Background: 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.
Methods: 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.
Results: 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.
Conclusions: 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.
A proposal to reduce global health architecture to three actors (one to handle financing, one to set norms and standards, and one for advocacy and accountability) will likely not work. In this proposal, other core functions of the global health system, such as monitoring and multi-lateral negotiations, that will be neglected. Assigning advocacy and accountability to one party is not the most effective way to fulfill these functions.
Background: New international laws have been proposed for various health issues, including those related to alcohol, biomedical research, chronic diseases, counterfeit drugs, and obesity. However, international law might not always be an appropriate response to global health challenges. We assessed the costs and consequences of international health law and developed criteria for its just use.
Methods: We used legal, political economy, and ethical frameworks to identify implications of international health laws that are not always considered, especially situations in which risks of negative consequences were particularly great.
Findings: International laws can be blunt instruments with many costs and they can be coercive and paternalistic. Direct costs include many meetings, air travel, legal fees, and support for decision-making bodies and secretariats. Indirect costs include lost opportunities to allocate limited resources to other important issues. Since all laws have costs, international laws cannot be exempt from normal priority-setting processes without justification. We identified four criteria for the use of international law to address global health challenges. The problem that a new international law addresses should be (1) transnational and (2) long term, and legal instruments should be (3) cost effective and (4) justify coercion. To be cost effective, the best-available research should suggest that a new law would provide a better cost to benefit ratio compared with other options. To justify coercion, the proposed law should either address multilateral challenges that cannot practically be addressed by one country only, enable collective action when the costs of common benefits are impractical for any individual state to pursue alone, or support humanitarian principles that are universally held. Use of international health law to dictate poor countries' policies and priorities from afar, or when less costly instruments (eg, non-binding soft laws) might be as effective, is inappropriate.
Interpretation: Not every global health challenge should be addressed with international law. Countries should consider our criteria before adopting new international laws. All available international instruments should be assessed to establish which is best for addressing each global health challenge.
International institutions should be as equal as they claim to be, especially since many of them assert superordinate normative authority based on having egalitarian governance structures. However, when defining equality with respect to states’ real-world influence in determining substantive outcomes, it is evident that there is an equality-influence gap between the rhetoric of parity among states and the reality of international politics. This is problematic because it undermines trust in those international institutions that falsely claim to embody equality among states when empirically they do not. Focusing on the United Nations System, this paper identifies three main causes of this disproportional influence among states in global decision making: (a) external imbalances in political capital; (b) internal economic barriers; and (c) surreptitious influence through non-state actors, funding and training. Six pragmatic strategies are proposed for mitigating these inequalities: (1) building capacity for leadership in global advocacy; (2) supporting global networks owned by developing countries; (3) equalizing multi-party partnerships; (4) facilitating evidence-informed global decision making; (5) enhancing accountability and independent evaluation; and (6) encouraging further discussion on institutional reforms. Notwithstanding sovereign equality’s deep flaws, it is hoped that challenging the egalitarian presumptions of global decision making will encourage further debate on this issue among those who can act upon it.
Health systems research is widely recognized as essential for strengthening health systems, getting costeffective treatments to those who need them, and achieving better health status around the world. However, there is significant ambiguity and confusion in this field’s characteristics, boundaries, definition and methods. Adding to this ambiguity are major conceptual barriers to the production, reproduction, translation and implementation of health systems research relating to both the complexity of health systems and research involving them. These include challenges with epistemology, applicability, diversity, comparativity and priority-setting. Three promising opportunities exist to mitigate these barriers and strengthen the important contributions of health systems research. First, health systems research can be supported as a field of scientific endeavour, with a shared language, rigorous interdisciplinary approaches, cross-jurisdictional learning and an international society. Second, national capacity for health systems research can be strengthened at the individual, organizational and system levels. Third, health systems research can be embedded as a core function of every health system. Addressing these conceptual barriers and supporting the field of health systems research promises to both strengthen health systems around the world and improve global health outcomes.
The Member States of the World Health Organization (WHO) are currently debating the substance and form of an international agreement to improve the financing and coordination of research and development (R&D) for health products that meet the needs of developing countries. In addition to considering the content of any possible legal or political agreement, Member States may find it helpful to reflect on the full range of implementation mechanisms available to bring any agreement into effect. These include mechanisms for states to make commitments, administer activities, manage financial contributions, make subsequent decisions, monitor each other's performance and promote compliance. States can make binding or non-binding commitments through conventions, contracts, declarations or institutional reforms. States can administer activities to implement their agreements through international organizations, sub-agencies, joint ventures or self-organizing processes. Finances can be managed through specialized multilateral funds, financial institutions, membership organizations or coordinated self-management. Decisions can be made through unanimity, consensus, equal voting, modified voting or delegation. Oversight can be provided by peer review, expert review, self-reports or civil society. Together, states should select their preferred options across categories of implementation mechanisms, each of which has advantages and disadvantages. The challenge lies in choosing the most effective combinations of mechanisms for supporting an international agreement (or set of agreements) that achieves collective aspirations in a way and at a cost that are both sustainable and acceptable to those involved. In making these decisions, WHO's Member States can benefit from years of experience with these different mechanisms in health and its related sectors.
Adjudicative tribunals are an integral part of health system governance, yet their real-world impact remains largely unknown. Most assessments focus on internal accountability and use anecdotal methodologies; few, studies if any, empirically evaluate their external impact and use these data to test effectiveness, track performance, inform service improvements and ultimately strengthen health systems. Given that such assessments would yield important benefits and have been conducted successfully in similar settings (e.g. specialist courts), their absence is likely attributable to complexity in the health system, methodological difficulties and the legal environment within which tribunals operate. We suggest practical steps for potential evaluators to conduct empirical impact evaluations along with an evaluation matrix template featuring possible target outcomes and corresponding surrogate endpoints, performance indicators and empirical methodologies. Several system-level strategies for supporting such assessments have also been suggested for academics, health system institutions, health planners and research funders. Action is necessary to ensure that policymakers do not continue operating without evidence but can rather pursue data-driven strategies that are more likely to achieve their health system goals in a cost-effective way.
Background: Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, cost-effectiveness and disappointing utilization of insecticide-treated nets (ITNs).
Methods: This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.
Results: The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14).
Conclusions: Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.