Carmen Huckel Schneider

Global public health and international relations: pressing issues – evolving governance

Global health has received increasing attention among scholars of international relations in recent years following several key developments. First, there has been a growing public awareness of how new and re-emerging infectious diseases are affecting populations around the world. The most prominent of these is HIV/AIDS, a pandemic which continues to spread and devastate communities, with the heaviest burdens in low and middle income countries. At the same time, diseases, such as tuberculosis and malaria, are increasing in prevalence despite being considered largely under control in the 1970s. The 2002/2003 SARS pandemic provided further momentum, making visible the vulnerability of communities around the world in an age of rapid movements of goods and people. Second has been the change in the nature of the response to growing inequalities in health, including a rapid influx of resources that have been flowing into global health funds and programmes in recent years. Following increasing political attention given to global health at G8 and UN General Australian Journal of International Affairs Vol. 62, No. 1, pp. 94 106, March 2008

Non-communicable diseases and implications for medical practice in Australia: a framework for analysis

Non‐communicable diseases (NCDs) have become leading causes of mortality and morbidity as part of historical epidemiological, demographic and nutritional transitions. There has been considerable historical analysis of the immediate and underlying causes of this change in the impacts of communicable diseases and NCDs, but far less historical analysis of how this transition has shaped medical practice. We lay out a framework for future historical analysis by proposing four domains of inquiry into key areas of change: changes in the concept of disease; evolution of medical technology; changes in workforce, including variation in roles and emerging areas of specialisation; and changes in health care structures including models of care, government responses and transitioning health systems. Our aim is to encourage analysis that takes into account key features in each of the four domains, thus enabling a more complete understanding of why, how and under what circumstances NCDs have had an effect on medical practice.

Challenges of integrating evidence into health policy and planning: linking multiple disciplinary approaches

OBJECTIVES To explore the challenges that arise through the multidisciplinary nature of evidence informed policy making (EIPM). Type of program or service: Education and practice for EIPM. METHODS This article summarises and compares four disciplinary approaches to EIPM with highly contrasting starting points: behavioural science, policy science, critical theory and intervention research. Key insights and theories are highlighted to provide a gateway into each, and to complement what is already known about the evidence needs of policy makers in terms of high-quality, timely and well-communicated research evidence. LESSONS LEARNT The extension of the evidence based medicine approach to EIPM has created interest in the processes of use of evidence in health policy and planning. Research in this field has spanned multiple disciplines; however, the disciplines use very different research methods and begin with different basic assumptions. Thus, despite the multidisciplinary nature of EIPM, true interdisciplinary research and action remain a challenge. We conclude with a set of key questions that can be used as a gateway to interdisciplinary EIPM in the future.

Generating Sustained Political Priority for Non-communicable Diseases: Towards a Suitable Governance Model

The 2011 high-level meeting of the United Nations General Assembly on non-communicable diseases (NCDs), and subsequent developments in global public policy on NCDs can be seen as a contemporary case study in global health governance. As the debate on what constitutes appropriate and desirable governance continues, highly contrasting models are being compared as starting points. We define these as the global health initiative model and the convention/strategy model. Each has a different strategy at its core and represents a different response to key normative challenges that are said to plague global health governance – participation, scope of action, balancing power, legitimacy and effectiveness. As the current structure of the Global Coordinating Mechanism for NCDs within the WHO emerges as a possible new model, we argue that these normative challenges need to be addressed to safeguard against potential policy ineffectiveness.

A population-based comparison of the post-operative outcomes of open and laparoscopic appendicectomy in children

OBJECTIVE To assess and compare the post-operative outcomes of open and laparoscopic appendicectomy in children. DESIGN Record linkage analysis of administrative hospital (Admitted Patient Data Collection) and emergency department (Emergency Department Data Collection) data.Participants, setting: Children under 16 years of age who underwent an appendicectomy in a public or private hospital in New South Wales between January 2002 and December 2013. MAIN OUTCOME MEASURES Association between type of appendicectomy and post-operative complications within 28 days of discharge, adjusted for patient characteristics and type of hospital. RESULTS Of 23 961 children who underwent appendicectomy, 19 336 (81%) had uncomplicated appendicitis and 4625 (19%) had appendicitis complicated by abscess, perforation, or peritonitis. The proportion of laparoscopic appendicectomies increased from 11.8% in 2002 to 85.8% in 2013. In cases of uncomplicated appendicitis, laparoscopic appendicectomy was associated with more post-operative complications (mostly symptomatic re-admissions or emergency department presentations) than open appendicectomy (7.4% v 5.8%), but with a reduced risk of post-operative intestinal obstruction (adjusted odds ratio [aOR], 0.59; 95% CI, 0.36-0.97). For cases of complicated appendicitis, the risk of wound infections was lower for laparoscopic appendicectomy (aOR, 0.67; 95% CI, 0.50-0.90), but not the risks of intestinal obstruction (aOR, 0.97; 95% CI, 0.62-1.52) or intra-abdominal abscess (aOR, 1.06; 95% CI, 0.72-1.55). CONCLUSION Post-appendicectomy outcomes were similar for most age groups and hospital types. Children with uncomplicated appendicitis have lower risk of post-operative bowel obstruction after laparoscopic appendicectomy than after open appendicectomy, but may be discharged before their post-operative symptoms have adequately resolved.

Global burden of pain and global pain policy—creating a purposeful body of evidence

Within the past decade or so, important signals about the burden of chronic pain at population level have emerged from separate fields of work. Broadly speaking, these fields can be divided into 2 main categories—(1) national and subnational population studies that have specifically focussed on characterising the burden of chronic pain in general, or specific pain conditions such as lowback pain, and (2) global studies that characterise and rank the leading causes of death and disability at population level, conducted under the umbrella of the Global Burden of Disease Project (GBD) and by the WHO, using similar methods. An implicit shared purpose of these 2 fields is to provide evidence to inform policy responses that will lead to overall improvement in population health. The connection between these 2 fields has, to date, mainly been limited to incorporation of data from some specific national and subnational population studies of chronic pain burden into the GBD estimation methods, and use of the significant methodological advances in how to measure burden of disease. The improvements in measurement have come from the GBD over more than 2 decades by researchers and governments in individual countries to improve local studies of burden of disease. Despite the evolution of a better evidence base, there has been a lack of translation into effective and coherent global pain policy. In this article, we suggest that there is considerable potential to use local policy action research to develop an evidence base that is both more robust and policy-relevant. We argue that such an approach would further the important aim of reducing the global burden of pain. The ultimate goal is to shift the goal away from statistical accuracy of burden metrics towards applying evidence and testing policy-oriented solutions. The aims of this article are as follows: (1) to summarise recent evidence about the global burden of pain coming from the GBD about musculoskeletal pain, (2) to contextualise this evidence with insights emerging from our broader understanding of pain at a population level and as a chronic condition, and (3) the production of evidence and its relationship to global priority setting and the global health policy landscape. We then propose an agenda for expanding the body of evidence for policy and promoting its use in global health policy/prioritisation.

Implementing system-wide risk stratification approaches: a review of critical success and failure factors

Risk stratification has become a widely used tool for linking people identified at risk of health deterioration to the most appropriate evidence-based care. This article systematically reviews recent literature to determine key factors that have been identified as critical enablers and/or barriers to successful implementation of risk stratification tools at a system level. A systematic search found 23 articles and four promising protocols for inclusion in the review, covering the use to 20 different risk stratification tools. These articles reported on only a small fraction of the risk stratification tools used in health systems; suggesting that while the development and statistical validation of risk stratification algorithms is widely reported, there has been little published evaluation of how they are implemented in real-world settings. Controlled studies provided some evidence that the use of risk stratification tools in combination with a care management plan offer patient benefits and that the use of a risk stratification tool to determine components of a care management plan may contribute to reductions in hospital readmissions, patient satisfaction and improved patient outcomes. Studies with the strongest focus on implementation used qualitative and case study methods. Among these, the literature converged on four key areas of implementation that were found to be critical for overcoming barriers to success: the engagement of clinicians and safeguarding equity, both of which address barriers of acceptance; the health system context to address administrative, political and system design barriers; and data management and integration to address logistical barriers.

The for-profit sector in humanitarian response: integrating ethical considerations in public policy decision making

Abstract The engagement of the for-profit private sector in health, social and humanitarian services has become a topic of keen interest. It is particularly contentious in those instances where for-profit organizations have become recipients of public funds, and where they become key decision-makers in terms of how, and to whom, services are provided. We put forward a framework for identifying and organizing the ethical questions to be considered when contracting government services to the for-profit sector, specifically in those areas that have traditionally remained in the public or not-for-profit spheres. The framework is designed to inform both academic debate and practical decision-making regarding the acceptability, feasibility and legitimacy of for-profit organizations carrying out humanitarian work. First, we outline the importance of posing ethical questions in government contracting for-profit vs. not-for-profit organizations. We then outline five key areas to be considered before then examining the extent to which ethics concerns are warranted and how they may be safeguarded.