Vivien Runnels

Medical tourism today: What is the state of existing knowledge?

AbstractOne manifestation of globalization is medical tourism. As its implications remain largely unknown, we reviewed claimed benefits and risks. Driven by high health-care costs, long waiting periods, or lack of access to new therapies in developed countries, most medical tourists (largely from the United States, Canada, and Western Europe) seek care in Asia and Latin America. Although individual patient risks may be offset by credentialing and sophistication in (some) destination country facilities, lack of benefits to poorer citizens in developing countries offering medical tourism remains a generic equity issue. Data collection, measures, and studies of medical tourism all need to be greatly improved if countries are to assess better both the magnitude and potential health implications of this trade.

Appraising the evidence: applying sex- and gender-based analysis (SGBA) to Cochrane systematic reviews on cardiovascular diseases.

OBJECTIVE To examine the use of sex- and gender-based analysis (SGBA) in systematic reviews of cardiovascular health in order to strengthen the evidence base for clinical practice and policy. METHODS To determine the current status of SGBA in systematic reviews, an appraisal tool was developed by the research team and applied by an independent reviewer to a random sample of 38 Cochrane systematic reviews. The sample was drawn from reviews addressing interventions for cardiovascular diseases (CVD). A random sample of Cochrane reviews in cardiovascular health was selected from the Cochrane Library, Issue 3, 2001, to Issue 3, 2007. The main outcome measure was the number of reviews that included analysis of sex or gender or both. RESULTS Our findings showed that SGBA was generally absent in the sampled reviews. Data were rarely disaggregated by sex; only 2 of 38 reviews reported any sex or gender research gaps. Only one quarter of the reviews included a rationale as to why any subgroup analyses by sex were or were not completed. None of the 38 reviews met all of the appraisal tool criteria. As well, we found that where sex or gender was mentioned, the terms were used interchangeably. CONCLUSIONS Despite increasing evidence over the past decade documenting that sex and gender frequently matter in CVD, this study demonstrated that SGBA was rarely considered in systematic reviews. We suggest this omission has important implications for assuring the quality of research and of evidence-based policy and practice and for achieving equitable health outcomes for women and men. To build a robust evidence base for future work in cardiovascular health, we propose that the methodologies of systematic reviews and of SGBA be refined and synchronized to enhance the collection, synthesis, and analysis of evidence for decision making.

The challenges of including sex/gender analysis in systematic reviews: a qualitative survey

BackgroundSystematic review methodology includes the rigorous collection, selection, and evaluation of data in order to synthesize the best available evidence for health practice, health technology assessments, and health policy. Despite evidence that sex and gender matter to health outcomes, data and analysis related to sex and gender are frequently absent in systematic reviews, raising concerns about the quality and applicability of reviews. Few studies have focused on challenges to implementing sex/gender analysis within systematic reviews.MethodsA multidisciplinary group of systematic reviewers, methodologists, biomedical and social science researchers, health practitioners, and other health sector professionals completed an open-ended survey prior to a two-day workshop focused on sex/gender, equity, and bias in systematic reviews. Respondents were asked to identify challenging or ‘thorny’ issues associated with integrating sex and gender in systematic reviews and indicate how they address these in their work. Data were analysed using interpretive description. A summary of the findings was presented and discussed with workshop participants.ResultsRespondents identified conceptual challenges, such as defining sex and gender, methodological challenges in measuring and analysing sex and gender, challenges related to availability of data and data quality, and practical and policy challenges. No respondents discussed how they addressed these challenges, but all proposed ways to address sex/gender analysis in the future.ConclusionsRespondents identified a wide range of interrelated challenges to implementing sex/gender considerations within systematic reviews. To our knowledge, this paper is the first to identify these challenges from the perspectives of those conducting and using systematic reviews. A framework and methods to integrate sex/gender analysis in systematic reviews are in the early stages of development. A number of priority items and collaborative initiatives to guide systematic reviewers in sex/gender analysis are provided, based on the survey results and subsequent workshop discussions. An emerging ‘community of practice’ is committed to enhancing the quality and applicability of systematic reviews by integrating considerations of sex/gender into the review process, with the goals of improving health outcomes and ensuring health equity for all persons.

Canadian physicians' responses to cross border health care

BackgroundThe idea for this survey emanated from desk research and two meetings for researchers that discussed medical tourism and out-of-country health care, which were convened by some of the authors of this article (VR, CP and RL).MethodsA Cross Border Health Care Survey was drafted by a number of the authors and administered to Canadian physicians via the Canadian Medical Association’s e-panel. The purpose of the survey was to gain an understanding of physicians’ experiences with and views of their patients acquiring health care out of country, either as medical tourists (paying out-of-pocket for their care) or out-of-country care patients funded by provincial/territorial public health insurance plans. Quantitative and qualitative results of the survey were analyzed.Results631 physicians responded to the survey. Diagnostic procedures were the top-ranked procedure for patients either as out-of-country care recipients or medical tourists. Respondents reported that the main reason why patients sought care abroad was because waiting times in Canada were too long. Some respondents were frustrated with a lack of information about out-of-country procedures upon their patients’ return to Canada. The majority of physician respondents agreed that it was their responsibility to provide follow-up care to medical travellers on return to Canada, although a substantial minority disagreed that they had such a responsibility.ConclusionsCross-border health care, whether government-sanctioned (out-of-country-care) or patient-initiated (medical tourism), is increasing in Canada. Such flows are thought likely to increase with aging populations. Government-sanctioned outbound flows are less problematic than patient-initiated flows but are constrained by low approval rates, which may increase patient initiation. Lack of information and post-return complications pose the greatest concern to Canadian physicians. Further research on both types of flows (government-sanctioned and patient-initiated), and how they affect the Canadian health system, can contribute to a more informed debate about the role of cross-border health care in the future, and how it might be organized and regulated.

Development and evaluation of 'briefing notes' as a novel knowledge translation tool to aid the implementation of sex/gender analysis in systematic reviews: a pilot study.

Background There is increasing recognition of sex/gender differences in health and the importance of identifying differential effects of interventions for men and women. Yet, to whom the research evidence does or does not apply, with regard to sex/gender, is often insufficiently answered. This is also true for systematic reviews which synthesize results of primary studies. A lack of analysis and reporting of evidence on sex/gender raises concerns about the applicability of systematic reviews. To bridge this gap, this pilot study aimed to translate knowledge about sex/gender analysis (SGA) into a user-friendly ‘briefing note’ format and evaluate its potential in aiding the implementation of SGA in systematic reviews. Methods Our Sex/Gender Methods Group used an interactive process to translate knowledge about sex/gender into briefing notes, a concise communication tool used by policy and decision makers. The briefing notes were developed in collaboration with three Cochrane Collaboration review groups (HIV/AIDS, Hypertension, and Musculoskeletal) who were also the target knowledge users of the briefing notes. Briefing note development was informed by existing systematic review checklists, literature on sex/gender, in-person and virtual meetings, and consultation with topic experts. Finally, we held a workshop for potential users to evaluate the notes. Results Each briefing note provides tailored guidance on considering sex/gender to reviewers who are planning or conducting systematic reviews and includes the rationale for considering sex/gender, with examples specific to each review group’s focus. Review authors found that the briefing notes provided welcome guidance on implementing SGA that was clear and concise, but also identified conceptual and implementation challenges. Conclusions Sex/gender briefing notes are a promising knowledge translation tool. By encouraging sex/gender analysis and equity considerations in systematic reviews, the briefing notes can assist systematic reviewers in ensuring the applicability of research evidence, with the goal of improved health outcomes for diverse populations.

Health worker migration from South Africa: causes, consequences and policy responses

BackgroundThis paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries—Jamaica, India, the Philippines, and South Africa—have historically been “sources” of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.MethodsThe study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.ResultsThere has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.ConclusionsIn the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving—a mixed method study

BackgroundDramatic increases in the migration of human resources for health (HRH) from developing countries like the Philippines can have consequences on the sustainability of health systems. In this paper, we trace the outflows of HRH from the Philippines, map out its key causes and consequences, and identify relevant policy responses.MethodsThis mixed method study employed a decentered, comparative approach that involved three phases: (a) a scoping review on health workers’ migration of relevant policy documents and academic literature on health workers’ migration from the Philippines; and primary data collection with (b) 37 key stakeholders and (c) household surveys with seven doctors, 329 nurses, 66 midwives, and 18 physical therapists.ResultsFilipino health worker migration is best understood within the context of macro-, meso-, and micro-level factors that are situated within the political, economic, and historical/colonial legacy of the country. Underfunding of the health system and un- or underemployment were push factors for migration, as were concerns for security in the Philippines, the ability to practice to full scope or to have opportunities for career advancement. The migration of health workers has both negative and positive consequences for the Philippine health system and its health workers. Stakeholders focused on issues such as on brain drain, gain, and circulation, and on opportunities for knowledge and technology transfer. Concomitantly, migration has resulted in the loss of investment in human capital. The gap in the supply of health workers has affected the quality of care delivered, especially in rural areas. The opening of overseas opportunities has commercialized health education, compromised its quality, and stripped the country of skilled learning facilitators. The social cost of migration has affected émigrés and their families. At the household level, migration has engendered increased consumerism and materialism and fostered dependency on overseas remittances. Addressing these gaps requires time and resources. At the same time, migration is, however, seen by some as an opportunity for professional growth and enhancement, and as a window for drafting more effective national and inter-country policy responses to HRH mobility.ConclusionsUnless socioeconomic conditions are improved and health professionals are provided with better incentives, staying in the Philippines will not be a viable option. The massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who cannot be absorbed by a system that is underfunded. This results in a paradox of underservice, especially in rural and remote areas, at the same time as underemployment and outmigration. Policy responses to this paradox have not yet been appropriately aligned to capture the multilayered and complex nature of these intersecting phenomena.

Past Fame, Present Frames and Future Flagship? An Exploration of How Health is Positioned in Canadian Foreign Policy

Canada has been regarded as a model global citizen with firm commitments to multilateralism. It has also played important roles in several international health treaties and conventions in recent years. There are now concerns that its interests in health as a foreign policy goal may be diminishing. This article reports on a thematic analysis of key Canadian foreign policy statements issued over the past decade, and interviews with key informants knowledgeable of, or experienced in the interstices of Canadian health and foreign policy. It finds that health is primarily and increasingly framed in relation to national security and economic interests. Little attention has been given to human rights obligations relevant to health as a foreign policy issue, and global health is not seen as a priority of the present government. Global health is nonetheless regarded as something with which Canadian foreign policy must engage, if only because of Canada’s membership in many United Nations and other multilateral fora. Development of a single global health strategy or framework is seen as important to improve intersectoral cooperation on health issues, and foreign policy coherence. There remains a cautious optimism that health could become the base from which Canada reasserts its internationalist status.

Causes, consequences, and policy responses to the migration of health workers: key findings from India

BackgroundThis study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries—Jamaica, India, the Philippines, and South Africa—that have historically been “sources” of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.MethodsData were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically.ResultsShortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration.ConclusionsConsequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

Global health diplomacy: A critical review of the literature

Global health diplomacy (GHD) describes the practices by which governments and non-state actors attempt to coordinate and orchestrate global policy solutions to improve global health. As an emerging field of practice, there is little academic work that has comprehensively examined and synthesized the theorization of Global Health Diplomacy (GHD), nor looked at why specific health concerns enter into foreign policy discussion and agendas. With the objective of uncovering the driving forces behind and theoretical explanations of GHD, we conducted a critical literature review. We searched three English-language scholarly databases using standardized search terms which yielded 606 articles. After screening of abstracts based on our inclusion/exclusion criteria, we retained 135 articles for importing into NVivo10 and coding. We found a lack of rigorous theorizing about GHD and fragmentation of the GHD literature which is not clearly structured around key issues and their theoretical explanations. To address this lack of theoretical grounding, we link the findings from the GHD literature to how theoretical concepts used in International Relations (IR) have been, and could be invoked in explaining GHD more effectively. To do this, we develop a theoretical taxonomy to explain GHD outcomes based on a popular categorization in IR, identifying three levels of analysis (individual, domestic/national, and global/international) and the driving forces for the integration of health into foreign policy at each level.