Reflections on the development of health economics in low- and middle-income countries

Health economics is a relatively new discipline, though its antecedents can be traced back to William Petty FRS (1623–1687). In high-income countries, the academic discipline and scientific literature have grown rapidly since the 1960s. In low- and middle-income countries, the growth of health economics has been strongly influenced by trends in health policy, especially among the international and bilateral agencies involved in supporting health sector development. Valuable and influential research has been done in areas such as cost–benefit and cost-effectiveness analysis, financing of healthcare, healthcare provision, and health systems analysis, but there has been insufficient questioning of the relevance of theories and policy recommendations in the rich world literature to the circumstances of poorer countries. Characteristics such as a country''s economic structure, strength of political and social institutions, management capacity, and dependence on external agencies, mean that theories and models cannot necessarily be transferred between settings. Recent innovations in the health economics literature on low- and middle-income countries indicate how health economics can be shaped to provide more relevant advice for policy. For this to be taken further, it is critical that such countries develop stronger capacity for health economics within their universities and research institutes, with greater local commitment of funding.     

Globalizing biosecurity

A harmonized international regime that enhances biosecurity is needed to reduce the risk of bioterrorism. Like other security regimes, this will entail mutually reinforcing strands, which need to include: enactment of legally binding control of access to dangerous pathogens, transparency for sanctioned biodefense programs, technology transfer and assistance to developing countries to jointly advance biosafety and biosecurity, global awareness of the dual-use dilemma and the potential misuse of science by terrorists, and development of a global ethic of compliance. To work, this effort must be undertaken collectively, utilizing the international and regional institutions that already have a role to play in providing safety and security. Most notably, it must grow in a top-down manner from the Biological Weapons Convention accord, in which States Parties have agreed to ban the development of biological weapons, and in a bottom-up manner from the scientific and health communities, which are engaged in the research and public health efforts that must be protected against misuse-especially involving the World Health Organization.     

International harmonization of health monitoring

Proper health surveillance is vitally important to the evaluation of the microbial status of laboratory animals and the performance of standardized experiments with a minimum number of animals. Sufficient and reliable information about animals health status has become even more important during the last decade with the rapid development and worldwide exchange of new genetically modified rodents. But a universal testing strategy for the assessment of pathogen status in rodent populations and internationally recognized standards and definitions of their quality do not exist, even though health data can provide consistent information only when based on systematic sampling and testing. Although there have been repeated calls for the development of international health monitoring standards and reporting, there are also objections. This article presents both the advantages and limitations of guidelines. After an overview of major factors to consider I discuss previous attempts to harmonize health monitoring procedures. The health monitoring recommendations for rodents issued by the Federation of European Laboratory Science Associations (FELASA) could serve as a model for global recommendations and for international harmonization. Given the increased significance of accurate health information when exchanging animals, research institutions and universities would benefit from universal standards, which would also help scientists as well as reviewers and readers of publications to better assess the validity of research results.     

Unequal protection for patient rights: The divide between university and health ethics committees

Despite recommendations from the Cartwright Report ethical review by health ethics committees has continued in New Zealand without health practitioners ever having to acknowledge their dual roles as health practitioners researching their own patients. On the other hand, universities explicitly identify doctor/research-patient relations as potentially raising conflict of role issues. This stems from the acknowledgement within the university sector itself that lecturer/research-student relations are fraught with such conflicts. Although similar unequal relationships are seen to exist between health resarchers and their patients, the patient/subjects are not afforded the levels of protection that are afforded student/subjects. In this paper we argue that the difference between universities and health research is a result of the failure of the Operational Standard Code for Ethics Committees to explicitly acknowledge the vulnerability of the patient and conflict of interests in the dual roles of health practitioner/researcher. We end the paper recommending the Ministry of Health consider the rewriting of the Operational Standard Code for Ethics Committees, in particular in the rewriting of section 26 of the Operational Standard Code for Ethics Committees. We also identify the value of comparative ethical review and suggest the New Zealand's Health Research Council's trilateral relationship with Australia's NHMRC (National Health and Medical Research Council) and Canada's CIHR (Canadian Institute of Health Research) as a useful starting point for such a process.     

Medical Education and Research: The Foundations of Quality Health Care

In May 1964 the Royal Commission on Health Services declared that “health research is essential to health progress”. However, since that time the means of providing adequate health care have received far less attention than have methods of payment for physicians'' services. Because medical education and research is the source from which all other health benefits flow, urgent attention must be paid to the adequate support of teacher-scientists, as set forth in the Woods, Gordon (Gundy) report. It is the numbers and quality of these men and women, more than any other factor, that will determine the shape of medical science and, hence, medical practice in Canada in the future. Expensive as it is, Canadian medicine and Canadian medical scientists must have generous support if medical care in this country is to be of high quality.     

Universities and medical schools: reflections on a half-century of Canadian medical education.

After 50 years of accelerated development, universities and medical schools have entered a period of uncertainty and instability. The Flexnerian paradigm of medical education, rooted in biomedical science and conducted under the aegis of a university, reached its apotheosis by the late 1960s and the early 1970s. Fuelled by the introduction of comprehensive, government-sponsored health care insurance and advances in technology, the demand for health care professionals and for access to facilities increased sharply. Medical education, research and advanced clinical services expanded dramatically aided by the emergence of academic health sciences centres and accompanied by a wave of medical curriculum reform. Now medical schools must strike a dynamic balance in responding to the continued expansion of knowledge and technology, the demand for social equity and the exigencies of prolonged fiscal constraint. They must also balance the biological and sociological approaches to medicine in establishing the foundations for the future development of Canadian medical education.     

The WHO must reform for its own health

The World Health Organization (WHO) is facing an unprecedented crisis that threatens its position as the premier international health agency. To ensure its leading role, it must rethink its internal governance and revamp its financing mechanisms.     

Global health and justice

In Australia, Japan, Sweden, and Switzerland, the average life expectancy is now greater than 80 years. But in Angola, Malawi, Sierra Leone, and Zimbabwe, the average life expectancy is less than 40 years. The situation is even worse than these statistics suggest because average figures tend to mask inequalities within countries. What are we to make of a world with such inequal health prospects? What does justice demand in terms of global health? To address these problems, I characterize justice at the local level, at the domestic or social level, and at the international or global level. Because social conditions, structures, and institutions have such a profound influence on the health of populations, I begin by focusing attention on the relationship between social justice and health prospects. Then I go on to discuss health prospects and the problem of global justice. Here I distinguish two views: a cosmopolitan view and a political view of global justice. In my account of global justice, I modify and use the political view that John Rawls developed in The Law of Peoples. I try to show why an adequate political account must include three duties: a duty not to harm, a duty to reconstruct international arrangements, and a duty to assist.     

Canadians pay for harsh economic policies with their health,physicians warn.

Canada''s fiscal policies are damaging the health of Canadians, two physicians told a conference that examined globalization''s impact on the country. Near-record unemployment levels and the recent recession have forced 41% of families in which the parents are 30 or younger to live below the poverty level; more than 21% of Canadian children are also considered to live in poverty. The impact tight fiscal policies have on health and well-being are enormous, say the dean of medicine at the University of Western Ontario and the chair of the Canadian Institute of Child Health.     

In visible bodies: minority women, nurses, time, and the new economy of care

Health care reform in Canadian hospitals has resulted in increased workloads and bureaucratization of patient care contributing to the development of a new economy of care. Interviews with nurses and visible (non-white) minority women who have given birth in institutions undergoing health care reform revealed that nurses felt compelled to avoid interactions with patients deemed too costly in terms of time. Overwhelmingly, these patients were members of culturally marginalized populations whose bodies were read by nurses as potentially problematic and time consuming. As their calls for assistance go unanswered, visible minority women complained of feeling invisible. Taken in context of historical and contemporary interethnic relations, these women regarded such avoidance patterns as evidence of racism. Obstetrical nurses, too, understood that the new economy of care wrought by health care restructuring has altered nursing practice and patient care to the detriment of minority women.     

Physicians in health care management: 1. Physicians as managers: roles and future challenges.

Physicians are increasingly expected to assume responsibility for the management of human and financial resources in health care, particularly in hospitals. Juggling their new management responsibilities with clinical care, teaching and research can lead to conflicting roles. However, their presence in management is crucial to shaping the future health care system. They bring to management positions important skills and values such as observation, problem-solving, analysis and ethical judgement. To improve their management skills physicians can benefit from management education programs such as those offered by the Physician-Manager Institute and several Canadian universities. To manage in the future environment they must increase their knowledge and skills in policy and political processes, financial strategies and management, human resources management, systems and program quality improvement and organizational design.     

A research agenda for malaria eradication: health systems and operational research

Health systems research and development is needed to support the global malaria eradication agenda. In this paper, we (the malERA Consultative Group on Health Systems and Operational Research) focus on the health systems needs of the elimination phase of malaria eradication and consider groupings of countries at different stages along the pathway to elimination. We examine the difference between the last attempt at eradication of malaria and more recent initiatives, and consider the changing health system challenges as countries make progress towards elimination. We review recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. Finally, we identify a number of needs for research and development, including tools for analyzing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.     

Migration and health in Canada: health in the global village

Background:

Immigration has been and remains an important force shaping Canadian demography and identity. Health characteristics associated with the movement of large numbers of people have current and future implications for migrants, health practitioners and health systems. We aimed to identify demographics and health status data for migrant populations in Canada.

Methods:

We systematically searched Ovid MEDLINE (1996–2009) and other relevant web-based databases to examine immigrant selection processes, demographic statistics, health status from population studies and health service implications associated with migration to Canada. Studies and data were selected based on relevance, use of recent data and quality.

Results:

Currently, immigration represents two-thirds of Canada’s population growth, and immigrants make up more than 20% of the nation’s population. Both of these metrics are expected to increase. In general, newly arriving immigrants are healthier than the Canadian population, but over time there is a decline in this healthy immigrant effect. Immigrants and children born to new immigrants represent growing cohorts; in some metropolitan regions of Canada, they represent the majority of the patient population. Access to health services and health conditions of some migrant populations differ from patterns among Canadian-born patients, and these disparities have implications for preventive care and provision of health services.

Interpretation:

Because the health characteristics of some migrant populations vary according to their origin and experience, improved understanding of the scope and nature of the immigration process will help practitioners who will be increasingly involved in the care of immigrant populations, including prevention, early detection of disease and treatment.Migration is an important component of globalization. International migration is estimated at 200 million people,¹ and the volume of migration continues to increase. Between 1990 and 2005, global migrants increased by some 33 million people, with the largest growth observed in the developed world. The movement of populations of this size has important implications for health practitioners, health systems² and the health of individuals.^3,4Health status is associated with quality of life and use of formal and informal health services.⁵ Overall, immigrants appear to be healthier than the Canadian-born population, by virtue of being capable, both physically and mentally, of successfully moving themselves, and often their families, from one country to another.⁶ However, over time, this healthy immigrant effect is lost.⁷Health status is not equivalent across all subgroups of immigrants. Certain migrant populations experience a higher risk of infectious diseases, cancer, diabetes and heart disease, which has clinical implications for those providing care to migrant communities.⁶ The health of migrants is a product of environmental, economic, genetic and socio-cultural factors related to when people migrated to Canada, where and how they lived in their original home country, and how and why they migrated. Their health is also influenced by postmigration factors involving integration into their new place of residence, employment, education and poverty, as well as the accessibility and responsiveness of health practitioners and responsiveness of the Canadian health care system to immigrants’ health needs.⁸Migration medicine is complicated by the use of similar terms, such as immigrant, refugee or migrant, for what are, in reality, different populations. This article will use standard Canadian immigration terminology. To help primary care practitioners interpret the clinical preventive recommendations of the Canadian Collaboration for Immigrant and Refugee Health, we aimed to identify demographics, health status reports, access to health care and health system implications of migrant populations in Canada.     

Evaluating ecosystem health

In the past decade, metaphors drawn from human health are finding increasing application in environmental assessment at ecosystem levels. If ecosystem medicine is to come of age, it must cope with three fundamental dilemmas. The first stems from the recognition that there are no strictly objective criteria for judging health. Assessments of health, as in humans, inevitably are based on some combination of established norms and desirable attributes. The second stems from the irregular pulse of nature which either precludes the early recognition of substantive changes or gives rise to false alarms. The third is posed by the quest for indicators that have the attributes of being holistic, early warning, and diagnostic. Indicators that excel in one of these aspects, often fail in another.Advances in ecosystem medicine are likely to come from closer collaboration with medical colleagues in both clinical and epidemiological areas. In particular the time appears ripe for a more systematic effort to characterize ecosystem maladies, to validate treatments and to develop more sophisticated diagnostic protocols. These aspects are illustrated with comparisons drawn from studies of environmental transformation in the Laurentian Great Lakes, the Baltic Sea and Canadian terrestrial ecosystems.Dedicated to Prof. J. Stan Rowe whose pioneering work in formulating a holistic perspective on ecosystem health has substantially contributed to the development of these ideas.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

Drivers for the emergence and re-emergence of vector-borne protozoal and bacterial diseases

In recent years, vector-borne parasitic and bacterial diseases have emerged or re-emerged in many geographical regions causing global health and economic problems that involve humans, livestock, companion animals and wild life. The ecology and epidemiology of vector-borne diseases are affected by the interrelations between three major factors comprising the pathogen, the host (human, animal or vector) and the environment. Important drivers for the emergence and spread of vector-borne parasites include habitat changes, alterations in water storage and irrigation habits, atmospheric and climate changes, immunosuppression by HIV, pollution, development of insecticide and drug resistance, globalization and the significant increase in international trade, tourism and travel. War and civil unrest, and governmental or global management failure are also major contributors to the spread of infectious diseases. The improvement of epidemic understanding and planning together with the development of new diagnostic molecular techniques in the last few decades have allowed researchers to better diagnose and trace pathogens, their origin and routes of infection, and to develop preventive public health and intervention programs. Health care workers, physicians, veterinarians and biosecurity officers should play a key role in future prevention of vector-borne diseases. A coordinated global approach for the prevention of vector-borne diseases should be implemented by international organizations and governmental agencies in collaboration with research institutions.     

Periodic health examination, 1999 update: 1. Detection,prevention and treatment of obesity

OBJECTIVES: (1) To evaluate the evidence relating to the effectiveness of methods to prevent and treat obesity, and (2) to provide recommendations for the prevention and treatment of obesity in adults aged 18 to 65 years and for the measurement of the body mass index (BMI) as part of a periodic health examination. OPTIONS: In adults with obesity (BMI greater than 27) management options include weight reduction, prevention of further weight gain or no intervention. OUTCOMES: The long-term (more than 2 years) effectiveness of (a) methods to prevent obesity and (b) methods to treat obesity. EVIDENCE: MEDLINE was searched for articles published from 1966 to April 1998 that related to the prevention and treatment of obesity; additional articles were identified from the bibliographies of review articles and the listings of Current Contents. Selection criteria were used to limit the analysis to prospective studies with at least 2 years'' follow-up. BENEFITS, HARM AND COSTS: Health benefits of weight reduction were evaluated in terms of alleviation of symptoms, improved management of obesity-related diseases and a reduction in major clinical outcomes. The health risk of weight-reduction methods were briefly evaluated in terms of increased mortality and morbidity. VALUES: The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be part of a periodic health examination. RECOMMENDATIONS: (1) Prevention: There is insufficient evidence to recommend in favour of or against community-based obesity prevention programs; however, because of considerable health risks associated with obesity and the limited long-term effectiveness of weight-reduction methods, the prevention of obesity should be a high priority for health care providers (grade C recommendation). (2) Treatment: (a) For obese adults without obesity-related diseases, there is insufficient evidence to recommend in favour of or against weight-reduction therapy because of a lack of evidence supporting the long-term effectiveness of weight-reduction methods (grade C recommendation); (b) for obese adults with obesity-related diseases (e.g., diabetes mellitus, hypertension), weight reduction is recommended because it can alleviate symptoms and reduce drug therapy requirements, at least in the short term (grade B recommendation). (3) Detection: (a) for people without obesity-related diseases, there is insufficient evidence to recommend the inclusion or exclusion of BMI measurement as part of a periodic health examination, and therefore BMI measurement is left to the discretion of individual health care providers (grade C recommendation); (b) for people with obesity-related diseases, BMI measurement is recommended because weight reduction should be considered with a BMI of more than 27 (grade B recommendation). VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care. SPONSORS: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.     

The emergence of pioneering public health education programs in the United States

This paper considers the social forces leading to the establishment of pioneering public health education programs in the United States. Schools of Public Health emerged in the United States as the result of a confluence of factors, including the changing nature of higher education, the development of commerce and industry, the rise to prominence of the science of bacteriology, and the urbanization of the nation, all coupled with a pervasive spirit of utility and a desire to be, in a word, useful. Each line leading to the establishment of five public health institutions at the Massachusetts Institute of Technology, Harvard-M.I.T., Yale, Michigan, and Pennsylvania is explored.     

Do health service organizations and community health centres have higher disease prevention and health promotion levels than fee-for-service practices?

We interviewed health care providers representing 23 fee-for-service (FFS) practices, 19 health service organizations (HSOs) and 11 community health centres (CHCs) in Ontario to compare self-reported approaches to disease prevention and health promotion. Few significant differences were found across practice types in the presence of recall systems for screening or in knowledge of, compliance with or estimated coverage for selected preventive maneuvers recommended by the Canadian Task Force on the Periodic Health Examination. CHCs reported a significantly greater variety of formal health promotion programs and a greater tendency to use nonphysician health care personnel to carry out both prevention and health promotion activities. The results must be interpreted with caution because of the use of self-reported data, the low response rate for FFS practices and the use of a restrictive definition of disease prevention tied to evidence from the reports of the task force. Thus, the results cast some doubt on the common assumption that increasing the population served by alternative modes of delivery such as HSOs and CHCs necessarily increases the level of disease prevention and health promotion activity.     

Japan's innovation for global health – GHIT's catalytic role

The global fight against infectious diseases, both emerging and re-emerging, endures. Japan's commitments and reputation as a good global citizen and its responsibility to uphold domestic and international human security mean that it is in Japan's best interest to leverage its innovative and technological capabilities for global infectious disease prevention and control. The Global Health Innovative Technology Fund (GHIT Fund), an international non-profit organization based in Tokyo, Japan, was established by the Japanese government, multiple Japanese pharmaceutical companies, and the Bill & Melinda Gates Foundation as the first fund of its kind, with an aim to tackle the global burden of infectious diseases by facilitating and funding global health R&D of drugs, vaccines, and diagnostics. Since its inception in 2013, the GHIT Fund has invested more than 209 million USD in more than 90 projects, which consist of collaborations among Japanese and non-Japanese entities, six of which have already progressed to clinical stage development. Japan will continue to play a major role in the global health arena by further advancing R&D innovations for infectious diseases.