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What drives people towards tobacco use? What prevents people from doing physical exercise or adopting preventive measures during a pandemic? What increases the likelihood that someone will adhere to treatment [...]

The article discusses the call for papers on building a health economy for all in 2023. Topics covered include the existing structural and economic inequalities exposed by the pandemic, and the reorientation of economies for health towards a vision in which every person and people can flourish physically and mentally with dignity and opportunity in a healthy living planet. Also noted are the four themes to build economies for health that the World Health Organization (WHO) Council focuses on.

The authors reflect on the global health inequalities in the efforts to achieve optimal health and the sustainable development goals (SDG) set by the United Nations worldwide. Other topics include the effects of the coronavirus disease 2019 (COVID-19) pandemic on programs to reduce income inequity among countries, and the authors' call for papers aimed at addressing inequalities in global health.

The article calls for papers addressing the health of vulnerable populations, constructs of social inclusion and exclusion, interventions for vulnerable populations in the context of sustainable development goals (SDG) at the micro- and macro-policy levels, and factors to vulnerabilities.

The contents of this theme section of the Bulletin of the World Health Organization on "Inequalities in health" have two objectives: to present the initial findings from a new generation of research that has been undertaken in response to renewed concern for health inequalities; and to stimulate movement for action in order to correct the problems identified by this research. The research findings are presented in the five articles which follow. This Critical Reflection proposes two initial steps for the action needed to alleviate the problem; other suggestions are given by the participants in a Round Table discussion which is published after these articles. The theme section concludes with extracts from the classic writings of the nineteenth-century public health pioneer, William Farr, who is widely credited as one of the founders of the scientific study of health inequalities, together with a commentary. This Critical Reflection contributes to the discussion of the action needed by proposing two initial steps for action. That professionals who give very high priority to the distinct but related objectives of poverty alleviation, inequality reduction, and equity enhancement recognize that their shared concern for the distributional aspects of health policy is far more important than any differences that may divide them. That health policy goals, currently expressed as societal averages, be reformulated so that they point specifically to conditions among the poor and to poor-rich differences. For example, infant mortality rates among the poor or the differences in infant mortality between rich and poor sectors would be more useful indicators than the average infant mortality rates for the whole population.

The aim of this paper is to contribute technical arguments to the debate about the importance of health examination surveys and their continued use during the post-pandemic health financing crisis, and in the context of a technological innovation boom that offers new ways of collecting and analysing individual health data (e.g. artificial intelligence). Technical considerations demonstrate that health examination surveys make an irreplaceable contribution to the local availability of primary health data that can be used in a range of further studies (e.g. normative, burden-of-disease, care cascade, cost and policy impact studies) essential for informing several phases of the health planning cycle (e.g. surveillance, prioritization, resource mobilization and policy development). Examples of the use of health examination survey data in the World Health Organization (WHO) European Region (i.e. Finland, Italy, Malta and the United Kingdom of Great Britain and Northern Ireland) and the WHO Region of the Americas (i.e. Chile, Mexico, Peru and the United States of America) are presented, and reasons why health provider-led data cannot replace health examination survey data are discussed (e.g. underestimation of morbidity and susceptibility to bias). In addition, the importance of having nationally representative random samples of the general population is highlighted and we argue that health examination surveys make a critical contribution to external quality control for a country's health system by increasing the transparency and accountability of health spending. Finally, we consider future technological advances that can improve survey fieldwork and suggest ways of ensuring health examination surveys are sustainable in low-resource settings. [ABSTRACT FROM AUTHOR]

Despite widespread acknowledgement that trust is important in a pandemic, few concrete proposals exist on how to incorporate trust into preparing for the next health crisis. One reason is that building trust is rightly perceived as slow and challenging. Although trust in public institutions and one another is essential in preparing for a pandemic, countries should plan for the possibility that efforts to instil or restore trust may fail. Incorporating trust into pandemic preparedness means acknowledging that polarization, partisanship and misinformation may persist and engaging with communities as they currently are, not as we would wish them to be. This paper presents a practical policy agenda for incorporating mistrust as a risk factor in pandemic preparedness and response planning. We propose two sets of evidence-based strategies: (i) strategies for ensuring the trust that already exists in a community is sustained during a crisis, such as mitigating pandemic fatigue by health interventions and honest and transparent sense-making communication; and (ii) strategies for promoting cooperation in communities where people mistrust their governments and neighbours, sometimes for legitimate, historical reasons. Where there is mistrust, pandemic preparedness and responses must rely less on coercion and more on tailoring local policies and building partnerships with community institutions and leaders to help people overcome difficulties they encounter in cooperating with public health guidance. The regular monitoring of interpersonal and government trust at national and local levels is a way of enabling this context-specific pandemic preparedness and response planning. [ABSTRACT FROM AUTHOR]

The World Health Organization (WHO) set up the messenger ribonucleic acid (mRNA) technology transfer programme in June 2021 with a development hub in South Africa and 15 partner vaccine producers in middle-income countries. The goal was to support the sustainable development of and access to life-saving vaccines for people in these countries as a means to enhance epidemic preparedness and global public health. This initiative aims to build resilience and strengthen local vaccine research, and development and manufacturing capacity in different regions of the world, especially those areas that could not access coronavirus disease 2019 (COVID-19) vaccines in a timely way. This paper outlines the current global vaccine market and summarizes the findings of a case study on the mRNA technology transfer programme conducted from November 2022 to May 2023. The study was guided by the vision of the WHO Council on the Economics of Health for All to build an economy for health using its four work streams of value, finance, innovation and capacity. Based on the findings of the study, we offer a mission-oriented policy framework to support the mRNA technology transfer programme as a pilot for transformative change towards an ecosystem for health innovation for the common good. Parts of this vision have already been incorporated into the governance of the mRNA technology transfer programme, while other aspects, especially the common good approach, still need to be applied to achieve the goals of the programme. [ABSTRACT FROM AUTHOR]

There is increasing use of machine learning for the health financing functions (revenue raising, pooling and purchasing), yet evidence lacks for its effects on the universal health coverage (UHC) objectives. This paper provides a synopsis of the use cases of machine learning and their potential benefits and risks. The assessment reveals that the various use cases of machine learning for health financing have the potential to affect all the UHC intermediate objectives -- the equitable distribution of resources (both positively and negatively); efficiency (primarily positively); and transparency (both positively and negatively). There are also both positive and negative effects on all three UHC final goals, that is, utilization of health services in line with need, financial protection and quality care. When the use of machine learning facilitates or simplifies health financing tasks that are counterproductive to UHC objectives, there are various risks -- for instance risk selection, cost reductions at the expense of quality care, reduced financial protection or over-surveillance. Whether the effects of using machine learning are positive or negative depends on how and for which purpose the technology is applied. Therefore, specific health financing guidance and regulations, particularly for (voluntary) health insurance, are needed. To inform the development of specific health financing guidance and regulation, we propose several key policy and research questions. To gain a better understanding of how machine learning affects health financing for UHC objectives, more systematic and rigorous research should accompany the application of machine learning. [ABSTRACT FROM AUTHOR]

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Law lies at the centre of successful national strategies for prevention and control of noncommunicable diseases. By law we mean international agreements, national and subnational legislation, regulations and other executive instruments, and decisions of courts and tribunals. However, the vital role of law in global health development is often poorly understood, and eclipsed by other disciplines such as medicine, public health and economics. This paper identifies key areas of intersection between law and noncommunicable diseases, beginning with the role of law as a tool for implementing policies for prevention and control of leading risk factors. We identify actions that the World Health Organization and its partners could take to mobilize the legal workforce, strengthen legal capacity and support effective use of law at the national level. Legal and regulatory actions must move to the centre of national noncommunicable disease action plans. This requires high-level leadership from global and national leaders, enacting evidence-based legislation and building legal capacities.

An introduction is presented to a series of papers focused on the scientific dialogue between sectors on health and economics, with topics including constitutional right to health, advancements in mental health as part of a well-being economy, and health taxonomy development to guide sustainable investment decisions.

The World Health Organization recognizes rehabilitation as an essential component of universal health coverage (UHC). In many countries, UHC builds on a standard benefits package of services that is informed by the country's essential medicines list, standard treatment guidelines and primary health care essential laboratory list. In South Africa, primary health care is largely provided and managed by primary health-care nurses and medical officers in accordance with primary health care standard treatment guidelines. However, rehabilitation is mostly excluded from these guidelines. This paper describes the 10-year process that led to rehabilitation referral recommendations being considered for inclusion in South Africa's primary health care standard treatment guidelines. There were five key events: (i) a breakthrough moment; (ii) producing a scientific evidence synthesis and formulating recommendations; (iii) presenting recommendations to the national essential medicines list committee; (iv) mapping rehabilitation recommendations onto relevant treatment guideline sections; and (v) submitting revised recommendations to the committee for final consideration. The main lesson learnt is that, by working together, rehabilitation professionals can be of sufficient number to make a difference, improve service delivery and increase referrals to rehabilitation from primary health care. A remaining challenge is the lack of a rehabilitation representative on the national essential medicines list committee, which could hamper understanding of rehabilitation and of the complexities of the supporting evidence. [ABSTRACT FROM AUTHOR]

The demographic transition towards an ageing population and the epidemiological transition from communicable to noncommunicable diseases have increased the demand for rehabilitation services globally. The aims of this paper were to describe the integration of rehabilitation into the Japanese health system and to illustrate how health information systems containing real-world data can be used to improve rehabilitation services, especially for the ageing population of Japan. In addition, there is an overview of how evidence-informed rehabilitation policy is guided by the analysis of large Japanese health databases, such as: (i) the National Database of Health Insurance Claims and Specific Health Checkups; (ii) the long-term care insurance comprehensive database; and (iii) the Long-Term Care Information System for Evidence database. Especially since the 1990s, the integration of rehabilitation into the Japanese health system has been driven by the country's ageing population and rehabilitation is today provided widely to an increasing number of older adults. General medical insurance in Japan covers acute and post-acute (or recovery) intensive rehabilitation. Long-term care insurance covers rehabilitation at long-term care institutions and community facilities for older adults with the goal of helping to maintain independence in an ageing population. The analysis of large health databases can be used to improve the management of rehabilitation care services and increase scientific knowledge as well as guide rehabilitation policy and practice. In particular, such analyses could help solve the current challenges of overtreatment and undertreatment by identifying strict criteria for determining who should receive long-term rehabilitation services. [ABSTRACT FROM AUTHOR]

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, we describe the evidence base for diet-related interventions based on fiscal policies and consider the key questions that need to be asked by both health and economic policy-makers. From the health sector's perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. We highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

Public health policy often involves implementing cost-efficient, large-scale interventions. When mandating or forbidding a specific behaviour is not permissible, public health professionals may draw on behaviour change interventions to achieve socially beneficial policy objectives. Interventions can have two main effects: (i) a direct effect on people initially targeted by the intervention; and (ii) an indirect effect mediated by social influence and by the observation of other people's behaviour. However, people's attitudes and beliefs can differ markedly throughout the population, with the result that these two effects can interact to produce unexpected, unhelpful and counterintuitive consequences. Public health professionals need to understand this interaction better. This paper illustrates the key principles of this interaction by examining two important areas of public health policy: tobacco smoking and vaccination. The example of antismoking campaigns shows when and how public health professionals can amplify the effects of a behaviour change intervention by taking advantage of the indirect pathway. The example of vaccination campaigns illustrates how underlying incentive structures, particularly anticoordination incentives, can interfere with the indirect effect of an intervention and stall efforts to scale up its implementation. Recommendations are presented on how public health professionals can maximize the total effect of behaviour change interventions in heterogeneous populations based on these concepts and examples. [ABSTRACT FROM AUTHOR]

Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory's data to describe the current distribution of - and trends in - transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization's Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network.

Triple elimination is an initiative supporting the elimination of mother-to-child transmission of three diseases - human immunodeficiency virus (HIV) infection, syphilis and hepatitis B. Significant progress towards triple elimination has been made in some regions, but progress has been slow in sub-Saharan Africa, the region with the highest burden of these diseases. The shared features of the three diseases, including their epidemiology, disease interactions and core interventions for tackling them, enable an integrated health-systems approach for elimination of mother-to-child transmission. Current barriers to triple elimination in sub-Saharan Africa include a lack of policies, strategies and resources to support the uptake of well established preventive and treatment interventions. While much can be achieved with existing tools, the development of new products and models of care, as well as a prioritized research agenda, are needed to accelerate progress on triple elimination in sub-Saharan Africa. In this paper we aim to show that health systems working together with communities in sub-Saharan Africa could deliver rapid and sustainable results towards the elimination of mother-to-child transmission of all three diseases. However, stronger political support, expansion of evidence-based interventions and better use of funding streams are needed to improve efficiency and build on the successes in prevention of mother-to-child transmission of HIV. Triple elimination is a strategic opportunity to reduce the morbidity and mortality from HIV infection, syphilis and hepatitis B for mothers and their infants within the context of universal health coverage. [ABSTRACT FROM AUTHOR]

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists' primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff's skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists' clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers.

The CARICOM Summit on Chronic Non-Communicable Diseases - the first government summit ever devoted to noncommunicable diseases (NCDs) - was convened by the Caribbean Community (CARICOM) in Trinidad and Tobago in September 2007. Leaders in attendance issued the declaration of Port of Spain, a call for the prevention and control of four major NCDs and their risk factors. An accountability instrument for monitoring compliance with summit commitments was developed for CARICOM by the University of the West Indies in 2008 and revised in 2010. The instrument - a one-page colour-coded grid with 26 progress indicators - is updated annually by focal points in Caribbean health ministries, verified by each country's chief medical officer and presented to the annual Caucus of Caribbean Community Ministers of Health. In this study, the G8 Research Group's methods for assessing compliance were applied to the 2009 reporting grid to assess each country's performance. Given the success of the CARICOM Summit, a United Nations high-level meeting of the General Assembly on the prevention and control of NCDs was held in September 2011. In May 2013 the World Health Assembly adopted nine global targets and 25 indicators to measure progress in NCD control. This study shows that the CARICOM monitoring grid can be used to document progress on such indicators quickly and comprehensibly. An annual reporting mechanism is essential to encourage steady progress and highlight areas needing correction. This paper underscores the importance of accountability mechanisms for encouraging and monitoring compliance with the collective political commitments acquired at the highest level.

Unless the concept is clearly understood, "universal coverage" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.

In China, alcohol consumption is increasing faster than anywhere else in the world. A steady increase in alcohol production has also been observed in the country, together with a rise in alcohol-related harm. Despite these trends, China's policies on the sale and consumption of alcoholic beverages are weak compared with those of other countries in Asia. Weakest of all are its policies on taxation, drink driving laws, alcohol sale to minors and marketing licenses. The authors of this descriptive paper draw attention to the urgent need for public health professionals and government officials in China to prioritize population surveillance, research and interventions designed to reduce alcohol use disorders. They describe China's current alcohol policies and recent trends in alcohol-related harm and highlight the need for health officials to conduct a thorough policy review from a public health perspective, using as a model the World Health Organization's global strategy to reduce the harmful use of alcohol.

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness-feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach.

Problem: Outbreak analysis and mathematical modelling are crucial for planning public health responses to infectious disease outbreaks, epidemics and pandemics. This paper describes the data analysis and mathematical modelling undertaken during and following the 2009 influenza pandemic, especially to inform public health planning and decision-making., Approach: Soon after A(H1N1)pdm09 emerged in North America in 2009, the World Health Organization convened an informal mathematical modelling network of public health and academic experts and modelling groups. This network and other modelling groups worked with policy-makers to characterize the dynamics and impact of the pandemic and assess the effectiveness of interventions in different settings., Setting: The 2009 A(H1N1) influenza pandemic., Relevant Changes: Modellers provided a quantitative framework for analysing surveillance data and for understanding the dynamics of the epidemic and the impact of interventions. However, what most often informed policy decisions on a day-to-day basis was arguably not sophisticated simulation modelling, but rather, real-time statistical analyses based on mechanistic transmission models relying on available epidemiologic and virologic data., Lessons Learnt: A key lesson was that modelling cannot substitute for data; it can only make use of available data and highlight what additional data might best inform policy. Data gaps in 2009, especially from low-resource countries, made it difficult to evaluate severity, the effects of seasonal variation on transmission and the effectiveness of non-pharmaceutical interventions. Better communication between modellers and public health practitioners is needed to manage expectations, facilitate data sharing and interpretation and reduce inconsistency in results.

Three decades since the human immunodeficiency virus (HIV) was identified, the pandemic of acquired immunodeficiency syndrome (AIDS) has developed into diverse epidemics around the world. In many populations, HIV infection has become endemic. While there is good progress on expanding access to treatment, with an estimated 6.6 million people on antiretroviral therapy at the end of 2010, prevention efforts are still highly inadequate with 2.6 million new infections occurring in 2009. Demand for treatment is increasing while funding is becoming more scarce and activism is waning. In 2007, the Joint United Nations Programme on HIV/AIDS (UNAIDS) established an independent forum called aids2031 to take a critical look at the global HIV/AIDS response. This paper outlines four key areas for a re-designed AIDS response based on the deliberations of this initiative and on the learning and experience of the first three decades of the epidemic: (i) a new culture of knowledge generation and utilization; (ii) transformed prevention and treatment to increase effectiveness; (iii) increased efficiency through better management and maximizing synergies with other programmes; and (iv) investment for the long term. Across all these areas is a strong emphasis on local capacity building, leadership, programme priorities and budgets.

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) services in China are provided through a large network of TB dispensaries. Even though hospitals are not as well placed to follow recommended standards of TB care, a significant proportion of people with TB symptoms seek care from hospitals. In spite of having a policy and mandate in place, the Ministry of Health had little success in encouraging hospitals to refer suspected TB cases to dispensaries. Following the epidemic of severe acute respiratory syndrome in 2003, the government set up a nationwide Internet-based communicable diseases reporting system. This achieved productive collaboration between hospitals and TB dispensaries. From 2004 to 2007, the percentage of TB suspects and patients needing referral from hospitals who arrived in TB dispensaries increased substantially from 58.7% to 77.8% and the contribution of hospitals to diagnosing sputum smear-positive TB cases doubled from 16.3% to 32.9%. Using the Internet-based reporting system, hospitals in China contributed to finding about one third of all sputum smear-positive TB cases and helped meet the global TB control target of detecting 70% of such cases. Based on the data available from routine surveillance facilitated by this Internet-based system, this paper details the process and outcomes of strengthening collaboration between hospitals and TB dispensaries using the Internet as a tool and its potential application to other country settings.

China is experiencing a syphilis epidemic of enormous proportions. The regions most heavily affected by syphilis correspond to regions where sexually transmitted HIV infection is also a major public health threat. Many high-risk patients in China fail to receive routine syphilis screening. This missed public health opportunity stems from both a failure of many high-risk individuals to seek clinical care and a disconnect between policy and practice. New point-of-care syphilis testing enables screening in non-traditional settings such as community organizations or sex venues. This paper describes the current Chinese syphilis policies, suggests a spatiotemporal framework (based on targeting high-risk times and places) to improve screening and care practices, and emphasizes a syphilis control policy extending beyond the clinical setting.

Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.

In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services - where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.

Scientific progress is a significant basis for change in public-health policy and practice, but the field also invests in value-laden concepts and responds daily to sociopolitical, cultural and evaluative concerns. The concepts that drive much of public-health practice are shaped by the collective and individual mores that define social systems. This paper seeks to describe the ethics processes in play when public-health mechanisms are established in low- and middle-income countries, by focusing on two cases where ethics played a crucial role in producing positive institutional change in public-health policy. First, we introduce an overview of the relationship between ethics and public health; second, we provide a conceptual framework for the ethical analysis of health system events, noting how this approach might enhance the power of existing frameworks; and third, we demonstrate the interplay of these frameworks through the analysis of a programme to enhance road safety in Malaysia and an initiative to establish a national ethics committee in Pakistan. We conclude that, while ethics are gradually being integrated into public-health policy decisions in many developing health systems, ethical analysis is often implicit and undervalued. This paper highlights the need to analyse public-health decision-making from an ethical perspective.

Health technology assessment (HTA) is the multidisciplinary study of the implications of the development, diffusion and use of health technologies. It supports health-policy decisions by providing a joint knowledge base for decision-makers. To increase its policy relevance, HTA tries to extend beyond effectiveness and costs to also considering the social, organizational and ethical implications of technologies. However, a commonly accepted method for analysing the ethical aspects of health technologies is lacking. This paper describes a model for ethical analysis of health technology that is easy and flexible to use in different organizational settings and cultures. The model is part of the EUnetHTA project, which focuses on the transferability of HTAs between countries. The EUnetHTA ethics model is based on the insight that the whole HTA process is value laden. It is not sufficient to only analyse the ethical consequences of a technology, but also the ethical issues of the whole HTA process must be considered. Selection of assessment topics, methods and outcomes is essentially a value-laden decision. Health technologies may challenge moral or cultural values and beliefs, and their implementation may also have significant impact on people other than the patient. These are essential considerations for health policy. The ethics model is structured around key ethical questions rather than philosophical theories, to be applicable to different cultures and usable by non-philosophers. Integrating ethical considerations into HTA can improve the relevance of technology assessments for health care and health policy in both developed and developing countries.

Problem: In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children., Approach: Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children., Local Setting: At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff., Lessons Learnt: The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required.

Objective: To provide global policy-makers with decision-making information for developing strategies for immunization of infants with a birth dose of hepatitis B vaccine, this paper presents a retrospective cost analysis, conducted in Indonesia, of delivering this vaccine at birth using the Uniject prefill injection device., Methods: Incremental costs or cost savings associated with changes in the hepatitis B immunization programme were calculated using sensitivity analysis to vary the estimates of vaccine wastage rates and prices for vaccines and injection devices, for the birth dose of hepatitis B vaccine., Findings: The introduction of hepatitis B vaccine prefilled in Uniject (HB-Uniject) single-dose injection devices for use by midwives for delivering the birth dose is cost-saving when the wastage rate for multidose vials is greater than 33% (Uniject is a trademark of BD, Franklin Lakes, NJ, USA)., Conclusion: The introduction of HB-Uniject for birth-dose delivery is economically worthwhile and can increase coverage of the critical birth dose, improve resource utilization, reduce transmission of hepatitis B and promote injection safety.

New drugs and vaccines are needed for tackling diseases of poverty in low- and middle-income countries. The lack of effective demand or market for these products translates into insufficient investment being made in research and development to meet the need for them. Many have advocated cost-reducing (push) and market-enhancing (pull) incentives to tackle this problem. Advance price or purchase commitments (APPCs) funded by international agencies and governments offer one way forward. This paper looks at design issues for APPCs for drugs and vaccines for diseases of poverty drawing on experience and lessons from three case studies: the introduction of the meningitis C vaccine in the United Kingdom; the Orphan Drug Act (ODA) in the United States of America (US); and the newly legislated US Project BioShield for bioterrorist interventions. Our key conclusion is that that APPCs have the potential to be a powerful tool and should be tried. The correct structure and design may only be determined through the process of taking action to set one up.

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIA's aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the community's experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to "expert" and "research-generated" evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

In the current information age, research synthesis is a particularly useful tool for keeping track of scientific research and making sense of the large volumes of frequently conflicting data derived from primary studies. The Cochrane Collaboration is a global initiative "to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions". In this paper we set the work of the Cochrane Collaboration in historical perspective, explain what a Cochrane review is, and describe initiatives for promoting worldwide dissemination of synthesized information. We also consider emerging evidence of the Cochrane Collaboration's impact on health-care practice, policy, research and education. Finally, we highlight the need for increased investment in the preparation and maintenance of Cochrane reviews, particularly those that address health issues that are relevant to people living in low- and middle-income countries.

Low fruit and vegetable consumption is an important contributor to the global burden of disease. In the wake of the United Nations High-level Meeting on Non-Communicable Diseases (NCDs), held in September 2011, a rise in the consumption of fruits and vegetables is foreseeable and this increased demand will have to be met through improved supply. The World Health Organization, the Food and Agriculture Organization and the World Bank have highlighted the potential for developing countries to benefit nutritionally and economically from the increased production and export of fruit and vegetables. Aid for Trade, launched in 2005 as an initiative designed to link development aid and trade holistically, offers an opportunity for the health and trade sectors to work jointly to enhance health and development. The Aid for Trade work programme stresses the importance of policy coherence across sectors, yet the commonality of purpose driving the Aid for Trade initiative and NCD prevention efforts has not been explored. In this paper food supply chain analysis was used to show health policy-makers that Aid for Trade can provide a mechanism for increasing the supply of fruits and vegetables in developing countries. Aid for Trade is an existing funding channel with clear accountability and reporting mechanisms, but its priorities are determined with little or no input from the health sector. The paper seeks to enable public health policy-makers, practitioners and advocates to improve coherence between trade and public health policies by highlighting Aid for Trade's potential role in this endeavour. [ABSTRACT FROM AUTHOR]

The last decade has seen a wide range of experiments in health care reform intended to contain costs and promote effectiveness. In the USA, managed care and disease management have been major strategies in this endeavour. It has been argued that their apparent success has strong implications for reform in other countries. However, in this paper we ask whether they are so easily exportable. We explain the concepts involved and set the development of managed care and disease management programmes in the context of the USA. The constituent elements of disease management are identified and discussed. Disease management is considered from the perspectives of the major stakeholders in the United Kingdom, and the differences between the models of health care in the United Kingdom's National Health Service and the USA are noted. A review is presented of evaluations of disease management programmes and of the weaknesses they highlight. The prospects for disease management in Europe are also discussed.

New assessment guidelines for measuring the overall impact of mental health problems in Latin America have served as a catalyst for countries to review their mental health policies. Latin American countries have taken various steps to address long-standing problems such as structural difficulties, scarce financial and human resources, and social, political, and cultural obstacles in the implementation of mental health policies and legislation. These policy developments, however, have had uneven results. Policies must reflect the desire, determination, and commitment of policy-makers to take mental health seriously and look after people's mental health needs. This paper describes the development of mental health policies in Latin American countries, focusing on published data in peer-reviewed journals, and legislative change and its implementation. It presents a brief history of mental health policy developments, and analyzes the basis and practicalities of current practice.

There is widespread agreement that both the configuration and the application of state authority in the health sector should be realigned in the interest of achieving agreed policy objectives. The desired outcome is frequently characterized as a search for good governance serving the public interest. The present paper examines the proposal in The World Health Report 2000 that the concept of stewardship offers the appropriate basis for reconfiguration. We trace the development of stewardship from its initial religious formulation to more recent ecological and sociological permutations. Consideration is given to the potential of stewardship for encouraging state decision-making that is both normatively based and economically efficient. Various dilemmas that could impede or preclude such a shift in state behaviour are examined. We conclude that the concept of stewardship holds substantial promise if adequately developed and effectively implemented.

The authors comment on the article "Time for a causal systems map of physical activity" by J. Nuzzo and colleagues. Topics discussed include argument of the authors regarding criticisms of their paper, description of the initial physical activity system map they included in their paper, and core challenge inherent in a complex systems approach to physical activity promotion.

This paper explores the possibility of integrating knowledge mapping into a conceptual framework that could serve as a tool for understanding the many complex processes, resources and people involved in a health system, and for identifying potential gaps within knowledge translation processes in order to address them. After defining knowledge mapping, this paper presents various examples of the application of this process in health, before looking at the steps that need to be taken to identify potential gaps, to determine to what extent these gaps affect the knowledge translation process and to establish their cause. This is followed by proposals for interventions aimed at strengthening the overall process. Finally, potential limitations on the application of this framework at the country level are addressed. [ABSTRACT FROM AUTHOR]

This paper examines the policy options for the regultion of dual job holding by medical professionals in highly resource-constrained settings. Such activity is generally driven by a lack of resources in the public sector and low pay, and has been associated with the unauthorized use of public resources and corruption. It is also typically poorly regulated; regulations are either lacking, or when they exists, are vague or poorly implemented because of low regulatory capacity. This paper draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. The approach taken in highlighting these broader social objectives seeks to avoid the value judgements regarding dual working and some of its solution to issues such as limited public sector resources (and incomes), low regulatory capacity and the interplay between market forces and human resources. This paper therefore offers some support for policies that allow for the official recognition of such activity and embrace a degree of professional self-regulation. In providing clearer policy guidance, future research in this area needs to adopt a more evaluative approach than that which has been used to date. [ABSTRACT FROM AUTHOR]

The Global strategy for women's, children's and adolescents' health (2016-2030) recognizes that people have a central role in improving their own health. We propose that community participation, particularly communities working together with health services (co-production in health care), will be central for achieving the objectives of the global strategy. Community participation specifically addresses the third of the key objectives: to transform societies so that women, children and adolescents can realize their rights to the highest attainable standards of health and well-being. In this paper, we examine what this implies in practice. We discuss three interdependent areas for action towards greater participation of the public in health: improving capabilities for individual and group participation; developing and sustaining people-centred health services; and social accountability. We outline challenges for implementation, and provide policy-makers, programme managers and practitioners with illustrative examples of the types of participatory approaches needed in each area to help achieve the health and development goals. [ABSTRACT FROM AUTHOR]

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists’ primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff’s skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists’ clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers. [ABSTRACT FROM AUTHOR]