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Boyce MR, Attal-Juncqua A, Lin J, McKay S, Katz R. Global Fund contributions to health security in ten countries, 2014-20: mapping synergies between vertical disease programmes and capacities for preventing, detecting, and responding to public health emergencies. LANCET GLOBAL HEALTH 2021; 9:e181-e188. [PMID: 33482139 PMCID: PMC8448292 DOI: 10.1016/s2214-109x(20)30420-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Global Fund to Fight AIDS, Tuberculosis and Malaria is a robust vertical global health programme. The extent to which vertical programmes financially support health security has not been investigated. We, therefore, endeavoured to quantify the extent to which the budgets of this vertical programme support health security. We believe this is a crucial area of work as the global community works to combine resources for COVID-19 response and future pandemic preparedness. METHODS We examined budgets for work in Kenya, Uganda, Vietnam, Democratic Republic of the Congo, Guatemala, Guinea, India, Indonesia, Nigeria, and Sierra Leone from January, 2014 to December, 2020. These ten countries were selected because of the robustness of investments and the availability of data. Using the International Health Regulations Joint External Evaluation (JEE) tool as a framework, we mapped budget line items to health security capacities. Two researchers independently reviewed each budget and mapped items to the JEE. Budgets were then jointly reviewed until a consensus was reached regarding if an item supported health security directly, indirectly, or not at all. The budgets for the study countries were inputted into a single Microsoft Excel spreadsheet and line items that mapped to JEE indicators were scaled up to their respective JEE capacity. Descriptive analyses were then done to determine the total amount of money budgeted for activities that support health security, how much was budgeted for each JEE capacity, and how much of the support was direct or indirect. FINDINGS The research team reviewed 37 budgets. Budgets totalled US$6 927 284 966, and $2 562 063 054 (37·0%) of this mapped to JEE capacities. $1 330 942 712 (19·2%) mapped directly to JEE capacities and $1 231 120 342 (17·8%) mapped indirectly to JEE capacities. Laboratory systems, antimicrobial resistance, and the deployment of medical countermeasures and personnel received the most overall budgetary support; laboratory systems, antimicrobial resistance, and workforce development received the greatest amount of direct budgetary support. INTERPRETATION Over one-third of the Global Fund's work also supports health security and the organisation has budgeted more than $2 500 000 000 for activities that support health security in ten countries since 2014. Although these funds were not budgeted specifically for health security purposes, recognising how vertical programmes can synergistically support other global health efforts has important implications for policy related to health systems strengthening. FUNDING Resolve to Save Lives: An Initiative of Vital Strategies.
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Affiliation(s)
- Matthew R Boyce
- Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
| | - Aurelia Attal-Juncqua
- Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
| | - Jessica Lin
- Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
| | - Stephanie McKay
- Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
| | - Rebecca Katz
- Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA.
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Luyckx VA, Biller-Andorno N, Saxena A, Tran NT. Health policy and systems research: towards a better understanding and review of ethical issues. BMJ Glob Health 2017; 2:e000314. [PMID: 29225934 PMCID: PMC5717951 DOI: 10.1136/bmjgh-2017-000314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/01/2017] [Accepted: 04/04/2017] [Indexed: 11/04/2022] Open
Abstract
Given the focus on health systems in the post-millennium development goal era and moving towards the sustainable development goals, there is a compelling need for a common framework for health policy and systems research ethics to guide researchers and facilitate review by research ethics committees. A consultation of global health policy and systems research and ethics experts was convened to identify ethical considerations relevant to health policy and systems research based on existing knowledge and to identify knowledge gaps through a scoping review and further expert deliberation. Health policy and systems research is highly complex and, in the absence of guidance documents, there is significant variability in ethics review. Although fundamental ethical principles pertain to both traditional clinical research and health policy and systems research, the application of these principles requires a comprehensive understanding of the nature of health policy and systems research with its distinct challenges. Such awareness must be raised among researchers and research ethics committees. Current research ethics committees lack familiarity with health policy and systems research and because health policy and systems research is conducted in real-world contexts, committees often have difficulties in determining whether a project is indeed research and/or requires ethical review. Given the strong current focus on health policy and systems research to rapidly improve health and health systems functioning globally, greater engagement and dialogue around the ethical concerns is required to optimise research review and research conduct in this rapidly evolving field.
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Affiliation(s)
- Valerie Ann Luyckx
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zürich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zürich, Switzerland
| | - Abha Saxena
- Global Health Ethics Unit, World Health Organization, Geneva, Switzerland
| | - Nhan T Tran
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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Pratt B, Paul A, Hyder AA, Ali J. Ethics of health policy and systems research: a scoping review of the literature. Health Policy Plan 2017; 32:890-910. [DOI: 10.1093/heapol/czx003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/12/2022] Open
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Gopichandran V, Luyckx VA, Biller-Andorno N, Fairchild A, Singh J, Tran N, Saxena A, Launois P, Reis A, Maher D, Vahedi M. Developing the ethics of implementation research in health. Implement Sci 2016; 11:161. [PMID: 27938400 PMCID: PMC5148832 DOI: 10.1186/s13012-016-0527-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/29/2016] [Indexed: 02/03/2023] Open
Abstract
Implementation research (IR) is growing in recognition as an important generator of practical knowledge that can be translated into health policy. With its aim to answer questions about how to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them, IR involves a range of particular ethical considerations that have not yet been comprehensively covered in international guidelines on health research ethics. The fundamental ethical principles governing clinical research apply equally in IR, but the application of these principles may differ depending on the IR question, context, and the nature of the proposed intervention. IR questions cover a broad range of topics that focus on improving health system functioning and improving equitable and just access to effective health care interventions. As such, IR designs are flexible and often innovative, and ethical principles cannot simply be extrapolated from their applications in clinical research. Meaningful engagement with all stakeholders including communities and research participants is a fundamental ethical requirement that cuts across all study phases of IR and links most ethical concerns. Careful modification of the informed consent process may be required in IR to permit study of a needed intervention. The risks associated with IR may be difficult to anticipate and may be very context-specific. The benefits of IR may not accrue to the same groups who participate in the research, therefore justifying the risks versus benefits of IR may be ethically challenging. The expectation that knowledge generated through IR should be rapidly translated into health policy and practice necessitates up-front commitments from decision-makers to sustainability and scalability of effective interventions. Greater awareness of the particular ethical implications of the features of IR is urgently needed to facilitate optimal ethical conduct of IR and uniform ethical review.
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Affiliation(s)
- Vijayaprasad Gopichandran
- Department of Community Medicine, ESIC Medical College and Postgraduate Institute of Medical Sciences and Research, KK Nagar, Chennai, 600078, India.
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and History of Medicine, Center for Medical Humanities, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, Center for Medical Humanities, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland
| | - Amy Fairchild
- Associate Dean of Academic Affairs, Texas A & M School of Public Health, College Station, Texas, USA
| | - Jerome Singh
- University of KwaZulu-Natal, Nelson Mandela School of Medicine, 719 Umbilo Road, Durban, 4001, South Africa
| | - Nhan Tran
- Alliance for Health Systems and Policy Research, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Abha Saxena
- Global Health Ethics Unit, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Pascal Launois
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
| | - Andreas Reis
- Global Health Ethics Unit, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Dermot Maher
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
| | - Mahnaz Vahedi
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
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Hyder AA, Rattani A, Krubiner C, Bachani AM, Tran NT. Ethical review of health systems research in low- and middle-income countries: a conceptual exploration. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:28-37. [PMID: 24521334 DOI: 10.1080/15265161.2013.868950] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Given that health systems research (HSR) involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include the nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board (IRB) and research ethics committee (REC) review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies.
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Varghese J, Raman Kutty V, Ramanathan M. The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study. BMJ Open 2013; 3:bmjopen-2012-001905. [PMID: 23457322 PMCID: PMC3612786 DOI: 10.1136/bmjopen-2012-001905] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme. DESIGN We used descriptive and analytical qualitative methods as it suited the research question. SETTING The data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process. PARTICIPANTS This involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities. RESULTS Unlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust. CONCLUSIONS Analysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.
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Affiliation(s)
- Joe Varghese
- Centre for Chronic Disease Control, New Delhi, India
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram, Kerala, India
| | - V Raman Kutty
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram, Kerala, India
| | - Mala Ramanathan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram, Kerala, India
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Agudelo-Suárez AA, Gil-González D, Vives-Cases C, Love JG, Wimpenny P, Ronda-Pérez E. A metasynthesis of qualitative studies regarding opinions and perceptions about barriers and determinants of health services' accessibility in economic migrants. BMC Health Serv Res 2012; 12:461. [PMID: 23245431 PMCID: PMC3565901 DOI: 10.1186/1472-6963-12-461] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 11/23/2012] [Indexed: 11/30/2022] Open
Abstract
Background Access to health services is an important health determinant. New research in health equity is required, especially amongst economic migrants from developing countries. Studies conducted on the use of health services by migrant populations highlight existing gaps in understanding which factors affect access to these services from a qualitative perspective. We aim to describe the views of the migrants regarding barriers and determinants of access to health services in the international literature (1997–2011). Methods A systematic review was conducted for Qualitative research papers (English/Spanish) published in 13 electronic databases. A selection of articles that accomplished the inclusion criteria and a quality evaluation of the studies were carried out. The findings of the selected studies were synthesised by means of metasynthesis using different analysis categories according to Andersen’s conceptual framework of access and use of health services and by incorporating other emergent categories. Results We located 3,025 titles, 36 studies achieved the inclusion criteria. After quality evaluation, 28 articles were definitively synthesised. 12 studies (46.2%) were carried out in the U.S and 11 studies (42.3%) dealt with primary care services. The participating population varied depending mainly on type of host country. Barriers were described, such as the lack of communication between health services providers and migrants, due to idiomatic difficulties and cultural differences. Other barriers were linked to the economic system, the health service characteristics and the legislation in each country. This situation has consequences for the lack of health control by migrants and their social vulnerability. Conclusions Economic migrants faced individual and structural barriers to the health services in host countries, especially those with undocumented situation and those experimented idiomatic difficulties. Strategies to improve the structures of health systems and social policies are needed.
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Affiliation(s)
- Andrés A Agudelo-Suárez
- Faculty of Dentistry, University of Antioquia, Calle 64 N° 52-59, Medellín, Antioquia, Colombia.
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Panisset U, Koehlmoos TP, Alkhatib AH, Pantoja T, Singh P, Kengey-Kayondo J, McCutchen B. Implementation research evidence uptake and use for policy-making. Health Res Policy Syst 2012; 10:20. [PMID: 22748142 PMCID: PMC3443065 DOI: 10.1186/1478-4505-10-20] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 07/02/2012] [Indexed: 11/10/2022] Open
Abstract
A major obstacle to the progress of the Millennium Development Goals has been the
inability of health systems in many low- and middle-income countries to effectively
implement evidence-informed interventions. This article discusses the relationships
between implementation research and knowledge translation and identifies the role of
implementation research in the design and execution of evidence-informed policy.
After a discussion of the benefits and synergies needed to translate implementation
research into action, the article discusses how implementation research can be used
along the entire continuum of the use of evidence to inform policy. It provides
specific examples of the use of implementation research in national level programmes
by looking at the scale up of zinc for the treatment of childhood diarrhoea in
Bangladesh and the scaling up of malaria treatment in Burkina Faso. A number of
tested strategies to support the transfer of implementation research results into
policy-making are provided to help meet the standards that are increasingly expected
from evidence-informed policy-making practices.
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Affiliation(s)
- Ulysses Panisset
- Department of Knowledge Management and Sharing, WHO, Avenue Appia 20, 1211 Geneva 27, Switzerland
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Dixon-Woods M, Amalberti R, Goodman S, Bergman B, Glasziou P. Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new. BMJ Qual Saf 2011; 20 Suppl 1:i47-51. [PMID: 21450771 PMCID: PMC3066840 DOI: 10.1136/bmjqs.2010.046227] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed.
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Affiliation(s)
- Mary Dixon-Woods
- Department of Health Sciences, Adrian Building, University of Leicester, Leicester LE1 7RH, UK.
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FAIRCHILD AMYL. Commentary: Beyond Historical Precedent. Milbank Q 2009; 87:571-4. [DOI: 10.1111/j.1468-0009.2009.00569.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lu CY, Macneill P, Williams K, Day R. Access to high cost medicines in Australia: ethical perspectives. AUSTRALIA AND NEW ZEALAND HEALTH POLICY 2008; 5:4. [PMID: 18489760 PMCID: PMC2412887 DOI: 10.1186/1743-8462-5-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 05/19/2008] [Indexed: 11/10/2022]
Abstract
Access to "high cost medicines" through Australia's Pharmaceutical Benefits Scheme (PBS) is tightly regulated. It is inherently difficult to apply any criteria-based system of control in a way that provides a fair balance between efficient use of limited resources for community needs and equitable individual access to care. We suggest, in relation to very high cost medicines, that the present arrangements be re-considered in order to overcome potential inequities. The biological agents for the treatment of rheumatoid arthritis are used as an example by which to discuss the ethical issues associated with the current scheme. Consideration of ethical aspects of the PBS and similar programs is important in order to achieve the fairest outcomes for individual patients, as well as for the community.
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Affiliation(s)
- Christine Y Lu
- Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts, USA.
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Béhague DP, Storeng KT. Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health. Am J Public Health 2008; 98:644-9. [PMID: 18309123 DOI: 10.2105/ajph.2007.123117] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.
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Affiliation(s)
- Dominique P Béhague
- Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
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Lunstroth J, Goldman J. Ethical intelligence from neuroscience: is it possible? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2007; 7:18-20. [PMID: 17497498 DOI: 10.1080/15265160701290280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Durán A, Gérvas J. [About the transfer of Western experiences to the Eastern Europe. Some avoidable errors when advising on health-care reforms]. GACETA SANITARIA 2007; 20:503-9. [PMID: 17198630 DOI: 10.1157/13096505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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González-Pier E, Gutiérrez-Delgado C, Stevens G, Barraza-Lloréns M, Porras-Condey R, Carvalho N, Loncich K, Dias RH, Kulkarni S, Casey A, Murakami Y, Ezzati M, Salomon JA. Priority setting for health interventions in Mexico's System of Social Protection in Health. Lancet 2006; 368:1608-18. [PMID: 17084761 DOI: 10.1016/s0140-6736(06)69567-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria--eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households--to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.
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