Primary health care contributions to universal health coverage, Ethiopia.

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population's health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

De nombreux organismes sanitaires internationaux, dont l'Organisation mondiale de la Santé, considèrent que les soins de santé primaires représentent un jalon essentiel du cheminement vers une couverture maladie universelle (CMU). Néanmoins, des inquiétudes subsistent quant à la faisabilité et à l'efficacité de cette approche dans les pays à faible revenu. L'Éthiopie a adopté cette approche depuis le milieu des années 1970, et les soins de santé primaires figurent au cœur du système sanitaire depuis 1993. Pourtant, rares sont les preuves exhaustives et généralisées concernant la pratique et le rôle des soins de santé primaires dans l'évolution vers une CMU en Éthiopie. Nous avons donc procédé à un examen des documents contenant des données qualitatives et quantitatives accessibles au public. À l'aide du cadre instauré par l'initiative PHCPI (Primary Health Care Performance Initiative), nous avons décrit et analysé la pratique des soins de santé primaires; nous avons également identifié les réussites et les défis. C'est grâce à des politiques, stratégies et programmes en adéquation avec les priorités nationales que cette méthode axée sur les soins de santé primaires a pu être mise en œuvre en Éthiopie. Le pays a emprunté une approche diagonale vis-à-vis des programmes de contrôle des maladies, tout en renforçant les systèmes de santé, l'autonomie des communautés et l'action multisectorielle. Ces stratégies lui ont permis d'augmenter la prise en charge des services de santé et d'améliorer l'état de santé de la population. Il reste cependant d'importants défis à relever: couverture insuffisante des services, inégalités d'accès, lenteur de transition entre systèmes sanitaires pour la fourniture de prestations liées aux maladies non transmissibles, qualité médiocre des soins et frais non remboursables élevés. Afin de combler les lacunes au sein et en dehors du système de santé, le pays doit revoir le montant du financement octroyé aux soins de santé à la hausse, mais aussi cibler les régions et populations défavorisées par le biais d'une approche de précision en matière de santé publique. Ces défis doivent être abordés tout au long du programme de développement durable.

Varias instituciones sanitarias mundiales, incluida la Organización Mundial de la Salud, opinan que la atención primaria de salud es la vía hacia el logro de la cobertura sanitaria universal (CSU). Sin embargo, persisten las preocupaciones acerca de la viabilidad y la eficacia de este enfoque en los países de bajos recursos. Etiopía aplica el enfoque de la atención primaria de salud desde mediados del decenio de 1970, por lo que la atención primaria de salud es el núcleo del sistema de salud desde 1993. No obstante, Etiopía carece de pruebas integrales y generales sobre la práctica y la función de la atención primaria de salud orientada a la CSU. Se realizó un análisis documental de los datos cualitativos y cuantitativos a disposición del público. Se describe y analiza la práctica de la atención primaria de salud y se determinan los éxitos y los desafíos por medio del marco de la Iniciativa sobre el desempeño de la atención primaria de salud. La aplicación del enfoque de la atención primaria de salud en Etiopía fue posible gracias a las políticas, las estrategias y los programas que se adaptaron a las prioridades del país. Existe un enfoque diagonal de los programas de control de enfermedades sumado al fortalecimiento de los sistemas sanitarios, a la participación de la comunidad y a las medidas multisectoriales. Gracias a estas estrategias, el país ha logrado aumentar la cobertura de los servicios sanitarios y mejorar el estado de salud de la población. Sin embargo, aún quedan por resolver algunos desafíos fundamentales, como la cobertura insuficiente de los servicios, la falta de equidad en el acceso, la lentitud de la transición de los sistemas sanitarios para prestar los servicios correspondientes a las enfermedades no transmisibles, la calidad deficiente de la atención y los elevados gastos de bolsillo. Para resolver las deficiencias del sistema sanitario y otros aspectos, el país debe mejorar su financiamiento nacional para la salud y centrarse en los lugares y las poblaciones desfavorecidos a través de un enfoque preciso de la salud pública. Se debe abordar estos desafíos en todo el programa de desarrollo sostenible.

Leaving no one behind: lessons from implementation of policies for universal HIV treatment to universal health coverage.

BACKGROUND: The third Sustainable Development Goal (SDG - 3) aims to ensure healthy lives and promote well-being for all at all ages. SDG-3 has a specific target on universal health coverage (UHC), which emphasizes the importance of all people and communities having access to quality health services without risking financial hardship. The objective of this study is to review progress towards UHC using antiretroviral treatment (ART) as a case study. METHODS: We used a mixed-methods design including qualitative and quantitative approaches. We reviewed and synthesised the evidence on the evolution of the WHO HIV treatment guidelines between 2002 and 2019. We calculated ART coverage over time by gender, age group, and location. We also estimated ART coverage differences and ratios. FINDINGS: ART guidelines have evolved from "treating the sickest" to "treating all". ART coverage increased globally from under 7% in 2005 to 62% in 2018. There have been successes in increasing ART coverage in all populations and locations. However, progress varies by population and location in many regions. There is inequity in ART coverage: women (68%) versus men (55%), and adults (62%) versus children (54%). This inequity has widened over time, and with expanded ART eligibility criteria. On the other hand, data from at least one high-burden country (Ethiopia) shows that inequity among regions has narrowed over time due to the improvements in the primary health care systems and implementation of the public health approach in the country. CONCLUSION: ART coverage has increased at global, regional and national levels to all population groups. However, the gains have not been equitable among locations and populations. Policies towards universality may widen the inequity in resource-limited settings unless countries take precautions and "put the last first". We argue that primary health care and public health approaches, with multi-sectoral actions and community engagement, are vital to minimize inequity, achieve UHC and leave no one behind.

Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia.

Weakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Since 2013, Ethiopia has had a decline in development assistance for health. Nevertheless, the Ethiopian Government has been able to compensate for this decline by increasing domestic resources. We argue that the diagonal investment approach can effectively strengthen PHC systems, achieve DCP targets, and sustain the gains. These goals can be achieved if a visionary and committed leadership coordinates its development partners and mobilises the local community, to ensure financial support to health services and improve population health. The lessons learnt from Ethiopia's efforts to improve its health services indicate that global-health initiatives should have a proactive and balanced investment approach to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains, in resource-poor settings.

Cambodia's health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility.

BACKGROUND: From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia. METHODS: This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility. RESULTS: Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms. CONCLUSION: The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.

Australia's overseas development aid commitment to health through the sustainable development goals: a multi-stakeholder perspective.

BACKGROUND: In 2018, the Australian Government, through a Senate-led Parliamentary Inquiry, sought the views of diverse stakeholders on Sustainable Development Goal (SDG) implementation both domestically and as part of Australia's Overseas Development Assistance (ODA) program. One hundred and sixty-four written submissions were received. The submissions offered perspective and guidance from a rich cross-section of those involved, and with keen interest in, Australia's ODA-SDG commitment. This article identifies and explores the submissions to that Inquiry which placed impetus on Australia's ODA-SDG and health and development nexus. It then compares how the synthesized views, concerns and priorities of selected Inquiry stakeholders align with and reflect the Australian Government's treatment of SDG 3 in its SDG Voluntary National Review (VNR), as well as with the final Inquiry report summarizing submission content. RESULTS: Four key themes were synthesized and drawn from the thirty-one stakeholder submissions included in our analysis. Disconnect was then found to exist between the selected stakeholder views and the Australian Government's SDG-VNR's treatment of SDG 3, as well as with the content of the Parliamentary Inquiry's final report with respect to the ODA-SDG and health and development nexus. CONCLUSIONS: We situate the findings of our analysis within the wider strategic context of the Australian Government's policy commitment to "step up" in the Pacific region. This research provides an insight into both multi-stakeholder and Federal Government views on ODA in the Indo-Pacific region, especially at a time when Australia's Pacific engagement has come to the forefront of both foreign and security policy. We conclude that the SDG agenda, including the SDG health and development agenda, could offer a unique vehicle for enabling a paradigm shift in the Australian Government's development approach toward the Pacific region and its diverse peoples. This potential is strongly reflected in stakeholder perspectives included in our analysis. However, study findings remind that the political determinants of health, and overlapping political determinants of SDG achievement, will be instrumental in the coming decade, and that stakeholders from different sectors need to be genuinely engaged in SDG-ODA policy-related decision-making and planning by governments in both developed and developing countries alike.

Community health extension program of Ethiopia, 2003-2018: successes and challenges toward universal coverage for primary healthcare services.

BACKGROUND: Ethiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services. METHODS: We conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies. FINDINGS: The HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP. CONCLUSION: The HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.

Health and the Sustainable Development Goals: Challenges for four Pacific countries.

Sustainable Development Goal 3 (SDG 3) focuses on health and well-being. To understand the in-country monitoring challenges for developing countries of reporting against SDG 3, this research sought published data for the four Pacific countries of Fiji, Papua New Guinea (PNG), the Solomon Islands, and Vanuatu-within a region with well-documented and significant health challenges. This research found that there are limited recent, comprehensive, and comparable data with identified sources against the SDG 3 outcome indicators at an in-country level. Without such data, there is a risk of relying on data that may be inaccurate because of aggregation, estimation, and modelling. The results from these data can influence the funding and other resources that could be made available to the Melanesian countries to address health inequities.

Validation of verbal autopsy methods using hospital medical records: a case study in Vietnam.

BACKGROUND: Information on causes of death (COD) is crucial for measuring the health outcomes of populations and progress towards the Sustainable Development Goals. In many countries such as Vietnam where the civil registration and vital statistics (CRVS) system is dysfunctional, information on vital events will continue to rely on verbal autopsy (VA) methods. This study assesses the validity of VA methods used in Vietnam, and provides recommendations on methods for implementing VA validation studies in Vietnam. METHODS: This validation study was conducted on a sample of 670 deaths from a recent VA study in Quang Ninh province. The study covered 116 cases from this sample, which met three inclusion criteria: a) the death occurred within 30 days of discharge after last hospitalisation, and b) medical records (MRs) for the deceased were available from respective hospitals, and c) the medical record mentioned that the patient was terminally ill at discharge. For each death, the underlying cause of death (UCOD) identified from MRs was compared to the UCOD from VA. The validity of VA diagnoses for major causes of death was measured using sensitivity, specificity and positive predictive value (PPV). RESULTS: The sensitivity of VA was at least 75% in identifying some leading CODs such as stroke, road traffic accidents and several site-specific cancers. However, sensitivity was less than 50% for other important causes including ischemic heart disease, chronic obstructive pulmonary diseases, and diabetes. Overall, there was 57% agreement between UCOD from VA and MR, which increased to 76% when multiple causes from VA were compared to UCOD from MR. CONCLUSIONS: Our findings suggest that VA is a valid method to ascertain UCOD in contexts such as Vietnam. Furthermore, within cultural contexts in which patients prefer to die at home instead of a healthcare facility, using the available MRs as the gold standard may be meaningful to the extent that recall bias from the interval between last hospital discharge and death can be minimized. Therefore, future studies should evaluate validity of MRs as a gold standard for VA studies in contexts similar to the Vietnamese context.

What did the Go4Health policy research project contribute to the policy discourse on the sustainable development goals? A reflexive review.

BACKGROUND: In 2012, the European Commission funded Go4Health-Goals and Governance for Global Health, a consortium of 13 academic research and human rights institutions from both Global North and South-to track the evolution of the Sustainable Development Goals (SDGs), and provide ongoing policy advice. This paper reviews the research outputs published between 2012 and 2016, analyzing the thematic content of the publications, and the influence on global health and development discourse through citation metrics. FINDINGS AND DISCUSSION: Analysis of the 54 published papers showed 6 dominant themes related to the SDGs: the formulation process for the SDG health goal; the right to health; Universal Health Coverage; voices of marginalized peoples; global health governance; and the integration of health across the other SDGs. The papers combined advocacy---particularly for the right to health and its potential embodiment in Universal Health Coverage-with qualitative research and analysis of policy and stakeholders. Go4Health's publications on the right to health, global health governance and the voices of marginalized peoples in relation to the SDGs represented a substantial proportion of papers published for these topics. Go4Health analysis of the right to health clarified its elements and their application to Universal Health Coverage, global health governance, financing the SDGs and access to medicines. Qualitative research identified correspondence between perceptions of marginalized peoples and right to health principles, and reluctance among multilateral organizations to explicitly represent the right to health in the goals, despite their acknowledgement of their importance. Citation metrics analysis confirmed an average of 5.5 citations per paper, with a field-weighted citation impact of 2.24 for the 43 peer reviewed publications. Citations in the academic literature and UN policy documents confirmed the impact of Go4Health on the global discourse around the SDGs, but within the Go4Health consortium there was also evidence of two epistemological frames of analysis-normative legal analysis and empirical research-that created productive synergies in unpacking the health SDG and the right to health. CONCLUSION: The analysis offers clear evidence for the contribution of funded programmatic research-such as the Go4Health project-to the global health discourse.

Correspondence regarding 'Assefa Y, et al., BMC Health Services Research. 2011; 11 (1):81 and 2014; 14(1):45': The Positive-Deviance approach for translating evidence into practice to improve patient retention in HIV care.

The purpose of this correspondence is to describe how the positive-deviance approach can be used to translate evidence into practice, based on successive studies conducted in Ethiopia. In earlier studies, it was identified that retention in antiretroviral treatment care was variable across health facilities; and, seeking compliance across facilities, a framework was developed based on the practices of those positive-deviant health facilities, where performance was noted to be markedly better. It was found that the positive deviance approach was effective in facilitating the transfer of innovative practices (using different mechanisms) from positive-deviant health facilities to negative-deviant health facilities. As a result, the variability in retention in care across health facilities narrowed over time, increasing from 83 to 96% in 2007/8 to 95-97% in 2013/14. In conclusion, the positive-deviance approach is a valuable tool to translate evidence into practice, spread good practices, and help achieving universal health coverage.

Great expectations: An analysis of researchers' and policy makers' perceptions of the potential value of the Australian indigenous burden of disease study for policy.

The "Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples" was commissioned by the Australian government as part of the Australian Burden of Disease study. This paper explores the extent to which key actors in the research and policy communities expected the Indigenous Burden of Disease study's findings to inform, influence, or drive federal decisions concerning Indigenous health in Australia. This qualitative research undertook interviews with 13 key informants with significant involvement in the Indigenous Burden of Disease study: six researchers, five policy makers, and two knowledge brokers. Interviews were recorded, transcribed, and analyzed, and the findings were triangulated with a review of the literature. Policy makers and researchers anticipated that the Indigenous Burden of Disease study would improve the available information for policy deliberations about Indigenous health. Beyond that, their expectations about its policy influence differed substantially, with researchers more confident of the study's capacity to guide health priorities, and policy makers situating findings in the context of other critical inputs. Expectations of policy influence are shaped by the disciplinary perspectives of actors, and their relationship to policy outcomes and cannot be examined without also considering the policy, political, and financing context of the study being analyzed.

Regulating the for-profit private healthcare providers towards universal health coverage: A qualitative study of legal and organizational framework in Mongolia.

BACKGROUND: Regulating the behavior of private providers in the context of mixed health systems has become increasingly important and challenging in many developing countries moving towards universal health coverage including Mongolia. This study examines the current regulatory architecture for private healthcare in Mongolia exploring its role for improving accessibility, affordability, and quality of private care and identifies gaps in policy design and implementation. METHODS: Qualitative research methods were used including documentary review, analysis, and in-depth interviews with 45 representatives of key actors involved in and affected by regulations in Mongolia's mixed health system, along with long-term participant observation. RESULTS: There has been extensive legal documentation developed regulating private healthcare, with specific organizations assigned to conduct health regulations and inspections. However, the regulatory architecture for healthcare in Mongolia is not optimally designed to improve affordability and quality of private care. This is not limited only to private care: important regulatory functions targeted to quality of care do not exist at the national level. The imprecise content and details of regulations in laws inviting increased political interference, governance issues, unclear roles, and responsibilities of different government regulatory bodies have contributed to failures in implementation of existing regulations.

Exploring governance for a One Health collaboration for leptospirosis prevention and control in Fiji: Stakeholder perceptions, evidence, and processes.

Fiji has a high burden of leptospirosis, with endemic infection and epidemic outbreaks with high mortality, often associated with flooding and cyclones. As a zoonosis, leptospirosis control requires interventions in sectors beyond the usual control of health-in Fiji, the dairy and sugar industries, and water and sanitation and rodent control in communities. This paper presents the findings of qualitative research to inform policy around governance for a One Health multisectoral approach to leptospirosis control. METHODS: Key informants from relevant government agencies and industry organizations were interviewed in late 2014, and the interviews analyzed and triangulated with documentary analysis. FINDINGS: The analysis identified 5 themes: perceptions of the impact of leptospirosis, governance processes, models for collaboration, leptospirosis control, and preferred leadership for leptospirosis management. Data were limited, with poor communication between ministries, and limited awareness of leptospirosis outside outbreaks. Collaboration during outbreaks was positive but not sustained in endemic periods. Mechanism for enhanced collaboration was developed for endemic and outbreak situations. CONCLUSION: The findings informed a One Health governance approach to leptospirosis, framed within a National Strategic Plan, with a specific National Action Plan for Leptospirosis. The process provides a research based One Health template for application to other zoonotic diseases.

The power of talk and power in talk: a systematic review of Indigenous narratives of culturally safe healthcare communication.

The study aimed to explore Indigenous narrative accounts of healthcare access within qualitative research papers, to better understand Indigenous views on culturally safe healthcare and health communication represented in that literature. A systematic literature review of peer-reviewed academic qualitative studies identified 65 papers containing Indigenous respondents' views on accessing healthcare. Analysis included all Indigenous voice (primary quotations) and author findings describing healthcare access across these studies. Healthcare communication, or 'talk', emerged as a key theme. Indigenous clients valued talk within healthcare interactions; it was essential to their experience of care, having the power to foster relationships of trust, strengthen engagement and produce positive outcomes. By mediating the power differentials between health professionals and Indigenous clients, talk could either reinforce powerlessness, through judgmental down-talk, medical jargon or withholding of talk, or empower patients with good talk, delivered on the client's level. Good talk is a critical ingredient to improving Indigenous accessibility and engagement with healthcare services, having the ability to minimise the power differentials between Indigenous clients and the healthcare system.

Access to medicines and hepatitis C in Africa: can tiered pricing and voluntary licencing assure universal access, health equity and fairness?

BACKGROUND: The recent introduction of Direct Acting Antivirals (DAAs) for treating Hepatitis C Virus (HCV) can significantly assist in the world reaching the international target of elimination by 2030. Yet, the challenge facing many individuals and countries today lies with their ability to access these treatments due to their relatively high prices. Gilead Sciences applies differential pricing and licensing strategies arguing that this provides fairer and more equitable access to these life-saving medicines. This paper analyses the implications of Gilead's tiered pricing and voluntary licencing strategy for access to the DAAs. METHODS: We examined seven countries in Africa (Egypt, Ethiopia, Nigeria, Democratic Republic of Congo, Cameroon, Rwanda and South Africa) to assess their financial capacity to provide DAAs for the treatment of HCV under present voluntary licensing and tiered-pricing arrangements. These countries have been selected to explore the experience of countries with a range of different burdens of HCV and shared eligibility for supply by licensed generic producers or from discounted Gilead prices. RESULTS: The cost of 12-weeks of generic DAA varies from $684 per patient treated in Egypt to $750 per patient treated in other countries. These countries can also procure the same DAA for 12-weeks of treatment from the originator, Gilead, at a cost of $1200 per patient. The current prices of DAAs (both from generic and originator manufacturers) are much more than the median annual income per capita and the annual health budget of most of these countries. If governments alone were to bear the costs of universal treatment coverage, then the required additional health expenditure from present rates would range from a 4% increase in South Africa to a staggering 403% in Cameroon. CONCLUSION: The current arrangements for increasing access to DAAs, towards elimination of HCV, are facing challenges that would require increases in expenditure that are either too burdensome to governments or potentially so to individuals and families. Countries need to implement the flexibilities in the Doha Declaration on Trade Related Intellectual Property Rights agreement, including compulsory licensing and patent opposition. This also requires political commitment, financial will, global solidarity and civil society activism.

A process for developing multisectoral strategies for zoonoses: the case of leptospirosis in Fiji.

BACKGROUND: Zoonotic diseases such as leptospirosis occur as a result of the often complex interactions that exist at the human-animal-environment interface. The most obvious consequence of this complexity is the need for the health sector to partner with institutions in other sectors of society such as agriculture, labour and local government. This multisectoral engagement is complicated by the different agendas and cultures of the various institutions and their ability to "see" their role and ant benefits in a collaborative response. METHODS: The research used a realist review methodology combined with systems thinking frameworks to determine the optimal strategy and governance for the prevention and control of leptospirosis in Fiji. The process included facilitated workshops with multiple stakeholders to determine the needs, issues and potential interventions that was guided by a synthesis of locally available data and information on the impact of leptospirosis. This process was informed by interviews with bureaucrats from different government ministries. RESULTS: Stakeholders concurred that leptospirosis generally only received wide-spread attention in outbreaks, when there is media coverage of deaths or a large number of hospitalisations. In general, all ministries expressed support for a multisectoral strategy but saw the Ministry of Health and Medical Services as the lead agency with overall responsibility. The final consultation workshop yielded a clearly articulated goal to reduce the case fatality rate attributable to leptospirosis by 50% by 2020 and 4 overarching strategies: 1) improved clinical management of leptospirosis, 2) improved surveillance for leptospirosis, 3) enhanced communication to minimise risk and improve health seeking behaviours, and 4) strengthening coordination and governance structures. CONCLUSION: Human mortality and morbidity remained the primary drive for government action, defining leptospirosis as a human health problem. The process of deliberative consultation, and the engagement of multidisciplinary partners has provided a platform for collaborative policy development, and a consensus for a National Action Plan from which further negotiated collaboration will be possible.

Cautionary Notes on a Global Tiered Pricing Framework for Medicines.

Recently, there has been a policy momentum toward creating a global tiered pricing framework, which would provide differentiated prices for medicines globally, based on each country's capacity to pay. We studied the most influential proposals for a tiered pricing framework since the 1995 World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights. We synthesized 6 critical questions to be addressed for a global framework to function and explored the many challenges of implementation. Although we acknowledge that there is the potential for an exceptional global commitment that would benefit both producers and those in developing countries in need of wider access to medicines, our greatest concern is to ensure that a global framework does not price out the poor from pharmaceutical markets nor threaten current flexibilities within the international patent regime.

From knowing our needs to enacting change: findings from community consultations with indigenous communities in Bangladesh.

INTRODUCTION: Indigenous peoples are among the most marginalized peoples in the world due to issues relating to well-being, political representation, and economic production. The research consortium Goals and Governance for Global Health (Go4Health) conducted a community consultation process among marginalized groups across the global South aimed at including their voices in the global discourse around health in the post-2015 development agenda. This paper presents findings from the consultations carried out among indigenous communities in Bangladesh. METHODS: For this qualitative study, our research team consulted the Tripura and Mro communities in Bandarban district living in the isolated Chittagong Hill Tracts region. Community members, leaders, and key informants working in health service delivery were interviewed. Data was analyzed using thematic analysis. FINDINGS: Our findings show that remoteness shapes the daily lives of the communities, and their lack of access to natural resources and basic services prevents them from following health promotion messages. The communities feel that their needs are impossible to secure in a politically indifferent and sometimes hostile environment. CONCLUSION: Communities are keen to participate and work with duty bearers in creating the conditions that will lead to their improved quality of life. Clear policies that recognize the status of indigenous peoples are necessary in the Bangladeshi context to allow for the development of services and infrastructure.

The individual, the government and the global community: sharing responsibility for health post-2015 in Vanuatu, a small island developing state.

INTRODUCTION: The end of 2015 will see the creation of the sustainable development goals - the new global framework for development. The process of creating universally relevant goals has involved community consultation throughout the world. Within this process it is vital that Pacific Island countries are included as they face particular development challenges due to their size and geographical location. As small island developing states, many Pacific Island countries struggle to overcome high rates of poverty and poor health outcomes. In order to include Pacific voices in the new health related sustainable development goals, Vanuatu was selected as a representative of the Pacific for this qualitative study. This paper presents the perspectives of communities throughout Vanuatu on their essential health needs and how best to meet them. METHODS: This paper examines the perspectives of 102 individuals from throughout Vanuatu. Ten focus group discussions and 2 individual interviews were conducted within communities in September 2013. Discussions focused on community perceptions of health, essential health needs, and responsibility in achieving health needs. Discussions were audio recorded and transcribed. The transcripts were then analysed using a theoretical thematic approach in order to identify central themes and subthemes. RESULTS: Individuals in this study demonstrated a comprehensive understanding of health, defining health in a holistic manner. Participants identified clear environmental and societal factors that impact upon health, and emphasized failures within the current health system as important barriers to attaining good health. Participants described the challenges faced in taking responsibility for one's health, and pointed to both the government and the international community as key players in meeting the essential health needs of communities. CONCLUSIONS: As a small island developing state, Vanuatu faces accentuated development challenges - particularly as globalisation and climate change progress. The individuals and communities in this study demonstrate a clear understanding of their needs, and show a strong desire for change. They point to both the government and the international community to assist in meeting health needs, and stress that respect for traditional governance and community involvement in decision-making are vital in this process. In order to ensure that the new health goals effectively meet local needs in Vanuatu such factors must be incorporated into policy and implementation decision-making.

Human resources for health in six healthcare arenas under stress: a qualitative study.

BACKGROUND: Research on "human resources for health" (HRH) typically focuses on the public health subsector, despite the World Health Organization's inclusive definition to the contrary. This qualitative research examines the profile of HRH in six conflict-affected contexts where the public health subsector does not dominate healthcare service provision and HRH is a less coherent and cohesive entity: Afghanistan, the Central African Republic (CAR), the Democratic Republic of Congo (DR Congo), Haiti, the Occupied Palestinian Territories and Somalia. METHODS: The study uses a multiple-country qualitative research design including documentary analysis and key informant interviews undertaken between 2010 and 2012. The documentary analysis included peer-reviewed articles, books, unpublished research and evaluations and donor and non-government organisation reviews. A common thematic guide, informed by this analysis, was used to undertake key informant interviews. Informants thought able to provide some insight into the research questions were identified from ministry of health organograms, and from listings of donors and non-government organisations. Local informants outside the familiar structures were also contacted. In CAR, 74 were interviewed; in Somalia 25; . in Haiti, 45; in Afghanistan, 41; in DR Congo, 32; and in the Occupied Palestinian Territories, 30. In addition, peer review was sought on the initial country reports. RESULTS: The study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically. CONCLUSION: When examining HRH, a reliance on information provided by the state health sector can only provide a partial and inadequate representation of reality. For policy-makers and planners in disrupted contexts to begin to appreciate fully current and potential HRH, there is a need to study the workforce using conceptual tools that reflect the situation on the ground, rather than idealised patterns generated by incomplete inventories and unrealistic standards.