Pathways from climate change to emotional wellbeing: A qualitative study of Kenyan smallholder farmers living with HIV.

Climate change is associated with adverse mental and emotional health outcomes. Social and economic factors are well-known drivers of mental health, yet comparatively few studies examine the social and economic pathways through which climate change affects mental health. There is additionally a lack of research on climate change and mental health in sub-Saharan Africa. This qualitative study aimed to identify potential social and economic pathways through which climate change impacts mental and emotional wellbeing, focusing on a vulnerable population of Kenyan smallholder farmers living with HIV. We conducted in-depth, semi-structured interviews with forty participants to explore their experience of climate change. We used a thematic analytical approach. We find that among our study population of Kenyan smallholder farmers living with HIV, climate change is significantly affecting mental and emotional wellbeing. Respondents universally report some level of climate impact on emotional health including high degrees of stress; fear and concern about the future; and sadness, worry, and anxiety from losing one's home, farm, occupation, or ability to support their family. Climate-related economic insecurity is a main driver of emotional distress. Widespread economic insecurity disrupts systems of communal and family support, which is an additional driver of worsening mental and emotional health. Our study finds that individual adaptive strategies used by farmers in the face of economic and social volatility can deepen economic insecurity and are likely insufficient to protect mental health. Finally, we find that agricultural policies can worsen economic insecurity and other mental health risk factors. Our proposed conceptual model of economic and social pathways relevant for mental health can inform future studies of vulnerable populations and inform health system and policy responses to protect health in a changing climate.

Cancer and climate change.

The acute impact of climate change on human health is receiving increased attention, but little is known or appreciated about the effect of climate change on chronic diseases, particularly cancer. This Review provides a synopsis of what is known about climate change and the exposures it generates relevant to cancer. In the context of the world's cancer burden and the probable direction we could expect to follow in the absence of climate change, this scoping review of the literature summarises the effects that climate change is having on major cancers, from environmental exposures to ultraviolet radiation, air pollution, disruptions in the food and water supply, environmental toxicants, and infectious agents. Finally, we explore the effect of climate change on the possible disruption of health systems that have been essential to cancer control practice. We conclude with potential responses and opportunities for intervention.

Measuring development assistance for health systems strengthening and health security: an analysis using the Creditor Reporting System database.

Background: Health systems strengthening (HSS) and health security are two pillars of universal health coverage (UHC). Investments in these areas are essential for meeting the Sustainable Development Goals and are of heightened relevance given the emergence of the 2019 novel coronavirus disease (COVID-19). This study aims to generate information on development assistance for health (DAH) for these areas, including how to track it and how funding levels align with country needs. Methods: We developed a framework to analyze the amount of DAH disbursed in 2015 for the six building blocks of the health system ('system-wide HSS') plus health security (emergency preparedness, risk management, and response) at both the global (transnational) and country level. We reviewed 2,427 of 32,801 DAH activities in the Creditor Reporting System (CRS) database (80% of the total value of disbursements in 2015) and additional public information sources. Additional aid activities were identified through a keyword search. Results: In 2015, we estimated that US$3.1 billion (13.4%) of the US$22.9 billion of DAH captured in the CRS database was for system-wide HSS and health security: US$2.5 billion (10.9%) for system-wide HSS, mostly for infrastructure, and US$0.6 billion (2.5%) for system-wide health security. US$567.1 million (2.4%) was invested in supporting these activities at the global level. If responses to individual health emergencies are included, 7.5% of total DAH (US$1.7B) was for health security. We found a correlation between DAH for HSS and maternal mortality rates, and we interpret this as evidence that HSS aid generally flowed to countries with greater need. Conclusions : Achieving UHC by 2030 will require greater investments in system-wide HSS and proactive health emergency preparedness. It may be appropriate for donors to more prominently consider country needs and global functions when investing in health security and HSS.

Improving resource mobilisation for global health R&D: a role for coordination platforms?

Achieving many of the health targets in the Sustainable Development Goals will not be possible without increased financing for global health research and development (R&D). Yet financing for neglected disease product development fell from 2009-2015, with the exception of a one-time injection of Ebola funding. An important cause of the global health R&D funding gap is lack of coordination across R&D initiatives. In particular, existing initiatives lack robust priority-setting processes and transparency about investment decisions. Low-income countries (LICs) and middle-income countries (MICs) are also often excluded from global investment initiatives and priority-setting discussions, leading to limited investment by these countries. An overarching global health R&D coordination platform is one promising response to these challenges. This analysis examines the essential functions such a platform must play, how it should be structured to maximise effectiveness and investment strategies for diversifying potential investors, with an emphasis on building LIC and MIC engagement. Our analysis suggests that a coordination platform should have four key functions: building consensus on R&D priorities; facilitating information sharing about past and future investments; building in accountability mechanisms to track R&D spending against investment targets and curating a portfolio of prioritised projects alongside mechanisms to link funders to these projects. Several design features are likely to increase the platform's success: public ownership and management; separation of coordination and financing functions; inclusion of multiple diseases; coordination across global and national efforts; development of an international R&D 'roadmap' and a strategy for the financial sustainability of the platform's secretariat.

[Investing in health: the economic case. Report of the WISH Investing in Health Forum 2016]. / Invirtiendo en salud: el argumento económico. Informe del Foro sobre Inversión en Salud de la Cumbre Mundial sobre Innovación para la Salud 2016.

Developing country governments and aid agencies face difficult decisions on how best to allocate their finite resources. Investments in many different sectors -including education, water and sanitation, transportation, and health- can all reap social and economic benefits. This report focuses specifically on the health sector. It presents compelling evidence of the value of scaling-up health investments. The economic case for increasing these investments in health has never been stronger. Having made progress in reducing maternal and child mortality, and deaths from infectious diseases, it is essential that policymakers do not become complacent. These gains will be quickly reversed without sustained health investments. Scaled-up investments will be needed to tackle the emerging non-communicable disease (NCD) burden and to achieve universal health coverage (UHC). The value of investment in health far beyond its performance is reflected in economic prosperity through gross domestic product (GDP). People put a high monetary value on the additional years of life that health investments can bring -an inherent value to being alive for longer, unrelated to productivity. Policymakers need to do more to ensure that spending on health reflects people's priorities. To make sure services are accessible to all, governments have a clear role to play in financing health. Without public financing, there will be some who cannot afford the care they need, and they will be forced to choose sickness -perhaps even death- and financial ruin; a devastating choice that already pushes 150 million people into poverty every year. In low-income countries (LICs) and middle-income countries (MICs), public financing should be used to achieve universal coverage with a package of highly cost-effective interventions ('best buys'). Governments failing to protect the health and wealth of their people in this way will be unable to reap the benefits of long-term economic prosperity and growth. Public financing has the benefit of being more efficient and better at controlling costs than private financing and is the only sustainable way to reach UHC. In addition, people put a high economic value on the protection against financial risk that public financing provides. This report addresses three key questions: 1) What is the economic rationale for investing in health?; 2) what is the best way to finance health?, and 3) which interventions should be prioritized?

Invirtiendo en salud: el argumento económico. Informe del Foro sobre Inversión en Salud de la Cumbre Mundial sobre Innovación para la Salud 2016 / Investing in health: the economic case. Report of the WISH Investing in Health Forum 2016

Resumen: Los gobiernos de los países en desarrollo y los organismos de ayuda internacional enfrentan decisiones difíciles en cuanto a la mejor manera de asignar sus recursos limitados. Las inversiones en distintos sectores -incluyendo educación, agua y saneamiento, transporte y salud- pueden generar beneficios sociales y económicos. Este informe se enfoca específicamente en el sector salud. Presenta evidencia contundente sobre el valor de ampliar las inversiones en salud. El argumento económico para incrementar estas inversiones en salud nunca ha sido más sólido. Con el progreso que se ha logrado en la reducción de la mortalidad materna e infantil y de las muertes por enfermedades infecciosas, es esencial que los responsables de la formulación de políticas no se vuelvan complacientes. Estos logros se revertirán rápidamente sin inversiones sostenidas en salud. Será 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 inversión en salud va mucho más allá de su rendimiento reflejado en la prosperidad económica a través del producto interno bruto (PIB). Las personas dan un gran valor monetario a los años de vida adicionales que las inversiones en salud pueden proporcionar -un valor inherente a permanecer con vida por más tiempo, que no tiene que ver con la productividad. Los encargados del diseño de políticas deben esforzarse más para asegurar que el gasto en salud refleje las prioridades de la gente. Para asegurar que los servicios sean accesibles para todos, la función del gobierno en el financiamiento de la salud es muy clara. Sin financiamiento público, habrá quienes no podrán costear los servicios que requieren y se verán forzados a elegir la enfermedad -o incluso la muerte- y la ruina económica, una elección devastadora que ya está llevando a 150 millones de personas a la pobreza cada año. En países de bajos ingresos (PBI) y países de ingresos medios (PIM), el financiamiento público debería 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 serán incapaces de obtener los beneficios de una prosperidad económica y un crecimiento a largo plazo. El financiamiento público tiene el beneficio de ser más eficiente y capaz de controlar los costos que el financiamiento privado, y es la única manera sostenible de lograr una CUS. Además, la gente atribuye un alto valor económico a la protección que le provee el financiamiento público contra los riesgos financieros. Este informe aborda tres preguntas clave: 1) ¿Cuál es el fundamento económico para invertir en salud?; 2) ¿cuál es la mejor manera de financiar la salud?, y 3) ¿cuáles son las intervenciones que deben tener prioridad?

Abstract: Developing country governments and aid agencies face difficult decisions on how best to allocate their finite resources. Investments in many different sectors -including education, water and sanitation, transportation, and health- can all reap social and economic benefits. This report focuses specifically on the health sector. It presents compelling evidence of the value of scaling-up health investments. The economic case for increasing these investments in health has never been stronger. Having made progress in reducing maternal and child mortality, and deaths from infectious diseases, it is essential that policymakers do not become complacent. These gains will be quickly reversed without sustained health investments. Scaled-up investments will be needed to tackle the emerging non-communicable disease (NCD) burden and to achieve universal health coverage (UHC). The value of investment in health far beyond its performance is reflected in economic prosperity through gross domestic product (GDP). People put a high monetary value on the additional years of life that health investments can bring -an inherent value to being alive for longer, unrelated to productivity. Policymakers need to do more to ensure that spending on health reflects people's priorities. To make sure services are accessible to all, governments have a clear role to play in financing health. Without public financing, there will be some who cannot afford the care they need, and they will be forced to choose sickness -perhaps even death- and financial ruin; a devastating choice that already pushes 150 million people into poverty every year. In low-income countries (LICs) and middle-income countries (MICs), public financing should be used to achieve universal coverage with a package of highly cost-effective interventions ('best buys'). Governments failing to protect the health and wealth of their people in this way will be unable to reap the benefits of long-term economic prosperity and growth. Public financing has the benefit of being more efficient and better at controlling costs than private financing and is the only sustainable way to reach UHC. In addition, people put a high economic value on the protection against financial risk that public financing provides. This report addresses three key questions: 1) What is the economic rationale for investing in health?; 2) what is the best way to finance health?, and 3) which interventions should be prioritized?

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

BACKGROUND: The 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. METHODS: We 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. RESULTS: Both 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. CONCLUSIONS: Policies 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.

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

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 Mexico's 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: Mexico's Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation.

Decision-making for delivery location and quality of care among slum-dwellers: a qualitative study in Uttar Pradesh, India.

BACKGROUND: In 2013, the Government of India launched the National Urban Health Mission (NUHM) in order to better address the health needs of urban populations, including the nearly 100 million living in slums. Maternal and neonatal health indicators remain poor in India. The objective of this study is to highlight the experiences of women, their husbands, and mothers-in-law related to maternal health services and delivery experiences. METHODS: In total, we conducted 80 in-depth interviews, including 40 with recent mothers, 20 with their husbands, and 20 with their mothers-in-law. Purposeful sampling was conducted in order to obtain differences across delivery experiences (facility vs. home), followed by their family members. RESULTS: Major factors that influence decision-making about where to seek care included household dynamics and joint-decision-making with families, financial barriers, and perceived quality of care. Women perceived that private facilities were higher quality compared to public facilities, but also more expensive. Disrespectful care, bribes in the facility, and payment challenges were common in this population. CONCLUSIONS: A number of programmatic and policy recommendations are highlighted from this study. Future endeavors should include a greater focus on health education and public programs, including educating women on how to access programs, who is eligible, and how to obtain public funds. Families need to be educated on their rights and expectations in facilities. Future programs should consider the role of husbands and mothers-in-law in reproductive decision-making and support during deliveries. Triangulating information from multiple sources is important for future research efforts.

Achieving a "Grand Convergence" in Global Health by 2035: Rwanda Shows the Way Comment on "Improving the World's Health Through the Post-2015 Development Agenda: Perspectives From Rwanda".

Global Health 2035, the report of The Lancet Commission on Investing in Health, laid out a bold, highly ambitious framework for making rapid progress in improving global public health outcomes. It showed that with the right health investments, the international community could achieve a "grand convergence" in global health-a reduction in avertable infectious, maternal, and child deaths down to universally low levels-within a generation. Rwanda's success in rapidly reducing such deaths over the last 20 years shows that convergence is feasible. Binagwaho and Scott have argued that 5 lessons from this success are the importance of equity, quality health services, evidence-informed policy, intersectoral collaboration, and effective collaboration between countries and multilateral agencies. This article re-examines these lessons through the lens of the Global Health 2035 report to analyze how the experience in Rwanda might be generalized for other countries to making progress towards achieving a grand convergence.

Social support in the practices of informal providers: The case of patent and proprietary medicine vendors in Nigeria.

The social and institutional environments in which informal healthcare providers operate shape their health and business practices, particularly in contexts where regulatory enforcement is weak. In this study, we adopt a social capital perspective to understanding the social networks on which proprietary and patent medicine vendors (PPMVs) in Nigeria rely for support in the operation of their shops. Data are drawn from 70 in-depth interviews with PPMVs in three states, including interviews with local leaders of the PPMV professional association. We find that PPMVs primarily relied on more senior colleagues and formal healthcare professionals for informational support, including information about new medicines and advice on how to treat specific cases of illness. For instrumental support, including finance, start-up assistance, and intervention with regulatory agencies, PPMVs relied on extended family, the PPMVs with whom they apprenticed, and the leaders of their professional association. PPMVs' networks also provided continual reinforcement of what constitutes good PPMV practice through admonishments to follow scope of practice limitations. These informal reminders, as well as monitoring activities conducted by the professional association, served to reinforce PPMVs' concern with avoiding negative customer health outcomes, which were perceived to be detrimental to their business reputations. That PPMVs' networks both encouraged practices to reduce the likelihood of poor health outcomes, and provided advice regarding customers' health conditions, highlights the potential impact of informal providers' access to different forms of social capital on their delivery of health services, as well as their success as microenterprises.

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.

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.