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BMJ Global Health blog

The intersection of gender, trauma and global health: what we know and what we should know

7 Sep, 17 | by BMJ

Many experts would argue that trauma is not just a one-time incident; it is a lifelong burden, affecting physical, psychosocial and emotional aspects of health. I have been interested in the subject of gender-based violence since childhood. As a child, I remember accompanying my mother to the domestic violence shelter where she volunteered on weekday evenings. Our conversation on the car ride home was peppered with discussion and questions that have continued to linger with me over the years: why does violence against women occur? How can we prevent it as a society? What is the impact of such violence on women’s physical, mental and emotional health?

As a medical student, I became interested in how such gender-based violence presents to the hospital – how it is identified (or not) by clinical providers, how healthcare professionals and social workers can assist and aid people who come into the hospital as a result of gender-based violence. Women and men who have experienced such violence may be coming into health care settings scared, fearful, and ashamed to share what has happened. As clinicians, I believe it is our duty to identify and support them as much as we can.

We know the majority of traumatic injuries that present to the hospital setting occur among males, in both higher and lower income countries. Differences in mechanisms of injury have also been explored along gender lines – for example, men are usually more likely to be injured in motor vehicle collisions than women. But what are the gender differences in outcomes for non-accidental trauma, such as assault and violence? Little has been explored in this area, largely due to lack of data, especially in lower–middle income countries. Comparing different countries can help shed light on the various ways in which women are being injured in different settings to help guide policies and practices.  For example, violent injuries against women via burns are more common in southeast Asia than other parts of the world. We were interested in knowing whether people fare differently based on their gender and how severely they were injured depending on the country in which they lived – for example, comparing the United States and India.

There is a large need for hospital-based assessment and resource provision in hospitals that take care of patients who are victims of gender-based violence. I have been involved in a study which seeks to fill this knowledge gap. Though not entirely conclusive, it is the first of its kind to show an association between gender and post-trauma outcomes based on intentionality of the injury – i.e. whether someone incurred an accidental or intentional (assault) injury. Most trauma data systems do not collect information on intentionality, but this is a crucial piece of data to add to the socio-demographic profile of a trauma patient.

In our study we found “Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying after motor vehicle collisions and 40 times the odds of dying after assaults when compared with US females”. It is difficult to pinpoint exactly why this is happening but the study is an important first step to understanding why there may exist differences in gender outcomes in different countries. Possible answers generated by this study include differences in hospital access for men and women, differences in social norms, and differences in intensity of injury. Our study opens the door to future investigation into this important topic. Ultimately, targeted improvement within health care systems to provide trauma-informed care and prevention programs to reduce violence may help ensure that such gender-based differences in outcomes after injury are addressed.

About the author: Mohini Dasari is a first-year general surgery resident at the University of Washington in Seattle, Washington, USA. She spent one year during medical school studying clinical outcomes in trauma in India and the United States, as well as electronic trauma registry implementation in Latin America. Her interests lie in the intersection of gender-based violence, trauma care and global public health.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and confirm I have no conflicts of interests to declare.


Fee-for-service – a bold measure by the Afghan health ministry

29 Aug, 17 | by BMJ

The Afghan Ministry of Public Health has recently announced a User Fee Regulation under which user fees will be levied for services in secondary and tertiary public health facilities. The details of how much will be charged, for what services, and when the regulation will actually come into effect are yet to be known. What is known at the moment is that primary health care services in Afghanistan will continue to remain free of charge. Moreover, the poor, the disabled, women victims of violence, women undergoing Caesarean section, and students availing services in secondary and tertiary care facilities will be exempt from charges.

Evidence from studies in other low- and middle-income countries  show that introduction of a fee-for-service leads to reduced utilisation of health services both preventive and curative in nature. Improvement in utilisation of curative services has only been observed when there was concomitant quality improvement affected with the introduction of user fees.

The government expects that the revenue generated from the tool for improving quality is the revenue from the fees, which could be used to provide necessary drugs, equip facilities with medical technology, and train staff. Some quality improvement for public sector may include the provision of necessary drugs, equipment, and staff. It must not be forgotten that respectful behaviour towards patients will have a significant impact on the perception of quality among the public and this can be challenging from the public policy perspective.

The implementation of this new regulation will entail several challenges. First, Afghanistan has an estimated 39% poor (~12 million people), and another 36% slightly above the poverty line of $1.25 per day (~10million), meaning that only around 30% of the population may be truly eligible to pay a fee-for-service. Second, identification of the poor will be a major challenge. With some nepotism and corruption the poor could be left outside the system and unreserved. The administration of distributing some kind of ID card for the poor requires a rigorous and transparent process and this is challenging in the current scenario.

Another challenge to user-fee implementation will be the manner in which revenue is managed. A centralised system of channelling the revenue through the finance department and redistributing it to all sectors can be bureaucratic and slow process to affect the quality of services. A decentralised system may be prone to embezzlement of the revenue. One option could be to establish local accountability committees to oversee the proper spending of the newly generated revenue. Local health facility councils could play that role in rural Afghanistan.

With the introduction of the fee-for-service regulation, a small window of opportunity through generating a sustainable revenue could be opened for the Afghan Ministry of Public Health. This is crucial in terms of the country’s current debacle when it is excessively dependent on foreign aid. The Ministry, however, must be prepared for the following:

  1. There will be a sharp decrease in health service utilisation, and thus a poorer health outcome in the coming months after the regulation takes effect, which could continue if the quality does not improve.
  2. The expected revenue from user fees will be limited due to a large proportion of poor in the country.
  3. If the revenue is not managed well, the Ministry could face a flood of criticism for local embezzlement of the new revenue or the disappearance of it in the core budget of the central government, with implications on the legitimacy of the overall government.
  4. As promised, if the quality of services does not improve, the gains in health outcomes in the past decade will be significantly jeopardized and the talk of equity in health services should be thrown out the back window.

Overall, it is a bold and risky measure by the Afghan Ministry of Public Health to strengthen the health system. Yet, as they say, the devil is in the detail: it is the details of implementation that will matter. In the long run, the overall development of the country’s economy is what that will make or break the public health system in Afghanistan.

About the author: Maisam Najafizada is an Assistant Professor of Health Policy at Memorial University of Newfoundland, Canada. He tweets @mayysam 

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I have no conflicts of interests to declare.

Tales of a small town surgeon in India: the case for global health investment on essential surgery

25 Jul, 17 | by BMJ

Dr. A works as a surgeon in a small town of India. Like any other small town doctor he has settled for a practice here because of affinity and close proximity to his home. Building up from the scratch, Dr. A has slowly set-up an infrastructure that provides the best possible quality and affordable healthcare to patients from surrounding rural areas who can’t afford highly expensive private hospitals or far-off government hospitals.

Dr. A juggles between multiple roles of surgeon, physician, administrator, treasurer and public health expert, often operating as a one-person medical team. While he still enjoys his profession, the lack of a ‘team’, as many doctors would agree, makes the job a daily-struggle and gruesome. Most of the support-staff hired in these clinics and hospitals are highly untrained and unskilled. For the lack of any better alternatives, doctors have to be content with this unfortunate setting. Often, this results in a team that lacks skills, discipline, experience and attitude to perform even regular procedures, leave alone highly complex surgeries. When one of the imaging machines malfunctioned in the middle of an operation, he had to wait almost a week for a technician to arrive from the state capital, and the surgery had to be continued blindly with archaic methods. In another instance, he had to use a manual orthopedic drill, when the automatic drill stopped functioning in the middle of another crucial operation. Lack of technical support, unskilled staff and frequent power-cuts makes this a usual occurrence. Inevitably quality of care and clinical outcomes are sub-optimal.

An anesthetist is the captain of the surgical ship, especially when things goes wrong. With only two anesthetists in town, there is a fierce scramble for his dates by orthopaedists, surgeons and obstetrician’s alike. Such issue gives add up to stress of doctors like Dr. A! Timely, affordable access to screened blood products is essential to delivery of quality surgical care. Most of the time blood products are scarce and even if available the improper and neglected maintenance of blood banks is a major cause of worry.

The challenges of chronic poverty limits access to surgical care. Out-of-pocket payment of hospital fees, supplies and medications demands the surgical care to be extremely affordable, often adequately provided by doctors. Culture belief and general mistrust of healthcare only adds to the challenges face by healthcare providers in small towns.

The seemingly disinterested Dr. A is also a part of a larger problem of burnout among doctors. Without any recreational facilities and dearth of whatsoever social life, numerous surgeons from smaller towns are a victim of burnout-associated symptoms such as emotional exhaustion, dissatisfaction and physical weariness. This has led to depersonalization, decline of empathy and reduced personal and professional satisfaction. The cause can be traced to widely varying factors such as overwhelming workload, poor specialists-patient’s ratio, deficiency of recreational facilities and insufficient support from medical organizations such as Indian Medical Association (IMA). IMA facilities in small towns have no provisions for recreational opportunities and CMEs and workshops are rare.

Medicine is a tough job no matter where you live, but it’s even more complicated when there is no formidable support system. Specialists like Dr. A continue to provide essential and specialized surgical care in rural areas and small towns without getting much recognition. While global health surgery has shed the tag of  the ‘neglected stepchild’ of global health, and is now  being recognized as an ‘indivisible, indispensable part of healthcare’ and  several transnational initiatives such as The Lancet Commission on Global Surgery (LCoGS) and The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) has been initiated . Timely and affordable access to essential surgical care is the key to equitable healthcare delivery in underdeveloped regions of the world. Yet, the challenges faced by surgical care providers in low resource settings and how they overcome these challenges to provide care to impoverished patients have hardly been understood. It is time that we recognize and value surgeons like Dr A, and also build up our health systems in a manner that they can function optimally. Universal health coverage includes essential and safer surgery and anesthesia and it is time that investments are made in this direction.

About the author: Ankit Raj is a final year medical student from Kasturba Medical College, Manipal, India and is a member of The International Student Surgical Network (InciSioN).

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I have no conflicts of interests to declare.

Chelsea Clinton and Devi Sridhar: Five tasks for the new WHO DG

24 May, 17 | by BMJ

Chelsea Clinton and Devi Sridhar set out five tasks for the newly elected DG of the WHO


Is India’s national health policy geared towards achieving the Sustainable Development Goals?

7 Apr, 17 | by BMJ

soumyadeep bhaumikThe adoption of Sustainable Development Goals (SDG’s) in 2015 marked a shift in the global development agenda from the earlier Millennium Development Goals (MDGs) era. SDGs are particularly important for the health sector, since they reaffirm the premise of the Alma Ata declaration that health cannot exist in isolation. SDG’s intrinsically link health with actions in several sectors outside healthcare. As a country which missed several of its MDG targets, the SDGs reflect a new set of challenges for India.

At the 2015 United Nations summit, India’s Prime Minister Narendra Modi said that the “Sustainable development of one-sixth of humanity will be of great consequence to the world and our beautiful planet,” while reiterating his confidence that they will be reached. But how well does India’s latest National Health Policy (NHP 2017) released last month, align with the health related SDG’s?

To its credit, the policy, at the outset, recognises the SDG’s to be of “pivotal importance” and has identified seven priority areas outside the health sector which can have an impact on preventing and promoting health. In the section on urban health policy, the NHP calls for “achieving convergence among the wider determinants of health.” The NHP has identified the following determinants specifically: “air pollution, better solid waste management, water quality, occupational safety, road safety, housing, vector control, and reduction of violence and urban stress.” The policy links this with the government’s focus on “smart cities,” seemingly in tandem with SDG 11. This is commendable. But the omission of other traditional determinants of health that are intrinsically linked to other SDG goals of reducing poverty, hunger, promoting quality education, gender equality, and reducing inequalities (SDG 1,2,4-6,10) is surprising.

In its national programmes on maternal and child health, the policy “seeks to address the social determinants through developmental action in all sectors.” It further says that “research on social determinants of health” will be promoted, combining this with “neglected health issues such as disability and transgender health.” It touches on Panchayati raj institutions “to play an enhanced role at different levels for health governance, including the social determinants of health.” In highlighting the need for “an empowered public health cadre,” the NHP explains they need to “to address social determinants of health effectively, by enforcing regulatory provisions.” And while this is not explicitly mentioned as a determinant in the NHP the insertion of gender based violence in national programs, and the call for increased sensitization of health systems to provide care “free and with dignity in the public and private sector,” is another welcome sign. But in its entirety, these issues that are outside of the healthcare sector are reduced to mere mentions, with very little clarity on policy direction or funding. This merits some concern, considering that the NHP in itself, even outside the realm of SDGs, has outlined equity as a key principle.

In transitioning from MDGs to SDGs, the mention of health was reduced from three goals to only one, seemingly in recognition of the need for concerted policies in tandem with related fields in order for them to have a lasting impact on population health. It would have been refreshing if India’s NHP had categorically specified frameworks for integrated action in non-health related SDG’s such as those focused on poverty, hunger, education, gender equality, clean water, and sanitation. Meaningfully executing any multi-sectoral mechanism means building successful partnerships within diverse ministries and with communities. Given all that has been said about the NHP 2017 repeating many of its targets from previous versions, a succinctly articulated vision for governance and financing for inter-ministerial work to address health would have been refreshing.

Soumyadeep Bhaumik is an associate editor for BMJ Global Health and an analysis advisor for The BMJ. He is a medical doctor working in the field of evidence syntheses and program evaluation in India.  Twitter: @DrSoumyadeepB 

Pritha Chatterjee is an MPH candidate at the Harvard T.H. Chan School of Public Health and an Aga Khan International Development Scholar. She is a health journalist from India, formerly with The Indian Express Ltd.  Twitter: @pritha88

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no other relevant conflicts of interests to declare.

Disclaimer: Views expressed are those of the authors and are personal in nature.

Naomi Hossain: The right to food is common sense in Bangladesh

6 Mar, 17 | by BMJ

Horrifying new reports of famine on a vast scale in Yemen, South Sudan, Somalia, and Nigeria are emerging, signalling the lack of a real right to food among tens of millions of people. Climate change and conflict are leading to recurrent food crises. These unfolding episodes resemble the story of the last famine in Bangladesh, which was in 1974. In 1970, the Bhola cyclone killed half a million and left thousands more hungry; this was followed by the war for Liberation in 1971 with its large-scale human rights abuses. And then in 1974, the new nation of Bangladesh was devastated by the famine from which possibly 1.5 million people, already gravely weakened by poverty and recent events, died.

What marks Bangladesh out is that the 1974 famine had a positive outcome: it established a strong right to food that provided the foundation for further progress. Because, after all, what good could development projects do, if people were not eating well enough to survive?

The elite, the rural poor, and aid donors agreed on basic food security as a priority as it provides the foundation for bare survival. And this “subsistence crisis contract” has held up across successive governments of Bangladesh of all parties and regimes. The state, working with aid agencies and NGOs, has strengthened food security, at times by freeing food markets, at others by intervening for the vulnerable. A path towards labour-intensive industry has been followed, and social services have improved. NGOs worked wonders, in the space allowed. And hunger levels and disaster deaths have dropped, even if nutrition remains a moving target.

What Bangladesh has can be termed as the common sense approach to the right to food. This has a strong political foundation in the country’s history, but no formal legal basis to date. Yet this “common sense” right is no trivial matter. It reflects a broad social agreement on the obvious point that every Bangladeshi should be able to eat. It also includes a clear mandate for the state to act to make sure they can. Everyone understands what this means in practice, even if it is not always easy to enforce.

Qualitative research I have been involved with in Bangladesh and nine other countries in which we  looked purposely into how people view the right to food suggests that views elsewhere are similar to those in Bangladesh. Food is widely seen as a natural right, and in times of disaster, protection against hunger is a matter of citizenship, obliging the state to act. We found a legal concept of the right to food was not always meaningful: some people in Vietnam and Indonesia thought it strange or irrelevant, while in Bolivia and Kenya, people with lawful rights to food were disillusioned with the reality of the right to food. I was struck by one popular political theory: that governments usually do their best to tackle subsistence crises because failure is so politically costly. In practice, of course, a government that fails is not easily held to account.

There is much talk, these days, of a lawful right to food to strengthen accountability for protecting against hunger and malnutrition. Human rights organisations like BLAST are championing a framework law to formalise the right to food. But the globalized effects of food price volatility, climate change, and conflict mean that the right to food is a transnational, and not only a national, challenge. With the “threat multiplier” that is climate change which poses an increasingly live threat to food security, Bangladesh has no time to lose in building itself a robust legal and institution framework for the right to food.

Naomi Hossain works at the Institute of Development Studies at the University of Sussex. Her book about the effects of the Bangladesh famine, The Aid Lab, was published in 2017.

Competing interests: None declared.

Priscilla Claeys: Ensuring the right to food for rural working people

10 Feb, 17 | by BMJ

On 18 January 2017, the issue of the human rights of agricultural workers with no land of their own and other people working in rural areas was placed on the agenda of the European Council Working Party on Human Rights (COHOM) for the first time. As a researcher studying how the human rights regime is responding to contemporary challenges, I attended this meeting with great interest.

The fact that 80% of people living in poverty worldwide predominantly live in rural areas and are mostly employed in the agricultural sector is well established. What is less recognized, is the systematic discrimination against rural working people in the Global North. “It is about time the EU acknowledges there are ‘peasants’ in Europe, and recognize the need to protect their rights”, said representatives of La Via Campesina, a transnational agrarian movement, at the COHOM.  This systematic discrimination has led the EU to lose as much as a third of all its small farms in the last decade. Land concentration is massive (3 % of farmers now own 52 % of total farm land) and access to land for young farmers is an emerging problem. While more than half of European farmers will retire within 10 years, there is no framework in place to organize farm succession.

At COHOM, La Via Campesina and FIAN International, an international human rights organization dedicated to the right to food, made their case for a UN Declaration on the Rights of Peasants and other people working in rural areas, which would recognize the rights of these groups to : a) access, manage, use, govern and control the land and other natural resources (forests, pastures, fisheries) they depend on for their livelihood, b) conserve, use, maintain and develop their own seeds, crops and genetic resources, and, c) a decent income and livelihood. Too often farmers have to sell products at prices that barely cover their production costs, as a result of unfair trade rules and corporate control over the food supply chain.

Though EU member states acknowledged the issue, they plainly rejected the need for a new international legal instrument. Denying the existence of normative gaps, EU delegates expressed the view that efforts should focus on fostering the—indeed lacking—implementation of existing human rights standards, such as the right to food. In my opinion, this position fails to recognize that, from the point of view of people living in rural areas, the right to food is really about the right to produce food.

For about half of the world’s population, the right to food is tied to the right to the means of production (land, seeds, water but also tools, credits, infrastructure) and to the right to public policies ensuring that one can make a living off the land. The draft UN Declaration explicitly recognizes the individual and collective right to land and natural resources, and the corresponding obligations of states to recognize and respect customary rights and the commons, protect rural communities from land grabbing, and conduct agrarian reforms where land concentration is too high. In addition, to ensure that peasants can sell their crops at fair prices, states would need to tackle abuses of corporate power and establish fair trade rules. These far-reaching implications make states reluctant to recognize these rights.

Fortunately, the UN Human Rights Council did not wait for the EU’s support to start negotiating the text of this Declaration. At its fourth session, in May 2017, an Intergovernmental Working Group will discuss a revised draft.. The EU has a few months to make it a priority to start addressing what the Secretary General of FIAN called an “urban bias”: the fact that the international human rights regime developed with no participation of rural people, in a way that only reflects the interests of urban populations, at the expense of food producers and the environment.  Will the EU stand for the rights of the rural poor, not only in the South but in the North as well? 

Priscilla Claeys is a Senior Research Fellow in Food Sovereignty, Human Rights and Resilience at the Centre for Agroecology, Water and Resilience (CAWR), Coventry University (UK). 

Competing Interest: PC is a member of the board of FIAN Belgium. I am committed to the global struggle for the right to food and food sovereignty and have no other relevant conflict of interest to declare.

R N Karuga: “Building a resilient and responsive health system needs strong community support”

27 Jan, 17 | by BMJ

“Forget about these people in the national office,” said Maria (not her real name). “They are not in touch with reality!” Maria is a district health manager in Kenya. This was her response when I asked how closely she works with the national Ministry of Health in delivering community health services.

In 2013, the governance system in Kenya changed from a centralized system to one in which decision making and the delivery of services such as healthcare was transferred to county governments. The national Ministry of Health however retains responsibility for policy formulation, development of standards and guidelines, and technical support to the counties. more…

What can we learn from the European Union’s first right to food law?

20 Jan, 17 | by BMJ

By Tomaso Ferrando and Roberto Sensi.

In this second article on the #RightToFood, part of a BMJ Global Health series, we discuss our experience of the conception and enactment of a right to food law in Lombardia, Italy. The “Recognition, Protection and Promotion of the Right to Food,” was approved by the Lombardia Regional Council in November 2015. The law was the first to recognise this right within the European Union and was the result of a desire to have a policy in place after EXPO Milano 2015, in line with the Milan Charter and its recognition of the right to food as fundamental right. In our opinion, the law rightly approached the problem holistically and recognised the importance of locally based food systems and democratic participation in order to fully guarantee the right to nutritious food. However, its implementation is still lagging behind expectations. more…

Jose Luis Vivero-Pol and Tomaso Ferrando: Let’s talk about the right to food

10 Jan, 17 | by BMJ

Legal recognition of the right to food and nutrition can create the grounds for effective and systemic solutions for hunger and malnutrition. Recently, the media was abuzz with news of plans by the Scottish Equalities Secretary to legislate the right to food within Scottish law. This would be a step towards tackling food poverty in Scotland. This potential legislation will be historic, as Scotland will be the first country in the European Union (EU) to expressly recognize the right to food.

Despite rising numbers of food insecure households and a rise in the use of food banks all over Europe (see here and here), the right to food is completely absent from the fundamental EU treaties, the European Convention on Human Rights, and from the jurisprudence of national and regional courts. In other words, the right to food does not exist in the European laws, except for the recent regional law in Lombardia, Italy and the yet-to-be approved draft bill on the right to food in Belgium. more…

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