Global Health Actors - 1 - 5 Flashcards
What is the Essential Medicines List?
Published by WHO - Medications considered to be most effective and safe to meet most important needs of health system.
How does the EML contribute to united health care?
Used by countries to develop their own local lists of essential medicines.
What two categories of medicines are included in the EML?
Core and complimentary
What do the core medicines in EML consist of?
Most cost-effective options for key health problems
Usable w/ little additional health resources
What do the complimentary medicines in EML consist of?
Require additional infrastructure:
- Specially trained HCW
- Diagnostic equipment leading to a decreased cost-benefit ratio
Is there another list for children?
Yes - Essential Medicines List for Children (EMLc) for children up to 12 y/o
What is the criteria for selection of essential medicines?
Disease burden
Sound + adequate data on efficacy, safety + comparative cost-effectiveness of available treatments
Stability in various conditions - need for special diagnostic/treatment facilities
When adequate scientific evidence not available, Expert Committee may either defer issue until more evidence becomes available or make recommendations based on expert opinion
Cost of total Tx and unit cost of medicine - patency not considered
Name two drugs that are in the process of applying for EML
Bedaquiline + Grazoprevir/elbasvir
What does bedaquiline treat?
MDR-TB as part of a combination Tx of pulmonary TB
Why is bedaquiline needed?
An estimated 9% of patients with MDR-TB had XDR-TB
In low resource settings, pts with MDR-TB are inadequately treated and often die because not enough medications are available
Second-line drugs often not available
Global stock-outs
Many MDR-TB cases go undetected and not placed on appropriate Tx, increasing risk of death +/- transmission of MDR-TB strains to others
What is the efficacy of bedaquiline?
82% in bedaquiline group and 62% in placebo
Highly likely to be cost-effective in both LICs and HICs –> faster rates of conversion so less time hospitalised
What are the S/E of bedaquiline?
QT prolongation - must take caution when co-prescribing with drugs that affect the liver
What is the top cause of disease burden worldwide?
Ischaemic Heart Disease
How have the top causes of disease burden changed in the last decade?
Shift from communicable diseases to NCDs
What is the largest contributor of lost DALYs?
Cardiovascular disease
Which condition receives the most international Development Assistance for Health (DAH)?
HIV/AIDS - 5 fold increase in DAH since 1990
Has declined though
Is funding relative to global burden of disease?
No - some conditions are top causes of GBD but relatively underfunded e.g. NCDs, maternal and reproductive health e.g. HIV/AIDS had 7.6% YLL but a 41.6% DAH whereas TB had 3.1% YLL and 3.3% DAH. GH actors decide on how diseases get funded
How has global health finance changed in the last decade?
In 90s used to be mainly bilateral GH relationship as main source of income i.e. aid given from one country to another. Now it is more a mixed landscape - more mixed pattern of funding as different actors come to play
Who is the largest donor of DAH globally?
The National Treasury of the USA
Who is the biggest contributor of global health financing?
NGOs and foundations, followed by the US. Most important funders of healthcare are national governments and their citizens
What are the 3 lens to view health spending through?
Health lens
Development lens
Ministry of Defence lens
Describe the health spending source in LICs
Rely on DAH and out-of-pocket financing - this can deter access to healthcare (if > 40% of income = catastrophic)
Describe the health spending source in MICs
Domestic spending but when governments lack the capacity to increase health spending, much is left to be financed out of pocket
Describe the health spending source in HICs
Mainly government spending and prepaid private insurance schemes with some out of pocket
What is the global governance for health? (GGH)
Collection of rules, norms, institutions and processes that shape the health of the world’s populations. Governance strategies aim to organise stakeholders + manage social, economic and political affairs to improve global health and narrow health inequalities - The Lance - University of Oslo commission
What is the global health system?
A constellation of actors whose primary purpose is to promote, restore or maintain health.
Sets of rules that prescribe behavioural roles, constrain activity and shape expectations.
Such actors may operate at the community, national or global levels and may include governmental, intergovernmental, private-for-profit +/- not-for profit entities (Slezak et al, 2010)
What diagram illustrates the global health system?
Frenk diagram, 2013
How many sectors does the Global Health system have?
3: State, Market + Civil society
What is the state sector in the GH system?
Legislature
Executive
Judiciary
Role of government - usually most powerful policy actor in a country
What is the market sector in the GH system?
Represents important political power: huge resources + major contributors of national economies
Private finance, provision, partnerships and joint ventures
Trade associations, think tanks and professional associations
What is the civil society sector in the GH system?
Voluntary, free association situated between market and state sector
“A buffer zone strong enough to keep both state and market in check, thereby preventing each from becoming too powerful and dominating” (Giddens, 2001)
What is the definition of global health?
Collaborative trans-national research and action for promoting health for all (Beaglehole et al.)
Advocates the importance of health + burden of disease on the progress + future stability of each country and the world as a transnational body through action fuelled by evidence-based MDT
What institutions does the global system used to deal with challenges to health that require cross-border collective action to address effectively?
Formal and informal
Give examples of formal institutions in the global system
WHO
Governments
Give examples of informal institutions in the global system
BMGF
MSF
Hold themselves in account + quality of care they are providing
Is there an independent regulatory body to critique financially independent organisations about their standards?
No! How do we ensure that they align their agenda to countries?
What is the global system being more and more influenced by?
Politics as formed by member states
Health is being seen as a commodity by countries
What are the trends and challenges in global health?
Vaccine-preventable diseases Infectious diseases Anti-microbial resistance Behaviour of people Climate change NCDs Population growth LICs to MICs - epidemiological transition Political environment is changing - BRIC (Brazil, Russia, India, China)
What are the 4 essential functions of the global health system?
Production global public goods i.e. R&D, standards and guidelines, comparative evidence and analyses
Management of externalities across countries e.g. surveillance and info sharing
Mobilisation of global solidarity - development financing, technical cooperation
Stewardship = convening for negotiation + cross-sector health advocacy
What category does MSF fall into?
All 3 - very little institutional funding; recruit local staff to do work
Who are the top 3 key global health actors?
WHO
BMFG
Gavi
What are the criticisms of the WHO?
Large institution but slow to act e.g. Ebola outbreak
Political institution and disconnect - people who run offices are political + a lot of autonomy that regional offices have so how much authority does the central Geneva office have?
Undermined by other economic giants e.g. BMGF + World Bank
Emergency medicine increasing capacity - pushes WHO beyond their status
Many policies don’t consider affordability - disconnect between policies and what happens on the ground
Unstable financial situation - mandatory contributions are much smaller than voluntary contributions - countries can decide what money is spent on
Why is the global health environment crucial for humanitarian settings?
Mapping of relevant institutions
Power dynamics
Shift from worldwide nation-based health policy making structures towards more diversity that puts emphasis on private sector actors
What are the global health priorities?
Health security + humanitarian biomedicine
Communicable diseases
Health system strengthening - to govern health in the new global context + strengthen local response - shift from health system strengthening to political and economic systems
How does humanitarian action play a part in global health setting?
Prominent part of the political and moral landscape - ideology of profession + a movement
Humanitarianism operates under the notion that there is agreement over the existence of a common core of universal humanitarian values
What is the policy triangle made up of?
Content Context Process Actors There is a central issue of power
What are the contextual factors?
Economic - different between countries Social/cultural - dominant national ideologies influence what is possible e.g. difficulties of reforming health system post conflict Ideological Political system Conflict Globalisation
What are the 3 groups of global actors?
Individuals
Groups
Organisations
Some sectors of the population may be more powerful than others e.g. young v old, rich v poor, hereditary powers, political affiliations
What is the policy process usually like?
A clear, rational and linear process for generation of policy is often not the case in practice + policies can enter at different stages of the process
POWER plays a massive part of the process
What is agenda setting like?
Inherently unstable - some issues are permanent, transient or cyclical
Interplay of actors/interests, ideas, institutions
Mediation is crucial - aims of a policy and practice of policies often don’t align
What is policy maintenance like?
Takes up a lot of time for policy makers - rarely policy leaps
Involves a diverse group of interests - formal and informal
Level of influence depends on how well connected they are + how successful they are at getting issues onto the policy agenda
What are the 10 steps of outbreaks?
Establish the presence of outbreak Diagnose Develop case definition Describe the epidemiology: time, place, person Active case finding, contact tracing Develop + test hypothesis about its cause.... re-evaluate Respond Repost (evaluate)
When did the ebola outbreak in West Africa occur?
Started in Guinea in December 2013 and then spread to Sierra Leone and Liberia
What are the 6 system building blocks?
Service delivery Health workforce Information Medical products, vaccines + technologies Financing Leadership/governance
What are the overall goals/outcomes of health systems?
Improved health (level and equity)
Responsiveness
Social and financial risk protection
Improved efficiency
What were the reasons for the Ebola outbreak spreading initially?
Lack of healthcare workforce - one doctor for 70 000 people
Mobile population when Ebola was unknown
Lack of surveillance and alerting system
Lack of cooperation across borders (started where 3 countries shared borders with each other)
Unwillingness to declare - financial implications
Lack of international response - travel restrictions
Complex coordination of response
How did the Ebola outbreak affect healthcare workers?
Up to 16% of cases were in HCW initially - had an effect afterwards as number of HCW decreased dramatically as number of cases increased
> 500 HCW died
What were the wider impacts of the effect on HCW during the Ebola outbreak?
Health facilities understaffed/closed
25% drop in malaria treatment
Expanded Programme on Immunization (EPI) activities stopped
Maternal deaths rose by about 30%
How did the MSF respond to the Ebola outbreak?
Patient management in Emergency Medical Clinics - maternal care for infected women, survivors’ clinics, anti-malarial distribution
Disinfection - homes, bodies; cremation
Training and support to others (Sierra Leone)
Training staff in Amsterdam, Brussels + Geneva
Vaccine research
What happened in Freetown, the capital of Sierra Leone during the Ebola outbreak 2013?
Prevalence rates would not go down in the densely populated city so divided city into administrative regions to different organisations e.g. MSF, Oxfam etc
Community education + mobilisation - targeted gangs
Support alert system (phone lines)
Set up community surveillance system - daily reporting
Improve contact tracing quality
Chart chains of transmission - find gaps
Dignified quarantine response
Pilot system
Successful and rolled out to other areas - hampered by multiple ministries + local communities
What are the 6 pillars of response?
Case management + isolation Case finding Contact tracing Safe + dignified burial Social mobilisation/community engagement Supporting and existing health structures
What are the negative lessons learnt from the Ebola outbreak?
Failure to invest in PH preventative systems - Delay in WHO declaring a Public Health Emergency of International Concern
Failure to focus on people - before and during
International response slow + poorly coordinated - self interest led to lack of commitment
Migration, movement + outbreaks
Public health response was insufficient
Impact of misinformation + media storm on public perception - affects political will
What are the positive lessons learnt from the Ebola outbreak?
Rapid implementation of research
Compassionate controls
