Ethics and governance of global health inequalities

Ethical Frameworks and Global Health: A Narrative Review of the "Leave No One Behind" Principle

The "Leave No One Behind" (LNOB) principle, a fundamental commitment of the United Nations' Sustainable Development Goals, emphasizes the urgent need to address and reduce global health inequalities. As global health initiatives strive to uphold this principle, they face significant ethical challenges in balancing equity, resource allocation, and diverse health priorities. This narrative review critically examines these ethical dilemmas and their implications for translating LNOB into actionable global health strategies. A comprehensive literature search was conducted using PubMed, Scopus, Web of Science, and Semantic Scholar, covering publications from January 1990 to April 2024. The review included peer-reviewed articles, gray literature, and official reports that addressed the ethical dimensions of LNOB in global health contexts. A thematic analysis was employed to identify and synthesize recurring ethical issues, dilemmas, and proposed solutions. The thematic analysis identified 4 primary ethical tensions that complicate the operationalization of LNOB: (1) Universalism versus Targeting, where the challenge lies in balancing broad health improvements with targeted interventions for the most disadvantaged; (2) Resource Scarcity versus Equity; highlighting the ethical conflicts between maximizing efficiency and ensuring fairness; (3) Top-down versus Bottom-up Approaches, reflecting the tension between externally driven initiatives and local community needs; and (4) Short-term versus Long-term Sustainability, addressing the balance between immediate health interventions and sustainable systemic changes. To navigate these ethical challenges effectively, global health strategies must adopt a nuanced, context-sensitive approach incorporating structured decision-making processes and authentic community participation. The review advocates for systemic reforms that address the root causes of health disparities, promote equitable collaboration between health practitioners and marginalized communities, and align global health interventions with ethical imperatives. Such an approach is essential to truly operationalize the LNOB principle and foster sustainable health equity.

Flourishing and Self-Control in Adolescence: The Role of Perceived Parenting

Self-control is the ability to control thoughts, emotions, and impulses to pursuit of long-term goals. Adolescents with high self-control experience higher flourishing levels. The latter refers to the fulfillment of needs for competence, relationship, and self-acceptance, as well as the possession of psychological capital such as flow and commitment. High levels of self-control also seem to be linked to a positive relationship with parents, which is crucial in adolescent flourishing. However, few studies investigated the association between flourishing, self-control, and perceived parenting in adolescence. The aim of this study was to investigate how the ability to exert self-control and the need to perceive and preserve a responsive relationship with parents would facilitate adolescents' experience of higher flourishing levels. The relationships among self-control, adolescents' perception of some paternal and maternal dimensions (closeness, communication, and parents' peer approval), and flourishing were analyzed in a sample of 335 Italian adolescents. Self-control was positively correlated with flourishing and the adolescent's perception of maternal and paternal dimensions. The PROCESS model showed that perceived maternal and paternal dimensions mediate the relationship between self-control and flourishing. These findings show the importance of self-control and parenting dimensions in promoting flourishing during adolescence.

Progress Toward Equitable Mpox Vaccination Coverage: A Shortfall Analysis - United States, May 2022-April 2023

More than 30,000 monkeypox (mpox) cases were reported in the United States during the 2022 multinational outbreak; cases disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Substantial racial and ethnic disparities in incidence were also reported (1). The national mpox vaccination strategy* emphasizes that efforts to administer the JYNNEOS mpox vaccine should be focused among the populations at elevated risk for exposure to mpox (2). During May 2022-April 2023, a total of 748,329 first JYNNEOS vaccine doses (of the two recommended) were administered in the United States.^† During the initial months of the outbreak, lower vaccination coverage rates among racial and ethnic minority groups were reported (1,3); however, after implementation of initiatives developed to expand access to mpox vaccination,^§ coverage among racial and ethnic minority groups increased (1,4). A shortfall analysis was conducted to examine whether the increase in mpox vaccination coverage was equitable across all racial and ethnic groups (5). Shortfall was defined as the percentage of the vaccine-eligible population that did not receive the vaccine (i.e., 100% minus the percentage of the eligible population that did receive a first dose). Monthly mpox vaccination shortfalls were calculated and were stratified by race and ethnicity; monthly percent reductions in shortfall were also calculated compared with the preceding month's shortfall (6). The mpox vaccination shortfall decreased among all racial and ethnic groups during May 2022-April 2023; however, based on analysis of vaccine administration data with race and ethnicity reported, 66.0% of vaccine-eligible persons remained unvaccinated at the end of this period. The shortfall was largest among non-Hispanic Black or African American (Black) (77.9%) and non-Hispanic American Indian or Alaska Native (AI/AN) (74.5%) persons, followed by non-Hispanic White (White) (66.6%) and Hispanic or Latino (Hispanic) (63.0%) persons, and was lowest among non-Hispanic Asian (Asian) (38.5%) and non-Hispanic Native Hawaiian and other Pacific Islander (NH/OPI) (43.7%) persons. The largest percentage decreases in the shortfall were achieved during August (17.7%) and September (8.5%). However, during these months, smaller percentage decreases were achieved among Black persons (12.2% and 4.9%, respectively), highlighting the need for a focus on equity for the entirety of a public health response. Achieving equitable progress in JYNNEOS vaccination coverage will require substantial decreases in shortfalls among Black and AI/AN persons.

Methodological guidance for incorporating equity when informing rapid-policy and guideline development

OBJECTIVES

We provide guidance for considering equity in rapid reviews through examples of published COVID-19 rapid reviews.

STUDY DESIGN AND SETTING

This guidance was developed based on a series of methodological meetings, review of internationally renowned guidance such as the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for equity-focused systematic reviews (PRISMA-Equity) guideline. We identified Exemplar rapid reviews by searching COVID-19 databases and requesting examples from our team.

RESULTS

We proposed the following key steps: 1. involve relevant stakeholders with lived experience in the conduct and design of the review; 2. reflect on equity, inclusion and privilege in team values and composition; 3. develop research question to assess health inequities; 4. conduct searches in relevant disciplinary databases; 5. collect data and critically appraise recruitment, retention and attrition for populations experiencing inequities; 6. analyse evidence on equity; 7. evaluate the applicability of findings to populations experiencing inequities; and 8. adhere to reporting guidelines for communicating review findings. We illustrated these methods through rapid review examples.

CONCLUSION

Implementing this guidance could contribute to improving equity considerations in rapid reviews produced in public health emergencies, and help policymakers better understand the distributional impact of diseases on the population.

Ethical Aspects of Kidney Donation and Transplantation for Migrants

Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.

Considering equity in global health collaborations: A qualitative study on experiences of equity

International collaborations have become the standard model for global health research and often include researchers and institutions from high income countries (HICs) and low- and middle-income countries (LMICs). While such collaborations are important for generating new knowledge that will help address global health inequities, there is evidence to suggest that current forms of collaboration may reproduce unequal power relations. Therefore, we conducted a qualitative study with scientists, researchers and those involved in research management, working in international health collaborations. Interviews were conducted between October 2019 and March 2020. We conducted 13 interviews with 15 participants. From our findings, we derive three major themes. First, our results reflect characteristics of equitable, collaborative research relationships. Here we find both relational features, specifically trust and belonging, and structural features, including clear contractual agreements, capacity building, inclusive divisions of labour, and the involvement of local communities. Second, we discuss obstacles to develop equitable collaborations. These include exclusionary labour practices, donor-driven research agendas, overall research culture, lack of accountability and finally, the inadequate financing of indirect costs for LMIC institutions. Third, we discuss the responsibilities for promoting science equity of funders, LMIC researchers, LMIC institutions, and LMIC governments. While other empirical studies have suggested similar features of equity, our findings extend these features to include local communities as collaborators in research projects and not only as beneficiaries. We also suggest the importance of funders paying for indirect costs, without which the capacity of LMIC institutions will continually erode. And finally, our study shows the responsibilities of LMIC actors in developing equitable collaborations, which have largely been absent from the literature.

Trends in inequalities in childhood stunting in Ethiopia from 2000 to 2016: a cross sectional study

BACKGROUND

The decrease in the magnitude of stunting over the past 20 years has been slow in Ethiopia. To date, in Ethiopia, the trends in and extent of inequality in stunting have not been investigated using methods suitably developed for disparity studies. This paper investigated both the extent and overtime dynamics of stunting inequality in Ethiopia over the last 17 years.

METHODS

Using the World Health Organization's Health Equity Assessment Toolkit software, data from the Ethiopia Demographic and Health surveys (EDHS) were analyzed between 2000 and 2016. The inequality analysis consisted of disaggregated rates of stunting using five equity stratifiers (economic status, education, residence, region and sex) and four summary measures (Difference, Population Attributable risk, Ratio and Absolute Concentration Index). A 95% uncertainty interval was constructed around point estimates to measure statistical significance.

RESULTS

The study showed that both absolute and relative inequalities in stunting exist in all the studied years in Ethiopia. The inequality disfavors children of mothers who are poor, uneducated and living in rural areas and specific regions such as Amhara. The pro-rich (R = 1.2; 1.1, 1.3 in 2000 to R = 1.7; 1.4, 2 in 2016) and pro-educated (R = 1.6; 95%UI = 1.3, 1.9 in 2000 and R = 2.3; 95%UI = 1.5, 3 in 2011) inequalities slightly increased with time. Male children bear a disproportionately higher burden of stunting, and the disparity increased between the first and the last time points (PAR = -1.5 95%UI = -2.5, -0.6 in 2000 and PAR = -2.9 95%UI = -3.9, -1.9) based on complex measures but remained constant with simple measures (R = 1; 95%UI = 0.9, 1.1 in 2000 and R = 1.1 95%UI = 1, 1.2 in 2016). Similarly, both the sub-national regional and residence-related stunting disparities generally widened over time according to some of the inequality measures.

CONCLUSIONS

Stunting appeared to be highly prevalent among certain sub-groups (i.e. poor, uneducated and living in rural regions). The subpopulations experiencing excessively high stunting prevalence should be the focus of policy makers' attention as they work to achieve the WHO 40% reduction in stunting target by 2025 and the UN Agenda 2030 for Sustainable Development Goals.

Country perspectives on improving technical assistance in the health sector

Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA's two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study.   Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.

Unequal discourses: Problems of the current model of world health development

The COVID-19 pandemic has exposed institutional deficiencies in world health development. This viewpoint paper examines the allegations about the partiality and political bias of the World Health Organization's (WHO) response to world health emergencies. We draw on quantitative and qualitative analysis of the WHO's Director-General's speeches pertaining to the COVID-19 and EVD outbreaks. We find that the WHO's discourse on COVID-19 praised the Chinese government's role in the containment. By contrast, the WHO's discourse on the African countries fighting to contain Ebola centered on the unpreparedness of these countries. We argue that the WHO's unbalanced emphasis on different practices and "traits" of member states paints a partial picture of global health emergencies, thus it fails to uphold its founding principles of egalitarianism and impartiality. Finally, we put forward suggestions about a more equal and fairer model of world health development.

Royal society of Canada COVID-19 report: Enhancing COVID-19 vaccine acceptance in Canada

COVID-19 vaccine acceptance exists on a continuum from a minority who strongly oppose vaccination, to the “moveable middle” heterogeneous group with varying uncertainty levels about acceptance or hesitancy, to the majority who state willingness to be vaccinated. Intention for vaccine acceptance varies over time. COVID-19 vaccination decisions are influenced by many factors including knowledge, attitudes, and beliefs; social networks; communication environment; COVID-19 community rate; cultural and religious influences; ease of access; and the organization of health and community services and policies.

Reflecting vaccine acceptance complexity, the Royal Society of Canada Working Group on COVID-19 Vaccine Acceptance developed a framework with four major factor domains that influence vaccine acceptance (people, communities, health care workers; immunization knowledge; health care and public health systems including federal/provincial/territorial/indigenous factors)—each influencing the others and all influenced by education, infection control, extent of collaborations, and communications about COVID-19 immunization. The Working Group then developed 37 interrelated recommendations to support COVID vaccine acceptance nested under four categories of responsibility: 1. People and Communities, 2. Health Care Workers, 3. Health Care System and Local Public Health Units, and 4. Federal/Provincial/Territorial/Indigenous. To optimize outcomes, all must be engaged to ensure co-development and broad ownership.

Impacts of the Global Gag Rule on sexual and reproductive health and rights in the Global South: A scoping review

The Global Gag Rule is a United States policy that blocks global health funding to foreign non-governmental organisations if they engage in abortion-related activities. It has been implemented by every Republican administration since 1984 and remains in operation at the time of writing in its most stringent and extensive form. It has been criticised for its implications for women's bodily autonomy, its censorship of non-governmental organisations and health professionals, and for its impact on the health of populations in affected countries. To capture the effects of the policy to date, we conducted a scoping review in April 2020. Forty-eight articles met our eligibility criteria, and were analysed thematically, noting the effects on: the operations of non-governmental organisations; maternal health; sexually transmitted infections; marginalised groups; reproductive rights. We found that the policy increased the abortion rate and had a negative impact on maternal health, STIs, and the health of marginalised groups. We conclude that the policy amounts to the neocolonial co-optation of sexual and reproductive health in the Global South to advance an ideological agenda in the Global North. We urge that the policy be repealed as part of the broader project of protecting and decolonising sexual and reproductive health globally.

Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the COVID-19 pandemic is a global health injustice due to moral failures of national governments and international organizations to prepare for, prevent and control it. Global and national health communities had a moral obligation to act in accordance with the current state of knowledge of pandemic preparedness. This obligation-a positive duty to develop and implement systems to reduce threats to and safeguard individuals' and, communities' abilities to flourish-stems from theories of global health justice and governance. The COVID-19 pandemic revealed and amplified the fragility and deficiencies in our global and domestic health institutions and systems. Moving forward, positive public health ethics is needed to set ethical standards for building and operating robust public health systems for resilient individuals and communities.

A tool to assess alignment between knowledge and action for health equity

Advancing health equity is a central goal and ethical imperative in public and global health. Though the commitment to health equity in these fields and among the health professions is clear, alignment between good equity intentions and action remains a challenge. This work regularly encounters the same power structures that are known to cause health inequities. Despite consensus about causes, health inequities persist-illustrating an uncomfortable paradox: good intentions and good evidence do not necessarily lead to meaningful action. This article describes a theoretically informed, reflective tool for assessing alignment between knowledge and action for health equity. It is grounded in an assumption that progressively more productive action toward health inequities is justified and desired and an explicit acceptance of the evidence about the socioeconomic, political, and power-related root causes of health inequities. Intentionally simple, the tool presents six possible actions that describe ways in which health equity work could respond to causes of health inequities: discredit, distract, disregard, acknowledge, illuminate, or disrupt. The tool can be used to assess or inform any kind of health equity work, in different settings and at different levels of intervention. It is a practical resource against which practice, policy, or research can be held to account, encouraging steps toward equity- and evidence-informed action. It is meant to complement other tools and training resources to build capacity for allyship, de- colonization, and cultural safety in the field of health equity, ultimately contributing to growing awareness of how to advance meaningful health equity action.

Attending to scalar ethical issues in emerging approaches to environmental health research and practice

Accelerated changes to the planet have created novel spaces to re-imagine the boundaries and foci of environmental health research. Climate change, mass species extinction, ocean acidification, biogeochemical disturbance, and other emergent environmental issues have precipitated new population health perspectives, including, but not limited to, one health, ecohealth, and planetary health. These perspectives, while nuanced, all attempt to reconcile broad global challenges with localized health impacts by attending to the reciprocal relationships between the health of ecosystems, animals, and humans. While such innovation is to be encouraged, we argue that a more comprehensive engagement with the ethics of these emerging fields of inquiry will add value in terms of the significance and impact of associated interventions. In this contribution, we highlight how the concept of spatial and temporal scale can be usefully deployed to shed light on a variety of ethical issues common to emerging environmental health perspectives, and that the potential of scalar analysis implicit to van Potter's conceptualization of bioethics has yet to be fully appreciated. Specifically, we identify how scale interacts with key ethical issues that require consideration and clarification by one health, ecohealth, and planetary health researchers and practitioners to enhance the effectiveness of research and practice, including justice and governance.

Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries

Some countries reached, in 2015, the Millennium Development Goal of reducing maternal mortality to 96 or less maternal deaths per 100,000 live births. Others, however, did not. This paper analyses the strength of the association between maternal mortality and each of the six components of Governance-a political determinant scarcely explored in the literature-in 174 countries. It was found that the greater the governance, the lower maternal mortality, independently of a country's wealth. We used all six indicators of the World Bank's Worldwide Governance Indicators Project in 2015: government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence. Findings were encouraging as maternal mortality in low-income countries with higher government effectiveness and regulatory quality was similar to that of medium-income countries with lower government effectiveness and regulatory quality. To achieve the post-2015 sustainable development goal on preventable maternal mortality-which persists despite economic development-all governance dimensions are essential and represent interdependent cornerstones.

Should Foreigners Get Costly Lifesaving Treatments in the United States?

Many foreign parents bring their children to the United States for medical treatments that are unavailable in their own country. Often, however, parents cannot afford expensive treatments. Doctors and hospitals then face a dilemma. Is it ethically permissible to consider the patient's citizenship and ability to pay? In this Ethics Rounds, we present a case in which a child from another country needs an expensive treatment. His parents cannot afford the treatment. He has come to a public hospital in the United States. We present responses from experts in pediatrics, bioethics, and health policy.

Ethical underpinnings for the development of health literacy in schools: ethical premises ('why'), orientations ('what') and tone ('how')

Background

Schools are seen as crucial environments to influence and develop the health literacy of new generations, but without sufficient reflection on the ethical underpinnings of intentions and interventions around health literacy. In contrast, we argue here that ethics are fundamental to all education. The article adopts a ‘One world’ approach that generalizes broadly across the so-called Global North and Global South. It also generalizes across various age groups among school pupils, advocating age appropriate application of the arguments advanced.

Main text

Our analysis examines why health literacy should be promoted in schools and argues that the purpose should embrace the values of social justice and should not stop at individual and national cost benefit analysis. Discussion about the orientation of health literacy highlights meta-cognitive skills around critical thinking, self-awareness and citizenship rather than lists of practical skills. Finally, approaches to health literacy in classrooms are presented with an ethical tone that draws attention to the power relations responsible for health inequities and that does not assume that such power relations are the given framework for health literacy interventions and activities. These arguments are reinforced by urging that related debates address dynamic social realities such as international migration.

Conclusions

We reiterate the need for ethical questions to be consciously and systematically addressed from early on, beginning with intentions to promote health literacy even before these intentions are translated into action, within the political space where education meets public health and health promotion. We underline again the context of fluidity and dynamism, as new challenges emerge within pedagogies and curricula, especially in response to changing populations in the society around.

Governance of Transnational Global Health Research Consortia and Health Equity

Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This article takes a conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short.

The development of capability measures in health economics: opportunities, challenges and progress

Recent years have seen increased engagement amongst health economists with the capability approach developed by Amartya Sen and others. This paper focuses on the capability approach in relation to the evaluative space used for analysis within health economics. It considers the opportunities that the capability approach offers in extending this space, but also the methodological challenges associated with moving from the theoretical concepts to practical empirical applications. The paper then examines three 'families' of measures, Oxford Capability instruments (OxCap), Adult Social Care Outcome Toolkit (ASCOT) and ICEpop CAPability (ICECAP), in terms of the methodological choices made in each case. The paper concludes by discussing some of the broader issues involved in making use of the capability approach in health economics. It also suggests that continued exploration of the impact of different methodological choices will be important in moving forward.

Lifestyle Vaccines and Public Health: Exploring Policy Options for a Vaccine to Stop Smoking

Experimental vaccines are being developed for the treatment of 'unhealthy lifestyles' and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of 'lifestyle vaccines' for public health. Based on findings from a qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The 'vaccinization' of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future.

From conceptual pluralism to practical agreement on policy: global responsibility for global health

BACKGROUND

As the human cost of the global economic crisis becomes apparent the ongoing discussions surrounding the post-2015 global development framework continue at a frenzied pace. Given the scale and scope of increased globalization moving forward in a post-Millennium Development Goals era, to protect and realize health equity for all people, has never been more challenging or more important. The unprecedented nature of global interdependence underscores the importance of proposing policy solutions that advance realizing global responsibility for global health.

DISCUSSION

This article argues for advancing global responsibility for global health through the creation of a Global Fund for Health. It suggests harnessing the power of the exceptional response to the combined epidemics of AIDS, TB and Malaria, embodied in the Global Fund to Fight AIDS, Tuberculosis and Malaria, to realize an expanded, reconceptualized Global Fund for Health. However this proposal creates both an analytical quandary embedded in conceptual pluralism and a practical dilemma for the scope and raison d'etre of a new Global Fund for Health. To address these issues we offer a logical framework for moving from conceptual pluralism in the theories supporting global responsibility for health to practical agreement on policy to realize this end. We examine how the innovations flowing from this exceptional response can be coupled with recent ideas and concepts, for example a global social protection floor, a Global Health Constitution or a Framework Convention for Global Health, that share the global responsibility logic that underpins a Global Fund for Health.

CONCLUSIONS

The 2014 Lancet Commission on Global Governance for Health Report asks whether a single global health protection fund would be better for global health than the current patchwork of global and national social transfers. We concur with this suggestion and argue that there is much room for practical agreement on a Global Fund for Health that moves from the conceptual level into policies and practice that advance global health. The issues of shared responsibility and mutual accountability feature widely in the post-2015 discussions and need to be addressed in a coherent manner. Our article argues why and how a Global Fund for Health effectuates this, thus advancing global responsibility for global health.

Obligations of low income countries in ensuring equity in global health financing

BACKGROUND

Despite common recognition of joint responsibility for global health by all countries particularly to ensure justice in global health, current discussions of countries' obligations for global health largely ignore obligations of developing countries. This is especially the case with regards to obligations relating to health financing. Bearing in mind that it is not possible to achieve justice in global health without achieving equity in health financing at both domestic and global levels, our aim is to show how fulfilling the obligation we propose will make it easy to achieve equity in health financing at both domestic and international levels.

DISCUSSION

Achieving equity in global health financing is a crucial step towards achieving justice in global health. Our general view is that current discussions on global health equity largely ignore obligations of Low Income Country (LIC) governments and we recommend that these obligations should be mainstreamed in current discussions. While we recognise that various obligations need to be fulfilled in order to ultimately achieve justice in global health, for lack of space we prioritise obligations for health financing. Basing on the evidence that in most LICs health is not given priority in annual budget allocations, we propose that LIC governments should bear an obligation to allocate a certain minimum percent of their annual domestic budget resources to health, while they await external resources to supplement domestic ones. We recommend and demonstrate a mechanism for coordinating this obligation so that if the resulting obligations are fulfilled by both LIC and HIC governments it will be easy to achieve equity in global health financing. Although achieving justice in global health will depend on fulfillment of different categories of obligations, ensuring inter- and intra-country equity in health financing is pivotal. This can be achieved by requiring all LIC governments to allocate a certain optimal per cent of their domestic budget resources to health while they await external resources to top up in order to cover the whole cost of the minimum health opportunities for LIC citizens.

Maternal mortality: a cross-sectional study in global health

BACKGROUND

Although most of maternal deaths are preventable, maternal mortality reduction programs have not been completely successful. As targeting individuals alone does not seem to be an effective strategy to reduce maternal mortality (Millennium Development Goal 5), the present study sought to reveal the role of many distant macrostructural factors affecting maternal mortality at the global level.

METHODS

After preparing a global dataset, 439 indicators were selected from nearly 1800 indicators based on their relevance and the application of proper inclusion and exclusion criteria. Then Pearson correlation coefficients were computed to assess the relationship between these indicators and maternal mortality. Only indicators with statistically significant correlation more than 0.2, and missing values less than 20% were maintained. Due to the high multicollinearity among the remaining indicators, after missing values analysis and imputation, factor analysis was performed with principal component analysis as the method of extraction. Ten factors were finally extracted and entered into a multiple regression analysis.

RESULTS

The findings of this study not only consolidated the results of earlier studies about maternal mortality, but also added new evidence. Education (std. B = -0.442), private sector and trade (std. B = -0.316), and governance (std. B = -0.280) were found to be the most important macrostructural factors associated with maternal mortality. Employment and labor structure, economic policy and debt, agriculture and food production, private sector infrastructure investment, and health finance were also some other critical factors. These distal factors explained about 65% of the variability in maternal mortality between different countries.

CONCLUSION

Decreasing maternal mortality requires dealing with various factors other than individual determinants including political will, reallocation of national resources (especially health resources) in the governmental sector, education, attention to the expansion of the private sector trade and improving spectrums of governance. In other words, sustainable reduction in maternal mortality (as a development indicator) will depend on long-term planning for multi-faceted development. Moreover, trade, debt, political stability, and strength of legal rights can be affected by elements outside the borders of countries and global determinants. These findings are believed to be beneficial for sustainable development in Post-2015 Development Agenda.

The multiple meanings of global health governance: a call for conceptual clarity

BACKGROUND

The term global health governance (GHG) is now widely used, with over one thousand works published in the scholarly literature, almost all since 2002. Amid this rapid growth there is considerable variation in how the term is defined and applied, generating confusion as to the boundaries of the subject, the perceived problems in practice, and the goals to be achieved through institutional reform.

METHODOLOGY

This paper is based on the results of a separate scoping study of peer reviewed GHG research from 1990 onwards which undertook keyword searches of public health and social science databases. Additional works, notably books, book chapters and scholarly articles, not currently indexed, were identified through Web of Science citation searches. After removing duplicates, book reviews, commentaries and editorials, we reviewed the remaining 250 scholarly works in terms of how the concept of GHG is applied. More specifically, we identify what is claimed as constituting GHG, how it is problematised, the institutional features of GHG, and what forms and functions are deemed ideal.

RESULTS

After examining the broader notion of global governance and increasingly ubiquitous term "global health", the paper identifies three ontological variations in GHG scholarship - the scope of institutional arrangements, strengths and weaknesses of existing institutions, and the ideal form and function of GHG. This has produced three common, yet distinct, meanings of GHG that have emerged - globalisation and health governance, global governance and health, and governance for global health.

CONCLUSIONS

There is a need to clarify ontological and definitional distinctions in GHG scholarship and practice, and be critically reflexive of their normative underpinnings. This will enable greater precision in describing existing institutional arrangements, as well as serve as a prerequisite for a fuller debate about the desired nature of GHG.

Who cares about health inequalities? Cross-country evidence from the World Health Survey

Reduction of health inequalities within and between countries is a global health priority, but little is known about the determinants of popular support for this goal. We used data from the World Health Survey to assess individual preferences for prioritizing reductions in health and health care inequalities. We used descriptive tables and regression analysis to study the determinants of preferences for reducing health inequalities as the primary health system goal. Determinants included individual socio-demographic characteristics (age, sex, urban residence, education, marital status, household income, self-rated health, health care use, satisfaction with health care system) and country-level characteristics [gross domestic product (GDP) per capita, disability-free life expectancy, equality in child mortality, income inequality, health and public health expenditures]. We used logistic regression to assess the likelihood that individuals ranked minimizing inequalities first, and rank-ordered logistic regression to compare the ranking of other priorities against minimizing health inequalities. Individuals tended to prioritize health system goals related to overall improvement (improving population health and health care responsiveness) over those related to equality and fairness (minimizing inequalities in health and responsiveness, and promoting fairness of financial contribution). Individuals in countries with higher GDP per capita, life expectancy, and equality in child mortality were more likely to prioritize minimizing health inequalities.

Health status and socio-economic factors associated with health facility utilization in rural and urban areas in Zambia

Abstracts

Neoliberal-oriented health care system answer to global competition or a threat to health equality for people with chronic illness

The aim of this article is to explore how a neoliberal-oriented health care system affects the experience of people living with chronic illness. We report findings from a critical hermeneutic phenomenological research study that explored how the social, economic, and political structures impinge on the lives of people with chronic illness. Research findings of this study show how the people with chronic illness in Colombia live through the effects and pressures of globalization and corporate agendas. Results also showed how the marked social inequities caused by the unequal distribution of power, services, and goods leads to health inequities and social exclusion of research participants.

Evaluating the capacity of theories of justice to serve as a justice framework for international clinical research

This article investigates whether or not theories of justice from political philosophy, first, support the position that health research should contribute to justice in global health, and second, provide guidance about what is owed by international clinical research (ICR) actors to parties in low- and middle-income countries. Four theories-John Rawls's theory of justice, the rights-based cosmopolitan theories of Thomas Pogge and Henry Shue, and Jennifer Ruger's health capability paradigm-are evaluated. The article shows that three of the four theories require the conduct of health research for justice in global health. The theories help identify the ends of justice to which ICR is to contribute, but they cannot tell us how to organize ICR to promote these ends. Aside from Ruger's health capability paradigm, the theories also lack an allocative principle for assigning specific duties to specific actors. This creates difficulties for establishing obligations for certain types of ICR actors.

Global health justice and governance

While there is a growing body of work on moral issues and global governance in the fields of global justice and international relations, little work has connected principles of global health justice with those of global health governance for a theory of global health. Such a theory would enable analysis and evaluation of the current global health system and would ethically and empirically ground proposals for reforming it to more closely align with moral values. Global health governance has been framed as an issue of national security, human security, human rights, and global public goods. The global health governance literature is essentially untethered to a theorized framework to illuminate or evaluate governance. This article ties global health justice and ethics to principles for governing the global health realm, developing a theoretical framework for global and domestic institutions and actors.

Global Health Governance at a Crossroads

This review takes stock of the global health governance (GHG) literature. We address the transition from international health governance (IHG) to global health governance, identify major actors, and explain some challenges and successes in GHG. We analyze the framing of health as national security, human security, human rights, and global public good, and the implications of these various frames. We also establish and examine from the literature GHG's major themes and issues, which include: 1) persistent GHG problems; 2) different approaches to tackling health challenges (vertical, horizontal, and diagonal); 3) health's multisectoral connections; 4) neoliberalism and the global economy; 5) the framing of health (e.g. as a security issue, as a foreign policy issue, as a human rights issue, and as a global public good); 6) global health inequalities; 7) local and country ownership and capacity; 8) international law in GHG; and 9) research gaps in GHG. We find that decades-old challenges in GHG persist and GHG needs a new way forward. A framework called shared health governance offers promise.

Control of Extensively Drug-Resistant Tuberculosis (XDR-TB): A Root Cause Analysis

The threat of global infectious agents has the potential to cripple national and global economies, as the outbreaks of SARS, Avian Flu, H1N1, and XDR-TB have demonstrated. This article offers a Root Cause Analysis (RCA) of one public health case study - the Speaker case of XDR-TB - pinpointing the underlying causal relationships associated with this global health incident and proposing recommendations for preventing its recurrence. An RCA approach identifies corrective actions directed at the root causes of the problem and advances them as necessary to eliminate global contagion with its major international public health risks. To my knowledge, this is the first root cause analysis of a global health problem. The reform this article proposes would be to add a standardized procedure akin to the informed consent process in clinical ethics, but within a shared health governance framework. This approach, addressing infectious agents at their origins or source, is potentially a more effective strategy to reduce uncertainty and avert global health threats.

Disparidad en Salud: Un Fenómeno Multidimensional

La Disparidad en Salud (DS) ha llamado la atención pública desde el siglo pasado, ha sido analizada desde diversas perspectivas y enfoques incluso variados términos han sido utilizados como sinónimos pudiendo llevar a confusión e inequidades al momento de su operacionalización. Sin embargo es importante señalar que las publicaciones coinciden en que la DS es uno de las determinantes esenciales a considerar al momento de definir polĺticas públicas. El propósito de esta publicación es analizar la disparidad en salud incorporando; a) los aspectos claves de su conceptualización, b) la evolución histórica del concepto, c) las estrategias que se han generado para enfrentarla, d) los factores considerados determinantes, y e) los aspectos éticos y la contribución de la investigación en la disminución de la DS.Health Disparities (HD) have been at the center of public attention for the past century. They have been analyzed from diverse perspectives utilizing various terms as synonyms that can lead to confusion and inequality at the moment of operationalization. Despite this, it is important to indicate that publications agree that HD are essential determinants that must be considered in the definition of public policy. The objective of this publication is to analyze health disparities incorporating; (a) key aspects in their conceptualization, (b) the historic evolution of the concept, (c) strategies that have been generated to confront them, (d) determining factors, and (e) ethical aspects and the contribution of research in decreasing HD.

Interdisciplinary Translational Research in Anthropology, Nutrition, and Public Health

This review focuses on several human population health research topics that exemplify interdisciplinary concepts and approaches from anthropology, nutrition, and public health with an emphasis on applied or translational global health implications. First, a recent study on neonatal survival in a resource-poor region emphasizes how health can be markedly improved with detailed translation and implementation of evidence from all three disciplines. Second, schistosomiasis, a parasitic worm infection, is reviewed with an emphasis on developing a consensus of its nutritional health burdens and the next translational research steps needed to improve control of both infection transmission and disease. Last, the author's long-term Samoan nutrition and health studies are described with a focus on new translational research to improve diabetes. This selective review attempts to provide a rationale for the intersections of anthropology, nutrition, and public health to proceed with fundamental biological, cultural, and behavioral research to reduce health inequalities globally and domestically.

International public health law: not so much WHO as why, and not enough WHO and why not?

To state the obvious, "health matters", but health (or its equitable enjoyment) is neither simple nor easy. Public health in particular, which encompasses a broad collection of complex and multidisciplinary activities which are critical to the wellbeing and security of individuals, populations and nations, is a difficult milieu to master effectively. In fact, despite the vital importance of public health, there is a relative dearth of ethico-legal norms tailored for, and directed at, the public health sector, particularly at the international level. This is a state of affairs which is no longer tenable in the global environment. This article argues that public health promotion is a moral duty, and that international actors are key stakeholders upon whom this duty falls. In particular, the World Health Organization bears a heavy responsibility in this regard. The article claims that better health can and must be better promoted through a more robust interpretation of the WHO's role, arguing that neither the WHO nor international law have yet played their necessary part in promoting health for all.

Can a single indicator measure both attainment and shortfall inequality?

When a distribution can be described either in terms of attainment or in terms of shortfall, the classical inequality measures appear to be one-sided. I show that it is possible to find indicators which simultaneously measure attainment and shortfall inequality. I derive one indicator belonging to the Gini family, and another belonging to Coefficient of Variation family. I also indicate how they are connected to other measures.

Mapping chronic illness in the age of globalization: reclaiming the good for the chronically ill

Until recently, infectious diseases were the main cause of death worldwide. New medical discoveries and the evolution of public health improved life expectancy and the ability to survive acute threats, thus changing the course of diseases from acute to chronic. Today, chronic illness is the most important health concern worldwide. Chronic illness increases existing poverty and pushes other people into it. As nurses, members of the healthcare system and members of this world, we cannot forget that our response toward globalization and chronic disease has to be centered in leadership through reorienting local and national healthcare systems. All actions must be grounded in the ethical treatment of the ill; we cannot close our eyes in hospitals or communities to what is happening now worldwide because our responsibility is to promote health, prevent disease, and care for human beings.

Living apart together: reflections on bioethics, global inequality and social justice

Significant inequalities in health between and within countries have been measured over the past decades. Although these inequalities, as well as attempts to improve sub-standard health, raise profound issues of social justice and the right to health, those working in the field of bioethics have historically tended to devote greater attention to ethical issues raised by new, cutting-edge biotechnologies such as life-support cessation, genomics, stem cell research or face transplantation. This suggests that bioethics research and scholarship may revolve around issues that, while fascinating and important, currently affect only a small minority of the world's population. In this article, we examine the accusation that bioethics is largely dominated by Anglophone and industrialized world interests, and explore what kinds of positive contributions a 'bioethics from below' (as Paul Farmer calls it) can make to the field of bioethics in general. As our guide in this exploration, we make use of some experiences and lessons learned in our collaborative bioethics project in the Democratic Republic of Congo, Building Bioethics Capacity and Justice in Health. We conclude that while there is some evidence of increased attention to bioethical challenges in developing countries, this development should be further cultivated, because it could help expand the horizons of the field and enhance its social relevance wherever it is practiced.

Globalisation and health: the need for a global vision

The reduction of health inequities is an ethical imperative, according to the WHO Commission on Social Determinants of Health (CSDH). Drawing on detailed multidisciplinary evidence assembled by the Globalization Knowledge Network that supported the CSDH, we define globalisation in mainly economic terms. We consider and reject the presumption that globalisation will yield health benefits as a result of its contribution to rapid economic growth and associated reductions in poverty. Expanding on this point, we describe four disequalising dynamics by which contemporary globalisation causes divergence: the global reorganisation of production and emergence of a global labour-market; the increasing importance of binding trade agreements and processes to resolve disputes; the rapidly increasing mobility of financial capital; and the persistence of debt crises in developing countries. Generic policies designed to reduce health inequities are described with reference to the three Rs of redistribution, regulation, and rights. We conclude with an examination of the interconnected intellectual and institutional challenges to reduction of health inequities that are created by contemporary globalisation.