Global Health Policy

This background document discusses transnational regulation in an effort to frame policy options for a formal, global approach for public agencies to regulate the supply of medicines. It also explores how the Council on Foreign Relations (CFR) can best facilitate the interests of the U.S. Food and Drug Administration (FDA) and other medicines regulatory agencies on this issue moving forward. The background document follows in three parts. The first part sketches the challenges facing public regulators regarding the diversification of global supply chains, including the consequent proliferation of substandard and counterfeit drugs and the need to leverage resources and build regulatory capacity globally to accomplish mandated domestic public health missions. The second part applies a theoretical framework for tackling these challenges and outlines a typology of policy options. The third part discusses how CFR might organize an initial meeting to discuss the experiences of other sectors in order to help advance discussions already underway by the Heads of Medicine Regulatory Agencies.

Hepatitis B virus (HBV) is causally linked to acute and chronic form of hepatitis, which due to continuous immune mediated inflammation and scarring may lead to cirrhosis and/or hepatocellular carcinoma. HBV spread via exchange of infected bodily fluids underlie unique public health considerations due to similarities with other community related issues such as sexually transmitted diseases (eg HIV) blood borne pathogens (Hepatitis-C) and perinatal transmissions (TORCH complex).

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The doctrine of the ‘minimum core’ (MCD)
has in recent decades achieved prominence within
international human rights law (IHRL) and practice. This
enhanced profile is largely attributable to the activities
of the United Nation’s Committee on Economic, Social and
Cultural Rights (henceforth, ‘the Committee’). As this
origin indicates, the MCD has been articulated in relation
to the sub-set of human rights, usually denominated as
‘economic, social and cultural rights’, that are set out in
the International Covenant on Economic, Social and Cultural
Rights (henceforth, ‘the Covenant’). In addition, some
regional and domestic legal regimes, notably in Africa and
South America, have recognized some version of the MCD in
relation to constitutional or legal rights. However, this
report will almost exclusively concentrate on the nature and
value of the MCD as it has developed within international
law and practice. This Report proceeds in the following
manner: (i) introduction; (ii) In section 2, an account is
offered of the formative point of IHRL in general; (iii) In
section 3, the concept of minimum core obligations of human
rights is explored, i.e. what it is that marks out such
obligations among other human rights standards; (iv) Section
4 contends that the main gist of the MCD is given by
interpretation; (v) In section 5, it is argued that
interpretation (a), standing alone, offers the best account
of the MCD; (vi) Section 6 addresses the difficult question
of how to determine the content of such obligations; (vii)
Section 7 responds to two major challenges confronting the
MCD; and (viii) Finally, Section 8 briefly examines how
indicators and benchmarks are statistical tools that can
help monitor and enhance compliance with minimum core obligations.

What makes a health system? What makes a good health system? What makes a health system equitable and how do we strengthen it? These are questions that frequently arise in global and public health debates around the world. Naturally, similar to other global and public health topics, there is always many perspectives to answer these questions. However, the ultimate goal of a health system (HS) is to improve health outcomes.

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

Background
A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

Methods
Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

Findings
In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8–98·1) in Iceland, followed by 96·6 (94·9–97·9) in Norway and 96·1 (94·5–97·3) in the Netherlands, to values as low as 18·6 (13·1–24·4) in the Central African Republic, 19·0 (14·3–23·7) in Somalia, and 23·4 (20·2–26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1–93·6) in Beijing to 48·0 (43·4–53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6–68·8) in Goa to 34·0 (30·3–38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

Interpretation
GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view—and subsequent provision—of quality health care for all populations.

"This sweeping text focuses on the reality of healthcare in 28 countries around the world. It is organized by wealth of each nation, and is broken up into three categories: wealthy, transitional, and very poor. From Japan to the Democratic Republic of the Congo, the authors discuss each nation's health needs, health system organization and management, the cost and price of healthcare, health resources and delivery, and future health outlook.

The book addresses the types of worldwide health problems, the relationship between medical care and health, entities influencing world healthcare, and health system efficiency. Almost every chapter is written by a representative of that country, giving readers a first-hand glimpse at the conditions and health status of each country's population."~Fried BJ, Gaydos LM. (2012)

Many low-income and crises-affected countries like Sierra Leone struggle with the recruitment and retention of their health professionals, particularly nurses and doctors. There are multiple factors that influence the 'recruitment to retention' pipeline. The first stage of an exploration into the issues influencing the availability of qualified health care workers may focus on the aspects which influence their entry into relevant educational programmes. This paper explores the reasons given by junior doctors in Sierra Leone for wanting to become a doctor. It also describes entry procedures into undergraduate medical education. In-depth interviews were conducted with purposively sampled junior doctors (n = 15) from the only medical school in Sierra Leone in October 2013. Digital diaries and two follow-up interviews were used to explore their evolving career experiences and aspirations until November 2016. In addition, semi-structured interviews with key informants (n = 20), i...

Mandatory vaccination is becoming an increasingly important policy intervention for governments trying to address low vaccination rates. Mandates require vaccination for a certain purpose, usually related to access to public services and provisions such as entry into state school or day-care or to receive benefits and welfare payments. However, the information about which countries have mandatory vaccination policy worldwide and discussions surrounding their impact have largely been limited to high-income countries. While many recent publications discuss the issue, none provide a comprehensive list. This is an obvious gap in the discussion about the merits of introducing mandatory vaccination into countries and will be a useful tool to inform government decision-making by enabling comparisons between countries and opening up the discussion to include low- and middle-income countries. This paper presents the first comprehensive list of vaccination policies worldwide, covering 149 countries. This list indicates whether a country has a mandatory vaccination policy and the strictness of the mandate on a scale ranging across four levels. It draws on extensive desk-based research analysing a mixture of sources. Supplementing this material, we consulted with a variety of experts from health authorities. The paper provides an overview of the state of mandatory vaccination across different countries, sets out the general trends and issues, and engages with a discussion about why, how, and where mandatory vaccination is put in place. The key finding, especially for high-income countries, is that historical context and occurrence of recent outbreaks is a major factor for mandatory vaccination. While the majority of low- and middle- income countries have mandatory vaccination policies but low vaccination rates because of problems with vaccine supply, delivery, and access.

Drivers of Healthcare Globalisation and Their Effects on Medical Tourism Globalisation has intensified in many parts of the world, becoming an important challenge for public health institutions and policymakers. Although many studies have been conducted on the role of globalization in healthcare, no consensus has been reached on its effects. In this commentary, we attempt to evaluate the drivers of healthcare globalization and their effect on medical tourism destination selection. The focus of the commentary is the effects of globalization on patients, whose primary purpose is to travel for planned treatment for health reasons. People from developed countries look for alternative healthcare services and travel to developing countries for cost-effective medical care. Factors which foster medical tourism include demographic changes, remodeling of the healthcare industry, modern technological changes and advanced medical practices, including cost and quality considerations. This commentary presents a list of key factors related to globalization and their effects on medical tourism.

Bringing health actors together to plan, strategize, and implement health programs is pivotal to the development and growth of modern healthcare systems. There is a critical need for healthcare providers, non-providers, and stakeholders to understand the importance of collaboration and integration of healthcare systems. To have an effective and efficient healthcare system, healthcare organizations and non-healthcare organizations, in particular, need a better understanding of healthcare delivery systems and how to strengthen the healthcare system to meet the needs of their clients. The objective of this article was to analyze the effect of collaboration and integration of healthcare delivery system. Content analysis was conducted among healthcare providers and non-providers in a fragile healthcare system. Findings revealed that there is a need for the collaboration of everyone involved in healthcare delivery because it is a human services oriented sector. It is important when healthcare providers, non-providers, government, and international donor institutions collaborate and integrate healthcare services, while policy and decision-makers ensure a balanced accountability to maximize service delivery.

Introduction: The globalization of the pharmaceutical supply chain has introduced new challenges, chief among them, fighting the international criminal trade in fake medicines. As the manufacture, supply, and distribution of drugs becomes more complex, so does the need for innovative technology-based solutions to protect patients globally. Areas covered: We conducted a multidisciplinary review of the science/health, information technology, computer science, and general academic literature with the aim of identifying cutting-edge existing and emerging 'digital' solutions to combat fake medicines. Our review identified five distinct categories of technology including mobile, radio frequency identification, advanced computational methods, online verification, and blockchain technology. Expert opinion: Digital fake medicine solutions are unifying platforms that integrate different types of anti-counterfeiting technologies as complementary solutions, improve information sharing and data collection, and are designed to overcome existing barriers of adoption and implementation. Investment in this next generation technology is essential to ensure the future security and integrity of the global drug supply chain.

This book brings a new focus and new insights to the phenomena of global education policies and, relatedly, international policy transfer. While both of these issues have gained popularity in the field of international and comparative education, there remains much that we do not know. In particular, while numerous studies have been produced which examine how global education policies—such as vouchers, charter schools, conditional-cash transfers, standardized testing, child-centered pedagogy, etc.—travel around the world and are implemented, we lack research which illuminates the origins and evolution of such policies. Put differently: scholars have yet to examine how such policies first emerge and then enter the global reform agenda for education. The present book addresses this critical gap in our knowledge by looking at multiple aspects of the trajectory of a particular policy which was born in El Salvador in the early 1990s and subsequently went global. This policy was known as “Education with Community Participation” and was an extreme form of community-based management that transferred (among other things) the responsibility for hiring, firing, and managing teachers from the central Ministry of Education to communities themselves. This book is also valuable in that it explicitly analyses the trajectory of global education policy with reference to the role of international organizations and within the larger international political and economic dynamics that affected the overall country context of El Salvador.

Beginning in the early 1990s, a new manner of articulating the threat posed by epidemics of infectious diseases took shape. ‘Global health security’ (GHS) emerged as a novel epistemic space as a response to the perceived threats posed by circulations and appearances of ‘global’ diseases. Marked throughout the 2000s by major events both political and pathogenic, GHS has undergone profound changes; from primarily a policy-legal framework to a forum for reconfiguring global health 'action'. This research examines how the problems that emerged in the 1990s are changing since the 2014 West African Ebola crisis and the announcement of new global health security projects and initiatives. How might these transformations constitute a new manner of thinking about, and acting on, epidemics as a ‘global’ problem?
  Contrasting genealogical-archival research with a series of field-based episodes, this dissertation explores how public health experts and technicians worked to define new problems and design the interventions aimed at addressing them. It juxtaposes a historical account of the emergence and transformation of GHS across the 2000s and 2010s against field-based ethnography of GHS during 2016 and 2017. Based on over a year working with a global health non-profit, the text’s episodes attend to day-to-day work that translated diffuse concepts of ‘threat' and ‘risk' into discrete technical practices and projects to mitigate and minimize those threats. Working with experts through the early stages of project development, attention is paid to the relational processes that went into making global health security a workable concept. Together, the episodes illustrate the routines and technical artistry that made GHS into a space not only to reimagine a ‘safer’ or ‘healthier’ world, but to build the means to realize it.
  The text also examines how communities of experts reworked their projects and programs during great destabilizations and disruptions, including both the 2016 US Presidential election as well as an Ebola outbreak in the Democratic Republic of Congo. It explores how global health organizations and experts attempted to better 'prevent, detect, and respond' to public health emergencies after Ebola in 2014. Unpacking various understandings of the ‘global’ in GHS, it examines how experts worked to build novel 'global assemblages’ and reposition ‘reciprocal obligations between nations'. The research looks at novel techniques and technologies designed to ensure a ‘global’ community of healthy nations—ones able to live up to their responsibilities to care for and protect their vulnerable populations.
    In 2014, Ebola set the stage for dramatic changes to global health as new actors and organizations came to understand a pressing need for change. ‘GHS' emerged as a response to these calls for reform and improvement, an urgent effort to improve vulnerable health systems in developing countries. This research explores how GHS and some of its technicians became entangled with these emerging and evolving mix of policies, practices, and possibilities for global health practice.

Since 31 December, the international community have been aware of the new coronavirus SARS-COV-2, which causes the disease known as Covid-19 that has since become a pandemic. It has spread across the globe and across state borders. The World Health Organisation (WHO) provides global health guidance and frameworks for collaboration amongst its members, but it is the responsibility of individual states to manage lockdowns and surveillance of cases.  There is in effect a trade-off between public health and economy, livelihoods and jobs are traded for safety, for the greatest number of people in a utilitarian one-off agreement between citizens and the state. Agencies and the international organisations have a role to facilitate international solidarity to balance these competing tensions, where states increasingly look to implement control measures and policing in surveillance.

This Review discusses three main themes since 15 May 2020. The creation of pandemic strategies. The stark social inequalities that have become so evident during this pandemic, and last, the increasing fracturing of politics which has provided evidence for greater deglobalisation and the need for solidarity amongst the international community, to deliver medicines, food and some economic security, in the form of crisis loans, increasing state social security. This paper focuses upon how Covid-19 impacts upon people worldwide, resources and how data and statistics are collected. How data is used and how social scientists explain the impact of the disease. Whilst mathematical modelling helps to inform and guide and inform control measures.

For the WHO, the International Monetary Fund  (IMF), The World Bank and the UN, the European Commission and  Africa and Latin America solidarity entails many different things, but international organisations within an international governance structure, wish to see arrangements for funding are fair and given to the most vulnerable in the global community. 

The failures and successes of containment of the disease within states, is often perceived by fatality rates amongst 100K of population.  It has become an emotive and human response to assess a pandemic which has resulted in over 25.12 Million reported cases and in the deaths of over 844,312 people .  Larger countries like the USA, Brazil, and Mexico and India, predictably produce the greatest fatalities, and cases, as population densities and urban areas create some of the right conditions for the virus to transmit more easily.  The USA has had 181,689 fatalities, amongst a population of 328.2M, and 5,899,540 confirmed cases . Brazil has had 120,462 fatalities, amongst a population of 209.5M, and 3,846,153 confirmed cases .  Whilst India with the largest and densely populated state of 1.353Bn has had 64,469 fatalities and 3,621,245 confirmed cases.  But the United Kingdom with a smaller population of 66.7 M, has lost 41,499 people and has 334,471 confirmed cases . The picture is therefore complicated, and each state has demonstrated a divergence in policies and outcomes. For instance, small countries such as Costa Rica, have done very well to suppress the illness, with very low death rates reported (418 deaths amongst 39,699 cases) . States which have done remarkably well include Sweden (5,821 deaths amongst 83,958 reported cases) , Denmark (621 deaths, amongst 16,700 cases) , Australia (611 deaths, amongst 25,670 confirmed cases)  and Austria (733 deaths, amongst 27,218).

According to the World Health Organization situation report, since the start of COVID-19 outbreak till 2 October 2020, a cumulative total of nearly 34 million cases and 1 million deaths have been reported. As per the present situation, health is being recognized as a major transboundary issue.  It requires a multilateral approach by collectively combating the diseases that cross national borders. By comparing their nations military expenditure and health expenditure, people across the world were claiming to focus on building modern health infrastructure to overcome pandemic like situation in future.

Many of the great successes in public heath and medicine also serve as important social milestones for humanity, especially with regard to the prevention and treatment of disease. While civic sanitation, water purification, immunization, and antibiotics have dramatically reduced the overall morbidity and the mortality of disease in advanced nations, much of the world is still ravaged by disease and epidemics, and new threats--including lifestyle diseases--constantly appear to challenge the most advanced medical and public health systems. // At its core, WMGH contains assessable explanations of many recent scientific advances in public health, advances in medicine, molecular biology, genetics, epidemiology, and related fields. // Another key and distinguishing feature of WMGH is an attempt to articulate links between science and social facets of global health issues. Despite their prevalence, many issues cannot be distantly cast from their intimate influence over daily life, economic impacts, and social context. Accordingly, a focus of WMGH is the attempt to identify the social determinants of health.  (continued, download to read more)  — Brenda Wilmoth Lerner & K. Lee Lerner; editors. Cambridge, Mass. April, 2015  [Selected for scholarly health science collections around the world, including collections at Princeton, Michigan. University of Texas Southwestern Medical Center, Emory, Duke, UNC; Notre Dame; University College London, and the National Library of Medicine.]

The proposed Framework Convention on Global Health envisages the imposition of a binding obligation on developed countries to assist developing countries in their quest to achieve the right to health for all their citizens. Looking at the current state of global health governance, this paper examines the normative human rights considerations that ought to be imbued within any such proposed extra-territorial obligation. It argues that the extra-territorial obligation instituted by the proposed treaty should be underpinned by three fundamental human rights considerations: i) an explicit recognition of the right to health, ii) a focus on long-term funding, as opposed to short-term strategic interventions, and iii) more representative and participatory funding mechanisms at the national and global level in order to ensure accountability. The article also highlights possible normative problems presented by an extra-territorial obligation to finance health projects.

The majority of the world's medical care facilities and research labs have limited access to optimal tools because of the exorbitant prices of proprietary equipment. This results in both reduced acute public health and slows the rate of medical science hampering future public health. The tremendous success of free and open source software in driving innovation and lowering costs has spread to the world of hardware. Free and open-source hardware (FOSH) provides the “code” for hardware including the bill of materials, schematics, instructions, computer aided designs (CAD), and other information needed to recreate a physical artifact. FOSH has already led to improved product innovation and reduced costs in a wide range of fields and can go far beyond simply sharing data in the medical community. By combining digital manufacturing such as 3-D printing with open-source microcontrollers, hundreds of high-quality low-cost medical and scientific tools have already been developed. Scientists and medical equipment engineers can design, share and build on one another's work to develop better and less costly medical devices. Such latterly scaled replication saves 90-99% of traditional costs. This article summarizes medical research policy to encourage maximizing the return on investment of public funding for medical equipment development by: 1) identifying, funding and disseminating FOSH design of the most costly medical equipment, 2) funding validation studies of this equipment, and 3) enacting purchasing policy preferences for FOSH. Past results indicate that these policies will directly save millions of dollars of public funding for health care, while supporting rapid innovation in medical equipment design.