Global health education in the United Kingdom: a review of university undergraduate and postgraduate programmes and courses.

OBJECTIVES: This study reviews the current state of global health education (GHE) in the United Kingdom (UK) through the collation and synthesis of data on undergraduate and postgraduate global health degree programmes. It examines both the curriculum provided and profile of the student currently studying global health in the UK. STUDY DESIGN: Descriptive, case study design. METHODS: A systematic review of the literature identified a set of global health 'core competencies' that students could acquire through their chosen programme of study. Those competencies were synthesized and then compared to core and elective courses currently offered by global health degree programmes at UK universities. A questionnaire was designed and sent electronically to all global health Programme Directors requesting generic information regarding the profile of their global health students. RESULTS: Fifteen universities in the UK, based in England and Scotland, offered twenty-five postgraduate and six undergraduate global health degree programmes in 2012-13. Two Universities were developing a full, three-year, undergraduate degree programme in global health. Sixteen core competencies for a medical and non-medical student constituency were identified. Of these, just three 'core competencies' - epidemiology of tropical diseases, health systems (including health system management), and health care services - corresponded directly to core and elective courses offered by >50% of UK universities. The five most frequently offered subjects were: health systems (including health system management), research methods, public health (including specialisations in prevention, treatment and care), epidemiology, and health economics. CONCLUSIONS: GHE in UK universities has seen comparable growth to North American institutions, becoming Europe's regional hub for undergraduate and postgraduate courses and programmes. As with the US and Canadian experience, GHE at the undergraduate level is offered primarily to medical students through intercalated degree programmes. At the postgraduate level, there is more innovation in content and mode of delivery, with a small number of UK universities providing students from a diversity of backgrounds the opportunity to study global health from multidisciplinary perspectives. Distance learning is also seeking to make the delivery of GHE truly global, with a growing number of universities recognizing its potential to further innovate in global health pedagogy. While demand for GHE is predicted to remain robust, to ensure the needs of students and practitioners are met, more critical reflection on global health curricula, the desired profile of graduates, and equity of access is required.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

'BRICS without straw'? A systematic literature review of newly emerging economies' influence in global health.

BACKGROUND: Since 2010, five newly emerging economies collectively known as 'BRICS' (Brazil, India, Russia, China and South Africa) have caught the imagination, and scholarly attention, of political scientists, economists and development specialists. The prospect of a unified geopolitical bloc, consciously seeking to re-frame international (and global) health development with a new set of ideas and values, has also, if belatedly, begun to attract the attention of the global health community. But what influence, if any, do the BRICS wield in global health, and, if they do wield influence, how has that influence been conceptualized and recorded in the literature? METHODS: We conducted a systematic literature review in (March-December 2012) of documents retrieved from the databases EMBASE, PubMed/Medline, Global Health, and Google Scholar, and the websites of relevant international organisations, research institutions and philanthropic organisations. The results were synthesised using a framework of influence developed for the review from the political science literature. RESULTS: Our initial search of databases and websites yielded 887 documents. Exclusion criteria narrowed the number of documents to 71 journal articles and 23 reports. Two researchers using an agreed set of inclusion criteria independently screened the 94 documents, leaving just 7 documents. We found just one document that provided sustained analysis of the BRICS' collective influence; the overwhelming tendency was to describe individual BRICS countries influence. Although influence was predominantly framed by BRICS countries' material capability, there were examples of institutional and ideational influence - particularly from Brazil. Individual BRICS countries were primarily 'opportunity seekers' and region mobilisers but with potential to become 'issue leaders' and region organisers. CONCLUSION: Though small in number, the written output on BRICS influence in global health has increased significantly since a similar review conducted in 2010 found just one study. Whilst it may still be 'early days' for newly-emerging economies influence in global health to have matured, we argue that there is scope to further develop the concept of influence in global health, but also to better understand the ontology of groups of countries such as BRICS. The BRICS have made a number of important commitments towards reforming global health, but if they are to be more than a memorable acronym they need to start putting those collective commitments into action. Keywords BRICS, global health, influence, newly emerging economies, Brazil, Russia, India, China, South Africa.

Flexibly funding WHO? An analysis of its donors' voluntary contributions.

INTRODUCTION: Since the 1970s, voluntary contributions have become an increasingly important component of WHO's budget. As voluntary contributions tend to be earmarked for donor-specified programmes and projects, there are concerns that this trend has diverted focus away from WHO's strategic priorities, made coordination and attaining coherence more difficult, undermined WHO's democratic structures and given undue power to a handful of wealthy donors. In the past few years, the WHO Secretariat has pushed for donors to increase the amount of flexible funding they provide. METHODS: This paper aims to add to the literature on WHO financing by constructing and analysing a dataset based on figures extracted from WHO documents for the period 2010-21. It aims to answer two questions: who funds WHO and how flexible is that funding? RESULTS: Our analysis demonstrates that in the last decade voluntary contributions have steadily increased as a proportion of WHO's budget, from 75% at the start of the period to 88% at the end. High-income countries and donors based in high-income countries provided 90% of voluntary contributions in 2020. Surprisingly, the share of voluntary contributions provided by upper middle-income countries was consistently less than the share by lower middle-income countries. Furthermore, in terms of their share of voluntary contributions, we found that upper middle-income countries contributed the least proportion of their gross national income to WHO. CONCLUSION: We conclude that WHO remains constrained by the conditions attached to the vast majority of funding that it receives from its donors. Further work on how to flexibly fund WHO is required. We recommend that the Agile Member States Task Group on Strengthening WHO's Budgetary, Programmatic and Financing Governance continues the work of the Working Group on Sustainable Financing by focusing on the incentives that determine donor support for specified and flexible voluntary contributions.

'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan.

BACKGROUND: Despite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs). METHODS: Semi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors. RESULTS: Stigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included:criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers. CONCLUSIONS: Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.

National and subnational HIV/AIDS coordination: are global health initiatives closing the gap between intent and practice?

BACKGROUND: A coordinated response to HIV/AIDS remains one of the 'grand challenges' facing policymakers today. Global health initiatives (GHIs) have the potential both to facilitate and exacerbate coordination at the national and subnational level. Evidence of the effects of GHIs on coordination is beginning to emerge but has hitherto been limited to single-country studies and broad-brush reviews. To date, no study has provided a focused synthesis of the effects of GHIs on national and subnational health systems across multiple countries. To address this deficit, we review primary data from seven country studies on the effects of three GHIs on coordination of HIV/AIDS programmes: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank's HIV/AIDS programmes including the Multi-country AIDS Programme (MAP). METHODS: In-depth interviews were conducted at national and subnational levels (179 and 218 respectively) in seven countries in Europe, Asia, Africa and South America, between 2006 and 2008. Studies explored the development and functioning of national and subnational HIV coordination structures, and the extent to which coordination efforts around HIV/AIDS are aligned with and strengthen country health systems. RESULTS: Positive effects of GHIs included the creation of opportunities for multisectoral participation, greater political commitment and increased transparency among most partners. However, the quality of participation was often limited, and some GHIs bypassed coordination mechanisms, especially at the subnational level, weakening their effectiveness. CONCLUSIONS: The paper identifies residual national and subnational obstacles to effective coordination and optimal use of funds by focal GHIs, which these GHIs, other donors and country partners need to collectively address.

Seven habits of highly effective global public-private health partnerships: practice and potential.

Global public-private health partnerships (GHPs) have become an established mechanism of global health governance. Sufficient evaluations have now been conducted to justify an assessment of their strengths and weaknesses. This paper outlines seven contributions made by GHPs to tackling diseases of poverty. It then identifies seven habits many GHPs practice that result in sub-optimal performance and negative externalities. These are skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions of the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonisation; and inappropriate incentives for staff engaging in partnerships. The analysis highlights areas where reforms are desirable and concludes by presenting seven actions that would assist GHPs to adopt better habits which, it is hoped, would make them highly effective and bring about better health in the developing world.

Democracy - the real 'ghost' in the machine of global health policy: Comment on "A ghost in the machine? politics in global health policy".

Politics is not the ghost in the machine of global health policy. Conceptually, it makes little sense to argue otherwise, while history is replete with examples of individuals and movements engaging politically in global health policy. Were one looking for ghosts, a more likely candidate would be democracy, which is currently under attack by a new global health technocracy. Civil society movements offer an opportunity to breathe life into a vital, but dying, political component of global health policy.

Has global fund support for civil society advocacy in the former Soviet Union established meaningful engagement or 'a lot of jabber about nothing'?

Although civil society advocacy for health issues such as HIV transmission through injecting drug use is higher on the global health agenda than previously, its impact on national policy reform has been limited. In this paper we seek to understand why this is the case through an examination of civil society advocacy efforts to reform HIV/AIDS and drugs-related policies and their implementation in three former Soviet Union countries. In-depth semi-structured interviews were conducted in Georgia, Kyrgyzstan and Ukraine by national researchers with representatives from a sample of 49 civil society organizations (CSOs) and 22 national key informants. We found that Global Fund support resulted in the professionalization of CSOs, which increased confidence from government and increased CSO influence on policies relating to HIV/AIDS and illicit drugs. Interviewees also reported that the amount of funding for advocacy from the Global Fund was insufficient, indirect and often interrupted. CSOs were often in competition for Global Fund support, which caused resentment and limited collective action, further weakening capacity for effective advocacy.

Understanding change in global health policy: ideas, discourse and networks.

How is radical change in global health policy possible? Material factors such as economics or human resources are important, but ideational factors such as ideas and discourse play an important role as well. In this paper, I apply a theoretical framework to show how discourse made it possible for public and private actors to fundamentally change their way of working together--to shift from international public and private interactions to global health partnerships (GHPs)--and in the process create a new institutional mechanism for governing global health. Drawing on insights from constructivist analysis, I demonstrate how discourse justified, legitimised, communicated and coordinated ideas about the practice of GHPs through a concentrated network of partnership pioneers. As attention from health policy analysts turns increasingly to ideational explanations for answers to global health problems, this paper contributes to the debate by showing how, precisely, discourse makes change possible.

Circus monkeys or change agents? Civil society advocacy for HIV/AIDS in adverse policy environments.

This paper explores the factors enabling and undermining civil society efforts to advocate for policy reforms relating to HIV/AIDS and illicit drugs in three countries in Eastern Europe and Central Asia: Georgia, Kyrgyzstan and Ukraine. It examines how political contexts and civil society actors' strengths and weaknesses inhibit or enable advocacy for policy change - issues that are not well understood in relation to specific policy areas such as HIV/AIDS, or particular regions of the world where national policies are believed to be major drivers of the HIV/AIDS epidemic. The study is based on in-depth interviews with representatives of civil society organizations (CSOs) (n = 49) and national level informants including government and development partners (n = 22). Our policy analysis identified a culture of fear derived from concerns for personal safety but also risk of losing donor largesse. Relations between CSOs and government were often acrimonious rather than synergistic, and while we found some evidence of CSO collective action, competition for external funding - in particular for HIV/AIDS grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria was often divisive. Development partners and government tend to construct CSOs as service providers rather than advocates. While some advocacy was tolerated by governments, CSO participation in the policy process was, ultimately, perceived to be tokenistic. This was because there are financial interests in maintaining prohibitionist legislation: efforts to change punitive laws directed at the behaviors of minority groups such as injecting drug users have had limited impact.

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.