Globalization and Health最新文献

Background: Alcohol is a global health issue with a high level of controversy. After being absent from World Health Organization (WHO) global governing body discussions for about 20 years, alcohol re-entered the agenda in 2005. The expression 'harmful use of alcohol' became the compromise language after hard negotiations, an example of 'adopted language" that has remained for almost 20 years. This article analyses the background and use of the expression 'harmful use of alcohol' in the context of WHO governing bodies, current challenges and implications for public health.

Methods: The article is based on textual analysis of source documents from the time periods 2004-2010 and 2019-2022 and the authors' experience from involvement in the global alcohol policy scene for more than 20 years: WHO governing body records and other documents were analysed, as well as Member State and Non-State Actors' positions and contributions in consultations and statements in WHO governing body debates.

Results: The introduction of the concept 'harmful use of alcohol' in WHO documents from 2005 onwards was a political compromise between approaches focussed either on 'alcohol abuse' or a wider concept of harm from alcohol consumption. It has permeated into national alcohol policy documents, academic literature about alcohol harm and UN documents, and been embraced by the alcohol industry. However, it has not prevented and some would argue that it has enabled development of normative statements from WHO that include recommendations for population wide interventions. The relatively new evidence of harm from alcohol at low levels and questioning of evidence suggesting a beneficial effect of moderate use of alcohol together with industry appropriation of 'harmful use' have led to increasing critique of the framing implied by 'harmful use of alcohol'.

Conclusions: The language used in WHO documents holds political power in that it may influence the subsequent course of events. This is accentuated by the normative role of WHO in global health policy and the uptake of negotiated language beyond WHO documents. In the next five years it will be possible and valuable to examine in more detail the extent to which this power was made manifest and the need and possible ways to effect change.

Background: Inattention to young child growth and development in a transitioning global environment can undermine the foundation of human capital and future progress. Diets that provide adequate energy and nutrients are critical for children's physical and cognitive development from 6 to 23.9 months of age and beyond. Still, over 70% of young children do not receive foods with sufficient nutrition particularly in low-and-middle income countries. Program evaluations have documented the effectiveness of large-scale behavior change interventions to improve children's diets, but the budgetary implications of programs are not known. This paper provides the incremental financial costs of strengthening three large-scale programs based on expenditure records from Bangladesh, Ethiopia, and Vietnam.

Results: The programs reached between one and 2.5 million mothers and children annually per country at unit costs of between $0.9 to $1.6 per mother and child reached. An additional 0.7 to 1.6 million people who were influential in supporting mothers and achieving scale were also engaged. The largest cost component was counselling of mothers. Rigorous external impact evaluations showed that over 434,500 children benefited annually from consuming a minimum acceptable diet in all countries combined, at an annual cost per country of $6.3 to $34.7 per child benefited.

Conclusions: Large scale programs to improve young children's nutrition can be affordable for low- and middle-income countries. The study provides the incremental costs of selectively strengthening key program components in diverse settings with lessons for future budgeting. The costs of treating a malnourished child are several-fold higher than prevention through improved improving young children's dietary practices. Differences across countries in program models, coverage, costs, and outcomes suggest that countries need a minimum investment of resources for strengthening high-reach service delivery and communication channels and engaging relevant behavioral levers and community support for mothers to achieve impact at scale.

Background: How do Northern Global Health scholars navigate authoritarian political contexts in their research in other countries? This question motivated the research project on which this article is based. Over ten months, we conducted in-depth qualitative interviews with sixteen European and North American scholars who were engaged in health-related research in an authoritarian country we refer to as Patria.

Results: All our interviewees recognized health as a political matter and acknowledged the importance of considering politics in Global Health research. Yet, they were reluctant to explicitly integrate politically sensitive topics and discuss questions related to local political context in their research. To gain and maintain access, and to protect themselves and their local collaborators in a politically sensitive and authoritarian context, the researchers employed practices of 'framing'. Such strategies included avoiding terms, scholarly references, and questions that were politically loaded; strategically conforming to the assumed apolitical language and methodologies of health research, and negotiating with and leaning on their local counterparts in processes of research dissemination and writing.

Conclusion: Drawing on frame theory and literature on fieldwork and authoritarianism we discuss the implications our findings have, not only for Global Health research, but for healthcare sciences more broadly. While researchers who work in authoritarian regimes may be particularly prone to engage in practices of framing, the strategies our interviewees used are not limited to Global Health researchers working in such settings. As anthropologists with experience researching health in multiple countries, including in the United States, we recognize the strategies that our interlocutors used from our own research. By including a discussion of some of the ways political factors have shaped our research we make an argument for the value of political reflexivity in health research: the critical scrutiny of the taken-for-granted presuppositions and norms that guide our research, and of the political environments and power dynamics that shape and are shaped by our research. A turn to political reflexivity in health research can unravel some of the tacit assumptions, biases, norms and practices that are integral to the health care sciences and which students and researchers must critically think about.

Introduction: This study analyses the relationship between SPAR and the COVID-19 resilience score (CRS) in 80 countries in 2021 to achieve its objective.

Methods: We adopted the concept of Bloomberg's COVID Resilience Ranking to form the CRS, which encompasses three indicators: Reopening Status, COVID Status, and Quality of Life. The average scores of 13 SPAR capacities focused on infectious disease control in 2021 were calculated. Paired t-tests were applied to evaluate the significance of monthly changes in countries' CRSs. Then, we conducted univariate and multivariate linear regressions to examine the relationship between the SPAR and CRS scores and each CRS indicator.

Results: The CRS in 80 countries fluctuated throughout 2021. Linear regression revealed a significant relationship between countries' SPAR scores and CRS (B = 0.03, 95% CI = 0.001, 0.06). Among the CRS indicators, the SPAR was significantly associated with only the Quality of Life indicator (B = 0.01, 95% CI = 0.002, 1.52) and not the Reopening Status and COVID Status indicators. An increase in SPAR score, along with an increase in Governmental Effectiveness, was associated with increased CRS (Adjusted R² = 0.52, p < 0.05). Moreover, an increase in countries' SPAR scores was significantly linked to an improvement in people's Quality of Life (Adjusted R² = 0.37, p < 0.05).

Conclusion: The significant relationship between the SPAR and COVID Resilience Scores, particularly the Quality of Life indicator indicates that the lack of accuracy in the ability of the SPAR score to predict COVID-19 control outcomes is attributed to the reliance of the measurement solely on the disease perspective and the limited inclusion of social aspects in the SPAR capacity assessments.

Clinical trial number: Not Applicable.

Background: Achieving Sustainable Development Goal 3 (SDG3): good health and well-being, requires significant health investments and effective governance. While many studies explored the influence of health expenditure and governance, little is known about how different levels of governance affect the relationship between health expenditure and SDG3 in a globalised world. Thus, this study aims to fill that gap by examining the marginal effects of health expenditure on SDG3 under varying levels of governance in BRICS economies.

Methods: This study uses quantitative data spanning a panel of 2000-2023 years. Governance is measured using worldwide governance indicators, while health spending is represented by current health costs, government health costs, and private health costs from the World Development Indicators. Data on SDG3 comes from the SDG Index. Cross-sectional dependency, stationarity and cointegration tests are employed to choose appropriate panel data models. The final results are obtained using Fully Modified OLS, while System GMM is used to address issues like endogeneity, autocorrelation, instrumentation, and causality. To ensure the results are reliable, the study also tests alternative measures of governance.

Results: 1% increase in current and government health spending improves SDG3 by 3.92% and 2.86%, respectively, while a 1% rise in private health spending reduces it by 0.677%. This negative impact in BRICS nations is likely due to market failures in private healthcare, where profit-driven models limit access and efficiency. The positive impact of current and government health expenditure on health outcomes is comparatively weaker at lower levels of governance but private health expenditure and SDG3 are weakening by governance at different levels which is indicative of inefficiencies in resource allocation and implementation. This study supports institutional theory, which states that strong governance improves the effectiveness of public health spending, leading to better health outcomes. The study highlights how the geopolitical prominence of governance frameworks interacts to optimise the benefits of health investments, demonstrating their role as leaders in advancing global health initiatives. Thus, policymakers need an integrated approach in health investments with institutional reforms in achieving health outcomes more effectively as good governance significantly amplifies the relationship.

Conclusions: This study highlights that governance plays a key role in improving the impact of health spending on SDG3. Strong governance boosts the benefits of public health expenditure and limits the negative effects of private health expenditure. Thus, the findings stress the importance of effective governance in enhancing health outcomes in BRICS economies.

New antibiotics active against multidrug resistant bacteria (MDR-B) are licensed by regulatory agencies based on pivotal trials that serve the primary purpose of obtaining marketing-authorization. There is increasing concern that they do not offer guidance on how to best use new antibiotics, in which population, and to what extent they overcome existing resistance. We reviewed the literature for pre-approval studies (phase 2 and 3 randomized controlled trials) and post-approval studies (randomized and non-randomized controlled trials) evaluating efficacy and safety of new antibiotics, classified by WHO as Reserve, approved in the European Union and the US from January 2010 to May 2023. Substantial failures occur in generating evidence to guide routine clinical use: preapproval studies lack representativeness, select outcomes and comparators to chase statistical significance, and often avoid using prespecified analytical methods. Three recommendations are key to enhance the quality and relevance of clinical data underpinning use of last resort molecules on the WHO AWaRe Reserve list active against carbapenem-resistant MDR-B i). separation of pivotal trials from post-approval studies, which should be funded by public programs and de-linked from commercial purposes, ii). development and maintenance of a global infrastructure to conduct post-approval public health focused studies, and iii). development of trial platforms that use efficient, adaptive designs to inform clinical decision making and country level technology appraisal. These solutions will allow clinicians to determine whether recently approved Reserve antibiotics are not only "newer" but also "better" for vulnerable patient populations at particular risk for infections by MDR-B.

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.