Publications

2014
Hoffman, S.J. & Røttingen, J.-A., 2014. Split WHO in Two: Strengthening Political Decision-Making and Securing Independent Scientific Advice. Public Health Journal , 128 (2) , pp. 188-94. PDFAbstract

The World Health Organization (WHO) has never fulfilled its original mission of simultaneously serving as the world's pre-eminent public health authority and intergovernmental platform for global health negotiations. While WHO's secretariat works hard to fulfill both functions, it is undermined by an institutional design that mixes technical and political mandates. This forces staff to walk uncomfortably along many fine lines: advising but never directing; guiding but never governing; leading but never advocating; evaluating but never judging. The result is mediocrity on both fronts. Instead, WHO should be split in two, separating its technical and political stewardship functions into separate entities, with collaboration in areas of overlap. The Executive Board and secretariat would be bifurcated, with technical units reporting to a Technical Board and political units reporting to a Political Board. Both boards would report to the World Health Assembly where all member states would continue to provide ultimate oversight. Such bold changes can be implemented either by revising WHO's constitution or through simpler mechanisms. Either way, structural governance reforms would need to be accompanied by complementary changes in culture that support strengthened political decision-making and scientific independence. States' inability to act on WHO's institutional design challenges will only lead them and non-state actors to continue bypassing the organization through the creation of new entities as they have done over the last 15 years. The key will be to mobilize those advocates and decision-makers who have the audacity to demand more from WHO and convince member states to elevate their ambitions in current WHO reform efforts. Continued progress in global health depends on it.

2013
Hoffman, S.J. & Røttingen, J.-A., 2013. Dark Sides of the Proposed Framework Convention on Global Health’s Many Virtues: A Systematic Review and Critical Analysis. Health & Human Rights Journal , 15 (1) , pp. 117-134. PDFAbstract

The costs of any proposal for new international law must be fully evaluated and compared with benefits and competing alternatives to ensure adoption will not create more problems than solutions. A systematic review of the research literature was conducted to categorize and assess limitations and unintended negative consequences associated with the proposed Framework Convention on Global Health (FCGH). A critical analysis then interpreted these findings using economic, ethical, legal, and political science perspectives. Of the 442 documents retrieved, nine met the inclusion criteria. Collectively, these documents highlighted that an FCGH could duplicate other efforts, lack feasibility, and have questionable impact. The critical analysis reveals that negative consequences can result from the FCGH’s proposed form of international law and proposed functions of influencing national budgets, realizing health rights and resetting global governance for health. These include the direct costs of international law, opportunity costs, reducing political dialogue by legalizing political interactions, petrifying principles that may have only contemporary relevance, imposing foreign values on less powerful countries, forcing externally defined goals on countries, prioritizing individual rights over population-wide well-being, further complicating global governance for health, weakening the World Health Organization (WHO), reducing participation opportunities for non-state actors, and offering sub-optimal solutions for global health challenges. Four options for revising the FCGH proposal are developed to address its weaknesses and strengthen its potential for impact. These include: 1) abandoning international law as the primary commitment mechanism and instead pursuing agreement towards a less formal “framework for global health”; 2) seeking fundamental constitutional reform of WHO to address gaps in global governance for health; 3) mobilizing for a separate political platform that completely bypasses WHO; or 4) narrowing the scope of sought changes to one particular governance issue such as financing for global health needs.

 

Hoffman, S.J. & Belluz, J., 2013. Don't Believe Medicine's Wizards of Oz. The National Post. Article
Belluz, J. & Hoffman, S.J., 2013. Dr. Oz's Miraculous Medical Advice. Slate Magazine. Article
Hoffman, S.J. & Tan, C., 2013. Following Celebrities' Medical Advice: Meta-Narrative Analysis. British Medical Journal , 347 , pp. f7151. PDFAbstract

Objective: To synthesize what is known about how celebrities influence people’s decisions on health.

Design: Meta-narrative analysis of economics, marketing, psychology, and sociology literatures. 

Data Sources: Systematic searches of electronic databases: BusinessSource Complete (1886-), Communication & Mass Media Complete (1915-), Humanities Abstracts (1984-), ProQuest Political Science (1985-), PsycINFO (1806-), PubMed (1966-), and Sociology Abstracts (1952-). 

Inclusion Criteria: Studies discussing mechanisms of celebrities’ influence on people in any context. 

Results: Economics literature shows that celebrity endorsements act as signals of credibility that differentiate products or ideas from competitors and can catalyze herd behaviour. Marketing studies show that celebrities transfer their desirable attributes to products and use their success to boost their perceived credibility. Psychology shows that people are classically conditioned to react positively to the advice of celebrities, experience cognitive dissonance if they do not, and are influenced by congruencies with their self conceptions. Sociology helps explain the spread of celebrity medical advice as a contagion that diffuses through social networks and people’s desire to acquire celebrities’ social capital. 

Conclusion: The influence of celebrity status is a deeply rooted process that can be harnessed for good or abused for harm. A better understanding of celebrity can empower health professionals to take this phenomenon seriously and use patient encounters to educate the public about sources of health information and their trustworthiness. Public health authorities can use these insights to implement regulations and restrictions on celebrity endorsements and design counter marketing initiatives—perhaps even partnering with celebrities—to discredit bogus medical advice while promoting evidence based practices.

Belluz, J. & Hoffman, S.J., 2013. Katie Couric and the Celebrity Medicine Syndrome. Los Angeles Times. Article
Hoffman, S.J. ed., 2013. Student Voices 5: Advocating for Global Health through Evidence, Insight and Action, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
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

Pages