International Journal of Health Policy and Management
Volume:10 Issue: 8, Aug 2021

The coronavirus disease 2019 (COVID-19) pandemic has created strong pressure on national health critical care systems. After its initial impact in Asia, the highest case growth is now in the Americas. The South American countries face a strong challenge due to the vulnerabilities of their health systems and the fragile socio-economic conditions of their population. This perspective looks at the impact of COVID-19 in South America and argues that the health critical care systems of these countries are particularly vulnerable due to the underestimation of the number of cases currently confirmed and the strong need for treatment of these patients in intensive care units (ICUs). In particular, Bolivia will need to increase the number of ICU beds 60-fold while Brazil will need to grow 12-fold to meet the growth rates of COVID-19 by the end of July 2020. In this sense, it is argued that national and transnational measures should be taken urgently to face this challenge. Furthermore, it is necessary to perform tests to detect COVID-19 cases earlier to alleviate the need for internment in ICUs.

Background Over the last 20 years, community health workers (CHWs) have become a mainstay of human resources for health in many low- and middle-income countries (LMICs). A large body of research chronicles CHWs’ experience of their work. In this study we focus on 2 narratives that stand out in the literature. The first is the idea that social, economic and health system contexts intersect to undermine CHWs’ experience of their work, and that a key factor underpinning this experience is that LMIC health systems tend to view CHWs as just an ‘extra pair of hands’ to be called upon to provide ‘technical fixes.’ In this study we show the dynamic and evolving nature of CHW programmes and CHW identities and the need, therefore, for new understandings.   Methods A qualitative case study was carried out of the Indian CHW program (CHWs are called accredited social health activists: ASHAs). It aimed to answer the research question: How do ASHAs experience being CHWs, and what shapes their experience and performance? In depth interviews were conducted with 32 purposively selected ASHAs and key informants. Analysis was focused on interpreting and on developing analytical accounts of ASHAs’ experiences of being CHWs; it was iterative and occurred throughout the research. Interviews were transcribed verbatim and transcripts were analysed using a framework approach (with Nvivo 11).   Results CHWs resent being treated as just another pair of hands at the beck and call of formal health workers. The experience of being a CHW is evolving, and many are accumulating substantial social capital over time – emerging as influential social actors in the communities they serve. CHWs are covertly and overtly acting to subvert the structural forces that undermine their performance and work experience.   Conclusion CHWs have the potential to be influential actors in the communities they serve and in frontline health services. Health systems and health researchers need to be cognizant of and consciously engage with this emerging global social dynamic around CHWs. Such an approach can help guide the development of optimal strategies to support CHWs to fulfil their role in achieving health and social development goals.

Background Despite Vietnam’s acclaiming achievements of reducing overall infant mortality rate (IMR), the IMR decline does not occur equally in all regions in Vietnam. This study aims to investigate dominant factors that affect the inequality of infant mortality across regions in Vietnam during the period 2005-2015.   Methods We use nationally representative data to construct a panel data of 6 economic regions in Vietnam from 2005 to 2015. We employ the structural equation modelling (SEM) approach to quantify the causal effect of socio-economic status (SES), accessing to skilled birth attendance (SBA) and other relevant factors on the disparity of IMR across regions.   Results SES, which is measured by 3 indicators – illiteracy rate (IR), poverty rate (PR) and income per capita – is the dominant factor causing regional inequalities of infant mortality, followed by the use of SBA. Among these indicators, the PR is the most important one causing the regional disparity of IMR and accessing to SBA. The total effect of SES on infant mortality disparity is 2.6 times as high as that of accessing skilled healthcare personnel.   Conclusion Bridging the regional gap of using skilled health personnel would contribute to improving the infant mortality inequality in Vietnam. This inequality, however, is not significantly improved only with medical interventions but also with broader and more comprehensive socio-economic interventions at both national and regional levels. Our findings confirm that poverty reduction and growth strategies should be the main focus to boost medical interventions and improve IMR all over the country.

Background Evidence emerging from qualitative studies suggests the existence of substantial variation in how health workers experience performance-based financing (PBF) within the same setting. To date, however, no study has quantified or systematically explored this within-setting heterogeneity. Considering that differences in health workers’ affective reactions to PBF likely constitute an important element mediating the effectiveness of PBF in improving health service delivery, systematic and tangible information will be highly valuable to policy-makers and program managers who aim to maximize positive impacts of PBF. Our study aimed at contributing to filling this gap in knowledge by quantifying health workers’ knowledge of, satisfaction with, and perceptions of PBF in Burkina Faso, and exploring factors associated with heterogeneity therein.   Methods The study employed a post-intervention cross-sectional explanatory mixed methods study design with a dominant quantitative component – a structured survey to a total of 1314 health workers from 396 intervention health facilities – and a small and focused qualitative component – key informant interviews with 5 program managers – to triangulate and further elucidate the quantitative findings. Quantitative data were analyzed descriptively as well as using 3-level mixed effects models. Qualitative data were analyzed in a largely deductive process along the quantitative variables and results.   Results Health workers were on average moderately satisfied with PBF overall, with a slight tendency towards the positive and large variation between individuals. Two-thirds of health workers did not have adequate basic knowledge of key PBF elements. Perceived fairness of the performance evaluation process, of the bonus distribution process, and satisfaction with the individual financial bonuses varied dramatically between respondents. Factors associated with heterogeneity in knowledge, satisfaction, and fairness perceptions included responsibility at the facility, general work attitudes, management factors, and training in and length of exposure to PBF.   Conclusion Findings imply that investments into staff training on PBF and manager training on organizational change processes might be beneficial to positive staff attitudes towards PBF, which in turn would likely contribute to improving the effectiveness of PBF.

The Comprehensive Economic and Trade Agreement between Canada and the European Union provides for an extension of Canadian patents for prescription drugs by up to 2 years. One of the arguments advanced for longer patent time is to compensate companies for the length of the overall drug development time (the time between patent application and market approval). This study investigates overall development time in Canada for different groups of drugs approved between January 1, 2009 and December 31, 2018 and how many of these drugs are eligible for up to 2 years of patent term extension. Based on a list of patents and dates of market approval, the change in overall development time for all drugs was calculated along with whether there were differences in development time between different groups of drugs. Using Canadian patent filing dates, overall development time for all drugs went from a mean of 2240 days (95% CI: 1832, 2648) in 2009 to 4197 days (95% CI: 3728, 4665) in 2018 (analysis of variance [ANOVA], P < .0001). Using first global patent filing dates, overall development time went from a mean of 4481 days (95% CI: 3053, 5908) in 2009 to 6298 days (95% CI: 4839, 7756) in 2018 (ANOVA, P = .0118). There was a statistically significant difference in the overall development mean time between small molecule drugs (3553, 95% CI: 3361, 3746) and biologics (3903, 95% CI: 3595, 4212), (t test, P = .0487) when using Canadian patent filing dates but not when first global patent filing dates were used. There was no statistically significant change in overall development time among drugs that were substantial, moderate or little to none additional therapeutic value compared to existing drugs. Out of 238 drugs, 218 (91.6%) would have been eligible for patent term extension with 195 (80.7%) eligible for the full 2 years. Patent term extension does not appear to be justified based on changes in overall development time, except possibly in the case of biologics. There are also trade offs in terms of increased expenditures that need to be considered if patent terms are lengthened.

The profound inadequacies of Western modernist ways of thinking have been revealed by the intimately connected catastrophes of climate destruction, and more recently, the coronavirus crisis. The pandemic has forced us to notice deepening inequalities and has generated troubling questions about its causes, and who and what can be sacrificed in a pandemic. The analysis offered in Evelyn de Leeuw’s essay “The rise of the consucrat” suggests that the particular type of patient advocates she calls consucrats are unlikely to engage in thinking together about these urgent questions. If anything, due to their narrow biomedical focus and alliances with the pharmaceutical industry, they are likely to facilitate catastrophe capitalism. However, within the field of patient advocacy, there is a diversity of ways of thinking, occasionally leading to bitter contention. A number of terms is needed to reflect this diversity. One group of patient advocates who have come to the fore in recent times might be called medical cosmopolitans, or cosmedics, those who are challenging opportunistic catastrophe capitalism during the pandemic and advocating for global access to essential medicines. Forcing us to notice our deep interdependencies and entanglements, the pandemic has revealed how ludicrous it is to think about patients as consumers, and the need to think about and imagine more-than-human patient advocacy.

Patient, public, consumer, and community (P2C2) engagement in healthcare delivery, research, and policy-making has been long considered an ethical obligation and is increasingly a regulatory requirement globally. The requirement to include a P2C2 member on various governing bodies may have inadvertently created what Evelyne de Leeuw calls the “consucrat” – a career consumer who has been designated and professionalized to function on behalf of a particular group or community. The concept of a consucrat can be problematic when a P2C2 member is co-opted by an institution governing body or in situations where institutions only seek and listen to the same voice over time. In this commentary, we suggest that one way to avoid these problems is to take seriously the concept and process of representation. Representation is only meaningful when P2C2 members are actively connected with those whom they represent. Doing so helps ensure P2C2 members remain grounded in the real-world concerns of their constituency and that representatives, backed by the voices of others, will be more powerful in effecting change.

The trend in ensuring adequate consumer representation across diverse activities and sectors, not least in healthcare, has been speedily implemented, sometimes at the expense of strategy. This commentary explores the concept of the consucrat as a consumer representative, presented by de Leeuw, which raised important questions regarding the way in which individuals and health services interact and collaborate. Adopting a complex services marketing lens, the position of the consucrat is discussed in relation to agency underpinning three tensions identified by de Leeuw: designation; professionalization, and; representation. For equality, professional service providers are referred to as ‘profecrats.’ Supporting de Leeuw, challenges are made to the underlying assumptions implicit in terms used around representation, the perspective that it is the consucrat only who needs to adapt, and the discourse around the competence of the consucrat. We should not be too cautious in our approach to consumer representation. Consucrats have agency – what next for the profecrat?

Do populist leaders contribute to the spread of coronavirus disease 2019 (COVID-19)? While all governments have struggled to respond to the pandemic, it is now becoming clear that some political leaders have performed much better than others. Among the worst performing are those that have risen to power on populist agendas, such as in the United States, Brazil, Russia, India, and the United Kingdom. Populist leaders have tended to: blame “others” for the pandemic, such as immigrants and the Chinese government; deny evidence and show contempt for institutions that generate it; and portray themselves as the voice of the common people against an out-of-touch ‘elite.’ In our short commentary, focusing on those countries with the most cases, we find that populist leaders appear to be undermining an effective response to COVID-19. Perversely, they may also gain politically from doing so, as historically populist leaders benefit from suffering and ill health. Clearly more research is needed on the curious correlation of populism and public health. Notwithstanding gaps in the evidence, health professionals have a duty to speak out against these practices to prevent avoidable loss of life.

Populist radical right (PRR) parties can impact population health through multiple mechanisms, including welfare chauvinistic policies, influencing mainstream parties, and eroding democratic norms. Rinaldi and Bekker survey the literature in order to motivate a wider research agenda. They highlight results from existing studies which show the importance of looking into the impact of PRR parties on welfare policy. This commentary considers some of the areas of research highlighted by the original article, as well as other possibilities for further research. The most important of these is to expand the sample of cases to Central and Eastern Europe, Latin America, and South East Asia.

Our paper responds to a narrative review on the influence of populist radical right parties (PRRPs) on welfare policy and its implications for population health in Europe. Five aspects of their review are striking: (i) welfare chauvinism is higher in tax-funded healthcare systems; (ii) PRRPs in coalition with liberal or social democratic parties are able to shift welfare reform in a more chauvinistic direction; (iii) coalitions involving PRRPs can buffer somewhat the drift to welfare chauvinism, but not by much; (iv) the European Union (EU) and its healthcare policies has served somewhat as a check on PRRPs’ direct influence on healthcare welfare chauvinism; (v) PRRPs perform a balancing act between supporting their base and protecting elected power. We note that PRRPs are not confined to Europe and examine the example of Trump’s USA, arguing that the Republican Party he dominates now comes close to the authors’ definition of a PRRP. We applaud the authors’ scoping review for adding to the literature on political determinants of health but note the narrow frame on welfare policy could be usefully expanded to other areas of public policy. We examine three of such areas: the extent to which policy protects those who are different from mainstream society in terms of race, ethnicity, gender or sexuality; the debate between free trade and protectionism; and the rejection of climate change science by many PRRPs. Our analysis concludes that PRRPs promote agendas which are antithetical to eco-socially just population health, and conclude for a call for more research on the political determinants of health.

Building on Rinaldi and Bekker’s scoping review of articles on the impact of populist radical right (PRR) politics on welfare and population health, this short article formulates three pointers towards a framework that might help structure future research into PRR, populist politics more generally, and coronavirus disease 2019 (COVID-19) and other health issues. First, we discuss the centrality of welfare chauvinism to the PRR’s impact on health, taking this as a cue for a broader reflection on the importance on distinguishing between the nativist and populist dimensions of PRR politics. Secondly, we turn our attention to the potential moderating effect of the PRR’s welfare chauvinism on the welfare cuts proposed by their right-wing coalition partners, comments we see as pointing to the need to focus on nativist, populist, neoliberal and other threats to welfare policy more generally, rather than on the PRR only. Thirdly, we reflect on the paradoxical nature of welfare chauvinism – its negative consequences for the health of the ‘own people’ it proclaims to defend – as a starting point for a brief discussion of the need to consider carefully the not-so-straightforward relation between the PRR’s political rhetoric, its (impact on) policy and institutions, and the outcomes of such policy.