Publications

2013
Hoffman, S.J. & Ali, M. ed., 2013. Student Voices 6: Political Analyses of Five Global Health Decisions, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Edge, J.S., et al., 2013. Research and Development Priorities to Achieve the “Grand Convergence”: An Initial Scan of Priority Research Areas for Public Health, Implementation Science and Innovative Financing for Neglected Diseases, London, UK: The Lancet. PDFAbstract

The purpose of this working paper is to explore the feasibility of compiling and synthesizing diseasespecific information to inform the deliberation and discourse on identifying priorities for research to improve health – with a specific focus on the dimensions of public health, implementation science and financing. This working paper is a companion to Working Paper 1, which focused on basic science and targeted product development, including diagnostics, drugs, vaccines, microbicides and vector control products [Working Paper 1: “Priority Research Areas for Basic Science and Product Development for Neglected Diseases” by Sue J. Goldie, Jennifer S. Edge, Christen Reardon, Cherie L. Ramirez]. 

Hoffman, S.J. & Rizvi, Z., 2013. Ten Years Since Canada's Access to Medicines Regime and Still Waiting for Results. Ottawa Citizen. Article
Hoffman, S.J. & Belluz, J., 2013. Why Celebrities and TV Doctors Can Be Bad for Your Health. C2C Journal. Article
Edge, J.S. & Hoffman, S.J., 2013. Empirical Impact Evaluation of the WHO Global Code of Practice on the International Recruitment of Health Personnel in Australia, Canada, UK and USA. Globalization & Health , 9 (60) , pp. 1-10. PDFAbstract

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.

Hoffman, S.J. & Røttingen, J.-A., 2013. Global Health Governance After 2015. The Lancet , 382 (9897) , pp. 1018. PDFAbstract

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.

2012
Hoffman, S.J. ed., 2012. Student Voices 4: Assessing Proposals for Access to Medicines Reform, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J., Røttingen, J.-A. & Frenk, J., 2012. The Economics of New International Health Laws. The Lancet , 380. PDFAbstract

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.

Hoffman, S.J., 2012. Foreign Aid Should Reflect Canada's Priorities: Equality, Democracy, Health. The Globe and Mail. Article
Hoffman, S.J., 2012. Mitigating Inequalities of Influence among States in Global Decision Making: Mitigating Inequalities in Global Decision Making. Global Policy , 3 (4) , pp. 421-432. PDFAbstract

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.

Hoffman, S.J., et al., 2012. A Review of Conceptual Barriers and Opportunities Facing Health Systems Research to Inform a Strategy from the World Health Organization. Geneva: World Health Organization. PDFAbstract

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.

Hoffman, S.J. ed., 2012. Student Voices 4: Assessing Proposals for Access to Medicines Reform, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J., 2012. You Can Focus on Trade, But Don't Call it Aid. The Globe and Mail. Article
Hoffman, S.J. & Røttingen, J.-A., 2012. Assessing Implementation Mechanisms for an International Agreement on Research and Development for Health Products. Bulletin of the World Health Organization , 90 (11) , pp. 854-63. PDFAbstract

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.

Hoffman, S.J. & Røttingen, J.-A., 2012. Be Sparing with International Laws. Nature , 483 (7389) , pp. 275. PDF
Hoffman, S.J. & Sossin, L., 2012. Empirically Evaluating the Impact of Adjudicative Tribunals in the Health Sector: Context, Challenges and Opportunities. Health Economics, Policy & Law , 7 (2) , pp. 147-74. PDFAbstract

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.

Hoffman, S.J. & Frenk, J., 2012. Producing and Translating Health System Evidence for Improved Global Health. Journal of Interprofessional Care , 26 (1) , pp. 4-5. PDF
Hoffman, S.J. & Rizvi, Z., 2012. WHO's Undermining Tobacco Control. The Lancet , 380 (9843) , pp. 727-8. PDF
2011
Lavis, J.N. & Hoffman, S.J., 2011. Dialogue Summary: Addressing Health and Emerging Global Issues in Canada, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J. & Lavis, J.N., 2011. Issue Brief: Addressing Health and Emerging Global Issues in Canada, Hamilton, Ontario, Canada: McMaster Health Forum. PDF

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