Health Equity: September 2007

Friday, September 28, 2007

[EQ] Categorizations of Race and Ethnicity: Useful or Outmoded in Medicine?

Categorizations of Race and Ethnicity: Useful or Outmoded in Medicine?

Vol. 4(9) September 2007 The PLoS Medicine

The issue image this month takes its theme from an essay (see Braun et al. e271) and a related perspective (see Ellison et al. e287) that explore the controversy and offer opinions on the best way to name, define, and study race and ethnicity in medicine. Human race and ethnicity, although socially determined categories, are routinely used to assign people to groups in research and clinical medicine.
But if these designations are socially determined, what do "black" and "white" really mean in biomedical science and clinical medicine? Is it even possible to reach a consensus on how most accurately and sensitively to name and define race and other groupings that are subject to social tension? The editorial (see Brown et al. e288) focuses on the editorial viewpoint of this question and surveys different solutions adopted by the publishing field.

Defining Human Differences in Biomedicine

Maggie Brown, The PLoS Medicine Editors
PLoS Med 4(9): e288 doi:10.1371/journal.pmed.0040288 September 25, 2007

Available online at: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0040288

".......Although race and ethnicity as contentious variables in research and clinical medicine are the most discussed in the literature, they are not the only possible sources of incorrect generalizations and possibly harmful bias. Others are sex/gender, age, sexual orientation, disease/disability, religion, socioeconomic status, and many more.

For example, the AMA Manual of Style (10th edition, section 11.10 [13]) and the CSE manual (7th edition, section 7.5 [14]) offer advice on inclusive language in the areas of race/ethnicity, age, disease/disabilities, religion, and sexual orientation, emphasizing in part that terminology should be nonstigmatizing and reflect the preferred designations of groups or individuals. In all of these areas humans have been subject to stereotyping and discrimination; thus a critical examination of all the names we call ourselves and others is warranted, and at least general guidelines should be developed for these areas, although consensus may take time...."

Racial Categories in Medical Practice: How Useful Are They?
Braun L, Fausto-Sterling A, Fullwiley D, Hammonds EM, Nelson A, et al.
Is it good medical practice for physicians to "eyeball" a patient's race when assessing their medical status or even to ask them to identify their race?

Racial Categories in Medicine: A Failure of Evidence-Based Practice?
Ellison GTH, Smart A, Tutton R, Outram SM, Ashcroft R, et al.
Race and ethnicity are imprecise markers of the genotypic and sociocultural determinants of health, argue the authors.

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[EQ] Achieving health equity: from root causes to fair outcomes

Achieving health equity: from root causes to fair outcomes

Professor Sir Michael Marmot, International Institute for Society and Health, University College London, UK
This paper is an abridged version of the Interim Statement of the Commission on Social Determinants of Health
The Lancet, Volume 370, Number 9593, 29 September 2007

Website: http://www.thelancet.com/journals/lancet/article/PIIS0140673607613853/abstract

"......Health is a universal human aspiration and a basic human need. The development of society, rich or poor, can be judged by the quality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill-health. Health equity is central to this premise and to the work of the Commission on Social Determinants of Health. Strengthening health equity—globally and within countries—means going beyond contemporary concentration on the immediate causes of disease. More than any other global health endeavour, the Commission focuses on the “causes of the causes”—the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age.

The time for action is now, not just because better health makes economic sense, but because it is right and just. The outcry against inequity has been intensifying for many years from country to country around the world. These cries are forming a global movement. The Commission on Social Determinants of Health places action to ensure fair health at the head and the heart of that movement...." WHO website: http://www.who.int/social_determinants/en/

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Thursday, September 27, 2007

[EQ] Financial resource requirements for AIDS

Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support

UNAIDS, the Joint United Nations Programme on HIV/AIDS, September 26, 2007

Cosponsors include UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank. Based in Geneva, the UNAIDS secretariat works on the ground in more than 75 countries world wide.

Available online as PDF file [36p.] at: http://data.unaids.org/pub/Report/2007/20070925_advocacy_grne2_en.pdf

UNAIDS has released a new report on the estimated financial resources required for the AIDS response. The report, puts forward three different approaches to financing the AIDS response including:

Scaling-up at current rates. This approach would require between US$ 14 to US$ 18 billion and would provide treatment for 8 million people by 2015.

Universal Access by 2010. This approach envisages significant increases in available resources and an urgent and dramatic scale-up of coverage in all countries. The approach would provide treatment for 14 million people by 2010 and would require between US$ 32 to US$51 billion. In 2015 the approach would require between US$ 45 and US$63 billion.

Phased scale-up to 2015. This approach assumes different rates of scale-up for each country based on current service coverage and capacity, with the achievement of different programmatic targets at different times and the achievement of universal access by all countries by 2015. The approach would require between US$ 41 and US$ 58 billion in 2015.

The estimates provided in the report, developed for 132 low- and middle-income countries, were based on the type of epidemic and nationally established targets using the latest available data. From: Izazola, Jose Antonio [izazolaj@unaids.org] http://www.unaids.org/en/MediaCentre/PressMaterials/FeatureStory/20070925_Resources_needs.asp

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[EQ] Education at a Glance 2007 - OECD INDICATORS

Education at a Glance 2007 - OECD INDICATORS

OECD Organisation for Economic Co-operation and Development - September 2007

Available online PDF [451p.] at: http://www.oecd.org/dataoecd/4/55/39313286.pdf

Governments are paying increasing attention to international comparisons as they search for effective policies that enhance individuals’ social and economic prospects, provide incentives for greater efficiency in schooling, and help to mobilise resources to meet rising demands. As part of its response, the OECD Directorate for Education devotes a major effort to the development and analysis of the quantitative, internationally comparable indicators that it publishes annually in Education at a Glance.

These indicators enable educational policy makers and practitioners alike to see their education systems in the light of other countries’ performances and, together with OECD’s country policy reviews, are designed to support and review the efforts that governments are making towards policy reform.

The main areas covered are:

- Participation and achievement in education
- Public and private spending on education
- The state of lifelong learning
- Conditions for pupils and teachers

The 2007 edition investigates the effects of expanding tertiary education on labour markets. Graduation rates from higher education have grown significantly in OECD countries in recent decades, but has the increasing supply of well-educated workers been matched by the creation of high-paying jobs? Or will everyone with a university degree some day work for the minimum wage?

Complete executive summary

Multilingual summaries

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Greek Finnish Hungarian Icelandic Italian

Japanese Korean Norwegian Polish Portuguese

Russian Slovak Spanish Swedish Turkish

Website: http://www.oecd.org/document/30/0,3343,en_2649_39263294_39251550_1_1_1_1,00.html

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[EQ] Legal Aspects of HIV/AIDS- A Guide for Policy and Law Reform

Legal Aspects of HIV/AIDS - A Guide for Policy and Law Reform

Lance Gable, Katharina Gamharter, Lawrence O. Gostin, James G. Hodge, Jr., Rudolf V. Van Puymbroeck
Global HIV/AIDS Program and Legal Vice Presidency - The World Bank, 2007

Available online as PDF file [250p.] at:
http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/LegalAspectsOfHIVAIDS.pdf

"......Dealing successfully with HIV/AIDS cuts across almost all areas of government responsibility, and as the breadth of the 65 topics included in the Guide shows, there are many ways in which laws and regulations can either underpin or undermine good public health programs and responsible personal behaviors.

The Guide indicates that statutes relating to many areas of human endeavor—from intimate private conduct to international travel—can contribute to stigma, discrimination, and exclusion or, contrariwise, can avoid and help remedy these inequities. Thus, in order to create a supportive legal framework it is important that governments identify and address effectively any gaps or other problematic aspects of their legislation and regulatory systems...."

Content:

Section 1 Public Health Policies and Practices
1.1 Surveillance, Screening, and Testing for HIV and AIDS
1.2 Prevention of Mother to Child Transmission of HIV (PMTCT)
1.3 Disclosure of HIV Information
1.4 Partner Notification: The Responsibility of the Patient
1.5 Partner Notification: The Duty of the Physician or Counselor
1.6 Partner Notification: The Powers of Government Agencies
1.7 Isolation and Quarantine
1.8 Blood/Tissue/Organ Supply
1.9 Universal Infection Control Precautions
1.10 Post-Exposure Prophylaxis
1.11 Access to the Technical Means of Prevention (Condoms)
1.12 Male Circumcision

Section 2 People Living with HIV: Discrimination
2.1 Protection Against Discrimination Based on HIV Status or Health Status
2.2 Antidiscrimination Protection under Disability Laws
2.3 The Workplace: Testing at Recruitment and Mandatory Testing During Employment
2.4 The Workplace: Denial of Employment
2.5 The Workplace: Differential Treatment
2.6 The Workplace: Disclosure and Confidentiality
2.7 Health Care: Refusal to Treat
2.8 Health Care: Differential Treatment
2.9 Issues at the Border: Travel and Immigration Restrictions
2.10 Issues at the Border: Refugees and Asylum
2.11 Discrimination in Public and Private Benefits

Section 3 Disclosure and Exposure
3.1 Duty to Disclose HIV Status to Partner
3.2 Negligent or Willful Exposure or Transmission

Section 4 Injecting Drug Use
4.1 Access to Clean Needles and Drug Paraphernalia Laws
4.2 Needle/Syringe Exchange Programs
4.3 Drug Substitution Programs
4.4 International Drug Conventions: Punitive v. Public Health Approach

Section 5 Sex Work
5.1 Criminal Statutes on Sex Work
5.2 Vague Criminal Statutes and Police Harassment
5.3 Regulatory Regimes (Labor, Health, Occupational Safety)
5.4 100% Condom Use Programs
5.5 Trafficking of Women for Sex Work

Section 6 Men Having Sex with Men
6.1 Gender Orientation in General Antidiscrimination Statutes
6.2 Sexual Offenses
6.3 Vague or Overbroad Criminal Statutes and Police Harassment
6.4 Rights of Association and Expression

Section 7 Women
7.1 Access to Medical Treatment
7.2 Property Ownership and Inheritance
7.3 Marital Rape
7.4 Reproductive Rights
7.5 Sexual Harassment and Violence
7.6 Traditional Practices

Section 8 Children
8.1 Orphans, Inheritance, Birth Registration, Caregivers
8.2 Discrimination in Education
8.3 Sexual Abuse, Legal Age, Child Marriage
8.4 Sexual and Economic Exploitation

Section 9 Clinical Research
9.1 Nondiscrimination in Selection of Research Subjects
9.2 Informed Consent
9.3 Confidentiality
9.4 Equitable Access to Information and Benefits
9.5 Ethics Boards

Section 10 Information
10.1 Informational and Educational Material; Censorship
10.2 Regulation of NGOs

Section 11 Access to Medicines
11.1 Patented and Generic Drugs: Overview
11.2 WTO Members: Special Considerations under the TRIPS Agreement
11.3 Parallel Importing, Exhaustion of Patent Rights, Differential Pricing
11.4 Free Trade Agreements: Special Considerations

Section 12 World Bank Policies and Procedures
12.1 IDA Grants for HIV and AIDS Projects
12.2 OP/BP 4.01 and Medical Waste Management
12.3 OP/BP 4.10 and Indigenous Peoples in HIV and AIDS Projects
12.4 Communities and CBOs: Fiduciary Issues
12.5 Procurement of Pharmaceutical Products
12.6 Procurement of Condoms

Lance Gable is Assistant Professor of Law at Wayne State University Law School and Scholar at the Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities. He is co-editor (with David Buchanan and Celia Fisher) of Ethical and Legal Issues in Research with High Risk Populations: Addressing Threats of Suicide, Child Abuse, and Violence (forthcoming 2007).

Katharina Gamharter is Counsel/Legal Associate in the Environmentally and Socially Sustainable Development and International Law Practice Group of the World Bank’s Legal Vice Presidency. She is the author of Access to Affordable Medicines: Developing Responses under the TRIPS Agreement and EC Law (Springer 2004) .

Lawrence O. Gostin is Associate Dean for Research and Academic Programs and Professor of Law at Georgetown University Law Center, Director of the Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, Professor of Law and Public Health at the Johns Hopkins University, Bloomberg School of Public Health, and Visiting Professor of Public Health at the Faculty of Medical Sciences, Oxford University. He is Member of the Institute of Medicine, National Academy of Sciences (lifetime), Editor (Health Law and Ethics), Journal of the American Medical Association, Co-Editor, Georgetown University Press book series, Ethics, Health, and Public Policy, and a member of the Editorial Board or Editorial Advisory Board of 20 professional journals. He is the author of The AIDS Pandemic: Complacency, Injustice, and Unfulfilled Expectations (U. of North Carolina Press 2004).

James G. Hodge is Associate Professor, Johns Hopkins Bloomberg School of Public Health, Executive Director, Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, Core Faculty, Berman Bioethics Institute, Johns Hopkins Bloomberg School of Public Health, and Adjunct Faculty, Georgetown University Law Center.

Rudolf V.Van Puymbroeck, formerly Lead Counsel, Public Health and HIV/AIDS, Legal Advisory Services, World Bank Legal Vice Presidency, is currently an independent adviser on health law and international development.

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Wednesday, September 26, 2007

[EQ] How to Build M&E Systems to Support Better Government

How to Build M&E Systems to Support Better Government

Keith Mackay, Senior Evaluation Officer, Independent Evaluation Group, World Bank

The International Bank for Reconstruction and Development / The World Bank, 2007

Available online as PDF file [172p.] at:

http://lnweb18.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/E58A95EC2BF96E378525731D00668AD3/$file/building_monitoring_and_evaluation_systems.pdf

“……A growing number of governments are working to improve their performance by creating systems to measure and help them understand their performance. These systems for monitoring and evaluation (M&E) are used to measure the quantity, quality, and targeting of the goods and services? the outputs? that the state provides and to measure the outcomes and impacts resulting from these outputs. These systems are also a vehicle to facilitate understanding of the causes of good and poor performance.

There are many reasons for the increasing efforts to strengthen government M&E systems. Fiscal pressures and ever-rising expectations from ordinary citizens provide a continuing impetus for governments to provide more government services and with higher standards of quality. ...."

Content:

1 Introduction

PART I—WHAT DO MONITORING AND EVALUATION HAVE TO OFFER GOVERNMENTS?

2 What Is M&E?—An M&E Primer

3 Contribution of M&E to Sound Governance

4 Key Trends Influencing Countries—Why Countries Are Building M&E Systems

PART II—SOME COUNTRY EXPERIENCE

5 Good Practice Countries—What Does “Success” Look Like?

6 Chile

7 Colombia

8 Australia

9 The Special Case of Africa

PART III—LESSONS

10 Building Government M&E Systems—Lessons from Experience

11 Incentives for M&E—How to Create Demand

PART IV—HOW TO STRENGTHEN A GOVERNMENT M&E SYSTEM

12 The Importance of Country Diagnosis

13 Preparing Action Plans

PART V—REMAINING ISSUES

14 Frontier Issues

15 Concluding Remarks

PART VI—Q&A: COMMONLY ASKED QUESTIONS

Annexes

A: Lessons on How to Ensure Evaluations Are Influential

B: A Country Diagnosis—The Example of Colombia

C: Terms of Reference for an In-Depth Diagnosis of Colombia’s M&E System

D: Evaluation of IEG’s Support for Institutionalizing M&E Systems

E: Glossary of Key Terms in M&E

Endnotes

Bibliography

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[EQ] Health Targets: Moving towards healthier futures

Health Targets: Moving towards healthier futures 2007/08

August 2007 Wellington: Ministry of Health.

Available online as PDF file [48p.] at: http://www.moh.govt.nz/moh.nsf/pagesmh/6635/$File/health-targets-aug07.pdf

"........ the New Zealand health sector is implementing Health Targets to focus resources and improve performance in 10 key areas. District Health Boards are working with the Ministry of Health to set and achieve them, and in so doing will contribute to overall improvement in the health of New Zealanders and reducing inequalities.

The 10 Health Target areas for 2007/08 will help us measure progress against achieving the Government's priority areas for health improvement. Along with addressing inequalities across population groups, improving Ma¯ori health and improving access for populations living with disabilities, these priority areas are:

• getting ahead of the chronic disease burden
• child and youth services
• primary health care
• health of older people
• elective services
• infrastructure
• value for money.

The selection of the specific targets within these priority areas was based on the principle that achieving the targets will make a significant contribution to improving health outputs or outcomes in these areas. There is enough detailed information available to allow that performance to be measured...."

Health Targets:

Target 1:   Improving immunisation coverage
Target 2:   Improving oral health
Target 3:   Improving elective services
Target 4:   Reducing cancer waiting times
Target 5:   Reducing ambulatory sensitive (avoidable) hospital admissions
Target 6:   Improving diabetes services
Target 7:   Improving mental health services
Target 8: Improving nutrition, increasing physical activity, reducing obesity
Target 9: Reducing the harm caused by tobacco
Target 10: Reducing the percentage of the health budget spent on the Ministry of Health

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and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members".
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[EQ] Promoting safety of medicines for children

Promoting safety of medicines for children

World Health Organization (WHO), September 2007

Available online PDF [64p.] at: http://www.who.int/medicines/publications/essentialmedicines/Promotion_safe_med_childrens.pdf

".....The lack of thorough and reliable clinical data on the way medicines affect children requires strengthened safety monitoring and vigilance of medicinal products. This is the fundamental message of Promoting safety of medicines for children.

The publication gives an overview of the problem and offers solutions on how best to address side effects from medicines in children; namely, through improved reporting systems and collaboration between governments, regulatory authorities, research institutions and the pharmaceutical industry..."

"......Monitoring the safety of medicine use in children is of paramount importance since, during the clinical development of medicines, only limited data on this
aspect are generated through clinical trials. Use of medicines outside the specifications described in the licence (e.g. in terms of formulation, indications,
contraindications or age) constitutes off-label and off-licence use and these are a major area of concern.

These guidelines are intended to improve awareness of medicine safety issues among everyone who has an interest in the safety of medicines in children and
to provide guidance on effective systems for monitoring medicine safety in the pediatric populations. The document will be of interest to all health-care
professionals, medicine regulatory authorities, pharmacovigilance centres, academia, the pharmaceutical industry and policy-makers.

Systems for monitoring medicine safety are described in Annex 1 - Pharmacovigilance methods and some examples of recent information on adverse reactions
to marketed medicines are discussed in Annex 2....."

Content:

1 Introduction

2 Current situation
2.1 Problems with medicine treatment in children and adolescents around the world
2.2 Consequences of present status of the use of medicines in children (environmental aspects).
2.3 General risk factors that predispose children to develop an adverse reaction to a medicine (medical aspects)
2.4 Differences between paediatric populations and adults
2.5 The need for additional, independent studies on the development of paediatric medicines
2.6 Current legal and regulatory framework .
2.7 Consequences of the lack of studies of medicines development in children and authorization of paediatric medicines

3 The essential role of safety monitoring in the life-cycle of a medicine.
3.1 Pre-marketing assessment of medicine safety
3.2 Post-marketing monitoring of medicine safety for medicines already on the market including those used “off-label”
3.3 Benefit-to-risk considerations in children
4 Medication errors.
4.1 Increased risk of medication errors in children
4.2 Incidence of medication errors .

5 Primary responsibility of stakeholders

6 Guidance: measures to be taken.
6.1 Improvement of awareness among stakeholders
6.2 Methods, approaches and infrastructure for an effective system for medicine safety monitoring at the national level.
6.3 Implementation of methods and structural changes for effective monitoring of medicine safety at the national level
6.4 Impact measurement and audit

7 Measures to be taken by WHO.
References
Annex I Annex 2

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