In the coming weeks and months SARS-CoV-2 may ravage countries with weak health systems and populations disproportionately affected by HIV, tuberculosis, and other infectious diseases. Without safeguards and proper attention to global health equity and justice, the effects of this pandemic are likely to exacerbate existing health and socio-economic inequalities. This paper argues that achieving global health equity in the context of COVID-19 will require that notions of reciprocity and relational equity (...) are introduced to the response. (shrink)

Much innovation has taken place in the development of medical schools and licensure exam processes across the African continent. Still, little attention has been paid to education that enables the multidisciplinary, critical thinking needed to understand and help shape the larger social systems in which health care is delivered. Although more than half of medical schools in Canada, the United Kingdom, and the United States offer at least one medical humanities course, this is less common in Africa. We report (...) on the “liberal arts approach” to medical curricula undertaken by the University of Global Health Equity beginning in 2019. The first six-month semester of the curriculum, called Foundations in Social Medicine, includes courses in critical thinking and communication, African history and global political economy, medical anthropology and social medicine, psychology and health, gender and social justice, information technology and health, and community-based training. Additionally, an inquiry-based pedagogy with relatively small classes is featured within an overall institutional culture that emphasizes health equity. We identify key competencies for physicians interested in pursuing global health equity and how such competencies relate to liberal arts integration into the African medical school curriculum and pedagogical approach. We conclude with a call for a research agenda that can better evaluate the impact of such innovations on physicians’ education and subsequent practices. (shrink)

Health research has been identified as a vehicle for advancing global justice in health. However, in bioethics, issues of global justice are mainly discussed within an ongoing debate on the conditions under which international clinical research is permissible. As a result, current ethical guidance predominantly links one type of international research (biomedical) to advancing one aspect of health equity (access to new treatments). International guidelines largely fail to connect international research to promoting broader aspects (...) of health equity – namely, healthier social environments and stronger health systems. Bioethical frameworks such as the human development approach do consider how international clinical research is connected to the social determinants of health but, again, do so to address the question of when international clinical research is permissible. It is suggested that the narrow focus of this debate is shaped by high-income countries' economic strategies. The article further argues that the debate's focus obscures a stronger imperative to consider how other types of international research might advance justice in global health. Bioethics should consider the need for non-clinical health research and its contribution to advancing global justice. (shrink)

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high-income countries have an obligation of justice to support health research in low and middle-income countries that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi-structured in-depth interviews were performed with 16 (...) grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with five key features that advance health equity: being conducted with worst-off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength. It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities. (shrink)

Community engagement is gaining prominence in global health research. So far, a philosophical rationale for why researchers should perform community engagement during such research has not been provided by ethics scholars. Its absence means that conducting community engagement is still often viewed as no more than a ‘good idea’ or ‘good practice’ rather than ethically required. In this article, we argue that shared health governance can establish grounds for requiring the engagement of low‐ and middle‐income country (LMIC) (...) community members in global health research, where such research aims to help reduce health disparities. This philosophical basis has important implications for the ethical goals ascribed to engagement and the approach adopted to undertake it. We suggest the ethical goals of engagement in equity‐oriented global health research should include: (a) generating research topics and questions that reflect the key problems disadvantaged groups face in accessing healthcare, services and broader social determinants of health and (b) promoting the translation of research findings into policy and practice in ways that benefit the health of disadvantaged groups. We propose engagement practice should have the following features: deliberation with LMIC community members to make a range of project decisions, beginning with setting research topics and questions; inclusion of members of disadvantaged groups and those with the power to change policy and practice to benefit them; and purposeful structuring of deliberations to minimize the impact of power disparities between LMIC community members. Finally, we reflect on how these features differ from those typical of much current community engagement practice in LMICs. (shrink)

Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This (...) article takes a conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short. (shrink)

Despite good intentions and decades of discussion addressing the need for transformative changes globally to reduce poverty and improve health equity, little progress has been made. A fundamental shift in framing the current conversation is critical to achieve “health for all,” moving away from the traditional approaches that use the more narrowly focused medical model, which is intent on treating and curing disease. A public health framework for action is needed, which recognizes and confronts the complex, (...) and often-times difficult-to-achieve social determinants of health. A restructuring of global health policy development and implementation will be ineffective unless key areas are addressed including primary education and the environment, in addition to economic considerations. A public health framework that embraces a community-based participatory approach would provide a comprehensive platform for identifying critical components that impact health, and for developing effective strategies for change. A participatory approach would encourage dialogue and problem-solving for region-specific issues among those most affected by the broader health and social justice issues, with those who create policy. (shrink)

As a worldwide economic crisis emerged at the end of 2008, international health agencies were quick to highlight its predictable impact on health in the poorest of communities. The World Health Organization underscored the need for a multisectoral approach to the crisis, “seeking health gains through demonstrating the importance of health in all policies” and whether current investments in health addressed the broader social determinants of health. However, despite good intentions and decades of (...) discussion addressing the need for transformative changes globally to reduce poverty and improve health equity, little progress has been made.A recent report on progress towards the Millennium Development Goals indicates that many targeted goals have not been met, with some goals lagging many years behind schedule. Although progress towards achieving the MDGs has been made for some specific conditions, where targeted interventions have had an immediate impact, limited progress is reported in more complex areas such as maternal child health. Such complex health issues require structural changes, strong political will, long-term funding, and consideration of other health determinants, such as education and exposure to environmental hazards. (shrink)

COVID-19 vaccination of children has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination (...) provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate healthy children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments. (shrink)

Nurses play a crucial role in reducing health disparities and advancing health equity for individuals and communities. The future nursing workforce relies on their nursing education to prepare them to promote health equity. Nursing educators prepare students through a variety of andragogical learning strategies in the classroom and in clinical experiences and by intentionally updating and revising curricular content to address knowledge and competency gaps. This critical review aimed to determine the extent to which (...) class='Hi'>health equity concepts are explicitly present in prelicensure undergraduate nursing curricula globally. Of 434 articles screened, 22 articles describing 20 studies met inclusion criteria. Frequency and quantity of health equity content, concepts and topics, teaching strategies, evaluation strategies, and the overall extent of integration varied widely. Notably, only two articles described overall well‐integrated explicit health equity content, and there was little attention to whether students transfer this learning into practice. A focus on individualism rather than population and community was noted, highlighting the presence of whiteness in nursing. Results from this review confirm that nursing education has room to improve with respect to health equity in the curricula. (shrink)

Background. Despite common recognition of joint responsibility for global health by all countries particularly to ensure justice in global health, current discussions of countries’ obligations for global health largely ignore obligations of developing countries. This is especially the case with regards to obligations relating to health financing. Bearing in mind that it is not possible to achieve justice in global health without achieving equity in health financing at both domestic (...) and global levels, our aim is to show how fulfilling the obligation we propose will make it easy to achieve equity in health financing at both domestic and international levels. Discussion. Achieving equity in global health financing is a crucial step towards achieving justice in global health. Our general view is that current discussions on global health equity largely ignore obligations of Low Income Country governments and we recommend that these obligations should be mainstreamed in current discussions. While we recognise that various obligations need to be fulfilled in order to ultimately achieve justice in global health, for lack of space we prioritise obligations for health financing. Basing on the evidence that in most LICs health is not given priority in annual budget allocations, we propose that LIC governments should bear an obligation to allocate a certain minimum percent of their annual domestic budget resources to health, while they await external resources to supplement domestic ones. We recommend and demonstrate a mechanism for coordinating this obligation so that if the resulting obligations are fulfilled by both LIC and HIC governments it will be easy to achieve equity in global health financing. Summary. Although achieving justice in global health will depend on fulfilment of different categories of obligations, ensuring inter- and intra-country equity in health financing is pivotal. This can be achieved by requiring all LIC governments to allocate a certain optimal per cent of their domestic budget resources to health while they await external resources to top up in order to cover the whole cost of the minimum health opportunities for LIC citizens. (shrink)

This is a pivotal moment in the global governance response to pandemic threats, with crucial global health law reforms being undertaken simultaneously in the coming years: the revision of the International Health Regulations, the implementation of the GHSA Legal Preparedness Action Package, and the negotiation of a new Pandemic Treaty. Rather than looking at these reforms in isolation, it will be necessary to examine how they fit together, considering: how these reforms can complement each other to (...) support pandemic prevention, preparedness, and response; what financing mechanisms are necessary to ensure sustainable health governance; and why vital norms of equity, social justice, and human rights must underpin this new global health system. (shrink)

The singular message in Global Health Law is that we must strive to achieve global health with justice—improved population health, with a fairer distribution of benefits of good health. Global health entails ensuring the conditions of good health—public health, universal health coverage, and the social determinants of health—while justice requires closing today’s vast domestic and global health inequities. These conditions for good health should be incorporated (...) into public policy, supplemented by specific actions to overcome barriers to equity. A new global health treaty grounded in the right to health and aimed at health equity—a Framework Convention on Global Health —stands out for its possibilities in helping to achieve global health with justice. This far-reaching legal instrument would establish minimum standards for universal health coverage and public health measures, with an accompanying national and international financing framework, require a constant focus on health equity, promote Health in All Policies and global governance for health, and advance the principles of good governance, including accountability. While achieving an FCGH is certainly ambitious, it is a struggle worth the efforts of us all. The treaty’s basis in the right to health, which has been agreed to by all governments, has powerful potential to form the foundation of global governance for health. From interpretations of UN treaty bodies to judgments of national courts, the right to health is now sufficiently articulated to serve this role, with the individual’s right to health best understood as a function of a social, political, and economic environment aimed at equity. However great the political challenge of securing state agreement to the FCGH, it is possible. States have joined other treaties with significant resource requirements and limitations on their sovereignty without significant reciprocal benefits from other states, while important state interests would benefit from the FCGH. And from integrating the FCGH into the existing human rights system to creative forms of compliance and enforcement and strengthened domestic legal and political accountability mechanisms, the treaty stands to improve right to health compliance. The potential for the FCGH to bring the right to health nearer universal reality calls for us to embark on the journey towards securing this global treaty. (shrink)

Journals have been described as “duty bearers” of upholding fundamental ethical principles that are essential for maintaining the ethical integrity of newly generated and disseminated knowledge. To play our part, we evaluated diversity and inclusion in the leadership and management of global and international health journals. We developed Journal Diversity Index (JDI) to measure three parameters of diversity and representation (gender, geographic, socioeconomic status). Relevant information regarding editorial board members of systematically screened journals was sequentially extracted and job (...) titles were categorized into five editorial roles. Chi-squared test was utilized to study associations between gender and geographic distribution of editors along with the Medline indexing of the journal and its impact factor. Out of 43 journals included, 62.7% were published from two high-income countries. Women comprised 44% of the total editors. Among all the editorial board members, we did not find any information suggesting the representation of non-binary and transgender individuals. Furthermore, 68.2% of editors were based in high-income countries with 67.3% of the editors belonging to the Global North. This disparity in geographic region and socioeconomic level was observed across all five editorial roles. Among all women editors, more than 70% worked in non-Medline and non-impact factor journals. Only two journals scored “excellent” on JDI. Despite the continuous evolution of the definition of global health ethics, marginalized individuals, and their perspectives remain underrepresented in this field. Thus, we call for swift action regarding the decentralization and redistribution of global and international health journal editorial boards. (shrink)

The emerging global climate crisis threatens human health in unprecedented ways, yet global health concerns have not been sufficiently considered within international climate change efforts. A more collaborative pathway could advance efforts to mitigate and adapt to climate change while protecting public health and social justice.

The grounds for global solidarity have been theorized and conceptualized in recent years, and many have argued that we need a global concept of solidarity. But the question remains: what can motivate efforts of the international community and nation-states? Our focus is the grounding of solidarity with respect to global inequities in health. We explore what considerations could motivate acts of global solidarity in the specific context of health migration, and sketch briefly what form (...) this kind of solidarity could take. First, we argue that the only plausible conceptualization of persons highlights their interdependence. We draw upon a conception of persons as ‘ecological subjects’ and from there illustrate what such a conception implies with the example of nurses migrating from low and middle-income countries to more affluent ones. Next, we address potential critics who might counter any such understanding of current international politics with a reference to real-politik and the insights of realist international political theory. We argue that national governments – while not always or even often motivated by moral reasons alone – may nevertheless be motivated to acts of global solidarity by prudential arguments. Solidarity then need not be, as many argue, a function of charitable inclination, or emergent from an acknowledgment of injustice suffered, but may in fact serve national and transnational interests. We conclude on a positive note: global solidarity may be conceptualized to helpfully address global health inequity, to the extent that personal and transnational interdependence are enough to motivate national governments into action. (shrink)

The sheer gamut of issues impacting transgender health equity may seem overwhelming. This article seeks to introduce readers to the breadth of topics addressed in this symposium edition, exemplifying that transgender health equity is a global issue that demands an interdisciplinary approach.

In May 2009 the World Health Assembly passed a resolution on reducing health inequities through action on the social determinants of health, based on the work of the global Commission on Social Determinants of Health, 2005–2008. The Commission's genesis and findings raise some important questions for global health governance. We draw out some of the essential elements, themes, and mechanisms that shaped the Commission. We start by examining the evolving nature of global (...) health and the Commission's foundational inspiration – the universal pattern of health inequity and the imperative, driven by a sense of social justice, to make better and more equal health a global goal. We look at how the Commission was established, how it was structured internally, and how it developed external relationships – with the World Health Organization, with global networks of academics and practitioners, with country governments eager to spearhead action on health equity, and with civil society. We outline the Commission's recommendations as they relate to the architecture of global health governance. Finally, we look at how the Commission is catalyzing a movement to bring social determinants of health to the forefront of international and national policy discourse. (shrink)

On August 28, 2008, Michael Marmot, Chair of the Commission on Social Determinants of Health, formally handed over the Commission’s Final Report to Margaret Chan, the Director-General of the World Health Organization, at the Palais des Nations in Geneva. It was a significant moment. Dr. Chan addressed a hall packed with representatives of the world’s communications media in a speech that was remarkably direct. Dr. Chan reiterated the Commission’s position that to improve health and health (...) class='Hi'>equity action needs to be taken not just across the health sector but across all social and economic policy areas, and stated, “Social deprivation is not a matter of fate. It is a marker of policy failure.” This was a bold statement from one of the world’s leading diplomats. Policy failure! The phrase echoes the Commission’s assertion that “a toxic combination of poor social policies, unfair economic arrangements and bad politics is killing people on a grand scale.” The Commission’s messages are far reaching. (shrink)

How international research might contribute to justice in global health has not been substantively addressed by bioethics. Theories of justice from political philosophy establish obligations for parties from high-income countries owed to parties from low and middle-income countries. We have developed a new framework that is based on Jennifer Ruger's health capability paradigm to strengthen the link between international clinical research and justice in global health. The ‘research for health justice’ framework provides direction on (...) three aspects of international clinical research: the research target, research capacity strengthening, and post-trial benefits. It identifies the obligations of justice owed by national governments, research funders, research sponsors, and investigators to trial participants and host communities. These obligations vary from those currently articulated in international research ethics guidelines. Ethical requirements of a different kind are needed if international clinical research is to advance global health equity. (shrink)

Global health law for pandemics currently lacks legal obligations to ensure distributional and reparative justice. In contrast, international environmental law contains several novel international legal mechanisms aimed at addressing the effects of colonialism and global injustices that arise from the disproportionate contributions to — and impacts of — climate change and biodiversity loss.

Research partnerships between institutions in the Global North and institutions in the Global South have many potential benefits, including sharing of knowledge and resources. However, such partnerships are traditionally exploitative to varying degrees. In order to promote equity in South‐North research partnerships, it is necessary to learn from the experiences of researchers collaborating internationally. This study analyzed transcripts from eleven semi‐structured qualitative interviews with researchers working at Clínica de Familia La Romana, an institution in the Dominican Republic (...) with decades of experience with research and research partnerships with institutions from the Global North. The findings of this study suggest that respect for resources invested in research, as well as for the researchers and institutions themselves, are vital components to a successful global health research partnership. These findings have implications for individual research partnerships, as well as the policies of journals and institutions providing funding that affect these partnerships. (shrink)

How international research might contribute to justice in global health has not been substantively addressed by bioethics. Theories of justice from political philosophy establish obligations for parties from high‐income countries owed to parties from low and middle‐income countries. We have developed a new framework that is based on Jennifer Ruger's health capability paradigm to strengthen the link between international clinical research and justice in global health. The ‘research for health justice’ framework provides direction on (...) three aspects of international clinical research: the research target, research capacity strengthening, and post‐trial benefits. It identifies the obligations of justice owed by national governments, research funders, research sponsors, and investigators to trial participants and host communities. These obligations vary from those currently articulated in international research ethics guidelines. Ethical requirements of a different kind are needed if international clinical research is to advance global health equity. (shrink)

Health systems research is widely identified as an indispensable means to achieve the goal of health equity between and within countries. Numerous health systems research consortia comprised of institutions from high-income countries and low and middle-income countries are currently undertaking programs of research in LMICs. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Recent conceptual work has explored what features (...) might be necessary for health systems research consortia and their research programs to promote health equity. Identified features include selecting research priorities that focus on improving access to high-quality health services and/or financial protection for disadvantaged populations in LMICs and conducting research capacity strengthening that promotes the independent conduct of health systems research in LMICs. Yet, there has been no attempt to investigate whether existing consortia have such characteristics. This paper describes the results of a survey undertaken with health systems research consortia leaders worldwide to assess how consistent current practice is with the proposed ethical guidance. The findings suggest that consortia may be fairly well organised to promote health equity, but have scope for improvement, particularly in terms of achieving inclusive priority-setting. (shrink)

Commentary on Pratt, B., and A. A. Hyder. 2016. Governance of transnational global health research consortia and health equity.

Global health research partnerships have many benefits, including the development of research capacity and improving the production and use of evidence to improve global health equity. These partnerships also include many challenges, with power and resource differences often leading to inequitable and unethical partnership dynamics. Responding to these challenges and to important gaps in partnership scholarship, the Canadian Coalition for Global Health Research conducted a three-year, multi-regional consultation to capture the research partnership experiences (...) of stakeholders in South Asia, Latin America, and sub-Saharan Africa. The consultation participants described persistent inequities in the conduct of global health research partnerships and called for a mechanism through which to improve accountability for ethical conduct within partnerships. They also called for a commitment by the global health research community to research partnership ethics. The Partnership Assessment Toolkit is a practical tool that enables partners to openly discuss the ethics of their partnership and to put in place structures that create ethical accountability. Clear mechanisms such as the PAT are essential to guide ethical conduct to ensure that global health research partnerships are beneficial to all collaborators, that they reflect the values of the global health endeavor more broadly, and that they ultimately lead to improvements in health outcomes and health equity. (shrink)

A transformation of global health research is urgently needed if it is to eliminate long‐standing structural inequities within the field and help reduce global health disparities. Ethics has a key role to play in fostering such a transformation: it can help identify what the transformation should entail. Yet, ethics scholarship linking global health research to greater equity and social justice has limited authority and capacity to do so for two related reasons: it largely (...) fails to apply theories and concepts of justice from the global South and it says little about whether or how to address the coloniality and epistemic injustices inherent within global health research. This paper develops a multidimensional social justice lens using social justice and decolonial theory from the global North and global South. This lens identifies five core dimensions of social justice: power, recognition, harmony, inclusion, and well‐being. This paper then applies the multidimensional lens to the global health research context. For each dimension of social justice, several key ways to transform global health research are identified and described. They include shifting control of global health research funding, education, conduct, and publishing away from the global North and making knowledge from the global South visible and valued. To conclude, potential objections are considered. (shrink)

This article outlines and compares current and proposed global institutional mechanisms to increase equitable access to COVID-19 vaccines, focusing on their institutional and operational complementarities and overlaps. It specifically considers the World Health Organization's (WHO’s) COVAX (COVID-19 Vaccines Global Access) model as part of the Access to COVID-19 Tools Accelerator (ACT-A) initiative, the WHO’s COVID-19 Technology Access Pool (C-TAP) initiative, the proposed TRIPS (Trade-Related Aspects of Intellectual Property Agreement) intellectual property waiver and other proposed WHO and World (...) Trade Organization technology transfer proposals. We argue that while various individual mechanisms each have their specific individual merits—and in some cases weaknesses—overall, many of these current and proposed mechanisms could be highly complementary if used together to deliver equitable global access to vaccines. Nonetheless, we also argue that there are risks posed by the proliferation of proposals in this context, including the potential to disperse stakeholder attention or to delay decisive action. Therefore, we argue that there is now a clear need for concerted global multilateral action to recognise the complementarities of specific models and to provide a pathway for collaboration in attaining global equitable access to vaccines. The institutional infrastructure or proposals to achieve this amply exist at this point in time—but much greater cooperation from industry and clear, decisive and coordinated action from states and international organisations are urgently needed. (shrink)

The post‐genomics era promises a revolution characterized by precision medicine and the integration of genomics into almost every area of biomedical research. At the same time, there are concerns that if care is not taken, the genomics revolution may widen global inequities in science and health. In Africa, these concerns are primarily linked to the underrepresentation of African populations in genomics research, limited genomics research capacity in Africa and associated macro‐level justice issues such as benefit sharing, inequitable international (...) research collaborations, and the contribution of genomics to the health and research priorities of Africa. Addressing these concerns requires an in‐depth reflection on how the ideals of global justice and equity may be advanced in genomics research. To contribute to the limited but growing scholarship on global genomics equity, especially in the African context, we performed a conceptual analysis of three accounts of justice and governance namely, Ubuntu, shared health governance and global governance of health, with the aim of identifying principles that could inform genomics governance in Africa. We used a convergence approach in the conceptual analysis, resulting in the identification of nine principles namely: solidarity, furthering the ideals of health justice, reciprocity, shared decision‐making, shared resources, shared responsibility, mutual trust, transparency, and mutual collective accountability. Examples of how the principles may be applied are provided. We recommend that these principles should form the foundation of any mechanism that seeks to systematically advance justice, fairness and equity in genomics research in Africa and more broadly, global health and science equity. (shrink)

Global health research partnerships are increasingly taking the form of consortia. Recent scholarship has proposed what features of governance may be necessary for these consortia to advance justice in global health. That guidance purports three elements of global health research consortia are essential — their research priorities, research capacity development strategies, research translation strategies — and should be structured to promote the health of the worst-off globally. This paper adopted a reflective equilibrium approach, (...) testing the proposed ethical guidance against the experience of a global health research consortium with equity objectives. Case study research was performed with Future Health Systems, a health systems research consortium funded over two phases. Data on FHS Phase-2 were gathered through in-depth interviews with steering committee members and junior researchers and collection of consortium-related documents. Thematic analysis of the data for consistency with the proposed guidance generated recommendations for how the guidance might be better articulated and identified areas where it could usefully be expanded. Factors facilitating FHS alignment with the ethical guidance were also identified, including early engagement and partnership with low and middle-income country stakeholders, the learning developed during FHS Phase-1, and aspects of the grant program funding it. (shrink)

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs’ ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. (...) Recognizing that ongoing and underlying disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic. (shrink)

In this issue of the Hastings Center Report, Govind Persad and Ezekiel Emanuel argue that “[t]he provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off.” I agree that we should not let the perfect get in the way of the good, but just providing cheaper, less effective treatment for utilitarian or other reasons is not a comprehensive approach (...) to global health. In my experience as an on-the-ground global health practitioner, the choice is never that simple. As time passes, dynamics evolve, and so should the responses to a global health problem. The goal of global health should be urgently improving responses toward better access to care and equity in health, without which the good may become the enemy of the better. In other words, there are places and times in which the approach Persad and Emanuel describe may be appropriate, but their recommendations fail to account for the realities of a population-level medical emergency and for the fact that once an emergency is initially or partially addressed in any setting, time can be the enemy, if it breeds complacency. (shrink)

The Grand Challenges were launched in 2003 by the Gates Foundation and other collaborators to address the health needs of developing countries. This paper outlines the current problem with health research and development in the context of inequality as conveyed by the 90/10 divide. The paper then looks at the focus and nature of press reporting of global health issues by analysing how press articles have portrayed the Grand Challenges in Global Health initiative. Analysis (...) of the mass media illustrates that the focus of reporting on the Grand Challenges tends to be on utilitarian themes, leaving issues related to justice and equity comparatively under-reported. (shrink)

Bioethics, Volume 36, Issue 4, Page 411-422, May 2022.

Scholarship focusing on how international research can contribute to justice in global health has primarily explored requirements for the conduct of clinical trials. Yet health systems research in low- and middle-income countries has increasingly been identified as vital to the reduction of health disparities between and within countries. This paper expands an existing ethical framework based on the health capability paradigm – research for health justice – to externally-funded health systems research in LMICs. (...) It argues that a specific form of health systems research in LMICs is required if the enterprise is to advance global health equity. “Research for health justice” requirements for priority setting, research capacity strengthening, and post-study benefits in health systems research are derived in light of the field's distinctive characteristics. Specific obligations are established for external research actors, including governments, funders, sponsors, and investigators. How these framework requirements differ from those for international clinical research is discussed. (shrink)

Efficiency as quantified and promoted by cost-effectiveness analysis sometimes conflicts with equity and other ethical values, such as the “rule of rescue” or rights-based ethical values. We describe the utilitarian foundations of cost-effectiveness analysis and compare it with alternative ethical principles. We find that while fallible, utilitarianism is usually superior to the alternatives. This is primarily because efficiency – the maximization of health benefits under a budget constraint – is itself an important ethical value. Other ethical frames may (...) be irrelevant, incompatible with each other, or have unacceptable implications. When alternatives to efficiency are considered for precedence, we propose that it is critical to quantify the trade-offs, in particular, the lost health benefits associated with divergence from strict efficiency criteria. Using an example from HIV prevention in a high-prevalence African country, we show that favoring a rights-based decision could result in 92–118 added HIV infections per $100,000 of spending, compared to one based on cost-effectiveness. (shrink)

Efficiency as quantified and promoted by cost-effectiveness analysis sometimes conflicts with equity and other ethical values, such as the “rule of rescue” or rights-based ethical values. We describe the utilitarian foundations of cost-effectiveness analysis and compare it with alternative ethical principles. We find that while fallible, utilitarianism is usually superior to the alternatives. This is primarily because efficiency – the maximization of health benefits under a budget constraint – is itself an important ethical value. Other ethical frames may (...) be irrelevant, incompatible with each other, or have unacceptable implications. When alternatives to efficiency are considered for precedence, we propose that it is critical to quantify the trade-offs, in particular, the lost health benefits associated with divergence from strict efficiency criteria. Using an example from HIV prevention in a high-prevalence African country, we show that favoring a rights-based decision could result in 92–118 added HIV infections per $100,000 of spending, compared to one based on cost-effectiveness. (shrink)

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the (...) distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community interms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. (shrink)

The world is suffering from a dearth of health care workers, and sub-Saharan Africa, an area of great need, is experiencing the worst shortage. Developed countries are making the problem worse by luring health care workers away from the countries that need them most, while developing countries do not have the resources to stem the flow or even replace those lost. Postmodern philosopher Emmanuel Levinas offers a unique ethical framework that is helpful in assessing both the irresponsibility inherent (...) in the current global health care situation and the responsibility and obligation held by the stakeholders involved in this global crisis. Drawing on Levinas’ exploration of individual freedom and self-pursuit, infinite responsibility for the Other, and the potential emergence of a just community, we demonstrate its effectiveness in explaining the health care worker crisis, and we argue in favor of a variety of policy and development assistance measures that are grounded in an orientation of non-indifference toward Others. (shrink)

Records the main presentations of an international conference convened to identify the ethical concerns that need to be addressed as WHO renew its health for all policy for the 21st century. The meeting was attended by more than 150 experts in the fields of ethics, human rights, philosophy, medicine, and public health. Their contributions illustrate the many complex issues that need to be addressed when formulating global health policies for the future, particularly in view of striking (...) recent changes in health care, disease patterns, market forces, and political systems. The report opens with a description of the WHO policy framework for achieving four goals in the 21st century: attainment by all of health rights, achievement of global health equity, increase in healthy life expectancy, and access for all to essential quality health services. Against this background, the first section traces the evolution of bioethics to its present concern with the health of populations and identifies some of the most important inequalities that confront contemporary society. Papers in section two discuss key policy issues, including the definition of essential public health functions and their relationship to primary health care, ethical issues raised by the use of Disability-Adjusted Life Years (DALYs) to prioritize health resources, and the potential conflict between policies aimed at reaching vulnerable groups and those seeking to achieve aggregate health benefits. Ethical issues are discussed in subsequent sections, which explore policy implications at global, regional, and national levels. The remaining sections consider the actions needed to ensure that ethical analysis plays a role in the renewal of the health for all strategy and discuss some of the practical requirements for gaining commitment to equity as an essential public health goal for the 21st century. (shrink)

Zika virus was recognised in 2016 as an important vector-borne cause of congenital malformations and Guillain-Barré syndrome, during a major epidemic in Latin America, centred in Northeastern Brazil. The WHO and Pan American Health Organisation, with partner agencies, initiated a coordinated global response including public health intervention and urgent scientific research, as well as ethical analysis as a vital element of policy design. In this paper, we summarise the major ethical issues raised during the Zika epidemic, highlighting (...) the PAHO ethics guidance and the role of ethics in emergency responses, before turning to ethical issues that are yet to be resolved. Zika raises traditional bioethical issues related to reproduction, prenatal diagnosis of serious malformations and unjust disparities in health outcomes. But the epidemic has also highlighted important issues of growing interest in public health ethics, such as the international spread of infectious disease; the central importance of reproductive healthcare in preventing maternal and neonatal morbidity and mortality; diagnostic and reporting biases; vector control and the links between vectors, climate change, and disparities in the global burden of disease. Finally, there are controversies regarding Zika vaccine research and eventual deployment. Zika virus was a neglected disease for over 50 years before the outbreak in Brazil. As it continues to spread, public health agencies should promote gender equity and disease control efforts in Latin America, while preparing for the possibility of a global epidemic. (shrink)