Decolonial framework for applying reflexivity and positionality in global health research.

Contemporary research practices link to colonial and imperialist knowledge creation and production and may promote harmful perspectives on marginalized and oppressed groups. We present a framework for a decolonial approach to research in global health and health promotion applicable across research settings. This framework is aimed at anticipating and alleviating potentially harmful practices inherent in dominant research methods. The framework focuses from a macro- and micro-level perspective on three critical dyads: 'context' and 'accountability'; 'researcher identity' and 'positionality'; and 'procedural ethics' and 'ethics in practice' considerations. We present guidance for how to consider reflexivity and positionality as they apply in this framework in global health and health promotion research practice.

The EU as a Political Determinant of Global Health: The Case of Research and Development Incentives for Orphan Medicines and Biotechnology.

CONTEXT: The European Union (EU) governs global health through its constituent laws, institutions, actors and policies. However, it is unclear whether or how these political factors interact to position the Union as a political determinant of global health. METHODS: A case study of the political factors (Rushton and Williams, 2012) influencing the adoption of the EU's Biotechnology Directive 98/44/EC and Orphan Medicines Regulation 141/2000. FINDINGS: The European Commission (EC) generally framed both of its proposals around economical and biomedical paradigms aligned with the needs of the EU's industry and patients, whereas the European Parliament (EP) contested some of these frames and proposed amendments supporting global access to medical products. The political factors influencing the adoption (in the Directive) or rejection (in the Regulation) of the EP's amendments include: the complementarity between the EP and EC proposals; the EP's power in the intra- and inter-institutional negotiating process; the existence and support of civil society; and the alignment with Member State(s)' priorities in the Council. CONCLUSIONS: In the late 1990s, the EU was an internally fragmented and politicised player concerning global health matters. These political factors should be considered for a coherent post-2022 EU strategy on global health.

Challenges in capacity building of national immunization programs and emergency or pandemic vaccination responses in the Global Health Security Agenda member countries.

The Immunization Action Package aims to increase the vaccination rate for vaccine-preventable diseases to save lives. To achieve this, member countries of the Global Health Security Agenda (GHSA) must have the capacity to implement sustainable national immunization programs (NIPs) and to respond to emergency vaccination scenarios. This article focuses on 4 major areas of NIP capacity, including in emergency situations: infrastructure capacity, sustainable financing capacity, vaccine access and equity, and vaccination hesitancy. Countries require resilient infrastructure to achieve high vaccination rates and develop preparedness for public health emergencies. Financial sustainability is crucial in achieving high vaccination coverage to best implement initiatives and national programs. Furthermore, challenges to NIPs include vaccine access and equity, as inequitable distribution and access to vaccines for coronavirus disease 2019 accelerated the impact of the pandemic. Lastly, the correlation between low acceptance and successful implementation of national initiatives suggests that vaccination hesitancy is another challenge to NIPs. In an attempt to overcome these challenges, the Expert Forum of the GHSA Seventh Ministerial Meeting was held to provide sessions allowing countries to share their national case studies and discuss strategies for capacity building of country-level NIPs, including for emergency responses.

The World Health Organization was born as a normative agency: Seventy-five years of global health law under WHO governance.

The World Health Organization (WHO) was born as a normative agency and has looked to global health law to structure collective action to realize global health with justice. Framed by its constitutional authority to act as the directing and coordinating authority on international health, WHO has long been seen as the central actor in the development and implementation of global health law. However, WHO has faced challenges in advancing law to prevent disease and promote health over the past 75 years, with global health law constrained by new health actors, shifting normative frameworks, and soft law diplomacy. These challenges were exacerbated amid the COVID-19 pandemic, as states neglected international legal commitments in national health responses. Yet, global health law reforms are now underway to strengthen WHO governance, signaling a return to lawmaking for global health. Looking back on WHO's 75th anniversary, this article examines the central importance of global health law under WHO governance, reviewing the past successes, missed opportunities, and future hopes for WHO. For WHO to meet its constitutional authority to become the normative agency it was born to be, we offer five proposals to reestablish a WHO fit for purpose: normative instruments, equity and human rights mainstreaming, sustainable financing, One Health, and good governance. Drawing from past struggles, these reforms will require further efforts to revitalize hard law authorities in global health, strengthen WHO leadership across the global governance landscape, uphold equity and rights at the center of global health law, and expand negotiations in global health diplomacy.

Pandemic treaty as an instrument to strengthen global health security: Global health diplomacy at its crux.

Background: The World Health Assembly (WHA), on 1st December 2021, unanimously agreed to launch a global process to draft and negotiate a convention, agreement, or other international instrument under the World Health Organization's (WHO's) constitution to strengthen pandemic prevention, preparedness, and response. We aimed to explore the role of global health diplomacy (GHD) in pandemic treaty negotiations by providing deep insight into the ongoing drafting process under the WHO leadership. Methods: We conducted a narrative review by searching Scopus, Web of Sciences, PubMed, MEDLINE, and Google Scholar search engine using the keywords "Pandemic Treaty," OR "International Health Regulations," OR "International conventions," OR "International treaties" in the context of recent COVID-19 pandemic. Besides, we included articles recommending the need for GHD, leadership and governance mechanisms for this international treaty drafting approved by the WHA. Results: Amid the COVID-19 pandemic, the concept of GHD bolstered the international system and remained high on the agendas of many national, regional and global platforms. As per Article 19 of the WHO constitution, the Assembly established an intergovernmental negotiating body (INB) to draft and negotiate this convention/ agreement to protect the world from disease outbreaks of pandemic potential. Since GHD has helped to strengthen international cooperation in health systems and address inequities in achieving health-related global targets, there is a great scope for the successful drafting of this pandemic treaty. Conclusion: The pandemic treaty is a defining moment in global health governance, particularly the pandemic governance reforms. However, the treaty's purpose will only be served if the equity considerations are optimized, accountability mechanisms are established, and a sense of shared responsibility is embraced. While fulfilling treaty commitments might be complex and challenging, it provides an opportunity to rethink and build resilient systems for pandemic preparedness and response in the future.

Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

BACKGROUND: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. METHODS AND FINDINGS: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. CONCLUSIONS: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

From Today to Tomorrow: Leveraging Digital Health to Move toward Health for All.

This series of papers explores the concept of essential digital health for the underserved. Several cross-cutting themes are highlighted in this paper, for example: (1) harmonizing journeys of different patient groups to understand diverse perspectives; (2) engaging health professionals in interoperability, change management and health human resource capacity building; (3) ensuring harmonization of micro, meso and macro levels of health services delivery; and (4) integrating evaluation iteratively to enable continuous improvement and learning. Adopting a learning health system (LHS) approach facilitates iterative growth and evolution, incorporating concepts from the software industry, as well as participatory processes such as failing forward, developing ecosystems for collaboration and engagement of stakeholders. The example of HealthLink BC's 811 as a digital front door is used to demonstrate how an LHS approach can enable meaningful system change. We welcome further dialogues and discussion on existing and emerging examples of health system implementation approaches that can help our Canadian health systems move continuously and progressively closer toward the ultimate goal of Health for All (WHO 2023).

Systematic review of individual-level, community-level, and healthcare system-level factors contributing to socioeconomic differences in healthcare utilisation in OECD countries with universal health coverage.

OBJECTIVES: Countries with universal health coverage (UHC) strive for equal access for equal needs without users getting into financial distress. However, differences in healthcare utilisation (HCU) between socioeconomic groups have been reported in countries with UHC. This systematic review provides an overview individual-level, community-level, and system-level factors contributing to socioeconomic status-related differences in HCU (SES differences in HCU). DESIGN: Systematic review following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The review protocol was published in advance. DATA SOURCES: Embase, PubMed, Web of Science, Scopus, Econlit, and PsycInfo were searched on 9 March 2021 and 9 November 2022. ELIGIBILITY CRITERIA: Studies that quantified the contribution of one or more factors to SES difference in HCU in OECD countries with UHC. DATA EXTRACTION AND SYNTHESIS: Studies were screened for eligibility by two independent reviewers. Data were extracted using a predeveloped data-extraction form. Risk of bias (ROB) was assessed using a tailored version of Hoy's ROB-tool. Findings were categorised according to level and a framework describing the pathway of HCU. RESULTS: Of the 7172 articles screened, 314 were included in the review. 64% of the studies adjusted for differences in health needs between socioeconomic groups. The contribution of sex (53%), age (48%), financial situation (25%), and education (22%) to SES differences in HCU were studied most frequently. For most factors, mixed results were found regarding the direction of the contribution to SES differences in HCU. CONCLUSIONS: SES differences in HCU extensively correlated to factors besides health needs, suggesting that equal access for equal needs is not consistently accomplished. The contribution of factors seemed highly context dependent as no unequivocal patterns were found of how they contributed to SES differences in HCU. Most studies examined the contribution of individual-level factors to SES differences in HCU, leaving the influence of healthcare system-level characteristics relatively unexplored.

Towards a Feminist Global Health Policy: Power, intersectionality, and transformation.

In the realm of global health policy, the intricacies of power dynamics and intersectionality have become increasingly evident. Structurally embedded power hierarchies constitute a significant concern in achieving health for all and demand transformational change. Adopting intersectional feminist approaches potentially mitigates health inequities through more inclusive and responsive health policies. While feminist approaches to foreign and development policies are receiving increasing attention, they are not accorded the importance they deserve in global health policy. This article presents a framework for a Feminist Global Health Policy (FGHP), outlines the objectives and underlying principles and identifies the actors responsible for its meaningful implementation. Recognising that power hierarchies and societal contexts inherently shape research, the proposed framework was developed via a participatory research approach that aligns with feminist principles. Three independent online focus groups were conducted between August and September 2022 with 11 participants affiliated to the global-academic or local-activist level and covering all WHO regions. The qualitative content analysis revealed that a FGHP must be centred on considerations of intersectionality, power and knowledge paradigms to present meaningful alternatives to the current structures. By balancing guiding principles with sensitivity for context-specific adaptations, the framework is designed to be applicable locally and globally, whilst its adoption is intended to advance health equity and reproductive justice, with communities and policymakers identified as the main actors. This study underscores the importance of dismantling power structures by fostering intersectional and participatory approaches for a more equitable global health landscape. The FGHP framework is intended to initiate debate among global health practitioners, policymakers, researchers and communities. Whilst an undeniably intricate and time-consuming process, continuous and collaborative work towards health equity is imperative to translate this vision into practice.

Brazilian primary dental care in a universal health system: Challenges for training and practice.

OBJECTIVES: To report the challenges for training and practice for the Brazilian primary dental care in a universal health system. METHODS: Health, education and protection rights against poverty are guaranteed by the 1988 Brazilian Constitution and public health in Brazil is provided by the Unified Health System (SUS), one of the largest public health systems in the world. According to SUS, every Brazilian citizen has the right to free primary oral health care as secondary and tertiary care, offering a unique opportunity to integrate oral care within general health care. RESULTS: The Brazilian undergraduate Dental curriculum was updated in 2021 aiming to graduate general practitioners with a major in comprehensive health care in primary health care, integrated with public and general health. This curriculum update requires at least 20% of the academic hours to be exercised outside the university walls (extramural or community work), preferably within the SUS. CONCLUSIONS: Considering the World Health Organization (WHO) agenda, Brazil needs to advance the innovative oral health workforce, the integration of oral health into primary care, the population access to essential dental medicines and optimal fluorides for caries control. CLINICAL SIGNIFICANCE: It is necessary political action and the engagement of multiple stakeholders, mainly from the health and education sectors, to improve primary health care.

Drug-resistant tuberculosis: a persistent global health concern.

Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.

Appraisal of universal health insurance and maternal health services utilization: pre- and post-context of the Jaminan Kesehatan Nasional implementation in Indonesia.

Introduction: The Indonesian government introduced universal health insurance through the National Social Security System (JKN) in 2014 to enhance overall healthcare. This study compares maternal health care (MHC) service utilization before and after JKN implementation in Indonesia. Method: Using 2012 and 2017 data from Indonesia Demographic and Health Surveys (DHS), we conducted a two-period cross-sectional design study following the Anderson model. We assessed how the JKN policy and population characteristics influenced healthcare utilization for women aged 15-49 who had given birth in the last 5 years. Multivariable logistic regression models were used to assess the impact of the JKN policy and related factors. Result: In two waves of Indonesia DHS with 14,782 and 15,021 subjects, this study observed a significant increase in maternal healthcare service utilization post-JKN implementation. Women were more likely to have at least four antenatal care visits (adjusted odds ratio, AOR = 1.17), receive skilled antenatal care (AOR = 1.49), obtain skilled birth assistance (AOR = 1.96), and access facility-based delivery (AOR = 2.45) compared with pre-JKN implementation. Conclusion: This study revealed a significant positive impact of JKN on enhancing MHS utilization. The introduction of universal health insurance coverage likely reduced financial barriers for specific demographics, resulting in increased service utilization. Our study may offer valuable insights for Asian countries with similar demographics and health insurance implementations.

Positioning implementation science in national immunization programmes to improve coverage equity and advance progress toward Immunization Agenda 2030: An urgent global health imperative.

Despite the availability of effective vaccines for preventing common childhood infectious diseases, there is still significant disparities in access and utilization across many low- and middle-income countries (LMIC). The factors that drive these disparities are often multilevel, originating from individuals, health facilities, health systems and communities, and also multifaceted. Implementation science has emerged as a field to help address "know-do" gaps in health systems, and can play a significant role in strengthening immunization systems to understand and solve implementation barriers that limit access and uptake within their contexts. This article presents a reflexive perspective on how to position implementation research in immunization programmes to improve coverage equity. Furthermore, key points of synergy between implementation research and vaccination are highlighted, and some potential practice changes that can be applied within specific contexts were proposed. Using a human rights lens, it was concluded that the cost that is associated with implementation failure in immunization programmes is significant and unjust, and future directions for implementation research to optimize its application in practice settings have been recommended.

A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities.

Introduction and aim: Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. Methods and analysis: A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. Conclusion and knowledge contribution: PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.