Knowledge integration in One Health policy formulation, implementation and evaluation.

The One Health concept covers the interrelationship between human, animal and environmental health and requires multistakeholder collaboration across many cultural, disciplinary, institutional and sectoral boundaries. Yet, the implementation of the One Health approach appears hampered by shortcomings in the global framework for health governance. Knowledge integration approaches, at all stages of policy development, could help to address these shortcomings. The identification of key objectives, the resolving of trade-offs and the creation of a common vision and a common direction can be supported by multicriteria analyses. Evidence-based decision-making and transformation of observations into narratives detailing how situations emerge and might unfold in the future can be achieved by systems thinking. Finally, transdisciplinary approaches can be used both to improve the effectiveness of existing systems and to develop novel networks for collective action. To strengthen One Health governance, we propose that knowledge integration becomes a key feature of all stages in the development of related policies. We suggest several ways in which such integration could be promoted.

Le concept «Un monde, une santé¼ a trait aux corrélations entre la santé humaine, la santé animale et l'environnement, et requiert la collaboration de différentes parties prenantes sur de nombreux plans culturels, disciplinaires, institutionnels et sectoriels. Or, la mise en œuvre de ce principe est rendue difficile par des défauts du cadre mondial de gouvernance en matière de santé. Les approches qui visent à regrouper les connaissances, à toutes les étapes de l'élaboration des politiques, pourraient permettre de résoudre ces défauts. Des analyses multicritères pourraient contribuer à définir des objectifs clés, à résoudre les compromis et à créer une vision et une direction communes. Une pensée systémique pourrait déboucher sur une prise de décisions d'après des éléments probants et transformer les observations en descriptions détaillant la manière dont des situations surviennent et pourraient évoluer dans l'avenir. Enfin, des approches transdisciplinaires pourraient permettre d'améliorer l'efficacité des systèmes existants tout en développant de nouveaux réseaux d'action collective. Afin de renforcer la gouvernance du principe «Un monde, une santé¼, nous proposons que le regroupement des connaissances devienne un élément clé de toutes les étapes de l'élaboration des politiques relatives à ce principe et suggérons plusieurs manières de favoriser ce regroupement.

El concepto de One Health cubre la interrelación entre la salud humana, animal y ambiental, y exige la colaboración de varias partes interesadas atravesando diversos límites culturales, disciplinarios, institucionales y sectoriales. Sin embargo, la implementación del enfoque de One Health parece verse obstaculizado por deficiencias en el marco global de la gobernanza sanitaria. Los enfoques de integración de conocimientos, en todas las etapas del desarrollo de la política, podrían contribuir a abordar estas deficiencias. Los análisis basados en numerosos criterios permiten respaldar la identificación de objetivos claves, la resolución de dilemas y la creación de una visión común y una dirección común. El pensamiento sistémico puede lograr la toma de decisiones basadas en pruebas y la transformación de las observaciones en textos donde se describa detalladamente cómo surgen las situaciones y cómo estas podrían desarrollarse en el futuro. Por último, pueden emplearse enfoques transdisciplinarios para mejorar la efectividad de los sistemas existentes y desarrollar redes innovadoras para la acción colectiva. A fin de fortalecer la gobernanza de One Health, proponemos que la integración de conocimientos se convierta en un aspecto clave de todas las etapas del desarrollo de las políticas relacionadas con One-Health. Sugerimos diferentes maneras de promover dicha integración.

System Thinking and Citizen Participation Is Still Missing in One Health Initiatives - Lessons From Fifteen Evaluations.

Tackling complex public health challenges requires integrated approaches to health, such as One Health (OH). A key element of these approaches is the integration of knowledge across sectors, disciplines and stakeholders. It is not yet clear which elements of knowledge integration need endorsement to achieve best outcomes. This paper assesses 15 OH initiatives in 16 African, Asian and European countries to identify opportunities to improve knowledge integration and to investigate geographic influences on knowledge integration capacities. Two related evaluation tools, both relying on semi-quantitative questionnaires, were applied to two sets of case studies. In one tool, the questions relate to operations and infrastructure, while the other assigns questions to the three phases of "design," "implementation," and "evaluation" of the project life cycle. In both, the question scores are aggregated using medians. For analysis, extreme values were identified to highlight strengths and weaknesses. Seven initiatives were assessed by a single evaluator external to the initiative, and the other eight initiatives were jointly assessed by several internal and external evaluators. The knowledge integration capacity was greatest during the project implementation stage, and lowest during the evaluation stage. The main weaknesses pointing towards concrete potential for improvement were identified to be a lack of consideration of systemic characteristics, missing engagement of external stakeholders and poor bridging of knowledge, amplified by the absence of opportunities to learn and evolve in a collective process. Most users were unfamiliar with the systems approach to evaluation and found the use of the tools challenging, but they appreciated the new perspective and saw benefits in the ensuing reflections. We conclude that systems thinking and associated practises for OH require not only specific education in OH core competencies, but also methodological and institutional measures to endorse broad participation. To facilitate meta-analyses and generic improvement of integrated approaches to health we suggest including knowledge integration processes as elements to report according to the COHERE guidelines.

Access and Benefit Sharing Under the Nagoya Protocol-Quo Vadis? Six Latin American Case Studies Assessing Opportunities and Risk.

BACKGROUND: Global challenges related to access and benefit sharing (ABS) of biological resources have become a key concern in the area of research on herbal medicines, ethnopharmacology, drug discovery, and the development of other high value products for which Intellectual Property protection can be secured. While the Convention on Biological Diversity (CBD, Rio 1992) has been recognized as a huge step forward, the implementation of the Nagoya Protocol (NP) and of new forms of collaboration often remain unresolved, especially in the context of "the fair and equitable sharing of benefits arising from the utilization of genetic resources" (Convention on Biological Diversity, 2011). The vision and the specific implementation of this international treaty vary from country to country, which poses additional challenges. AIMS: Using a case study approach, in this analysis we aim at understanding the specific opportunities and challenges for implementing international collaborations regarding ABS in six Latin American countries-Chile, Colombia, Guatemala, México, Panama, and Peru. Based on that analysis, we provide recommendations for the path ahead regarding international collaborations under ABS agreements in ethnopharmacological research. RESULTS AND DISCUSSIONS: The implementation of the NP varies in the six countries; and while they are all rich in biodiversity, access and benefit sharing mechanisms differ considerably. There is a need to engage in a consultation process with stakeholders, but this has often come to a halt. Institutional infrastructures to implement national policies are weak, and the level of knowledge about the NP and the CBD within countries remains limited. CONCLUSIONS: Different policies in the six countries result in very diverse strategies and opportunities relating to the equitable use of biodiversity. A long-term strategy is required to facilitate a better understanding of the treaties and the resulting opportunities for a fairer development and implementation of transparent national polices, which currently differ in the six countries. So far, the benefits envisioned by the CBD and the NP remain unfulfilled for all stakeholders involved including local communities.

Patient-centered boundary mechanisms to foster intercultural partnerships in health care: a case study in Guatemala.

BACKGROUND: Up to one half of the population in Africa, Asia and Latin America has little access to high-quality biomedical services and relies on traditional health systems. Medical pluralism is thus in many developing countries the rule rather than the exception, which is why the World Health Organization is calling for intercultural partnerships to improve health care in these regions. They are, however, challenging due to disparate knowledge systems and lack of trust that hamper understanding and collaboration. We developed a collaborative, patient-centered boundary mechanism to overcome these challenges and to foster intercultural partnerships in health care. To assess its impact on the quality of intercultural patient care in a medically pluralistic developing country, we conducted and evaluated a case study. METHODS: The case study took place in Guatemala, since previous efforts to initiate intercultural medical partnerships in this country were hampered by intense historical and societal conflicts. It was designed by a team from ETH Zurich's Transdisciplinarity Lab, the National Cancer Institute of Guatemala, two traditional Councils of Elders and 25 Mayan healers from the Kaqchikel and Q'eqchi' linguistic groups. It was implemented from January 2014 to July 2015. Scientists and traditional political authorities collaborated to facilitate workshops, comparative diagnoses and patient referrals, which were conducted jointly by biomedical and traditional practitioners. The traditional medical practices were thoroughly documented, as were the health-seeking pathways of patients, and the overall impact was evaluated. RESULTS: The boundary mechanism was successful in discerning barriers of access for indigenous patients in the biomedical health system, and in building trust between doctors and healers. Learning outcomes included a reduction of stereotypical attitudes towards traditional healers, improved biomedical procedures due to enhanced self-reflection of doctors, and improved traditional health care due to refined diagnoses and adapted treatment strategies. In individual cases, the beneficial effects of traditional treatments were remarkable, and the doctors continued to collaborate with healers after the study was completed. Comparison of the two linguistic groups illustrated that the outcomes are highly context-dependent. CONCLUSIONS: If well adapted to local context, patient-centered boundary mechanisms can enable intercultural partnerships by creating access, building trust and fostering mutual learning, even in circumstances as complex as those in Guatemala. Creating multilateral patient-centered boundary mechanisms is thus a promising approach to improve health care in medically pluralistic developing countries.

Maya phytomedicine in Guatemala - Can cooperative research change ethnopharmacological paradigms?

ETHNOPHARMACOLOGICAL RELEVANCE: This paper presents one of the first large-scale collaborative research projects in ethnopharmacology, to bring together indigenous stakeholders and scientists both in project design and execution. This approach has often been recommended but rarely put into practice. The study was carried out in two key indigenous areas of Guatemala, for which very little ethnopharmacological fieldwork has been published. AIM OF THE STUDY: To document and characterize the ethno-pharmacopoeias of the Kaqchikel (highlands) and Q'eqchi' (lowlands) Maya in a transdisciplinary collaboration with the two groups Councils of Elders. MATERIALS AND METHODS: The project is embedded in a larger collaboration with five Councils of Elders representing important indigenous groups in Guatemala, two of which participated in this study. These suggested healing experts reputed for their phytotherapeutic knowledge and skills. Ethnobotanical fieldwork was carried out over 20 months, accompanied by a joint steering process and validation workshops. The field data were complemented by literature research and were aggregated using a modified version of the International Classification of Diseases (ICD-10) and Trotter & Logan's consensus index. RESULTS: Similar numbers of species were collected in the two areas, with a combined total of 530 species. This total does not represent all of the species used for medicinal purposes. Remedies for the digestive system, the central nervous system & behavioral syndromes, and general tissue problems & infections were most frequent in both areas. Furthermore, remedies for the blood, immune & endocrine system are frequent in the Kaqchikel area, and remedies for the reproductive system are frequent in the Q'eqchi' area. Consensus factors are however low. The Kaqchikel, in contrast to the Q'eqchi', report more remedies for non-communicable illnesses. They also rely heavily on introduced species. DISCUSSION AND CONCLUSIONS: The transdisciplinary research design facilitated scientifically rigorous and societally relevant large-scale fieldwork, which is clearly beneficial to indigenous collaborators. It provided access and built trust as prerequisites for assembling the largest comparative ethnopharmacological collection, vastly extending knowledge on Maya phytotherapy. The collection represents knowledge of the two groups' most reputed herbalists and is a representative selection of the Guatemalan medicinal flora. ICD-10 proved useful for making broad comparisons between the groups, but more refined approaches would be necessary for other research objectives. Knowledge in the two areas is highly diverse and seems fragmented. New approaches are required to assess how coherent Maya phytotherapy is. The documented 'traditional' ethno-pharmacopoeias demonstrate dynamic change and acculturation, reflecting the two linguistic groups' sociocultural history and context. This highlights the adaptive potential of phyto-therapeutic knowledge and calls the equation of local indigenous pharmacopoeias with 'traditional' medicine into question. We suggest using the term 'local' pharmacopoeias, and reserving the term 'traditional' for the study of indigenous pharmacopoeias with a clear delineation of ancient knowledge.