200 stakeholders in the Executive Board Room of the WHO Headquarters in Geneva, Switzerland. Their common aim was to a launch the "Rehabilitation 2030" call to action and to present the WHO Recommendations on rehabilitation in health systems. These initiatives are meant to draw attention to the increasing unmet need for rehabilitation in the world; to highlight the role of rehabilitation in achieving the Sustainable Development Goals proposed by the United Nations; to call for coordinated and concerted global action towards strengthening rehabilitation in health systems. The aim of this paper is to report on the scientific events of these 2 days, which will most likely mark the history of rehabilitation.

Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative

Abstract: Importance Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost. Objectives To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation’s health and fiscal integrity. Evidence Review Qualitative synthesis of 19 National Academy of Medicine–commissioned white papers, with supplemental review and analysis of publicly available data and published research findings. Findings The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation’s health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities—pay for value, empower people, activate communities, and connect care—recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs—measure what matters most, modernize skills, accelerate real-world evidence, and advance science—were the most commonly cited foundational elements to ensure progress. Conclusions and Relevance The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

Building resilient health systems: a proposal for a resilience index

Abstract: Health system resilience begins with measurement of critical capacities ahead of crisis say Margaret E Kruk and colleagues The 2014 west African Ebola epidemic shone a harsh light on the health systems of Guinea, Liberia, and Sierra Leone. While decades of domestic and international investment had contributed to substantial progress on the Millennium Development Goals,12 national health systems remained weak and were unable to cope with the epidemic. Routine care of the population also deteriorated during the outbreak.1234 Surveillance systems did not function effectively, allowing Ebola to spread within and between the countries. Global institutions were slow to respond to the crisis, squandering an opportunity to stem its course.567 Since then, diverse panels of experts have pointed to political and technical deficiencies in multilateral organisations in tackling health crises.891011 These reports have noted that the first line of defence against future pandemics is an effective national health system. They have also called for better measurement of public health capacity, and investment to build resilient health systems—systems that can withstand health shocks while maintaining routine functions.10 The issue of how global bodies can support countries in withstanding future health shocks is playing out now in the election of the new director general of WHO, with several candidates making health system resilience part of their election planks. Based on recent literature, this paper defines health system resilience as “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganise if conditions require it.”12 Health system resilience is relevant in all countries facing health shocks—whether sudden (Ebola, earthquakes, terror attacks, refugees), slower moving (new pathogens such as …

Trauma is a public health issue.

Abstract: Exposure to trauma is pervasive in societies worldwide and is associated with substantial costs to the individual and society, making it a significant global public health concern. We present evidence for trauma as a public health issue by highlighting the role of characteristics operating at multiple levels of influence - individual, relationship, community, and society - as explanatory factors in both the occurrence of trauma and its sequelae. Within the context of this multi-level framework, we highlight targets for prevention of trauma and its downstream consequences and provide examples of where public health approaches to prevention have met with success. Finally, we describe the essential role of public health policies in addressing trauma as a global public health issue, including key challenges for global mental health and next steps for developing and implementing a trauma-informed public health policy agenda. A public health framework is critical for understanding risk and protective factors for trauma and its aftermath operating at multiple levels of influence and generating opportunities for prevention.

Health workforce and governance: the crisis in Nigeria

Abstract: In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. We aimed to review recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria. We conducted a scoping literature search of PubMed to identify studies on health workforce and health governance in Nigeria. A critical analysis, with extended commentary, on recent health workforce crises (2010–2016) and the health system in Nigeria was conducted. The Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population. An encompassing stakeholders’ forum in the Nigerian health sector remain essential. The national health system needs a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders. It is hoped that this paper may prompt relevant reforms in health workforce and governance in Nigeria toward better health service delivery in the country.

One health contributions towards more effective and equitable approaches to health in low- and middle-income countries.

Abstract: Emerging zoonoses with pandemic potential are a stated priority for the global health security agenda, but endemic zoonoses also have a major societal impact in low-resource settings. Although many...

Big Data Science: Opportunities and Challenges to Address Minority Health and Health Disparities in the 21st Century

Abstract: Addressing minority health and health disparities has been a missing piece of the puzzle in Big Data science. This article focuses on three priority opportunities that Big Data science may offer to the reduction of health and health care disparities. One opportunity is to incorporate standardized information on demographic and social determinants in electronic health records in order to target ways to improve quality of care for the most disadvantaged popula­tions over time. A second opportunity is to enhance public health surveillance by linking geographical variables and social determinants of health for geographically defined populations to clinical data and health outcomes. Third and most impor­tantly, Big Data science may lead to a better understanding of the etiology of health disparities and understanding of minority health in order to guide intervention devel­opment. However, the promise of Big Data needs to be considered in light of significant challenges that threaten to widen health dis­parities. Care must be taken to incorporate diverse populations to realize the potential benefits. Specific recommendations include investing in data collection on small sample populations, building a diverse workforce pipeline for data science, actively seeking to reduce digital divides, developing novel ways to assure digital data privacy for small populations, and promoting widespread data sharing to benefit under-resourced minority-serving institutions and minority researchers. With deliberate efforts, Big Data presents a dramatic opportunity for re­ducing health disparities but without active engagement, it risks further widening them. Ethn.Dis; 2017;27(2):95-106; doi:10.18865/ed.27.2.95.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration*

Abstract: The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA-the need to provide timely access, coordination of care, and consistent high quality across a diverse system-mirror those of the larger US health care system.

Advancing the Right to Health--The Vital Role of Law.

Abstract: This report aims to raise awareness about the role that the reform of public health laws can play in advancing the right to health and in creating the conditions for people to live healthy lives. By encouraging a better understanding of how public health law can be used to improve the health of the population, the report aims to encourage and assist governments to reform their public health laws in order to advance the right to health. The report highlights important issues that may arise during the process of public health law reform. It provides guidance about issues and requirements to be addressed during the process of developing public health laws. It also includes case studies and examples of legislation from a variety of countries to illustrate effective law reform practices and some features of effective public health legislation. [Chapter 13: Tobacco control, . See also, mention of 'alcohol' throughout report.]

Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review.

Abstract: Review question/objective What are the experiences and the meaning of teamwork in primary health care settings for health care professionals? Inclusion criteria Types of participants The populations to be included are all officially regulated health professionals that work in primary health settings: Dentistry, medicine, midwives, nursing, nutrition, occupational therapy, pharmacy, physical education, physiotherapy, psychology, social workers, speech therapy. It will also include a community health worker, nursing assistants, licensed practical nursing and other allied health workers. Phenomena of interest The phenomena of interest is to investigate experiences and the meaning of teamwork in the primary healthcare settings. Context The context is Primary Health Care settings, that include health care centers, health maintenance organizations, national health surgery, integrative medicine practices, integrative health care, family practices, primary care organizations and family medical clinics.

Performance of community health workers: situating their intermediary position within complex adaptive health systems.

Abstract: Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors. This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs’ feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs’ perceptions of support received, respect, competence, honesty, fairness and recognition. The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

Strengthening health systems through embedded research.

Abstract: Realizing the health-related sustainable development goals (SDGs) requires integrated action on system-wide challenges. To address gaps in health service delivery, we need evidence on which government agencies, research institutions, donors and civil society can act. (1) Unless research is relevant to specific health systems, the evidence that it generates can be dismissed by policy-makers. (2) For example, there is plenty of evidence for the effectiveness of standard interventions to prevent maternal and child deaths, but countries vary widely in the degree to which these interventions have been implemented. (3) We argue that embedding of research in real world policy, practice and implementation is needed to strengthen health systems worldwide. Embedded research conducted in partnership with policymakers and implementers, integrated in different health system settings and that takes into account context-specific factors can ensure greater relevance in policy priority-setting and decision-making. (4) Collaboration between researchers, implementers and policy-makers has been shown to improve uptake of health systems research. (5) However, in many places, prioritization and conduct of research is often done solely by academics. (6) Health research is also largely focused on biomedical and clinical interventions, while health systems and implementation research remains underfunded globally. (7) Often, knowledge translation is an add-on activity after the completion of research projects. The World Health Organization's report, Changing mindsets: strategy on health policy and systems research, called for the embedding of research into health systems processes. (6) This report explained that when embedding happens, researchers and decision-makers are linked through a system in which the need for evidence to inform policy is understood by decision-makers. The Alliance for Health Policy and Systems Research (AHPSR) and the United Nations Children's Fund (UNICEF) developed a model for implementation research that addresses research priorities identified by decision-makers and specific challenges of local health systems. (8) In this model, policy-makers and implementers at different levels in the health system are engaged as co-investigators and are involved in all phases of a research project. The approach is meant to enhance policymakers' and implementers' ownership of health systems and policy research. The collaboration is designed to prioritize research on empirical questions of local relevance, generate feasible recommendations and integrate evidence into policymaking and health system strengthening. Policy-makers, implementers and researchers are increasingly keen to collaborate on the design and conduct of research to ensure that it contributes to health policy-making. (9,10) Since 2013, AHPSR, UNICEF and Gavi, the Vaccine Alliance, have supported 26 embedded research projects in 15 low- and middle-income countries. These projects aim to foster a better understanding of health systems implementation issues linked to maternal, newborn and child health policies and programmes. (11) Through its African Health Initiative, the Doris Duke Charitable Foundation is also supporting embedded research that aims to enhance the performance of health systems in Africa. (12) In these contexts, embedding research in local health systems helped address real concerns of implementers and supports action to alleviate implementation barriers. Our experience is consistent with evidence showing that embedded research facilitates the integration of scientific findings in policy implementation and health systems strengthening. …

Nationwide citizen access to their health data: analysing and comparing experiences in Denmark, Estonia and Australia.

Abstract: Most countries face an ageing population, increasing chronic diseased, and constrictions on budget for providing health services. Involving patients in their own care by allowing them access to their patient data is a trend seen in many places. Data on the type and level of access citizens have to their own health data in three countries was gathered from public sources. Data from each individual country is presented and the experiences of Denmark, Estonia and Australia are examined whilst similarities and differences explored. The discussion adopts a citizen-centred perspective to consider how the different e-portal systems support, protect and structure citizen interactions with their own health data in three key areas: Security, privacy and data protection; User support; and Citizen adoption and use. The paper highlights the impact of opt-in/opt-out approaches on citizen access and the lack of a structured approach to addressing differences in citizen health and e-health literacy. This research also confirms while current data provides detail on the availability and use of personal health data by citizens, questions still remain over the ultimate impact on patient outcomes of these initiatives. It is anticipated the insights generated from the three countries experiences, supporting citizen access to their health data will be useful to improve these initiatives and guide other countries aspiring to support similar initiatives.

Governing multisectoral action for health in low- and middle-income countries

Abstract: Kumanan Rasanathan and colleagues argue that the potential of multisectoral collaboration for improving health remains untapped in many low- and middle-income countries.

Implementation of the European health interview survey (EHIS) into the German health update (GEDA)

Abstract: This methodological paper describes the integration of the ‘European Health Interview Survey wave 2’ (EHIS 2) into the ‘German Health Update’ 2014/2015 (GEDA 2014/2015-EHIS). GEDA 2014/2015-EHIS is a cross-sectional health survey. A two-stage stratified cluster sampling approach was used to recruit persons aged 15 years and older with permanent residence in Germany. Two different modes of data collection were used, self-administered web questionnaire and self-administered paper questionnaire. The survey instrument implemented the EHIS 2 modules on health status, health care use, health determinants and social background variables and additional national questions. Data processing was conducted according to the quality and validation rules specified by Eurostat. In total, 24,824 questionnaires were completed. The response rate was 27.6%. The two-stage cluster sample method seems to have been successful in achieving a sample with high representativeness. The final micro data file was inspected, approved and certified by Eurostat. Access to micro data of the EHIS 2 can be provided by Eurostat via research contract and to the GEDA 2014/2015-EHIS public use file by the Research Data Centre of the Robert Koch Institute. First EHIS 2 results are available at the Eurostat website. Integrating a multinational health survey into an existing national health monitoring system was a challenge in Germany. The national survey methodology for conducting the survey had to be further developed in order to meet the overarching goal of harmonizing the health information from national statistical offices and public health research institutes across the European Union. The harmonized EHIS 2 data source will profoundly impact international public health research in the near future. The next EHIS wave 3 will be conducted around 2019.

A Bridge Back to the Future: Public Health Ethics, Bioethics, and Environmental Ethics

Abstract: Contemporary biomedical ethics and environmental ethics share a common ancestry in Aldo Leopold's and Van Rensselaer Potter's initial broad visions of a connected biosphere. Over the past five decades, the two fields have become strangers. Public health ethics, a new subfield of bioethics, emerged from the belly of contemporary biomedical ethics and has evolved over the past 25 years. It has moved from its traditional concern with the tension between individual autonomy and community health to a wider focus on social justice and solidarity. Public health has a broad focus that includes individual, community, and environmental health. Public health ethics attends to these broad commitments reflected in the increasing concern with the connectedness of health of individuals to the health of populations, to the health of animals, to the health of the environment; it is well situated to reconnect all three “fields” of ethics to promote a healthier planet.

The Changing Roles of Community Health Workers

Abstract: Objective To examine what different types of employers value in hiring community health workers (CHWs) and determine what new competencies CHWs might need to meet workforce demands in the context of an evolving payment landscape and substantial literature suggesting that CHWs are uniquely qualified to address health disparities. Study Design We used a multimethod approach, including a literature review, development of a database of 76 programs, interviews with 24 key informants, and a qualitative comparison of major CHW competency lists. Principal Findings We find a shift in CHW employment settings from community-based organizations to hospitals/health systems. Providers that hire CHWs directly, as opposed to partnering with community organizations, report that they value education and training more highly than traditional characteristics, such as peer status. We find substantial similarities across competency lists, but a gap in competencies that relate to CHWs’ ability to integrate into health systems while maintaining their unique identity. Conclusions As CHW integration into health care organizations advances, and as states move forward with CHW certification efforts, it is important to develop new competencies that relate to CHW–health system integration. Chief among them is the ability to explain and defend the CHW's unique occupational identity.

Incorporating one health into medical education

Abstract: One Health is an emerging concept that stresses the linkages between human, animal, and environmental health, as well as the need for interdisciplinary communication and collaboration to address health issues including emerging zoonotic diseases, climate change impacts, and the human-animal bond. It promotes complex problem solving using a systems framework that considers interactions between humans, animals, and their shared environment. While many medical educators may not yet be familiar with the concept, the One Health approach has been endorsed by a number of major medical and public health organizations and is beginning to be implemented in a number of medical schools. In the research setting, One Health opens up new avenues to understand, detect, and prevent emerging infectious diseases, and also to conduct translational studies across species. In the clinical setting, One Health provides practical ways to incorporate environmental and animal contact considerations into patient care. This paper reviews clinical and research aspects of the One Health approach through an illustrative case updating the biopsychosocial model and proposes a basic set of One Health competencies for training and education of human health care providers.

Out-of-pocket healthcare expenditure and chronic disease – do Australians forgo care because of the cost?

Abstract: Although we do know that out-of-pocket healthcare expenditure is relatively high in Australia, little is known about what health conditions are associated with the highest out-of-pocket expenditure, and whether the cost of healthcare acts as a barrier to care for people with different chronic conditions. Cross-sectional analysis using linear and logistic regression models applied to the Commonwealth Fund international health policy survey of adults aged 18 years and over was conducted in 2013. Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition (95% CI: 50-193%); and adults with depression, anxiety and other mental health conditions had 95% higher household out-of-pocket expenditure (95% CI: 33-187%). People with a chronic condition were also more likely to forego care because of cost. People with depression, anxiety and other mental health conditions had 7.65 times higher odds of skipping healthcare (95% CI: 4.13-14.20), and people with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare (95% CI: 3.30-11.50) than did people with no health condition. People with chronic health conditions in Canada, the United Kingdom, Germany, France, Norway, Sweden and Switzerland were all significantly less likely to skip healthcare because of cost than were people with a condition in Australia. The out-of-pocket cost of healthcare in Australia acts as a barrier to accessing treatment for people with chronic health conditions, with people with mental health conditions being likely to skip care. Attention should be given to the accessibility and affordability of mental health services in Australia.

The role of women's leadership and gender equity in leadership and health system strengthening

Abstract: Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.