A rapid mixed-methods assessment of Libya's primary care system.

BACKGROUND: Libya has experienced decades of violent conflict that have severely disrupted health service delivery. The Government of National Unity is committed to rebuilding a resilient health system built on a platform of strong primary care. AIM: Commissioned by the government, we set out to perform a rapid assessment of the system as it stands and identify areas for improvement. DESIGN AND SETTING: We used a rapid applied policy explanatory-sequential mixed-methods design, working with Libyan data and Libyan policymakers, with supporting interview data from other primary care policymakers working across the Middle East and North Africa region. METHOD: We used the Primary Health Care Performance Initiative framework to structure our assessment. Review of policy documents and secondary analysis of WHO and World Bank survey data informed a series of targeted policymaker interviews. We used deductive framework analysis to synthesise our findings. RESULTS: We identified 11 key documents and six key policymakers to interview. Libya has strong policy commitments to providing good quality primary care, and a high number of health staff and facilities. Access to services and trust in providers is high. However, a third of facilities are non-operational; there is a marked skew towards axillary and administrative staff; and structural challenges with financing, logistics, and standards has led to highly variable provision of care. CONCLUSION: In reforming the primary care system, the government should consolidate leadership, clarify governance structures and systems, and focus on setting national standards for human resources for health, facilities, stocks, and clinical care.

Pandemic treaty as an instrument to strengthen global health security: Global health diplomacy at its crux.

Background: The World Health Assembly (WHA), on 1st December 2021, unanimously agreed to launch a global process to draft and negotiate a convention, agreement, or other international instrument under the World Health Organization's (WHO's) constitution to strengthen pandemic prevention, preparedness, and response. We aimed to explore the role of global health diplomacy (GHD) in pandemic treaty negotiations by providing deep insight into the ongoing drafting process under the WHO leadership. Methods: We conducted a narrative review by searching Scopus, Web of Sciences, PubMed, MEDLINE, and Google Scholar search engine using the keywords "Pandemic Treaty," OR "International Health Regulations," OR "International conventions," OR "International treaties" in the context of recent COVID-19 pandemic. Besides, we included articles recommending the need for GHD, leadership and governance mechanisms for this international treaty drafting approved by the WHA. Results: Amid the COVID-19 pandemic, the concept of GHD bolstered the international system and remained high on the agendas of many national, regional and global platforms. As per Article 19 of the WHO constitution, the Assembly established an intergovernmental negotiating body (INB) to draft and negotiate this convention/ agreement to protect the world from disease outbreaks of pandemic potential. Since GHD has helped to strengthen international cooperation in health systems and address inequities in achieving health-related global targets, there is a great scope for the successful drafting of this pandemic treaty. Conclusion: The pandemic treaty is a defining moment in global health governance, particularly the pandemic governance reforms. However, the treaty's purpose will only be served if the equity considerations are optimized, accountability mechanisms are established, and a sense of shared responsibility is embraced. While fulfilling treaty commitments might be complex and challenging, it provides an opportunity to rethink and build resilient systems for pandemic preparedness and response in the future.

Engaging with the Private Sector for Noncommunicable Disease Prevention and Control: Is it Possible to Create "Shared Value?"

Noncommunicable diseases (NCDs) are the leading cause of premature mortality worldwide. Corporate interests are sometimes well-aligned with public health, but profiteering from the consumption of products that are known to be the major contributors to the noncommunicable disease burden undermines public health. This paper describes the key industry actors shaping the NCD landscape; highlights the unhealthy commodities' impact on health and the growing burden of NCDs; and outlines challenges and opportunities to reduce exposure to those risk factors. Corporations deploy a wide array of strategies to maximize profits at the expense of health, including sophisticated marketing techniques, interference in the policy-making process, opposition and distortion of research and evidence, and whitewashing of health-harming activities through corporate social responsibility initiatives. There can be no shared value for industries that sell goods that harm health irrespective of consumption patterns (such as tobacco and likely alcohol), so government actions such as regulation and legislation are the only viable policy instruments. Where shared value is possible (for example, with the food industry), industry engagement can potentially realign corporate interests with the public health interest for mutual benefit. Deliberate, careful, and nuanced approaches to engagement are required.

Non-communicable disease policy implementation in Libya: A mixed methods assessment.

The Libyan Ministry of Health is keen to understand how it can introduce policies to protect its population from non-communicable diseases (NCDs). We aimed to perform an implementation research assessment of the current situation, including challenges and opportunities. We used an explanatory sequential mixed methods design. We started with a quantitative assessment of NCD policy performance based on review of the WHO NCD Progress Monitor Reports. Once we had identified Libya's NCD policy gaps we performed a systematic review to identify international lessons around barriers and successful strategies for the policies Libya has not yet implemented. Finally, we performed a series of key stakeholder interviews with senior policymakers to explore their perspectives around promising policy actions. We used a realist paradigm, methods triangulation, and a joint display to synthesise the interpretation of our findings and develop recommendations. Libya has not fully implemented any of the recommended policies for diet, physical activity, primary care guidelines & therapeutics, or data collection, targets & surveillance. It does not have robust tobacco policies in place. Evidence from the international literature and policymaker interviews emphasised the centrality of according strong political leadership, governance structures, multisectoral engagement, and adequate financing to policy development activities. Libya's complex political and security situation are major barriers for policy implementation. Whilst some policies will be very challenging to develop and deploy, there are a number of simple policy actions that could be implemented with minimum effort; from inviting WHO to conduct a second STEPS survey, to signing the international code on breast-milk substitutes. Like many other fragile and conflict-affected states, Libya has not accorded NCDs the policy attention they demand. Whilst strong high-level leadership is the ultimate key to providing adequate protections, there are a range of simple measures that can be implemented with relative ease.

The economics of malaria control and elimination: a systematic review.

BACKGROUND: Declining donor funding and competing health priorities threaten the sustainability of malaria programmes. Elucidating the cost and benefits of continued investments in malaria could encourage sustained political and financial commitments. The evidence, although available, remains disparate. This paper reviews the existing literature on the economic and financial cost and return of malaria control, elimination and eradication. METHODS: A review of articles that were published on or before September 2014 on the cost and benefits of malaria control and elimination was performed. Studies were classified based on their scope and were analysed according to two major categories: cost of malaria control and elimination to a health system, and cost-benefit studies. Only studies involving more than two control or elimination interventions were included. Outcomes of interest were total programmatic cost, cost per capita, and benefit-cost ratios (BCRs). All costs were converted to 2013 US$ for standardization. RESULTS: Of the 6425 articles identified, 54 studies were included in this review. Twenty-two were focused on elimination or eradication while 32 focused on intensive control. Forty-eight per cent of studies included in this review were published on or after 2000. Overall, the annual per capita cost of malaria control to a health system ranged from $0.11 to $39.06 (median: $2.21) while that for malaria elimination ranged from $0.18 to $27 (median: $3.00). BCRs of investing in malaria control and elimination ranged from 2.4 to over 145. CONCLUSION: Overall, investments needed for malaria control and elimination varied greatly amongst the various countries and contexts. In most cases, the cost of elimination was greater than the cost of control. At the same time, the benefits of investing in malaria greatly outweighed the costs. While the cost of elimination in most cases was greater than the cost of control, the benefits greatly outweighed the cost. Information from this review provides guidance to national malaria programmes on the cost and benefits of malaria elimination in the absence of data. Importantly, the review highlights the need for more robust economic analyses using standard inputs and methods to strengthen the evidence needed for sustained financing for malaria elimination.

Hospitalists, value and the future.

Health systems face increasing pressure to optimise value: providing the best quality care for the lowest possible cost. In the US, changes in modern healthcare, along with early efforts to contain costs, fuelled the growth of a new cadre of inpatient clinicians known as hospitalists. This commentary briefly reviews the history of the hospitalist movement through the lens of healthcare value, examines the evidence for value improvement in the care and training provided by hospitalists, and concludes by exploring both the lessons learned and remaining challenges facing hospitalists. We believe that openness to challenging the status quo was a critical enabler of the US hospitalist's impact on both the healthcare workforce and the American care delivery model. This spirit of re-engineering has far-reaching implications, both in the USA and abroad.

Achieving a "Grand Convergence" in Global Health: Modeling the Technical Inputs, Costs, and Impacts from 2016 to 2030.

BACKGROUND: The Commission on Investing in Health published its report, GlobalHealth2035, in 2013, estimating an investment case for a grand convergence in health outcomes globally. In support of the drafting of the Sustainable Development Goals (SDGs), we estimate what the grand convergence investment case might achieve-and what investment would be required-by 2030. METHODS AND FINDINGS: Our projection focuses on a sub-set of low-income (LIC) or lower-middle-income countries (LMIC). We start with a country-based (bottom-up) analysis of the costs and impact of scaling up reproductive, maternal, and child health tools, and select HIV and malaria interventions. We then incorporate global (top-down) analyses of the costs and impacts of scaling up existing tools for tuberculosis, additional HIV interventions, the costs to strengthen health systems, and the costs and benefits from scaling up new health interventions over the time horizon of this forecast. These data are then allocated to individual countries to provide an aggregate projection of potential cost and impact at the country level. Finally, incremental costs of R&D for low-income economies and the costs of addressing NTDs are added to provide a global total cost estimate of the investment scenario. RESULTS: Compared with a constant coverage scenario, there would be more than 60 million deaths averted in LIC and 70 million deaths averted in LMIC between 2016 and 2030. For the years 2015, 2020, 2025, and 2030, the incremental costs of convergence in LIC would be (US billion) $24.3, $21.8, $24.7, and $27, respectively; in LMIC, the incremental costs would be (US billion) $34.75, $38.9, $48.7, and $56.3, respectively. CONCLUSION: Key health outcomes in low- and low-middle income countries can significantly converge with those of wealthier countries by 2030, and the notion of a "grand convergence" may serve as a unifying theme for health indicators in the SDGs.