Journals

2018
Groux, G.M.N., Hoffman, S.J. & Ottersen, T., 2018. A Typology of Scientific Advisory Committees. Global Challenges. ArticleAbstract
The era of evidence‐informed decision‐making has seen increased use of the scientific advisory committee (SAC) to provide decision‐makers with scientific advice, despite limited evidence of the effectiveness or best strategies for designing these committees. In this study, an in‐depth review of academic and gray literature is undertaken to outline the global landscape of SACs. The development of a typology is also undertaken that categorizes SACs along six dimensions: 1) sector, 2) level of operation, 3) permanence, 4) target audience, 5) autonomy, and 6) nature of advice. It is found that SACs differ profoundly in each of these dimensions and provide examples demonstrating this variation. The landscape and typology can help decision‐makers understand the key elements of SAC design and reform, and the results will also inform future research on the design and effectiveness of SACs. With SACs expected to promote evidence‐informed decision‐making, it is imperative that the design of these committees themselves is guided by evidence.
Fafard, P., et al., 2018. Contested roles of Canada’s Chief Medical Officers of Health. Canadian Journal of Public Health. ArticleAbstract
The roles and responsibilities of Canada’s Chief Medical Officers of Health (CMOHs) are contested. On the one hand, they are senior public servants who confidentially advise government on public health matters and manage the implementation of government priorities. On the other hand, CMOHs are perceived as independent communicators and advocates for public health. This article analyzes public health legislation across Canada that governs the CMOH role. Our legal analysis reveals that the presence and degree of advisory, communication, and management roles for the CMOH vary considerably across the country. In many jurisdictions, the power and authority of the CMOH is not clearly defined in legislation. This creates great potential for confusion and conflict, particularly with respect to CMOHs’ authority to act as public health advocates. We call on governments to clarify their preferences when it comes to the CMOH role and either amend the relevant statute or otherwise find ways to clarify the mandate of their CMOHs.
Gopinathan, U., et al., 2018. Global governance and the broader determinants of health: A comparative case study of UNDP's and WTO's engagement with global health. Global Public Health. Article
Katwyk, S.R.V., Jones, S.L. & Hoffman, S.J., 2018. Mapping Educational Opportunities for Healthcare Workers on Antimicrobial Resistance and Stewardship Around the World. Human Resources for Health . Article
Hoffman, S.J. & Cole, C., 2018. Defining the Global Health System and Systematically Mapping its Network of Actors. Globalization and Health. Article
Fafard, P. & Hoffman, S.J., 2018. Rethinking Knowledge Translation for Public Health Policy. Evidence and Policy. Article
Nixon, S.A., et al., 2018. Canada’s Role in Global Health: Supporting Equity and Global Citizenship as a Middle Power. The Lancet. Article
2017
Hoffman, S.J., 2017. Canada Should Not Legalize Cannabis Until It Withdraws from the UN Drug Control Treaties. Centre for International Governance Innovation. Article
Katwyk, S.R.V., et al., 2017. Government policy interventions to reduce human antimicrobial use: protocol for a systematic review and meta-analysis. Systematic Reviews , 6 (256) , pp. 1-10. PDFAbstract

Background

Antimicrobial resistance (AMR) is a recognized threat to global public health. Increasing AMR and a dry pipeline of novel antimicrobial drugs have put AMR in the international spotlight. One strategy to combat AMR is to reduce antimicrobial drug consumption. Governments around the world have been experimenting with different policy interventions, such as regulating where antimicrobials can be sold, restricting the use of last-resort antimicrobials, funding AMR stewardship programs, and launching public awareness campaigns. To inform future action, governments should have access to synthesized data on the effectiveness of large-scale AMR interventions. This planned systematic review will (1) identify and describe previously evaluated government policy interventions to reduce human antimicrobial use and (2) estimate the effectiveness of these different strategies.

Methods

An electronic search strategy has been developed in consultation with two research librarians. Seven databases (MEDLINE, CINAHL, EMBASE, CENTRAL, PAIS Index, Web of Science, and PubMed excluding MEDLINE) will be searched, and additional studies will be identified using several gray literature search strategies. To be included, a study must (1) clearly describe the government policy and (2) use a rigorous design to quantitatively measure the impact of the policy on human antibiotic use. The intervention of interest is any policy intervention enacted by a government or government agency in any country to change human antimicrobial use. Two independent reviewers will screen for eligibility using criteria defined a priori.

Data will be extracted with Covidence software using a customized extraction form. If sufficient data exists, a meta-analysis by intervention type will be conducted as part of the effectiveness review. However, if there are too few studies or if the interventions are too heterogeneous, data will be tabulated and a narrative synthesis strategy will be used.

Discussion

This evidence synthesis is intended for use by policymakers, public health practitioners, and researchers to inform future government policies aiming to address antimicrobial resistance. This review will also identify gaps in the evidence about the effectiveness of different policy interventions to inform future research priorities.

Lamontagne, F., Hoffman, S.J. & et al, 2017. Evidence-Based Guidelines for Supportive Care of Patients with Ebola Virus Disease. The Lancet online-first. ArticleAbstract
The 2013–16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.
Tejpar, A. & Hoffman, S.J., 2017. Canada’s Violation of International Law during the 2014–16 Ebola Outbreak. Canadian Yearbook of International Law , 54 , pp. 1-18. Abstract
Hoffman, S.J. & Prado, M.M., 2017. The Concept of an International Institutional Bypass. Special Issue of the American Journal of International Law , 111. PDFAbstract
The rapid proliferation of international institutions has been a defining feature of the postwar international architecture. Since the end of the Second World War, the international system has seen the creation of thousands of international treaties and organizations that have established rules governing a multitude of issues that range from international security to human rights, and from international trade to the environment.
Hoffman, S.J. & Prado, M.M., 2017. Introduction to Symposium on International Institutional Bypass. Special Issue of the American Journal of International Law , 111 , pp. 229-230. PDFAbstract

The concept of an institutional bypass—that is, creating a parallel institution that performs exactly the same function of the dysfunctional institution—has already proven useful for analyzing institutional reforms undertaken at the domestic level. However, it has only recently been suggested as potentially applicable to the global governance context as well. To explore this possibility further, this project brought together a group of researchers who specialize in international governance and asked them whether the concept could be applied to their respective areas of expertise.

Among other things, these discussions revealed at least one major challenge with the use of institutional bypasses in the international context: while the possibility of “bypassing” existing institutions may be counterintuitive in the domestic sphere, it may actually constitute the norm, rather than the exception, in international governance. This is because sovereign states are often assumed to hold a monopoly in the provision of certain services and the performance of certain functions at the domestic level, as is notably the case with policing. Thus, recognizing that states can operate parallel institutions side by side, and in some cases even make them compete with each other, may constitute a paradigm shift for those concerned with institutional reforms and good governance in the domestic sphere. However, this same assumed monopoly does not exist in international governance, where academic researchers have extensively documented the related phenomena of institutional proliferation and duplication.

Accordingly, a question arises as to what value, if any, the concept of institutional bypasses can provide to the existing international governance literature. This is the first—and perhaps the main—challenge in applying the concept of institutional bypasses at the international level, especially since the phenomenon of institutional proliferation and duplication has already been extensively described and scrutinized across multiple disciplines, including law, political science, and sociology. The framing essay in this symposium attempts to provide an answer to this question by presenting a definition of international institutional bypasses, all the while articulating why this concept may prove useful to work on global governance.

Having framed the scope of our project, the other essays in this symposium provide three sets of examples that illustrate the application of international institutional bypasses. The first takes the form of the New Development Bank and the Asian Infrastructure Investment Bank, which serve as bypasses of the World Bank and the Asian Development Bank, respectively. The second set of examples are regional swap lines and regional central banks, which are presented as bypasses of the International Monetary Fund (IMF). Finally, regional institutions in West Africa, and particularly those providing health services, are framed as bypasses of domestic institutions that serve the same functions. 

Taken together, these three sets of examples offer interesting illustrations of what we call “horizontal” and “vertical” international bypasses. The former refers to those bypasses that operate within the same jurisdiction as the dominant institution, as in the case of the China-led multilateral development banks that serve as international bypasses of a dominant international institution. By contrast, a vertical bypass means that the dominant institution and the bypass are located at different jurisdictional levels. This notion includes a domestic or a regional institution that tries to bypass an international one, or vice-versa. The international institution can thus be either the dominant institution being bypassed, as illustrated by the IMF essay, or the bypassing one, as illustrated by the West African Health Organization essay.

In summary, our aim in this symposium is to introduce readers to the concept of international institutional bypasses, provide concrete examples, and show that this concept can be of great value in attempts to understand and analyze changes and innovations in global governance. That being said, this is only the first step in a much larger and more ambitious project. Thus, we hope it will also serve as an invitation for readers to further explore the many interesting questions and implications of institutional bypasses in the international context

Hoffman, S.J. & Prado, M.M. ed., 2017. Special Issue of the American Journal of International Law. , 111. PDF
2016
Katwyk, S.R.V., et al., 2016. Developing an approach to assessing the political feasibility of global collective action and an international agreement on antimicrobial resistance. Global Health Research and Policy , 1 (20) , pp. 1-10. PDFAbstract

 

Background: Antimicrobial resistance (AMR) is a global issue. International trade, travel, agricultural practices, and environmental contamination all make it possible for resistant microbes to cross national borders. Global collective action is needed in the form of an international agreement or other mechanism that brings states together at the negotiation table and commits them to adopt or implement policies to limit the spread of resistant microorganisms. This article describes an approach to assessing whether political and stakeholder interests can align to commit to tackling AMR.

Methods: Two dimensions affecting political feasibility were selected and compared across 82 countries: 1) states’ global influence and 2) self-interest in addressing AMR. World Bank GDP ranking was used as a proxy for global influence, while human antibiotic consumption (10-year percent change) was used as a proxy for self-interest in addressing AMR. We used these data to outline a typology of four country archetypes, and discuss how these archetypes can be used to understand whether a proposed agreement may have sufficient support to be politically feasible.

Results: Four types of countries exist within our proposed typology: 1) wealthy countries who have the expertise and financial resources to push for global collective action on AMR, 2) wealthy countries who need to act on AMR, 3) countries who require external assistance to act on AMR, and 4) neutral countries who may support action where applicable. Any international agreement will require substantial support from countries of the first type to lead global action, and from countries of the second type who have large increasing antimicrobial consumption levels. A large number of barriers exist that could derail efforts towards global collective action on AMR; issues of capacity, infrastructure, regulation, and stakeholder interests will need to be addressed in coordination with other actors to achieve an agreement on AMR.

Conclusions: Achieving a global agreement on access, conservation, and innovation – the three pillars of AMR – will not be easy. However, smaller core groups of interested Initiator and Pivotal Countries could develop policy and resolve many issues. If highly influential countries take the lead, agreements could then be scaled up to achieve global action.

Keywords: AMR, Antibiotic Resistance, Global Health, Political Feasibility, International Affairs

 

Tam, V., Edge, J.S. & Hoffman, S.J., 2016. Empirically evaluating the WHO global code of practice on the international recruitment of health personnel’s impact on four high-income countries four years after adoption. Globalization and Health , 12 (62) , pp. 1-12. PDFAbstract

 

Background

Shortages of health workers in low-income countries are exacerbated by the international migration of health workers to more affluent countries. This problem is compounded by the active recruitment of health workers by destination countries, particularly Australia, Canada, UK and USA. The World Health Organization (WHO) adopted a voluntary Code of Practice in May 2010 to mitigate tensions between health workers’ right to migrate and the shortage of health workers in source countries. The first empirical impact evaluation of this Code was conducted 11-months after its adoption and demonstrated a lack of impact on health workforce recruitment policy and practice in the short-term. This second empirical impact evaluation was conducted 4-years post-adoption using the same methodology to determine whether there have been any changes in the perceived utility, applicability, and implementation of the Code in the medium-term.

Methods

Forty-four respondents representing government, civil society and the private sector from Australia, Canada, UK and USA completed an email-based survey evaluating their awareness of the Code, perceived impact, changes to policy or recruitment practices resulting from the Code, and the effectiveness of non-binding Codes generally. The same survey instrument from the original study was used to facilitate direct comparability of responses. Key lessons were identified through thematic analysis.

Results

The main findings between the initial impact evaluation and the current one are unchanged. Both sets of key informants reported no significant policy or regulatory changes to health worker recruitment in their countries as a direct result of the Code due to its lack of incentives, institutional mechanisms and interest mobilizers. Participants emphasized the existence of previous bilateral and regional Codes, the WHO Code’s non-binding nature, and the primacy of competing domestic healthcare priorities in explaining this perceived lack of impact.

Conclusions

The Code has probably still not produced the tangible improvements in health worker flows it aspired to achieve. Several actions, including a focus on developing bilateral codes, linking the Code to topical global priorities, and reframing the Code’s purpose to emphasize health system sustainability, are proposed to improve the Code’s uptake and impact.

Keywords

Health worker recruitment Migration Health systems sustainability Impact evaluation World Health Organization

 

Fafard, P. & Forest, P.-G., 2016. The loss of that which never was: Evaluating changes to the senior management of the Public Health Agency of Canada. Canadian Public Administration , 59 (3) , pp. 448-466. ArticleAbstract

In the fall of 2014, the Government of Canada formally split the role of the Chief Public Health Officer (CPHO) into two positions: the CPHO and the President of the Public Health Agency of Canada. Despite concerns raised by the public health community, these changes are consistent with the CPHO's authority. However, the nature of responsible government means that the CPHO cannot simultaneously serve as an independent advocate for policies and programs that might prevent disease and as a senior advisor to the government of the day.

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À l'automne 2014, le gouvernement du Canada a annoncé le dédoublement officiel du rôle de l'Administrateur en chef de la santé publique (ACSP) en deux postes : l'ACSP et le président de l'Agence de la santé publique du Canada. Malgré les inquiétudes exprimées dans les milieux de la santé publique, ces changements sont compatibles avec le mandat original de l'ACSP. La nature d'un gouvernement responsable suppose que l'ACSP ne peut à la fois s'instituer en champion indépendant de politiques ou de programmes favorables à la santé et conserver son rôle de conseiller principal du gouvernement du jour.

Mendelson, M., et al., 2016. A global antimicrobial fund for low-and middle-income countries. International Journal of Infectious Diseases , 51 , pp. 70-72. PDF
Ottersen, T., Hoffman, S.J. & Groux, G., 2016. Ebola again shows the international health regulations are broken: What can be done differently to prepare for the next epidemic?. American Journal of Law and Medicine , 42 (2-3) , pp. 356-392. PDFAbstract

Epidemics are among the greatest threats to humanity, and the International Health Regulations are the world's key legal instrument for addressing this threat. Since their revision in 2005, the IHR have faced two big tests: the 2009 H1N1 influenza pandemic and the 2014 Ebola epidemic in West Africa. Both exposed major shortcomings of the IHR, and both offered profound lessons for the future.

The objective of this Article is twofold. First, we seek to compare the lessons learned from H1N1 and Ebola for reforming the IHR in order to test the hypothesis that they are similar. Second, we seek to examine the barriers to implementing these lessons and to identify strategies for overcoming those barriers.

We find that the lessons from H1N1 and Ebola are indeed similar, and that opportunities to act on lessons from H1N1 were woefully missed. We identify many political barriers to global collective action and implementation of lessons for the IHR. On that basis, we describe strategies to overcome these barriers, which will hopefully be deployed now to reform the IHR before the policy window following Ebola closes, and before the inevitable next epidemic comes. The emerging threat of the Zika virus underscores that we have no time to waste.

aljm_ebola_shows_international_health_regulations_broken_2016.pdf
Laxminarayan, R., et al., 2016. UN High-Level Meeting on antimicrobials—what do we need?. The Lancet , 388 , pp. 218-220. PDF

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