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BMJ Global Health | 2017

Towards an agenda for implementation science in global health : there is nothing more practical than good (social science) theories

Sara Van Belle; Remco van de Pas; Bruno Marchal

### Summary box Ridde recently called for a commitment to implementation science and for ‘better quality research in order to have a greater understanding of how to implement health interventions’.1 He argued for better use of theory and implementation science studies that contribute to theory. This is indeed of paramount importance, especially for interventions in complex settings such as health systems. In practice, however, few researchers take up the challenge; all too often, implementation studies adopt a mixed methods approach that is a-theoretical. If there is a lack of theory in the field of implementation science, it is not for want of theories. In the case of health governance, for instance, theory development and empirical research testing such theories have been taking place in the fields of economics and political science. However, there has been little, if any, systematic crossing over of recent governance theories to the field of health policy and systems research. This does not only apply to health (system) governance; research on health worker motivation and strategic decision-making at operational level, for instance, could use a healthy injection of recent theories and methods from other disciplines. In applied research fields, such as global environmental studies, there are more signs of effective cross-pollination. The study of global climate change is an example of how the integration of different paradigms yields new theoretical insights that drive empirical research; for example, the late Elinor Ostroms conceptualisation of polycentricity in efforts to address global …


Global Challenges | 2017

Global health governance in the sustainable development goals: Is it grounded in the right to health?

Remco van de Pas; Peter S. Hill; Rachel Hammonds; Gorik Ooms; Lisa Forman; Attiya Waris; Claire E. Brolan; Martin McKee; Devi Sridhar

Abstract This paper explores the extent to which global health governance – in the context of the early implementation of the Sustainable Development Goals is grounded in the right to health. The essential components of the right to health in relation to global health are unpacked. Four essential functions of the global health system are assessed from a normative, rights‐based, analysis on how each of these governance functions should operate. These essential functions are: the production of global public goods, the management of externalities across countries, the mobilization of global solidarity, and stewardship. The paper maps the current reality of global health governance now that the post‐2015 Sustainable Development Goals are beginning to be implemented. In theory, the existing human rights legislation would enable the principles and basis for the global governance of health beyond the premise of the state. In practice, there is a governance gap between the human rights framework and practices in global health and development policies. This gap can be explained by the political determinants of health that shape the governance of these global policies. Current representations of the right to health in the Sustainable Development Goals are insufficient and superficial, because they do not explicitly link commitments or right to health discourse to binding treaty obligations for duty‐bearing nation states or entitlements by people. If global health policy is to meaningfully contribute to the realization of the right to health and to rights based global health governance then future iterations of global health policy must bridge this gap. This includes scholarship and policy debate on the structure, politics, and agency to overcome existing global health injustices.


Global Affairs | 2015

Ebola, the epidemic that should never have happened

Remco van de Pas; Sara Van Belle

At the time of writing (November 2014), the death toll from the Ebola outbreak in West Africa has exceeded 5000 people. This number is likely to be an underestimate. The first Ebola outbreak occurred four decades ago, in 1976, in former Zaire, current DRC (Piot, 2012). There have been over 20 outbreaks since, but the current one has led to more cases and fatalities than the aggregated total of all the former outbreaks. Why is that the case? In this article, we argue that besides the challenge of ecological thresholds and other driving factors, an analysis of the political economy underlying bilateral development cooperation for health might provide insight into the dynamics of the current epidemic. Secondly, an assessment of the response of the World Health Organization (WHO), the mandated UN institution to deal with international outbreaks of epidemics, may shed light on what the actual policy space is and point to future challenges related to managing emerging infectious diseases such as Ebola, through international cooperation (Chang, 2005). The social, cultural and ecological determinants that contributed to the current Ebola outbreak, the marginal position of these WestAfrican countries in the global political economy, as well as the belated international response indicate a complex interplay between different systems and (political) drivers. This requires interdisciplinary research, necessarily complementing public health with other perspectives. Land reforms, deforestation and investment in palm oil plantations have lowered the ecological threshold for Ebola to emerge (Wallace et al., 2014). In addition, rapid urbanization on the African continent, with inadequate housing, water and sanitation in slums, provides fertile ground for human to human transmission on a large scale. This is the first time that Ebola has emerged in the West-African region. After an initial outbreak in a rural forested part of Guinea in December 2013, a small, localized outbreak ensued, without proper diagnosis of the virus nor containment until mid-March 2014. By the time national authorities and the international humanitarian organization


Human Resources for Health | 2016

The Code of Practice and its enduring relevance in Europe and Eastern and Southern Africa

Remco van de Pas; Linda Mans; Giulia de Ponte; Yoswa Dambisya

BackgroundThe relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Personnel will be reviewed by the World Health Assembly in 2015. The origins of the Code of Practice and the global health diplomacy process before and after its adoption are analyzed herein.Methods and ResultsCase studies from the European and eastern and southern African regions describe in detail successes and failures of the policy implementation of the Code. In Europe, the Code is effective and even more relevant than before, but might require some tweaking. In Eastern and Southern Africa, the code is relevant but far from efficient in mitigating the negative effects of health workforce migration.ConclusionsSolutions to strengthen the Code include clarification of some of its definitions and articles, inclusion of a governance structure and asustainable and binding financing system to reimburse countries for health workforce losses due to migration, and featuring of health worker migration on global policy agendas across a range of institutional policy domains.


Health Policy and Planning | 2017

Interrogating resilience in health systems development.

Remco van de Pas; Majdi Ashour; Anuj Kapilashrami; Suzanne Fustukian

Abstract The Fourth Global Symposium on Health Systems Research was themed around ‘Resilient and responsive health systems for a changing world.’ This commentary is the outcome of a panel discussion at the symposium in which the resilience discourse and its use in health systems development was critically interrogated. The 2014‐15 Ebola outbreak in West‐Africa added momentum for the wider adoption of resilient health systems as a crucial element to prepare for and effectively respond to crisis. The growing salience of resilience in development and health systems debates can be attributed in part to development actors and philanthropies such as the Rockefeller Foundation. Three concerns regarding the application of resilience to health systems development are discussed: (1) the resilience narrative overrules certain democratic procedures and priority setting in public health agendas by ‘claiming’ an exceptional policy space; (2) resilience compels accepting and maintaining the status quo and excludes alternative imaginations of just and equitable health systems including the socio‐political struggles required to attain those; and (3) an empirical case study from Gaza makes the case that resilience and vulnerability are symbiotic with each other rather than providing a solution for developing a strong health system. In conclusion, if the normative aim of health policies is to build sustainable, universally accessible, health systems then resilience is not the answer. The current threats that health systems face demand us to imagine beyond and explore possibilities for global solidarity and justice in health.


BMJ Global Health | 2017

Comment — WHO's weakness is not technical, but due to lack of accountability

David Legge; Claudio Schuftan; Fran Baum; Remco van de Pas; David Sanders; Lori Hanson; David McCoy; Amit Sengupta

Negin and Dhillons proposal that functions presently carried out by WHO should be ‘outsourced’ to the Gates Foundation, the Gates-funded Institute for Health Metrics and Evaluation (IHME), Medicins Sans Frontieres and national drug regulatory agencies such as the US Food and Drug Administration (FDA), lacks evidence, relies on flawed logic and serves to obscure critical causes of WHOs failures, in particular the donor chokehold. Negin and Dhillon cite a Cochrane review of outsourcing of healthcare in low-income and middle-income countries.1 Yet this review found only three studies that met its inclusion criteria all of which had a low quality of evidence and showed a high risk of bias. WHOs accountability is …


International journal of health policy and management | 2016

Global Health in the Anthropocene: Moving Beyond Resilience and Capitalism; Comment on “Health Promotion in an Age of Normative Equity and Rampant Inequality”

Remco van de Pas

There has been much reflection on the need for a new understanding of global health and the urgency of a paradigm shift to address global health issues. A crucial question is whether this is still possible in current modes of global governance based on capitalist values. Four reflections are provided. (1) Ecological –centered values must become central in any future global health framework. (2) The objectives of ‘sustainability’ and ‘economic growth’ present a profound contradiction. (3) The resilience discourse maintains a gridlock in the functioning of the global health system. (4) The legitimacy of multi-stakeholder governance arrangements in global health requires urgent attention. A dual track approach is suggested. It must be aimed to transform capitalism into something better for global health while in parallel there is an urgent need to imagine a future and pathways to a different world order rooted in the principles of social justice, protecting the commons and a central role for the preservation of ecology.


International journal of health policy and management | 2018

Framing the Health Workforce Agenda Beyond Economic Growth

Remco van de Pas; Linda Mans; Marielle Bemelmans; Anja Krumeich

The fourth Global Forum on Human Resources (HRH) for Health was held in Ireland November 2017. Its Dublin declaration mentions that strategic investments in the health workforce could contribute to sustainable and inclusive growth and are an imperative to shared prosperity. What is remarkable about the investment frame for health workforce development is that there is little debate about the type of economic development to be pursued. This article provides three cautionary considerations and argues that, in the longer term, a perspective beyond the dominant economic frame is required to further equitable development of the global health workforce. The first argument includes the notion that the growth that is triggered may not be as inclusive as proponents say it is. Secondly, there are considerable questions on the possibility of expanding fiscal space in low-income countries for public goods such as health services and the sustainability of the resulting economic growth. Thirdly, there is a growing consideration that economic growth solely expressed as increasing gross domestic product (GDP) might have intrinsic problems in advancing sustainable development outcomes. Economic development goals are a useful approach to guiding health workforce policies and health employment but this depends very much on the context. Alternative development models and policy options, such as a Job Guarantee scheme, need to be assessed, deliberated and tested. This would meet considerable political challenges but a narrow single story and frame of economic development is to be rejected.


The Lancet | 2017

False and real, but avoidable, dichotomies.

Gorik Ooms; Walter Flores; Moses Mulumba; Malabika Sarker; Remco van de Pas; Albrecht Jahn

This letter was published in The Lancet [© 2017 Lancet Publishing Group] and the definitive version is available at : http://doi.org/10.1016/S0140-6736(17)31445-9 The Journals website is at: https://www.sciencedirect.com/science/article/pii/S0140673617314459?via%3Dihub


International journal of health policy and management | 2017

The Global Health Policies of the EU and its Member States: A Common Vision?

Lies Steurs; Remco van de Pas; Sarah Delputte; Jan Orbie

Background: This article assesses the global health policies of the European Union (EU) and those of its individual member states. So far EU and public health scholars have paid little heed to this, despite the large budgets involved in this area. While the European Commission has attempted to define the ‘EU role in Global Health’ in 2010, member states are active in the domain of global health as well. Therefore, this article raises the question to what extent a common ‘EU’ vision on global health exists. Methods: This is examined through a comparative framing analysis of the global health policy documents of the European Commission and five EU member states (France, Germany, the United Kingdom, Belgium, and Denmark). The analysis is informed by a two-layered typology, distinguishing global health from international health and four ‘global health frames,’ namely social justice, security, investment and charity. Results: The findings show that the concept of ‘global health’ has not gained ground the same way within European policy documents. Consequently, there are also differences in how health is being framed. While the European Commission, Belgium, and Denmark clearly support a social justice frame, the global health strategies of the United Kingdom, Germany, and France put an additional focus on the security and investment frames. Conclusion: There are different understandings of global/international health as well as different framings within relevant documents of the EU and its member states. Therefore, the existence of an ‘EU’ vision on global health is questionable. Further research is needed on how this impacts on policy implementation.

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Sara Van Belle

Institute of Tropical Medicine Antwerp

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Bruno Marchal

Institute of Tropical Medicine Antwerp

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Wim Van Damme

Institute of Tropical Medicine Antwerp

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Alexandre Delamou

Institute of Tropical Medicine Antwerp

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