A pandemic treaty, revised international health regulations, or both?

BACKGROUND: A special session of the World Health Assembly (WHA) will be convened in late 2021 to consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response - a so-called 'Pandemic Treaty'. Consideration is given to this treaty as well as to reform of the International Health Regulations (IHR) as our principal governing instrument to prevent and mitigate future pandemics. MAIN BODY: Reasons exist to continue to work with the IHR as our principal governing instrument to prevent and mitigate future pandemics. All WHO member states are party to it. It gives the WHO the authority to oversee the collection of surveillance data and to issue recommendations on trade and travel advisories to control the spread of infectious diseases, among other things. However, the limitations of the IHR in addressing the deep prevention of future pandemics also must be recognized. These include a lack of a regulatory framework to prevent zoonotic spillovers. More advanced multi-sectoral measures are also needed. At the same time, a pandemic treaty would have potential benefits and drawbacks as well. It would be a means of addressing the gross inequity in global vaccine distribution and other gaps in the IHR, but it would also need more involvement at the negotiation table of countries in the Global South, significant funding, and likely many years to adopt. CONCLUSIONS: Reform of the IHR should be undertaken while engaging with WHO member states (and notably those from the Global South) in discussions on the possible benefits, drawbacks and scope of a new pandemic treaty. Both options are not mutually exclusive.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions.

BACKGROUND: The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. METHODS: In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. RESULTS: In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool - the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. CONCLUSION: Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

The institutional context of tobacco production in Zambia.

BACKGROUND: Tobacco production is said to be an important contributor to Zambia's economy in terms of labour and revenue generation. In light of Zambia's obligations under the WHO Framework Convention of Tobacco Control (FCTC) we examined the institutional actors in Zambia's tobacco sector to better understand their roles and determine the institutional context that supports tobacco production in Zambia. METHODS: Findings from 26 qualitative, semi-structured individual or small-group interviews with key informants from governmental, intergovernmental and non-governmental organisations were analysed, along with data and information from published literature. RESULTS: Although Zambia is obligated under the FCTC to take steps to reduce tobacco production, the country's weak economy and strong tobacco interests make it difficult to achieve this goal. Respondents uniformly acknowledged that growing the country's economy and ensuring employment for its citizens are the government's top priorities. Lacklustre coordination and collaboration between the institutional actors, both within and outside government, contributes to an environment that helps sustain tobacco production in the country. A Tobacco Products Control Bill has been under review for a number of years, but with no supply measures included, and with no indication of when or whether it will be passed. CONCLUSIONS: As with other low-income countries involved in tobacco production, there is inconsistency between Zambia's economic policy to strengthen the country's economy and its FCTC commitment to regulate and control tobacco production. The absence of a whole-of-government approach towards tobacco control has created an institutional context of duelling objectives, with some government ministries working at cross-purposes and tobacco interests left unchecked. With no ultimate coordinating authority, this industry risks being run according to the desire and demands of multinational tobacco companies, with few, if any, checks against them.

Causes, consequences, and policy responses to the migration of health workers: key findings from India.

BACKGROUND: This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been "sources" of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study. METHODS: Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically. RESULTS: Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration. CONCLUSIONS: Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

Knowledge and potential impact of the WHO Global code of practice on the international recruitment of health personnel: Does it matter for source and destination country stakeholders?

The WHO Global Code of Practice on the International Recruitment of Health Personnel was implemented in May 2010. The present commentary offers some insights into what is known about the Code five years on, as well as its potential impact, drawing from interviews with health care and policy stakeholders from a number of 'source' and 'destination' countries.

Health worker migration from South Africa: causes, consequences and policy responses.

BACKGROUND: This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries-Jamaica, India, the Philippines, and South Africa-have historically been "sources" of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa. METHODS: The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically. RESULTS: There has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself. CONCLUSIONS: In the near past, South Africa's health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

Canadian physicians' responses to cross border health care.

BACKGROUND: The idea for this survey emanated from desk research and two meetings for researchers that discussed medical tourism and out-of-country health care, which were convened by some of the authors of this article (VR, CP and RL). METHODS: A Cross Border Health Care Survey was drafted by a number of the authors and administered to Canadian physicians via the Canadian Medical Association's e-panel. The purpose of the survey was to gain an understanding of physicians' experiences with and views of their patients acquiring health care out of country, either as medical tourists (paying out-of-pocket for their care) or out-of-country care patients funded by provincial/territorial public health insurance plans. Quantitative and qualitative results of the survey were analyzed. RESULTS: 631 physicians responded to the survey. Diagnostic procedures were the top-ranked procedure for patients either as out-of-country care recipients or medical tourists. Respondents reported that the main reason why patients sought care abroad was because waiting times in Canada were too long. Some respondents were frustrated with a lack of information about out-of-country procedures upon their patients' return to Canada. The majority of physician respondents agreed that it was their responsibility to provide follow-up care to medical travellers on return to Canada, although a substantial minority disagreed that they had such a responsibility. CONCLUSIONS: Cross-border health care, whether government-sanctioned (out-of-country-care) or patient-initiated (medical tourism), is increasing in Canada. Such flows are thought likely to increase with aging populations. Government-sanctioned outbound flows are less problematic than patient-initiated flows but are constrained by low approval rates, which may increase patient initiation. Lack of information and post-return complications pose the greatest concern to Canadian physicians. Further research on both types of flows (government-sanctioned and patient-initiated), and how they affect the Canadian health system, can contribute to a more informed debate about the role of cross-border health care in the future, and how it might be organized and regulated.

Reflections on the ethics of recruiting foreign-trained human resources for health.

BACKGROUND: Developed countries' gains in health human resources (HHR) from developing countries with significantly lower ratios of health workers have raised questions about the ethics or fairness of recruitment from such countries. By attracting and/or facilitating migration for foreign-trained HHR, notably those from poorer, less well-resourced nations, recruitment practices and policies may be compromising the ability of developing countries to meet the health care needs of their own populations. Little is known, however, about actual recruitment practices. In this study we focus on Canada (a country with a long reliance on internationally trained HHR) and recruiters working for Canadian health authorities. METHODS: We conducted interviews with health human resources recruiters employed by Canadian health authorities to describe their recruitment practices and perspectives and to determine whether and how they reflect ethical considerations. RESULTS AND DISCUSSION: We describe the methods that recruiters used to recruit foreign-trained health professionals and the systemic challenges and policies that form the working context for recruiters and recruits. HHR recruiters' reflections on the global flow of health workers from poorer to richer countries mirror much of the content of global-level discourse with regard to HHR recruitment. A predominant market discourse related to shortages of HHR outweighed discussions of human rights and ethical approaches to recruitment policy and action that consider global health impacts. CONCLUSIONS: We suggest that the concept of corporate social responsibility may provide a useful approach at the local organizational level for developing policies on ethical recruitment. Such local policies and subsequent practices may inform public debate on the health equity implications of the HHR flows from poorer to richer countries inherent in the global health worker labour market, which in turn could influence political choices at all government and health system levels.

Governing antimicrobial resistance: a narrative review of global governance mechanisms.

Antimicrobial resistance (AMR), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around 700,000 per year globally. The international community has signaled its commitment to exploring and implementing effective policy responses to AMR, with a Global Action Plan on AMR approved by the World Health Assembly in 2015. Major governance challenges could thwart collective efforts to address AMR, along with limited knowledge about how to design effective global governance mechanisms. To identify common ground for more coordinated global actions we conducted a narrative review to map dominant ideas and academic debates about AMR governance. We found two categories of global governance mechanisms: binding and non-binding and discuss advantages and drawbacks of each. We suggest that a combination of non-binding and binding governance mechanisms supported by leading antimicrobial use countries and important AMR stakeholders, and informed by One Health principles, may be best suited to tackle AMR.

TOBACCO, TRADE, AND THE RIGHT TO HEALTH.

This article describes how states which have committed to the right to health in international human rights law are obligated to take measures to respect and fulfill this right for their citizens, including measures to protect against the harm to health caused by tobacco. It also reaffirms the duality of both international trade and investment law, and international human rights law. Yet challenges are faced in controlling tobacco production and sale, despite the WHO Framework Convention on Tobacco Control. Recent cases are reviewed wherein health and economic norms embodied in trade and investment rules have intersected.

Managing health professional migration from sub-Saharan Africa to Canada: a stakeholder inquiry into policy options.

BACKGROUND: Canada is a major recipient of foreign-trained health professionals, notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries, while comparatively small, is rising. African countries, meanwhile, have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada? METHODS: We interviewed a small sample of émigré South African physicians (n = 7) and a larger purposive sample of representatives of Canadian federal, provincial, regional and health professional departments/organizations (n = 25); conducted a policy colloquium with stakeholder organizations (n = 21); and undertook new analyses of secondary data to determine recent trends in health human resource flows between sub-Saharan Africa and Canada. RESULTS: Flows from sub-Saharan Africa to Canada have increased since the early 1990s, although they may now have peaked for physicians from South Africa. Reasons given for this flow are consistent with other studies of push/pull factors. Of 8 different policy options presented to study participants, only one received unanimous strong support (increasing domestic self-sufficiency), one other received strong support (increased health system strengthening in source country), two others mixed support (voluntary codes on ethical recruitment, bilateral or multilateral agreements to manage flows) and four others little support or complete rejection (increased training of auxiliary health workers in Africa ineligible for licensing in Canada, bonding, reparation payments for training-cost losses and restrictions on immigration of health professionals from critically underserved countries). CONCLUSION: Reducing pull factors by improving domestic supply and reducing push factors by strengthening source country health systems have the greatest policy traction in Canada. The latter, however, is not perceived as presently high on Canadian stakeholder organizations' policy agendas, although support for it could grow if it is promoted. Canada is not seen as "actively' recruiting" ("poaching") health workers from developing countries. Recent changes in immigration policy, ongoing advertising in southern African journals and promotion of migration by private agencies, however, blurs the distinction between active and passive recruitment.

Community health workers in Canada and other high-income countries: A scoping review and research gaps.

OBJECTIVES: Community health workers (CHWs) have been deployed to provide health-related services to their fellow community members and to guide them through often complex health systems. They help address concerns about how marginalized populations in many countries experience health inequities that are due, in part, to lack of appropriate primary health care services, possibly resulting in inappropriate use of higher-cost health services or facilities. This paper reviews studies on CHW interventions in a number of high-income countries, including Canada, to identify research gaps on CHW roles. METHODS: A scoping review using 68 sources of interventions involving CHWs was undertaken. The five-step Arksey and O'Malley model guided this review with the aim of summarizing research findings and identifying research gaps in the existing literature on CHWs in Canada (23 sources). A standardized extraction tool was employed to synthesize the literature. SYNTHESIS: We found that CHWs provide a wide range of health-related services but in a manner that, in Canada, is unrecognized and unregulated. In highincome countries, CHW interventions have contributed to health-related issues in communities and demonstrated potential to both reduce health inequity in marginalized populations and reduce the cost of medical services. CONCLUSION: CHWs are an under-recognized, and therefore underutilized, public health workforce, which has a promising capacity to reduce health inequities in marginalized populations in Canada. There is growing support to suggest that CHW roles need to be better integrated within the broader health and social services systems to enable their full potential to be realized.

Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project.

BACKGROUND: The 4-year (2007-2011) Revitalizing Health for All international research program (http://www.globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 low- and middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacity-enhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSIONS: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include:1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures)3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation)4. Support for community advocacy and engagement in health and social systems decision makingThese characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.

Medical tourism today: what is the state of existing knowledge?

One manifestation of globalization is medical tourism. As its implications remain largely unknown, we reviewed claimed benefits and risks. Driven by high health-care costs, long waiting periods, or lack of access to new therapies in developed countries, most medical tourists (largely from the United States, Canada, and Western Europe) seek care in Asia and Latin America. Although individual patient risks may be offset by credentialing and sophistication in (some) destination country facilities, lack of benefits to poorer citizens in developing countries offering medical tourism remains a generic equity issue. Data collection, measures, and studies of medical tourism all need to be greatly improved if countries are to assess better both the magnitude and potential health implications of this trade.

Aplicación, efectividad y contexto político de la atención primaria integral de salud: resultados preliminares de una revisión de la literatura mundia / Implementation, effectiveness and political context of comprehensive primary health care: preliminary findings of a global literature review

La atención primaria de salud (APS) ocupa nuevamente un lugar de privilegio en la agenda internacional...