Globalization and Health最新文献

A forgotten aspect of the decolonizing global health movement is the impact of monolingualism on the practice of medicine and global health. Thousands of languages are spoken worldwide yet remarkably few are used in these fields. English, in particular, plays an extraordinarily dominant role. The status of English as the global medical lingua franca perpetuates inequities in research, medical education and healthcare delivery, disproportionately affecting many low-and middle-income countries (LMICs). This linguistic hegemony creates barriers to accessing health information for minoritized populations and discriminates against researchers from non-native English-speaking backgrounds. Even the speakers of major world languages such as Arabic and Hindi are marginalized, with little research published in these languages and medical education generally unavailable in them. This inequality affects patients' ability to receive care and access information in their own languages and contributes to mistrust and exclusion. This is particularly the case in formerly colonized countries where exploitative medical practices remain a painful legacy. A paradigm shift is urgently needed in the global health field to address these inequities. We propose solutions include expanding foreign language education, supporting minoritized languages in health promotion, and mandating the dissemination of research output in the languages of the studied populations. Ultimately, the languages we choose to use as global health practitioners shape power dynamics, determine whose voices are heard, and impact the effectiveness of our actions. Without urgent and systemic change, the dominance of a few languages, particularly English, risks perpetuating inequities and excluding those most in need of inclusion.

Background: Although international mobility of medical personnel has gained scholarly attention, there has been limited empirical research on overseas-educated dietetic professionals. China has experienced a notable return of highly skilled professionals. This study aims to explore the experiences of Chinese overseas-educated dietetic returnees, focusing on their practice areas, job satisfaction, motivations for returning, post-return challenges, and career development strategies.

Methods: A web-based survey, conducted from July to December 2022, targeted dietetic returnees with degree(s) from institutions outside mainland China. Participants were recruited from professional group chats on a social media platform. Job satisfaction was assessed using a 7-item scale, with responses ranging from 0 to 5 for each item. Its internal consistency was evaluated via Cronbach's alpha. Responses were analyzed using descriptive statistics, t tests, and ANOVA. A multivariate regression helps further predict job satisfaction. Thematic analysis guides the analysis of an open-ended question.

Results: Participants (N = 138) were mainly female (86.2%), had a master's degree (79.0%), and had studied in the United States (37.7%). Clinical roles dominated post-return employment, but returnees also pursued biomedicine, biotechnology, and media. The mean job satisfaction score of 3.39 indicated moderate satisfaction. Job satisfaction varied across subgroups (e.g., older participants); however, in the multivariable regression model, only salary level remained a significant predictor. Key motivations for returning included familial ties, societal connections, and a desire to contribute to home country development. Returnees identified limited domestic networking connections as a top challenge. Meanwhile, they demonstrated agency in navigating post-return career development, such as by leveraging transnational social networks. Returnees also envisioned systematic workforce changes, such as improving licensure and regulation for foreign-trained professionals.

Conclusion: Returnees have diverse career pathways. Post-return job satisfaction, however, was significantly predicted only by salary level, emphasizing the critical role of compensation and economic viability in sustaining careers in the dietetic field. Our findings suggest that while returnees were primarily motivated by personal and cultural factors, they faced significant re-entry challenges that warrant attention from educators and policymakers. Future research should explore the global mobility of the dietetic profession and its potential to contribute to 'brain gain' in China's healthcare sector.

Background: There is a global shortage of doctors, and governments worldwide are concerned with expanding national medical workforces to improve services. Since 2013 the Government of Brazil has introduced the Mais Médicos (More Doctors) Legislation (MML), which included policies to liberalise the medical education market and boost deployment to rural areas, and implemented quotas in public universities to improve diversity in the supply of physicians. Such experience provides an insight for the global debate on the role of the private sector in medical education.

Methods: We draw from the analysis of unique medical demography datasets to assess the impact of those policies on the number and distribution of doctors and medical students, composition of the workforce, and quality of training. To analyze the increasing trend of students and physicians, interrupted time-series analysis was conducted using segmented linear regression, comparing two time periods considering the MML as the start of the intervention. Staff-to- student ratios and ENADE educational attainment data were used to compare the quality of teaching between public and private institutions.

Findings: Within the context of Brazil's population and economic growth over the last decades, we find that since 2003 Brazil has almost doubled its medical workforce to 2.77 per 1,000 population, with the largest increase recorded after the 2013 legislation. Our analysis shows such growth has benefited poorer, remote states, although the bulk of new doctors and students are still located in the country's richer regions. The diversity of medical students increased significantly since the More Doctors Legislation, with more female (61.4% in 2023 as opposed to 55.5% in 2013), and mixed-race enrolments (25.5% and 19.4%). However, medical students are still predominantly white (68.7% and 71.6%), and from fee-paying secondary schools (68.1% and 75.8%). Comparison of student achievement scores and of deployed resources also show a significantly lower quality of teaching in private medical schools.

Conclusions: We conclude that Brazil's policy approach has delivered a substantial overhaul of its medical workforce through a combination of public and private sector policies. However, progress in students' diversity and quality of education has been mixed. Brazil's experiment suggests that private schools can be an option for rapid health workforce expansions in middle-income economies. However, close monitoring of their outputs would be needed, as our analysis shows they do little to address inequalities, and casts doubt on the quality of the training offered.

This is the first published study examining whether, and to what degree, innovative financing could effectively support the financing needs of the global pandemic prevention, preparedness and response (PPPR) agenda.

Background: What is already known? In the context of global health, innovative financing encompasses a range of financial instruments that supplement international development assistance and other traditional sources of financing, with the intention of mobilising additional resources and channelling them more effectively. Examples including Advance Market Commitments (AMCs), Advance Purchase Commitments (APCs), vaccine bonds and pandemic bonds, have been used in the past to address major disease outbreaks, such as the Ebola and Covid-19 crises. Following the Covid-19 outbreak, innovative financing has been proposed as a major vehicle to fund PPPR.

Results: What are the new findings? Despite recent pronouncements that innovative financing has 'huge untapped potential' for PPPR, there is little evidence within the literature to support such claims. This has been confirmed by our examination of four innovative financing mechanisms and their historical use in response to disease outbreaks. Our findings suggest that flaws and trade-offs in the design and application of these mechanisms have resulted in failure to deliver on their promise, raising concerns regarding their prospective use in financing PPPR. Although innovative financing could play a role, existing mechanisms in health have not generated the scale of funds proposed. In addition, the amounts generated have historically focused on specific interventions, which threaten to enhance fragmentation (disjointed financing of health) and alignment failures (not well integrated within overall national strategic plans) with and within PPPR.

Conclusions: What do the new findings imply? Our findings reveal a set of innovative financing tools shrouded in unsubstantiated claims to success and effectiveness that look to have underwhelming promise of 'value for money' in global health. This stems from evidence suggesting design flaws, inadequate application, lack of transparency, private sector profiteering and associated opportunity costs. Thus, contrary to popular claims, they may not be the 'silver bullet' for bridging PPPR financing gaps and addressing costly, complex and multifaceted PPPR interventions.

This paper presents a conceptual model for understanding cross-border precarity during the COVID-19 pandemic. It examines how public health emergencies exacerbate the challenges faced by expatriates and their families in cross-border contexts. The case study illustrates the complex nature of precarity, emphasising how its various forms like systemic, institutional, economic, health, social, and psychological are interacted and intensified during the pandemic, leading to lasting instability for expatriates that extends beyond borders and impacts their families. Findings indicate that restrictive immigration policies, delayed repatriation efforts, and inadequate support mechanisms exacerbated expatriates' hardships, which in turn amplified the economic and psychological strains faced by dependents in Kerala. This paper argues for integrating expatriate needs into the International Health Regulations (IHR) for managing public health emergencies, including comprehensive guidelines for repatriation and expatriate-inclusive country capacity assessments. This model serves as a tool to inform policymakers, social work practitioners, and public health professionals in designing interventions and policies that address the unique and intersecting forms of precarity in times of crisis, ultimately contributing to a more inclusive, transnational approach to public health resilience.

Background: South Africa is reported to have one of the highest per capita rates of alcohol consumption among drinkers globally, with alcohol harms exacerbating socio-economic inequalities in the country. The Draft Liquor Amendment Bill 2016 proposed new restrictions on alcohol advertising, availability, and liability of retailers and manufacturers for harm related to any contravention of the regulations. To date, the Bill has not progressed through the legislative process. The alcohol industry is known to use a diverse set of strategies to delay evidence-based policies globally.

Methods: We aimed to explore Bill-related activity by industry within the National Economic and Development Labour Council, a multi-stakeholder forum that assesses socio-economic policies before they reach parliament. On 06 July 2023 we made a Request for Access to Record, using form two of the Promotion of Access to Information Act (PAIA), no. 2 of 2000 to the National Economic and Development Labour Council for access to minutes of all meetings, reports, and any other publications related to the Bill between January 2016 and December 2022. Informed by Ulucanlar et al's (2023) model and taxonomies of corporate political activity, we extracted data on industry Bill-related activity and thematically analysed key events, presented here as a narrative synthesis.

Results: We identified activity by 14 alcohol industry organisations related to the Bill between 2016 and 2022. Industry representation on five National Economic and Development Labour Council-related committees identified between 2017 and 2021 facilitated their involvement in Bill-related discussions and supported access to other government departments. Community representation was low in all committees compared to industry, labour, and government. Industry funded two socio-economic assessments of the Bill in 2017 and 2022, despite an independent socio-economic impact assessment having already been completed. The 2017 report delayed progress of the Bill, and the 2022 're-evaluation' was more critical of the proposed measures, with the differing conclusions attributed to different methodologies. During the covid-19 pandemic, industry used a 'carrot and stick' approach of legal threats and donations to attempt to move towards self-regulation via a social compact. The National Economic and Development Labour Council confirmed in 2023 that the social compact was unsuccessful.

Conclusions: Early 'regulatory capture' gave the alcohol industry the opportunity to shape assessment of the Bill within the National Economic and Development Labour Council. Our findings are in line with previous studies on corporate influence on policy globally, and support calls for a reassessment of the role and proportion of industry representation within the National Economic and Development Labour Council locally.

The meat industry showcases the precarity of employment arrangements as part of broader global economic liberalization. In many countries, its workforce consists mostly of precariously employed immigrant and resident foreign-born workers. Categorized as "essential workers", they worked throughout the COVID-19 pandemic, while facing high infection risk. Using case-studies in three country contexts - Illinois/USA, the Netherlands, and North Rhine-Westphalia/Germany - we analyzed policy documents, investigative reports, publicly available data, and informal expert consultation to examine structural causes of protection gaps for workers in the meat industry as well as facilitators and barriers to improving occupational safety and health. The Framework Method was applied to systematize and compare the overall data.Our analysis yields two key findings: First, immigrant workers in the meat industry face similar structural conditions across country contexts, with intersecting immigration- and employment-related precarity, generating gaps in social and health protection and deficiencies in the realization of theoretically held rights. Second, as policy responses to SARS-CoV-2 outbreaks varied, our case-studies showcase fundamentally different approaches to state responsibility for worker wellbeing as part of food supply chain (FSC) governance. The sacrificial-worker approach, observed in Illinois/USA, prioritized industry interests over worker and public health. In the Netherlands, a passive government delegated responsibilities to industry actors who forestalled systemic change through ad hoc adjustments, leaving the core problem of workers' precarity intact. In Germany, the government leveraged the COVID-19 pandemic as a catalyst for change by enforcing a ban on subcontracting workers in the meat industry, with the potential to fundamentally shift industrial relations and thus address the root causes of worker precarity. Our results highlight economic liberalization and related worker precarity as central determinants of health inequities; and they underscore the imperative for more equitable social and health protection of all workers as part of FSC governance, and as part of food systems transformation for sustainability.

Addressing global health challenges requires complex coordination and collaboration between actors, often through the process of Global Health Diplomacy (GHD). Although considerable scholarship argues the importance of improving this process to build better health policies and systems, few studies have investigated the 'health diplomats' directly leading this work. In this study, we seek to better understand GHD from a practitioners' view by exploring perceptions of knowledge acquisition, capacity building, and network development amongst those who coordinate and orchestrate global policy solutions. Taking an inductive qualitative approach, we conduct interviews of 54 experienced GHD professionals working across government, civil society, and private industry in 23 countries and identify key themes that outline challenges and opportunities for capacity building in GHD. Findings indicate a nascent global community bound by shared identity and motivations, but also hurdles regarding the transfer of tacit knowledge, network integration, and the improvement of institutional leadership. These findings highlight the boundaries by which knowledge and capacity are difficult for health diplomats to acquire or transfer, which help explain limitations to achieving better outcomes for global health. Further, this study may assist scholars and practitioners' work by considering GHD as a purposeful community of practice.

Background: During the COVID-19 pandemic corruption risks were amplified in health systems globally, increasing health inequities within and between countries. During the pandemic, the deployment of COVID-19 vaccines, particularly concerning their procurement and distribution, had corruption risks given the large amounts of public and private funding allocated to them, the need for speed, the involvement of a high number of stakeholders, and often insufficient oversight. To explore this issue further, we conducted a descriptive, qualitative study of corruption risks in the COVID-19 vaccine deployment process.

Methods: We conducted a descriptive, qualitative study triangulating two data sources between May and August 2022: (1) published academic and grey literature and (2) key informant interviews with representatives from organizations involved with the COVAX Facility, representatives from COVAX donor and recipient countries, and individuals with expert knowledge of the COVID-19 vaccine deployment process (e.g., consultants for international organizations involved in COVID-19 vaccine deployment, members of non-governmental organizations, etc.).

Results: We identified 44 academic articles and policy documents and triangulated. Documentary data with 16 key informant interviews. A review of the literature identified several corruption risks in the international COVID-19 vaccine procurement and distribution process such as a lack of transparency in the vaccine procurement process; a lack of transparency in the operation of the COVAX Facility; a risk of bribery; and a risk of vaccine theft or the introduction of substandard and falsified vaccines at the point of distribution. Key informants further articulated concerns about a lack of transparency in vaccine pricing and contracts and the exclusion of civil society organizations from the vaccine deployment process. Reported anti-corruption, transparency, and accountability (ACTA) mechanisms implemented across the many levels of the vaccine procurement and distribution deployment included institutional oversight processes, blockchain-based supply-chain solutions, and civil society engagements.

Conclusion: Public health emergencies require nimble and quick actions on the part of governments, international organizations and other actors Our study on the COVID-19 vaccine deployment process highlights the pressing need for more robust ACTA mechanisms to reduce corruption risks and ensure fair and equitable access to lifesaving vaccines for populations.

Background: Trade liberalisation has contributed to obesogenic food environments globally. Small Island Developing States (SIDS) have some of the world's highest rates of obesity and nutrition-related noncommunicable diseases. Nutrition regulations have been recognised as necessary population health measures for combating malnutrition, however, legally-binding trade and investment agreements (TIAs) can constrain the policy options available to governments. Geographical, economic, historical, and cultural contexts of SIDS may place them at greater risk of TIA constraints resulting in barriers to the uptake of public health nutrition policies. This article explores the perceptions and experiences of key SIDS nutrition and trade policy stakeholders regarding SIDS' ability to formulate and implement healthy nutrition policies in the context of TIAs.

Methods: Twelve semi-structured interviews were conducted with key Pacific and Caribbean stakeholders. Analysis was performed via a critical realist grounded theory approach. TIA constraints to policy space, challenges faced by SIDS, and solutions for improving nutrition policy space were identified.

Findings: Participants identified that TIAs did not substantively constrain nutrition policy so long as the policy targeted a legitimate public health objective, was evidenced-based, non-discriminatory, non-arbitrary, necessary, and the least trade-restrictive measure available. However, TIAs were perceived to pose structural and procedural constraints in the form of regulatory chill, increased burden of ensuring trade-compliant nutrition policies, unfair TIA negotiation processes, inconsistent perceptions of 'unhealthy' foods, trade liberalisation ideology, and industry interference. These constraints were noted to be particularly acute for SIDS due to their financial and capacity constraints, industry influence and limited international power.

Conclusion: TIA obligations were deemed unlikely to substantively prevent meaningful public health nutrition policies from being developed and implemented in SIDS if nutrition policy met specific trade principles. However, concerns were noted that some of these principles may impose procedural and structural constraints that risked preventing, postponing or diluting potential nutrition policies. These constraints may be particularly problematic for SIDS due to their contextual challenges. Despite this, local, regional and international actors can increase SIDS' policy space through capacity building, fostering multisectoral collaboration, developing conflict of interest policies, improving TIA negotiation processes, and championing the prioritisation of public health nutrition in trade governance.