Naomi Beyeler

Immigration as a Social Determinant of Health

Although immigration and immigrant populations have become increasingly important foci in public health research and practice, a social determinants of health approach has seldom been applied in this area. Global patterns of morbidity and mortality follow inequities rooted in societal, political, and economic conditions produced and reproduced by social structures, policies, and institutions. The lack of dialogue between these two profoundly related phenomena-social determinants of health and immigration-has resulted in missed opportunities for public health research, practice, and policy work. In this article, we discuss primary frameworks used in recent public health literature on the health of immigrant populations, note gaps in this literature, and argue for a broader examination of immigration as both socially determined and a social determinant of health. We discuss priorities for future research and policy to understand more fully and respond appropriately to the health of the populations affected by this global phenomenon.

The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review

Background The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access. Objectives and Methods We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings. Results Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes. Conclusions Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.

A Systematic Review of the Role of Proprietary and Patent Medicine Vendors in Healthcare Provision in Nigeria

Background Interventions to reduce the burden of disease and mortality in sub-Saharan Africa increasingly recognize the important role that drug retailers play in delivering basic healthcare services. In Nigeria, owner-operated drug retail outlets, known as patent and proprietary medicine vendors (PPMVs), are a main source of medicines for acute conditions, but their practices are not well understood. Greater understanding of the role of PPMVs and the quality of care they provide is needed in order to inform ongoing national health initiatives that aim to incorporate PPMVs as a delivery mechanism. Objective and Methods This paper reviews and synthesizes the existing published and grey literature on the characteristics, knowledge and practices of PPMVs in Nigeria. We searched published and grey literature using a number of electronic databases, supplemented with website searches of relevant international agencies. We included all studies providing outcome data on PPMVs in Nigeria, including non-experimental studies, and assessed the rigor of each study using the WHO-Johns Hopkins Rigor scale. We used narrative synthesis to evaluate the findings. Results We identified 50 articles for inclusion. These studies provided data on a wide range of PPMV outcomes: training; health knowledge; health practices, including drug stocking and dispensing, client interaction, and referral; compliance with regulatory guidelines; and the effects of interventions targeting PPMVs. In general, PPMVs have low health knowledge and poor health treatment practices. However, the literature focuses largely on services for adult malaria, and little is known about other health areas or services for children. Conclusions This review highlights several concerns with the quality of the private drug retail sector in Nigeria, as well as gaps in the existing evidence base. Future research should adopt a more holistic view of the services provided by PPMV shops, and evaluate intervention strategies that may improve the services provided in this sector.

Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030

Summary Background The United Nations Sustainable Development Goal for health (SDG3) poses complex challenges for signatory countries that will require clear roadmaps to set priorities over the next 15 years. Building upon the work of the Commission on Investing in Health and published estimates of feasible global mortality SDG3 targets, we analysed Mexicos mortality to assess the feasibility of reducing premature (0–69 years) mortality and propose a path to meet SDG3. Methods We developed a baseline scenario applying 2010 age-specific and cause-specific mortality rates from the Mexican National Institute of Statistics and Geography (INEGI) to the 2030 UN Population Division (UNPD) population projections. In a second scenario, INEGI age-specific and cause-specific trends in death rates from 2000 to 2014 were projected to 2030 and adjusted to match the UNPD 2030 mortality projections. A third scenario assumed a 40% reduction in premature deaths across all ages and causes. By comparing these scenarios we quantified shortfalls in mortality reductions by age group and cause, and forecasted life expectancy pathways for Mexico to converge to better performing countries. Findings UNPD-projected death rates yield a 25·9% reduction of premature mortality for Mexico. Accelerated reductions in adult mortality are necessary to reach a 40% reduction by 2030. Mortality declines aggregated across all age groups mask uneven gains across health disorders. Injuries, particularly road traffic accidents and homicides, are the main health challenge for young adults (aged 20–49 years) whereas unabated diabetes mortality is the single most important health concern for older adults (aged 50–69 years). Interpretation Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. Funding Mexicos Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation.

Integrating informal providers into a people-centered health systems approach: qualitative evidence from local health systems in rural Nigeria

BackgroundThe presence of a large informal healthcare sector in many low- and middle-income countries poses both challenges and opportunities for achieving a people-centered health system. However, few studies have considered how informal providers may fit into a people-centered health systems approach. We examine the self-described roles and motivations of informal medicine vendors and public healthcare workers in rural Nigeria, as well as interactions between them, with the aim of identifying how local health systems may be reoriented for improved service delivery through a people-centered approach.MethodsWe analyzed data from in-depth interviews with 70 medicine vendors and 21 staff of public health facilities in 30 villages across Kogi, Kwara and Enugu states in Nigeria. Interview guides covered the respondent’s or her facility’s role in providing health services to the local community, motivation to work in her respective profession, and relationships and interactions with other frontline healthcare providers. Data were analyzed in Atlas.ti using an open coding approach.ResultsBoth medicine vendors and staff of public health facilities viewed themselves as fulfilling an essential primary healthcare function in their villages, and described their main motivation as the desire to help their communities. Medicine vendors were acknowledged by both groups to play an important role in providing care close to underserved rural communities, but within a limited scope of practice. Vendors described referring cases beyond their self-defined capacity to the local public facility. Health facility staff also sent clients to vendors to purchase drugs that were out of stock. However, referrals were informal and unspecific in nature, and the degree to which relationships between vendors and health facility staff were collaborative was highly context-dependent despite their recognized interdependencies in health services provision.ConclusionsPolicies aimed at fostering people-centered health systems should consider the role of informal providers in the delivery of integrated care. In the context of our rural study sites in Nigeria, supporting stronger and more consistent linkages between medicine vendors and public health facilities is a key step towards improving health service delivery.

Invirtiendo en salud: el argumento económico. Informe del Foro sobre Inversión en Salud de la Cumbre Mundial sobre Innovación para la Salud 2016

Resumen: Los gobiernos de los paises en desarrollo y los organismos de ayuda internacional enfrentan decisiones dificiles en cuanto a la mejor manera de asignar sus recursos limitados. Las inversiones en distintos sectores -incluyendo educacion, agua y saneamiento, transporte y salud- pueden generar beneficios sociales y economicos. Este informe se enfoca especificamente en el sector salud. Presenta evidencia contundente sobre el valor de ampliar las inversiones en salud. El argumento economico para incrementar estas inversiones en salud nunca ha sido mas solido. Con el progreso que se ha logrado en la reduccion de la mortalidad materna e infantil y de las muertes por enfermedades infecciosas, es esencial que los responsables de la formulacion de politicas no se vuelvan complacientes. Estos logros se revertiran rapidamente sin inversiones sostenidas en salud. Sera necesario ampliar las inversiones para hacer frente a la carga generada por las enfermedades no transmisibles (ENT) emergentes y para alcanzar la cobertura universal de salud (CUS). El valor de la inversion en salud va mucho mas alla de su rendimiento reflejado en la prosperidad economica a traves del producto interno bruto (PIB). Las personas dan un gran valor monetario a los anos de vida adicionales que las inversiones en salud pueden proporcionar -un valor inherente a permanecer con vida por mas tiempo, que no tiene que ver con la productividad. Los encargados del diseno de politicas deben esforzarse mas para asegurar que el gasto en salud refleje las prioridades de la gente. Para asegurar que los servicios sean accesibles para todos, la funcion del gobierno en el financiamiento de la salud es muy clara. Sin financiamiento publico, habra quienes no podran costear los servicios que requieren y se veran forzados a elegir la enfermedad -o incluso la muerte- y la ruina economica, una eleccion devastadora que ya esta llevando a 150 millones de personas a la pobreza cada ano. En paises de bajos ingresos (PBI) y paises de ingresos medios (PIM), el financiamiento publico deberia ser utilizado para alcanzar la cobertura universal con un paquete de intervenciones altamente costo-efectivas (mejores inversiones u opciones). Los gobiernos que no protejan la salud y el patrimonio de su pueblo de esta manera seran incapaces de obtener los beneficios de una prosperidad economica y un crecimiento a largo plazo. El financiamiento publico tiene el beneficio de ser mas eficiente y capaz de controlar los costos que el financiamiento privado, y es la unica manera sostenible de lograr una CUS. Ademas, la gente atribuye un alto valor economico a la proteccion que le provee el financiamiento publico contra los riesgos financieros. Este informe aborda tres preguntas clave: 1) ?Cual es el fundamento economico para invertir en salud?; 2) ?cual es la mejor manera de financiar la salud?, y 3) ?cuales son las intervenciones que deben tener prioridad?