Women on the frontline: exploring the gendered experience for Pacific healthcare workers during the COVID-19 pandemic.

Background: Women comprise 90% of patient-facing global healthcare workers (HCWs), yet remain underpaid, undervalued, and under-represented in leadership and decision-making positions, particularly across the Pacific region. The COVID-19 pandemic has exacerbated these health workplace inequalities. We sought to understand Pacific women HCWs experience from the COVID-19 frontline to contribute to policies aimed at addressing gendered gaps in regional health systems. Methods: Our interpretative phenomenological study used critical feminist and social theory, and a gendered health systems analytical framework. Data were collected using online focus groups and in-depth interviews with 36 Pacific regional participants between March 2020 and July 2021. Gender-specific content and women's voices were privileged for inductive analysis by Pacific and Australian women researchers with COVID-19 frontline lived experience. Findings: Pacific women HCWs have authority and responsibility resulting from their familial, biological, and cultural status, but are often subordinate to men. They were emancipatory leaders during COVID-19, and as HCWs demonstrated compassion, situational awareness, and concern for staff welfare. Pacific women HCWs also faced ethical challenges to prioritise family or work responsibilities, safely negotiate childbearing, and maintain economic security. Interpretation: Despite enhanced gendered power differentials during COVID-19, Pacific women HCWs used their symbolic capital to positively influence health system performance. Gender-transformative policies are urgently required to address disproportionate clinical and community care burdens and to protect and support the Pacific female health workforce. Funding: Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Lessons from the frontline: Documenting the experiences of Pacific emergency care clinicians responding to the COVID-19 pandemic.

Low- and middle-income countries (LMICs) across the Pacific region have been severely impacted by the COVID-19 pandemic, and emergency care (EC) clinicians have been on the frontline of response efforts. Their responsibilities have extended from triage and clinical management of patients with COVID-19 to health system leadership and coordination. This has exposed EC clinicians to a range of ethical and operational challenges.This paper describes the context and methodology of a rapid, collaborative, qualitative research project that explored the experiences of EC clinicians in Pacific LMICs during the COVID-19 pandemic. The study was conducted in three phases, with data obtained from online regional EC support forums, key informant interviews and focus group discussions. A phenomenological approach was adopted, incorporating a hybrid inductive and deductive thematic analysis. Research findings, reported in other manuscripts in this collection, will inform multi-sectoral efforts to improve health system preparedness for future public health emergencies. Funding: Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z (Phases 1 and 2A) and an Australasian College for Emergency Medicine Foundation International Development Fund Grant.

Lessons from the frontline: Leadership and governance experiences in the COVID-19 pandemic response across the Pacific region.

Background: Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region. Methods: Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework. Findings: Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses. Interpretation: Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals. Funding: Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Lessons from the frontline: Documenting the pandemic emergency care experience from the Pacific region - Infrastructure and equipment.

Background: The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses. Methods: A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.' Findings: Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients. Interpretation: Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The value of emergency care processes and data to pandemic responses across the Pacific region.

Background: Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses. Methods: The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'. Findings: Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data. Interpretation: Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The COVID-19 pandemic emergency care experience from a human resource perspective in the Pacific region.

Background: This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge. Methods: Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management. Findings: 116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity. Interpretation: This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised. Funding: Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

"When all else fails you have to come to the emergency department": Overarching lessons about emergency care resilience from frontline clinicians in Pacific Island countries and territories during the COVID-19 pandemic.

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning. Search strategy and selection criteria: Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Court as a health intervention to advance Canada's achievement of the sustainable development goals : a multi-pronged analysis of Vancouver's Downtown Community Court.

BACKGROUND: The increase in problematic substance use is a major problem in Canada and elsewhere, placing a heavy burden on health and justice system resources given a spike in drug-related offences. Thus, achievement of Sustainable Development Goal (SDG) Target 3.5 to 'Strengthen the prevention and treatment of substance abuse' is important for Canada's overall realization of the SDGs, including SDG 3 (Good Health and Wellbeing). Since 2008, Vancouver's Downtown Community Court (DCC) has pioneered an innovative partnership among the justice, health and social service systems to address individuals' needs and circumstances leading to criminal behaviour. While researchers have examined the DCC's impact on reducing recidivism, with Canada's SDG health commitments in mind, we set out to examine the ways health and the social determinants of health (SDH) are engaged and framed externally with regard to DCC functioning, as well as internally by DCC actors. We employed a multi-pronged approach analyzing (1) publicly available DCC documents, (2) print media coverage, and (3) health-related discourse and references in DCC hearings. RESULTS: The documentary analysis showed that health and the SDH are framed by the DCC as instrumental for reducing drug-related offences and improving public safety. The observation data indicate that judges use health and SDH in providing context, understanding triggers for offences and offering rationale for sentencing and management plans that connect individuals to healthcare, social and cultural services. CONCLUSIONS: Our study contributes new insights on the effectiveness of the DCC as a means to integrate justice, health and social services for improved health and community safety. The development of such community court interventions, and their impact on health and the SDH, should be reported on by Canada and other countries as a key contribution to SDG 3 achievement, as well as the fulfillment of other targets under the SDG framework that contain the SDH. Consideration should be given by Canada as to how to capture and integrate the important data generated by the DCC and other problem-solving courts into SDG reporting metrics. Certainly, the DCC advances the SDGs' underlying Leave No One Behind principle in a high-income country context.

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.

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.

A potential Human Rights Act in Queensland and inclusion of the right to health.

OBJECTIVE: To identify the level of public support for a Human Rights Act for Queensland (HRAQ) and for inclusion of the right to health by participants in a public inquiry process. METHODS: We reviewed the 492 written submissions to the Legal Affairs and Community Safety Committee's Inquiry into a potential HRAQ and the transcripts documenting the public hearings held by the Committee in 2016. RESULTS: A total of 465 written submissions were analysed; 419 (90%) were for a HRAQ. More than 80% of the 'for' submissions advocated the right to health's inclusion. At the seven public hearings, 72 persons made verbal submissions and most supported a HRAQ. Five major themes were identified in our synthesis of the public hearing transcripts. Three related specifically to health and human rights: 1) the need to consider the holistic health and human rights of Indigenous Queenslanders and Indigenous Queensland communities; 2) instilling a human rights culture in Queensland; and 3) access to health care and the underlying determinants of health. The other two themes related to the conduct of the Inquiry: 4) the importance of community participation in developing a HRAQ; and 5) concerns about the public consultation processes. CONCLUSION: This study found strong support in the majority of submissions for the Queensland Parliament to draft and enact a HRAQ, and for the inclusion of the right to health in such legislation. Implications for public health: The Queensland Parliament's enactment of a HRAQ that expressly included the right to health would increase the accountability and transparency of government health (and related) decision making and resource allocation, and would better identify and address health inequities across the state. This Act is imperative for improving the health and wellbeing of all Queenslanders, particularly rural and remote and Aboriginal and Torres Strait Islander Queenslanders.

Did the right to health get across the line? Examining the United Nations resolution on the Sustainable Development Goals.

Since the new global health and development goal, Sustainable Development Goal (SDG) 3, and its nine targets and four means of implementation were introduced to the world through a United Nations (UN) General Assembly resolution in September 2015, right to health practitioners have queried whether this goal mirrors the content of the human right to health in international law. This study examines the text of the UN SDG resolution, Transforming our world: the 2030 Agenda for Sustainable Development, from a right to health minimalist and right to health maximalist analytic perspective. When reviewing the UN SDG resolution's text, a right to health minimalist questions whether the content of the right to health is at least implicitly included in this document, specifically focusing on SDG 3 and its metrics framework. A right to health maximalist, on the other hand, queries whether the content of the right to health is explicitly included. This study finds that whether the right to health is contained in the UN SDG resolution, and the SDG metrics therein, ultimately depends on the individual analyst's subjective persuasion in relation to right to health minimalism or maximalism. We conclude that the UN General Assembly's lack of cogency on the right to health's position in the UN SDG resolution will continue to blur if not divest human rights' (and specifically the right to health's) integral relationship to high-level development planning, implementation and SDG monitoring and evaluation efforts.

Civil Registration and Vital Statistics, Emergencies, and International Law: Understanding the Intersection.

Civil registration and vital statistics (CRVS) systems are typically run by governments to record every birth, adoption, death, marriage, and divorce that occurs among a country's population. Registration of vital events provides individuals with a formal relationship with the State and each other, and is the foundation of a person's identity, nationality, and legal status. At a population level, vital statistics are essential for effective planning and implementation of policies and services. Globally, strong CRVS systems are increasingly recognised as a crucial backbone for redressing health inequities and as a priority in strengthening global health and development efforts. Many countries, however, currently lack adequate and reliable CRVS systems, leaving many people vulnerable to statelessness, limited access to important government services (such as education and health services), and effective legal protection. Public health and humanitarian emergencies in such contexts can expose those already disadvantaged and marginalised to heightened risk. CRVS systems weakened by crises make registration difficult or impossible and unregistered people may be displaced or separated from their families, exacerbating their susceptibility. The presence of a strong CRVS system, therefore, can facilitate effective and cost-effective emergency responses, help prevent exploitation of individuals (particularly women and children), and help to rebuild communities post-crisis. This article will consequently review the international legal mandates that exist to strengthen CRVS systems globally, with particular view to public health and humanitarian emergencies. Identity and citizenship, and the socio-political contexts in which these concepts co-exist, are inevitably interconnected with CRVS. This can create potential for CRVS systems and data to be exploited as a political instrument. Grounding CRVS strengthening in a single binding, human rights law instrument is a potential way forward.