The objective of this review was to describe and situate the burden and treatment of diabetes within the broader context of the French health care system.
Literature review on the burden, treatment and outcomes of diabetes in France, complemented by personal communication with with diabetes experts in the Paris public hospital system.
Prevalence of diabetes in the French population is estimated at 6%. Diabetes has the highest prevalence among all chronic conditions covered 100% by France’s statutory health insurance (SHI), and the number of covered patients has doubled in the past 10 years. In 2010, the SHI cost for pharmacologically-treated diabetes patients amounted to €17.7 billion, including an estimated €2.5 billion directly related to diabetes treatment and prevention and €4.2 billion for treatment of diabetes-related complications. In 2007, the average annual SHI cost was €6 930 for patients with type 1 diabetes and €4 890 for patients with type 2 diabetes. Complications are associated with significantly increased costs. Diabetes is a leading cause of adult blindness, amputation and dialysis in France, which also has one of the highest rates of end-stage renal disease in Europe. Cardiovascular disease is the leading cause of death among people with diabetes. Historically, the French health care system has been more oriented to curative acute care rather than preventive medicine and management of long-term chronic diseases. More recently, the government has focused on primary prevention as part of its national nutrition and health program, with the goal of reducing overweight and obesity in adults and children. It has also recognized the critical role of the patient in managing chronic diseases such as diabetes and has put into place a free patient support program called “sophia”. Additional initiatives focus on therapeutic patient education (TPE) and the development of personalized patient pathways.
While France has been successful in protecting patients from the financial consequences of diabetes through its SHI coverage, improvements are necessary in the areas of prevention, monitoring and reducing the incidence of complications. Systemic changes must be made to improve the coordination and delivery of chronic care.
France; Diabetes; Complications; Cost; Chronic disease management
Glivec (imatinib mesylate), produced by the pharmaceutical company Novartis, is prescribed in the case of Chronic Myeloid Leukemia, one of the most common blood cancers in eastern countries. After more than a decade of legal battles surrounding its patentability, the Supreme Court of India gave its final decision on April 1st of 2013, rejecting the appeal of the Swiss giant drug manufacturer. In 2006, the Indian Patent Office first refused Glivec’s patent under Section 3(d) of the Indian Patent Act arguing that it was only a modified version of an existing drug, Imatinib, and therefore that the drug was not innovative. Novartis replied filing legal challenges against the Indian government but the final verdict in April of 2013 ends the battle. Indeed, the Supreme Court stated that even if the bioavailability of the drug was improved, it did not demonstrate enhanced efficacy and that Glivec was not patentable.
The research primarily focused on journal, newspaper and magazine articles relevant to the time frame of the lawsuit (from 1994 to 2013) as well as news searches through Google, Factiva, ProQuest, PubMed, and YouTube where press articles from court verdicts were obtained by using the following keywords: “India”, “Novartis”, “Glivec”, “Patent”, “Novartis Case”, and “Supreme Court of India”. The data sources were interpreted and analyzed according to the authors’ own prior knowledge and understanding of the exigencies of the TRIPS Agreement.
This case illuminates how India is interpreting international law to fit domestic public health needs.
The Novartis case arguably sets an important precedent for the global pharmaceutical industry and ideally will help improve access to lifesaving medicines in the developing world by demanding that patient health needs supersede commercial interests. The Supreme Court of India’s decision may affect the interpretation of the article of the TRIPS Agreement, which states members shall be free to determine the appropriate method of implementing the provisions of this Agreement within their own legal system and practice.
India; Novartis; Glivec; Patents; Generic drugs; TRIPS agreement; Drug industry; Pharmaceuticals
Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.
Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.
Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.
Global surgery; Essential surgery; Value innovation; Surgical technology; External fixator; Laparostomy; Ventriculo-peritoneal shunt; Mesh hernia repair; Intra-ocular lens; Flutter valve
Background and objectives
The expanding diabetes epidemic worldwide could have potentially devastating effects on the development of healthcare systems and economies in emerging countries, both in terms of direct health care costs and loss of working time and disability. This study aims to review evidence on the burden, expenditure, complications, treatment, and outcomes of diabetes in Indonesia and its implications on the current health system developments.
We conducted a comprehensive literature review together with a review of unpublished data from the Ministry of Health and a public health insurer (Askes). Studies presenting evidence on prevalence, incidence, mortality, costs, complications and cost of complications, treatment, and outcomes were included in the analysis.
A limited number of international, national and local studies on the burden and cost of diabetes in Indonesia were identified. National survey data suggests that in 2007 the prevalence of diabetes was 5.7%, of which more than 70% of cases were undiagnosed. This estimate hides large intracountry variation. There was very limited data available on direct costs and no data on indirect costs. The most commonly-identified complication was diabetic neuropathy.
There were a number of limitations in the data retrieved including the paucity of data representative at the national level, lack of a clear reference date, lack of data from primary care, and lack of data from certain regions of the country.
If left unaddressed, the growing prevalence of diabetes in the country will pose a tremendous challenge to the Indonesian healthcare system, particularly in view of the Government’s 2010 mandate to achieve universal health coverage by 2014. Essential steps to address this issue would include: placing diabetes and non-communicable diseases high on the Government agenda and creating a national plan; identifying disparities and priority areas for Indonesia; developing a framework for coordinated actions between all relevant stakeholders.
Diabetes mellitus; Diabetes costs; Diabetes complications; Indonesia
Very little is known about multimorbidity and chronic diseases in low and middle income countries, particularly Sub-Saharan Africa, and more information is needed to guide the process of adapting the health systems in these countries to respond adequately to the increasing burden of chronic diseases. We conducted a hospital-based survey in an urban setting in Ghana to determine the prevalence of multimorbidity and its associated risk factors among adult patients presenting to an inner city clinic.
Between May and June 2012, we interviewed adult patients (aged 18 years and above) attending a routine outpatient clinic at an inner-city hospital in Accra using a structured questionnaire. We supplemented the information obtained from the interviews with information obtained from respondents’ health records. We used logistic regression analyses to explore the risk factors for multimorbidity.
We interviewed 1,527 patients and retrieved matching medical records for 1,399 (91.6%). The median age of participants was 52.1 years (37–64 years). While the prevalence of multimorbidity was 38.8%, around half (48.6%) of the patients with multimorbidity were aged between 18–59 years old. The most common combination of conditions was hypertension and diabetes mellitus (36.6%), hypertension and musculoskeletal conditions (19.9%), and hypertension and other cardiovascular conditions (11.4%). Compared with patients aged 18–39 years, those aged 40–49 years (OR 4.68, 95% CI: 2.98–7.34), 50–59 years (OR 12.48, 95% CI: 8.23–18.92) and 60 years or older (OR 15.80, 95% CI: 10.66–23.42) were increasingly likely to present with multimorbidity. While men were less likely to present with multimorbidity, (OR 0.71, 95% CI: 0.45–0.94, p = 0.015), having a family history of any chronic disease was predictive of multimorbidity (OR 1.43, 95% CI: 1.03–1.68, p = 0.027).
Multimorbidity is a significant problem in this population. By identifying the risk factors for multimorbidity, the results of the present study provide further evidence for informing future policies aimed at improving clinical case management, health education and medical training in Ghana.
Comorbidity; Chronic disease; Non-communicable conditions; Ghana; Africa
The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. We offer the first empirical evaluation of the Code’s impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking developed countries with the greatest number of migrant health workers.
42 key informants from across government, civil society and private sectors were surveyed to measure their awareness of the Code, knowledge of specific changes resulting from it, overall opinion on the effectiveness of non-binding codes, and suggestions to improve this Code’s implementation.
60% of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries.
This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision-makers.
Health worker recruitment; Migration; Health systems; International law; Impact evaluation; World Health Organization
Globally, about 350.000 women die every year from pregnancy related causes and more than half of these deaths occur in sub-Saharan Africa (SSA). Approximately 12% of the maternal deaths are associated with hypertensive disorders in pregnancy such as pregnancy induced hypertension (PIH). However, very little is known about PIH and associated determinants in many SSA countries such as Ghana. We therefore sought to assess rural and urban differences in blood pressure (BP) and PIH among pregnant women in Ghana.
We conducted a cross-sectional study among 967 rural (677) and urban (290) pregnant women with a gestational age of more than 20 weeks. PIH was defined as a systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg.
Women in urban Ghana had a higher mean systolic and diastolic BP than women in rural Ghana (105/66 mmHg versus 102/61 mmHg, p < 0.001 for both systolic and diastolic BP). The prevalence of PIH was also higher in urban Ghana (3.1%) than in rural Ghana (0.4%) (p = 0.014). The urban and rural difference in mean diastolic blood pressure persisted even after adjustments for the study characteristics in a linear regression model. In both rural and urban Ghana, BMI, heart rate and a family history of hypertension were independently associated with BP.
Our findings suggest higher mean BP levels and PIH in urban Ghana than in rural Ghana. BMI was independently related to high BP. Left unchecked, the increasing prevalence of overweight and obesity in Ghana will exacerbate PIH levels in Ghana.
Blood pressure; Pregnancy induced hypertension; Pregnancy; Ghana
External challenges to health systems, such as those caused by global economic, social and environmental changes, have received little attention in recent debates on health systems’ performance in low-and middle-income countries (LMICs). One such challenge in coming years will be increasing prices for petroleum-based products as production from conventional petroleum reserves peaks and demand steadily increases in rapidly-growing LMICs. Health systems are significant consumers of fossil fuels in the form of petroleum-based medical supplies; transportation of goods, personnel and patients; and fuel for lighting, heating, cooling and medical equipment. Long-term increases in petroleum prices in the global market will have potentially devastating effects on health sectors in LMICs who already struggle to deliver services to remote parts of their catchment areas. We propose the concept of “localization,” originating in the environmental sustainability literature, as one element of response to these challenges. Localization assigns people at the local level a greater role in the production of goods and services, thereby decreasing reliance on fossil fuels and other external inputs. Effective localization will require changes to governance structures within the health sector in LMICs, empowering local communities to participate in their own health in ways that have remained elusive since this goal was first put forth in the Alma-Ata Declaration on Primary Health Care in 1978. Experiences with decentralization policies in the decades following Alma-Ata offer lessons on defining roles and responsibilities, building capacity at the local level, and designing appropriate policies to target inequities, all of which can guide health systems to adapt to a changing environmental and energy landscape.
Health systems reform; Climate change; Decentralization; Rural health; Localization; Access to care; Developing countries
In 30 years of experience in responding to the HIV epidemic, critical decisions and program characteristics for successful scale-up have been studied. Now leaders face a new challenge: sustaining large-scale HIV prevention programs. Implementers, funders, and the communities served need to assess what strategies and practices of scaling up are also relevant for sustaining delivery at scale.
We reviewed white and gray literature to identify domains central to scaling-up programs and reviewed HIV case studies to identify how these domains might relate to sustaining delivery at scale.
We found 10 domains identified as important for successfully scaling up programs that have potential relevance for sustaining delivery at scale: fiscal support; political support; community involvement, integration, buy-in, and depth; partnerships; balancing flexibility/adaptability and standardization; supportive policy, regulatory, and legal environment; building and sustaining strong organizational capacity; transferring ownership; decentralization; and ongoing focus on sustainability. We identified one additional potential domain important for programs sustaining delivery at scale: emphasizing equity.
Today, the public and private sector are examining their ability to generate value for populations. All stakeholders are aiming to stem the tide of the HIV epidemic. Implementers need a framework to guide the evolution of their strategies and management practices. Greater research is needed to refine the domains for policy and program implementers working to sustain HIV program delivery at scale.
Scale-up; Sustainability; Large-scale; HIV; Literature review; Framework; Public health; Care delivery
Diabetes is an expensive disease in Argentina as well as worldwide, and its prevalence is continuously rising affecting the quality of life of people with the disease and their life expectancy. It also imposes a heavy burden to the national health care budget and on the economy in the form of productivity losses.
To review and discuss a) the reported evidence on diabetes prevalence, the degree of control, the cost of care and outcomes, b) available strategies to decrease the health and economic disease burden, and c) how the disease fits in the Argentinian health care system and policy. Finally, to propose evidence-based policy options to reduce the burden of diabetes, both from an epidemiological as well as an economic perspective, on the Argentinian society. The evidence presented is expected to help the local authorities to develop and implement effective diabetes care programmes.
A comprehensive literature review was performed using databases such as MEDLINE, EMBASE and LILACS (Latin American and Caribbean Health Sciences). Literature published from 1980 to 2011 was included. This information was complemented with grey literature, including data from national and provincial official sources, personal communications and contacts with health authorities and diabetes experts in Argentina.
Overall diabetes prevalence increased from 8.4% in 2005 to 9.6% 2009 at national level. In 2009, diabetes was the seventh leading cause of death with a mortality rate of 19.2 per 100,000 inhabitants, and it accounted for 1,328,802 DALYs lost in the adult population, mainly affecting women aged over fifty. The per capita hospitalisation cost for people with diabetes was significantly higher than for people without the disease, US$ 1,628 vs. US$ 833 in 2004. Evidence shows that implementation of combined educative interventions improved quality of care and outcomes, decreased treatment costs and optimised the use of economic resources.
Based on the evidence reviewed, we believe that the implementation of structured health care programmes including diabetes education at every level, could improve quality of care as well as its clinical, metabolic and economic outcomes. If implemented across the country, these programmes could decrease the disease burden and optimise the use of human and economic resources.
Diabetes; Costs; Argentina; Prevalence; Diabetes management
There is a lack of effective and affordable technologies to address health needs in the developing world. One way to address problems of innovation and affordability is to design global health technologies to follow agreed-upon standards. This Debate article argues that we can better develop standards for global health technologies if we learn lessons from other industries.
The article’s Background section begins by explaining why standards are needed in global health. For example, if global health technologies can be modularized into independent interfacing parts, these parts can then interact via well-defined standards in a “plug and play” fashion. This can avoid development of mutually incompatible solutions by different organizations, speed the pace of innovation, unlock health systems from single providers and approaches, and lower barriers to entry. The Background then gives a brief primer on standards and discusses incentives for health standards. The article’s Discussion section begins with brief relevant cases of standards development from other industries, including electricity, container shipping, CD standards, Universal Serial Bus (USB), and the Internet. It then explores lessons from these and other industries that suggest how to develop standards for global health technologies. The remainder of the Discussion considers intellectual property and regulatory issues and standards-based global health business models, and ends with a checklist of considerations for health standards development leaders. (The associated Additional file discusses observations from standards development for cell phones and semiconductors, as well as challenges in the standards development process itself.) Throughout the article, point-of-care diagnostics are used as an illustrative example. An initiative is already underway to explore standardized diagnostics platforms.
This Debate article aims to convince the reader that standards can benefit global health technologies if we learn lessons from other industries. The article draws from historical examples and the authors’ experiences to suggest principles, challenges, and opportunities in developing these standards. If implemented well, standardized platforms can lower barriers to entry, improve affordability, and create a vibrant ecosystem of innovative new global health technologies.
Global health; Standards; Interoperability; Affordability; Interface; Modularity; Diagnostics
There is an unresolved debate about the potential effects of financial speculation on food prices and price volatility. Germany’s largest financial institution and leading global investment bank recently decided to continue investing in agricultural commodities, stating that there is little empirical evidence to support the notion that the growth of agricultural-based financial products has caused price increases or volatility. The statement is supported by a recently published literature review, which concludes that financial speculation does not have an adverse effect on the functioning of the agricultural commodities market. As public health professionals concerned with global food insecurity, we have appraised the methodological quality of the review using a validated and reliable appraisal tool. The appraisal revealed major shortcomings in the methodological quality of the review. These were particularly related to intransparencies in the search strategy and in the selection/presentation of studies and findings; the neglect of the possibility of publication bias; a lack of objective or rigorous criteria for assessing the scientific quality of included studies and for the formulation of conclusions. Based on the results of our appraisal, we conclude that it is not justified to reject the hypothesis that financial speculation might have adverse effects on food prices/price volatility. We hope to initiate reflections about scientific standards beyond the boundaries of disciplines and call for high quality, rigorous systematic reviews on the effects of financial speculation on food prices or price volatility.
Financial speculation; Food prices; Price volatility; Food security; Systematic review; Critical appraisal; Global health
Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. Brokerage inherent in hospital-to-hospital partnerships can boost relationships between “evidence” and “policy” communities and move developing countries towards evidence based patient safety policy. In particular, we use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. This rapidly expanding field of enquiry is ripe for shared learning across continents, in keeping with the principles and spirit of health systems development in a globalized world.
Patient safety; Global health; Policy-making; Evidence-based practice; Africa; Hospitals
The administration of antimicrobial drugs to food animals at low doses for extended durations for growth promotion and disease prevention has been linked to the global health crisis of antimicrobial resistance. Internationally, multiple jurisdictions have responded by restricting antimicrobial use for these purposes, and by requiring a veterinary prescription to use these drugs in food animals. Opponents of these policies have argued that restrictions have been detrimental to food animal production where they have been adopted.
We surveyed the antimicrobial use policies of 17 political jurisdictions outside of the United States with respect to growth promotion, disease prevention, and veterinary oversight, and reviewed the available evidence regarding their production impacts, including measures of animal health. Jurisdictions were included if they were a top-five importer of a major U.S. food animal product in 2011, as differences between the policies of the U.S. and other jurisdictions may lead to trade barriers to U.S. food animal product exports. Jurisdictions were also included if information on their policies was publicly available in English. We searched the peer-reviewed and grey literatures and corresponded with jurisdictions’ U.S. embassies, regulators, and local experts.
Jurisdictions were categorized by whether they prohibit use of antimicrobials for growth promotion and/or use of antimicrobials without a veterinary prescription. Of the 17 jurisdictions surveyed, six jurisdictions have prohibited both types of use, five jurisdictions have prohibited one use but not the other use, and five jurisdictions have not prohibited either use, while information was not available for one jurisdiction. Data on the production impacts of these prohibitions were limited, although available data, especially from Denmark and Sweden, suggest that restrictions on growth promotion use can be implemented with minimal production consequences.
A majority of leading U.S. trade partners have more stringent policies regarding antibiotic use and veterinary oversight in food animal production. Available data suggest that restrictions on growth promotion may not be detrimental to production in the long run, although additional research could be useful. There is evidence that discordance between the U.S. and other jurisdictions with respect to antimicrobial use in food animals may be detrimental to U.S. access to export markets for food animal products. The available economic evidence strengthens the rationale for restricting antimicrobial use in U.S. food animals.
Antimicrobial; Antibiotic; Drug resistance; Bacteria; Food animal; Agriculture; Veterinarian; Trade
Is existing provision of health services in Europe affordable during the recession or could cuts damage economic growth? This debate centres on whether government spending has positive or negative effects on economic growth. In this study, we evaluate the economic effects of alternative types of government spending by estimating “fiscal multipliers” (the return on investment for each $1 dollar of government spending).
Using cross-national fixed effects models covering 25 EU countries from 1995 to 2010, we quantified fiscal multipliers both before and during the recession that began in 2008.
We found that the multiplier for total government spending was 1.61 (95% CI: 1.37 to 1.86), but there was marked heterogeneity across types of spending. The fiscal multipliers ranged from −9.8 for defence (95% CI: -16.7 to −3.0) to 4.3 for health (95% CI: 2.5 to 6.1). These differences appear to be explained by varying degrees of absorption of government spending into the domestic economy. Defence was linked to significantly greater trade deficits (β = −7.58, p=0.017), whereas health and education had no effect on trade deficits (peducation=0.62; phealth= 0.33).
Our findings indicate that government spending on health may have short-term effects that make recovery more likely.
Health spending; Government spending; Economic growth
Canadian reports have recommended that health as a human right must be Canada’s overarching global commitment and that the primacy of human rights should be prioritized over other elements of international law including international trade and investment law as it applies to access to pharmaceuticals. This paper uses a series of case reports to examine Canada’s commitment to this goal. Specifically it examines cases where improved access has been in conflict with increased intellectual property rights. The 6 cases are: Canada’s position when 39 pharmaceutical companies took South Africa to court in 1998 over its legislation to allow parallel importation of patented medicines and to regulate the price of medications; the stance that Canada took in the negotiations around the Doha Declaration in 2001; the passage of Canada’s Access to Medicines Regime in 2004 and subsequent attempts to amend the legislation in 2011 and 2012; Canada’s involvement in the final declaration at the United Nations High-Level meeting on non-communicable diseases in 2012; Canada’s views about the terms in the Anti-Counterfeiting Trade Agreement as expressed in 2009; and Canada’s 2013 position on the extension of the exemption for least developed countries from having to comply with the terms of the Trade Related Aspects of Intellectual Property Rights Agreement. In the first case Canada was neutral but in the remaining 5 cases Canada prioritized intellectual property rights over access. This position is consistent with how Canada has acted around domestic issues involving intellectual property rights for pharmaceutical products. Canada has supported strengthened rights despite the fact that their touted benefits have not been realized either domestically or in developing countries. As a result Canada has failed in its humanitarian duty to protect the human right to health in the form of safe and low cost medicines for the people in developing countries.
Access; Anti-Counterfeiting Trade Agreement; Canada; Canada’s Access to Medicines Regime; Doha Declaration; Intellectual property rights; Least developed countries; Non-communicable diseases; TRIPS
The notion of “reverse innovation”--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.
In this paper we review two recent paradigmatic shifts and consider how a two-way flow in innovation has been critical to the emergence of new thinking and new practices. The first area relates to our understanding of the nature of public health systems and the shift from a medical paradigm to a more holistic paradigm which emphasises the social, economic and environmental origins of ill-health and looks to these as key arenas in which to tackle persistent inequalities in populations’ health experiences. In respect of this paradigmatic shift, it is argued, developing countries were in advance of their more developed counterparts. Specifically, the Alma Ata Declaration and the Primary Health Care Approach which was central to its implementation pre-figured elements of what was to be called in developed countries The New Public Health such as the need for greater community involvement and recognition of the importance of other sectors in determining health outcomes. But this paradigmatic shift added a new complexity to our understanding which made the identification of appropriate policy responses increasingly difficult. However, a parallel shift was taking place in the cognate field of operational research/systems analysis (OR/SA) which was adding greatly to our ability to analyse and to identify key points of intervention in complex systems. This led to the emergence of new techniques for problem structuring which overcame many of the limitations of formal mathematical models which characterised the old paradigm. In this paradigmatic shift developed countries have led the way, specifically in the new fields of Community Operational Research and Operational Research for Development, but only by drawing strongly on the experience and philosophies to be found in developing countries.
Public health; Systems analysis; Operational research; Reverse innovation
Health partnerships between institutions in the UK and Low or Lower- middle Income Countries are an increasingly important model of development, yet analysis of partnerships has focused on benefits and costs to the Low and Lower- Middle Income partner. We reviewed the evidence on benefits and costs of health partnerships to UK individuals, institutions & the NHS and sought to understand how volunteering within partnerships might impact on workforce development and service delivery.
A systematic review of both published literature and grey literature was conducted. Content relating to costs or benefits to the UK at an individual, institutional or system level was extracted and analysed by thematic synthesis. The benefits of volunteering described were mapped to the key outcome indicators for five different UK professional development structures. A framework was developed to demonstrate the link between volunteer experience within partnerships and improved UK service delivery outcomes.
The literature review (including citation mapping) returned 9 published papers and 32 pieces of grey literature that met all inclusion criteria. 95% of sources cited benefits and 32% cited costs. Most literature does not meet high standards of formal academic rigor. Forty initial individual benefits codes were elicited. These were then grouped into 7 key domains: clinical skills; management skills; communication & teamwork; patient experience & dignity; policy; academic skills; and personal satisfaction & interest. A high degree of concordance was shown between professional benefits cited and professional development indicators within UK work force development frameworks. A theoretical trajectory from volunteer experience to UK service delivery outcomes was demonstrated in most areas, but not all. 32% of sources cited costs, yielding 15 initial codes which were grouped into 5 domains: financial; reputational; health & security; loss of staff; and opportunity costs.
There is little published or unpublished literature on the impact of volunteering within health partnerships to British individuals, institutions or the UK. The existing evidence base is descriptive and focuses on the benefits of volunteering. More work is required to quantify the costs and benefits of volunteering within health partnerships for individuals and institutions, and the associated challenges and barriers. Despite these limitations our analysis suggests that there is a strong theoretical argument that the skills acquired through volunteering are transferable to service delivery within the NHS and that the benefits to individuals and institutions could be maximised when volunteering is formally embedded within continuing professional development processes.
‘Reverse innovation,’ a principle well established in the business world, describes the flow of ideas from emerging to more developed economies. There is strong and growing interest in applying this concept to health care, yet there is currently no framework for describing the stages of reverse innovation or identifying opportunities to accelerate the development process. This paper combines the business concept of reverse innovation with diffusion of innovation theory to propose a model for reverse innovation as a way to innovate in health care. Our model includes the following steps: (1) identifying a problem common to lower- and higher-income countries; (2) innovation and spread in the low-income country (LIC); (3) crossover to the higher-income country (HIC); and (4) innovation and spread in the HIC. The crucial populations in this pathway, drawing from diffusion of innovation theory, are LIC innovators, LIC early adopters, and HIC innovators. We illustrate the model with three examples of current reverse innovations. We then propose four sets of specific actions that forward-looking policymakers, entrepreneurs, health system leaders, and researchers may take to accelerate the movement of promising solutions through the reverse innovation pipeline: (1) identify high-priority problems shared by HICs and LICs; (2) create slack for change, especially for LIC innovators, LIC early adopters, and HIC innovators; (3) create spannable social distances between LIC early adopters and HIC innovators; and (4) measure reverse innovation activity globally.
Open innovation, which refers to combining internal and external ideas and internal and external paths to market in order to achieve advances in processes or technologies, is an attractive paradigm for structuring collaborations between developed and developing country entities and people. Such open innovation collaborations can be designed to foster true co-creation among partners in rich and poor settings, thereby breaking down hierarchies and creating greater impact and value for each partner. Using an example from Concern Worldwide’s Innovations for Maternal, Newborn &Child Health initiative, this commentary describes an early-stage pilot project built around open innovation in a low resource setting, which puts communities at the center of a process involving a wide range of partners and expertise, and considers how it could be adapted and make more impactful and sustainable by extending the collaboration to include developed country partners.
Partnerships; Innovation; Global health; Maternal; Newborn; Child; Maker movement; Open innovation; Disruptive innovation; Frugal innovation
The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.
Global Fund; Health technology assessment; Cost-effectiveness analysis; Program evaluation; Global health
The body of research and practice regarding student volunteer abroad experiences largely focuses on ensuring the optimal learning experience for the student from the Global North, without equivalent attention to the benefits, if any, to the host institution in the Global South. In this debate article, we examine an often overlooked component of global student volunteer programs: the views of the local partner on what makes for a mutually beneficial partnership between volunteers from the Global North and institutions in the Global South.
To guide our discussion, we drew upon the experiences of a Kenyan NGO with a Canadian student volunteer in the summer of 2012, organized via a formalized partnership with a Canadian university. We found that the approach of the NGO to hosting the student mirrored the organizational behaviour theories of Margaret J. Wheatley, who emphasized a disorderly or ‘chaotic’ approach to acquiring impactful change, coupled with a focus on building solid human relationships. Rather than following a set of rigid goals or tasks, the student was encouraged to critically engage and participate in all aspects of the culture of the organization and country, to naturally discover an area where his priorities aligned with the needs of the NGO. Solid networks and interpersonal connections resulted in a process useful for the organization long after the student’s short-term placement ended.
Our discussion reveals key features of successful academic volunteer abroad placements: equal partnership in the design phase between organizations in the Global North and Global South; the absence of rigid structures or preplanned tasks during the student’s placement; participatory observation and critical engagement of the student volunteer; and a willingness of the partners to measure impact by the resultant process instead of tangible outcomes.
Global health; Study abroad; Student volunteers; Volunteer tourism; Critical engagement; Medical education
Patients engage in medical tourism when they privately obtain a medical care abroad. Previous research shows that many medical tourists travel abroad with friends and family members who provide support and assistance. Meanwhile, very little is known about this important stakeholder group, referred to here as caregiver-companions. In this article we examine the challenges that can be posed by caregiver-companions and the overall practice of informal caregiving in medical tourism from an industry perspective. Specifically, we report on the findings of interviews conducted with international patient coordinators (IPCs) who work at destination facilities. IPCs come into regular contact with caregiver-companions in their professional positions and thus are ideally suited to comment on trends they have observed among this stakeholder group as well as the challenges they can pose to medical tourists, health workers, and facilities.
We conducted 20 semi-structured interviews with 21 IPCs from 16 different facilities across nine countries. Topics probed in the interviews included caregiver-companion roles, IPCs’ and others’ interaction with caregiver-companions, and potential health and safety risks posed to medical tourists and caregiver-companions. Thematic analysis of the verbatim transcripts was employed.
Although most participants encouraged medical tourists to travel with a caregiver-companion, many challenges associated with caregiver-companions were identified. Three themes best characterize the challenges that emerged: (1) caregiver-companions require time, attention and resources; (2) caregiver-companions can disrupt the provision of quality care; and (3) caregiver-companions can be exposed to risks. IPCs pointed out that caregiver-companions may, for example, have a negative impact on the patient through cost of accompaniment or inadequate care provision. Caregiver-companions may also create unanticipated or extra work for IPCs, as additional clients and by ignoring established organizational rules, routines, and expectations. Furthermore, caregiver-companions may be susceptible to stresses and health and safety risks, which would further deteriorate their own abilities to offer the patient quality care.
Although caregiver-companions can pose challenges to medical tourists, health workers, and medical tourism facilities, they can also assist in enhancing best care and offering meaningful support to medical tourists. If caregiver-companions are open to collaboration with IPCs, and particularly in the form of information sharing, then their experience abroad can be safer and less stressful for themselves and, by extension, for the accompanied patients and facility staff.
Medical tourism; Informal caregiving; International patient coordinators; Patient; International health care