Geneva Health Forum Archive

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Securing WHO FCTC Article 11 Compliance Through Legislative Advocacy: the Philippines

Author(s) Patricia Miranda1, Diana Cecilia Trivino2, Karla Mae Rocas3, Evita Mariz Ricafort4.
Affiliation(s) 1Legal Team, HealthJustice Philippines, Antipolo City, Philippines, 2Legal Team, HealthJustice, Quezon City, Philippines, 3Legal Team, HealthJustice Philippines, Quezon City, Philippines, 4Legal Team, HealthJustice Philippines, Quezon City,Philippines.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary Under the WHO FCTC, the Philippines obligated itself to require effective health warnings on cigarette packs by 2008. That deadline has long passed. Thus, HealthJustice Philippines (HJ) and Social Weather Stations (SWS) conducted a nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco" to gauge the behavioral response of Filipino youth towards graphic health information (GHI) on cigarette packages. The results show, among others, that 82% of current smokers believe that GHI shall be effective in preventing the increase of smokers. The survey is one of the launching points of HJ's legislative advocacy to ensure the passage of a GHI law in the 16th Congress.
What challenges does your project address and why is it of importance? The biggest challenge to the GHI legislative advocacy plan is the strong pro-tobacco lobby of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. The NLA has been known to deliver a "solid vote" against tobacco control measures in the Philippines. Currently, the Philippines is implementing Republic Act No. 9211, otherwise known as the Tobacco Regulation Act of 2003 (RA 9211), which provides for text-only warnings at the bottom portion of only one side of the pack. The contents of the warnings have not changed since the enactment of RA 9211 in 2003. Notably, RA 9211 does not comply with Philippine obligations under the WHO FCTC. Under this treaty, the Philippines is obligated enact effective measures requiring the placement of GHI on tobacco product packages by 2008. Thus, the Philippines has breached its international obligations when it missed its deadline to comply with the WHO FCTC. As a member of the family of nations, the Philippines agreed to be bound by generally accepted rules for the conduct of its international relations.
How have you addressed these challenges? Do you see a solution? It is urgent and necessary that Congress pass a law or laws guaranteeing that all our policies are in compliance with the WHO FCTC. One such legislative measure is the passage of a law requiring the placement of graphic health GHI on tobacco product packages, and banning the use of misleading descriptors thereon.HJ is currently with individual lawmakers and lawmaking bodies to gain support for GHI. As part of its legislative advocacy plan, HJ has prepared the following documents:
(a) brief on implementing Article 11 of the WHO FCTC in the Philippines;
(b) draft model bill incorporating the requirements of the WHO FCTC and its Implementing Guidelines;
(c) legislator's toolkit containing reports, surveys and studies relating to the effectivity of GHI in other countries; and
(d) presentation containing data which includes the results of the HJ-SWS nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco."At the time of this writing, there are currently seven Graphic Health Information bills. In the Senate, there are two bills filed by Senate President Franklin Drilon and Senator Pia Cayetano. In the House of Representatives, there are currently five bills on GHI, filed by Representatives Marcelino Teodoro of Marikina City, Niel Tupas of Iloilo, Joseph Violago of Nueva Ecija, Leah Paquiz of Ang Nars Party List, and Eric Singson of Ilocos Sur. All of these bills have been read on First Reading and are pending in their respective committees on health and/or trade. It should be noted that Eric Singson is a member of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. This may prove to be a sign that there is public clamor for more health promotive policies, particularly one requiring the placement of graphic health GHI on tobacco product packages. Hence, the solution lies in pushing for the passage of a law requiring GHI, particularly because of the presence and commitment of dedicated champions, the recent re-filing of the bills in both Houses of Congress, and the filing of a bill from a member of the NLA.
How do you know whether you have made a difference? One can only hope to make a difference, since the passage of any tobacco control measure in the Philippines entails coordination and teamwork between public health advocates. This is because the Philippines has the strongest tobacco lobby in Asia. Thus, one crucial gauge to determine if tobacco control advocates have made a difference in pushing for WHO FCTC compliant measures is to determine the number of tobacco control measures passed.
Have you or the project mobilized others and if so, who, why and how? The HJ Project Team is still currently mobilizing legislators and government agencies. Hence, the results of the "Usage and Attitudes of Filipino Youth Towards Tobacco," as well as the contents of the draft WHO FCTC-compliant bill, is being made available to the public.
When your donor funding runs out how will your idea continue to live? While donor funding may have been useful in drafting the documents submitted to the legislators in the Senate and Congress, these documents are also made available to the public. Hence, even if donor funding runs out, the documents meant to promote standardized tobacco product packaging and labeling in accordance with the Article 11 Guidelines would still be available to other tobacco control advocates, both public and private partners, to use and disseminate as they fit. The end goal would be amending RA 9211 to ensure its compliance with the WHO FCTC. The Department of Health, the Civil Service Commission, and the Metropolitan Manila Development Authority are government agency partners of HJ. These agencies have shown a strong support for the implementation of tobacco control policies in the Philippines.

Cataloguing New York City Legislation Relevant to Chronic Disease Prevention, 2002-2013.

Author(s) Brennan Rhodes-Bratton1, Gina Lovasi2, Ryan Demmer3
Affiliation(s) 1Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health , New York , United States, 2Department of Epidemiology, Columbia University, Mailman School of Public Health , New York, United States, 3Department of Epidemiology, Columbia University, Mailman School of Public Health , New York, United States.
Country - ies of focus United States
Relevant to the conference tracks Governance and Policies
Summary The overall aim of this project is to systematically detail the timing and substance of health-relevant New York City (NYC) policies and initiatives from 2002-2013. This is the initial phase of research proposing to evaluate the effectiveness of these efforts in reducing chronic disease morbidity and mortality rates. Local governments around the United States have taken policy action to mitigate the adverse effects of health determinants beyond the health care sector, such as tobacco smoke, physical inactivity, low dietary quality, and air pollution. NYC has been at the vanguard of municipal efforts to decrease the chronic disease using a multi-sectorial approach.
Background Chronic diseases represent the leading causes of death and disability among developing and developed nations (Yach et al, 2004; Beaglehole & Bonita, 2008). Among the most deadly chronic diseases, are atherosclerotic cardiovascular disease (CVD) and cancer, accounting for >65% of global mortality in 2002. This is projected to remain stable through the year 2020 at which point CVD and cancer together will account for nearly 40 million global deaths – nearly twice the number of deaths projected due to injuries and infectious disease combined (Yach et al, 2004). Respiratory diseases including emphysema and chronic obstructive pulmonary disease (COPD) are projected to become the third most common cause of death by 2020, accounting for another 10% of global mortality. It is well established that leading modifiable risk factors for chronic disease development include tobacco use, excess adiposity, low dietary quality, and exposure to particulate air pollution. The increasing concentration of populations in urban centres, while previously discussed as potentially contributing to risk (Vlahov, 2002), also represents an opportunity to enhance the public’s health through the enactment of local health promotion efforts in densely populated cities such as New York City.
Objectives Over the past twelve years, NYC has been led by the Michael Bloomberg administration, which has prioritized public health initiatives in response to the chronic disease burden of New Yorkers. Bloomberg worked closely with Health Commissioners, but the efforts were not limited to Department of Health and Mental Hygiene. A variety of governmental approaches including taxation, regulation, marketing/advertising campaigns, and infrastructure investments were proposed and implemented throughout the five boroughs. If the Bloomberg administration significantly decreased the chronic disease burden of the city dwellers, such policies can guide the nation to similar results. Currently, a comprehensive catalogue of all health-related NYC policy proposals, enacted laws and implemented initiatives does not exist.The aim of this research project was to systematically catalogue the nature and deployment of policies and initiatives relevant to public health. We will specifically focus on policies and programs enacted in NYC during the Bloomberg Administration, 2002-2013, related to the following four chronic disease risk factors: 1) tobacco, 2) obesity, 3) diet quality, and 4) air quality.
Methodology This study identifies policies and initiatives relevant to public health proposed and enacted in NYC. Specifically, it addresses the following research questions: (1) How many policies and initiatives related to public health were proposed and enacted in NYC legislation during 2002-2013 (2) Which local governmental agencies and departments were involved in the enact of such efforts.The systematic development of the catalogue of relevant policies and initiatives was generated in three phases. First, online state and city legislative record portals (,, and the PubMed database have been used with search terms for each of the selected chronic disease risk factors. Secondly, the searches were narrowed by selecting specific terms for each of the four chronic disease risk factors. For example, when searching legislation in regards to air pollution, the following terms, (air quality, air pollution, and greenhouse gases) were systematically used to provide consistency and a thorough assessment of relevant policies. Lastly, the search was restricted to include only the years of 2002-2013, the Bloomberg Administration’s term in office. The final catalogue includes the policy legislation number, date created, date enacted (if applicable), data enforced (if applicable), current status (as of August 2013), the primary agency that sponsored the bill, and a brief description. Note only citywide policies and regulations were included in the final catalogue.
Results Overall during 2002-2013 there were a total of 113 policies relevant to public health that were introduced and 33 enacted. Legislation that reduced the risk factor of tobacco included 33 introduced and 7 enacted policies. The New York City Council’s committee of health sponsored the majority of this legislation. The most notable legislated passed includes: Smoke Free Act of 2002, Cigarette Tax Increase, Smoking Ban at Abatement Sites, Smoking Ban at Construction Sites, Smoking Ban at Hospitals, Tobacco Product Regulation, and Smoke Free Act of 2002 (Amendment). Legislation that reduced the risk factor of air quality included 32 introduced and 12 enacted policies. The New York City Council’s committee of environmental protection sponsored the majority of this legislation. The most notable legislation passed includes: Use of clean heating oil in New York City, Requiring retrofitting and the use of ultra-low sulphur diesel fuel for school buses that transport fewer than 10 students at one time, and City's purchase of cleaner vehicles. Legislation that reduced the risk factor of physical activity included 13 introduced and 2 enacted policies. The New York City Department of Health and Mental Hygiene sponsored the majority of this legislation. The most notable initiatives include the increase of bike lanes throughout the city as well as the Citi Bike public bike sharing system. Legislation that reduced the risk factor of diet quality included 35 introduced and 12 enacted policies. The New York City Council’s committee of health sponsored the majority of this legislation. The most notable legislated proposed was the Sugary Drink Size Ban and Minimally nutritious food ban in schools. The most notable legislation passed includes Maximizing the enrolment of eligible New Yorkers in the food stamp program and the Trans fats ban.The process of developing the catalogue of public health related polices and initiatives is limited by the information that was available on the online city and state portal as of August 2013. In addition, some citywide initiatives were programs that did not require legislation thus those projects and programs are not included in the presented catalogue. Moreover, at this time the health outcome data has not been analysed thus it is not possible to quantify the impact of such polices on the health of New Yorkers which is our overall goal.
Conclusion This initial effort has highlighted that changing temporal trends in chronic disease outcomes may be attributed to one or many of the concurrent efforts, and evaluations of any one approach should be at once cautious and clever. The catalogue presented is the preliminary phase of an on-going research project to identify the magnitude and effect municipal policies impact health outcomes. Our future research includes strategies to place the temporal patterns of legislation relevant to each risk factor (Figure 2) in the broader context of other local or citywide efforts. Through this work, it will be possible to describe the cumulative “dose-response” relationship of municipal policy initiatives with population health outcomes. Strategies are also proposed using outcome specificity, differential latency periods, and multiple control comparisons that may help us to distil some evidence on the relative effectiveness of particular policies or risk factor targets. Further, we hope through an examination of scientific citation networks to shed light on the evidence base supporting such efforts. This consensus building analysis aims to provide a clearer picture of the stages at which scientific knowledge may inform decision-making, and the opportunities for municipal policies to serve as natural experiments to foster the generation of new scientific knowledge. Upon the completion of this research information about how local policies are developed, implemented can be applied to the future development of disease prevention polices.

Analysis of Medicine Entitlement Programs for NCDs in the Philippines.

Author(s) Raoul Bermejo1, Beverly Lorraine Ho2, Wim Van Damme3
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Health Unit, Philippine Institute of Development Studies, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary In response to rising non-communicable disease prevalence and access to medicines challenges for the worst-off, the national government has launched three medicines access programs. Data were collected from informant interviews, site visits and document reviews. These were analyzed by first creating a chronology of events. Then, using a health policy framework, strategies and actions used along with the results were examined. Findings revealed that the rapid roll out of the NCD access programs exhibited strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success.
Background As more Filipinos continue to be exposed to non-communicable disease risk factors such as tobacco and alcohol use, unhealthy diets and physical inactivity, prevalence for hypertension and diabetes mellitus have risen to 21% and 7.7 % respectively in 2008, and are expected to increase further. Cardiovascular disease and diabetes, along with cancer and chronic respiratory disease account for 57% of total deaths during the same year. According to the National Health Accounts, 52.7% of health expenditures are out-of-pocket. Of these, pharmaceuticals – accounting for 65.75% of household spending – are the single largest item of health care expenditures for households. Republic Act 9502, a law providing for cheaper and quality medicines was enacted in 2009.The Department of Health’s National Center for Pharmaceutical Access and Management launched three medicine access programs, namely DOH Complete Treatment Pack (ComPack), Valsartan (VAP) and Insulin Access Programs (IAP). ComPack provides complete (monthly) treatment regimens at no cost to the poorest families identified under the NHTS who are diagnosed to have diabetes and hypertension. VAP and IAP make available patent-protected Valsartan and Insulin at 60% lower cost than market prices.
Objectives The paper aims to document the policy process of three NCD medicine acces programs in the Philippines using a health policy analytical framework. Specifically, the paper seeks to understand the interaction of strategies that were employed and the factors that contributed greatly to policy advancement.
Methodology A qualitative, case study methodology using an in-depth longitudinal, prospective examination of events was employed for each of the three programs. Primary and secondary data were collected from (1) interviews with key policy and programme stakeholders; (2) visits to programme implementation sites; and (3) review of government documents, development partner reports, meeting records, conference proceedings and media clips. Representatives from government, academic institutions, nongovernment organizations, multilateral and bilateral agencies were interviewed. The interview guide reflected the three themes of emergence, formulation and implementation as described in the analytical framework by Lemieux (2002). A chronology of events was developed and process tracing was conducted. Triangulation of multiple data sources and discussion/verification with key actors supported interpretation and minimized bias.
Results Emergence: Our analysis shows that the following were critical in moving the access programs forward: (1) political commitment to achieve Universal Health Coverage by 2016, (2) availability of national health budget, (3) strong NCD policy community and access to medicines alliances, (4) increasing focus for the worst-off population and (5) strong industry lobbying.Formulation: The policy unit responsible for the programs was operational for less than 3 years when the policies were conceptualized and launched, and did not receive full technical support as was required. A relatively participative process was undertaken to define the contents but there was minimal integration into the health system.Implementation: Full subsidy of $15 million/annum and $400,000 are allocated for the ComPack and VAP. IAP has no subsidy since it is procured on a supply now-pay later (or consignment scheme). Information activities, implementation and evaluation support were constrained for all three programs largely due to funding limitations. The non-uniformity of information across health workers and patients resulted in a varied application of the policy in different implementation sites. Implementation was compromised by immediate national roll-out and devolved set-up for ComPack and the limited access sites for IAP and VAP. Availability of an efficient means for monitoring and responding to stock-outs remained a major challenge. To date, no plans for program evaluation have been articulated. IAP and VAP were also unable to address access challenges especially for the worst-off.
Conclusion The rapid roll out of the NCD access programs exhibit strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success. Findings indicate that that rapid rollout of access to medicines programs is possible only if strategies employed are purposeful and contextually sensitive. Favorable conditions for the emergence of a policy may not always exist but can be created.

Understanding Policy Development of an NCD Benefit Package: Philippines

Author(s) Raoul Bermejo1, Pura Angela Wee2, Wim Van Damme3.
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Zuellig Center for Asian Business Transformation, Asian Institute of Management, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary There is increasing global attention on Non-Communicable Diseases (NCDs). In the Philippines, the burden of NCDs is growing but government response remains weak. The study is a policy research that looks at the development of a new benefit package for non-communicable diseases within the Philippine social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed in shaping the policy. The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.
Background There has been increasing attention to non-communicable disease (NCDs) globally since the run-up to the high-level summit at the United Nations in September 2011 (Beaglehole 2011). In the Philippines, the burden of NCDs is growing (Shaw 2010). Although the government has started to develop policies and programs to address NCDs, there is still poor financing especially for prevention activities and comprehensive primary care services, lack of health human resource and weak political support (Higuchi 2010; Dans 2011). At the community level, the implementation of NCD programs, comprising mainly of healthy lifestyle clubs and occasional screening activities, remain weak (Lorenzo 2011). Overall, there is an inadequate response considering increasing burden of disease (Bermejo 2011; Van Olmen 2011).The improvement of the health financing mechanisms and particularly of the national health insurance agency, PhilHealth, is seen as a key in decreasing inequities and improving access (Romualdez 2011). One of the new Philhealth benefit packages that is ready to be piloted is the “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia” also known as the "Primary Care Benefit 2" (PCB2).
Objectives The study is essentially a policy research which looks at the development of a new benefit package for non-communicable diseases within the Philippines social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed to shaping the policy. The study will also identify different streams in the discourse around PCB2 and analyze how and why this specific policy window emerged.Philhealth is emerging to be one of largest purchasers of healthcare services in the Philippines. It is an agency attached to the Department of Health and is increasingly seen as one of the institutions that shape the healthcare landscape in the country. This research will help to gain insight into its policy making processes, what and who these affect and how these are influenced. This study will help us identify opportunities for improvement of the policy processes at Philhealth and develop recommendations to inform current health policy.
Methodology Study design
A case study methodology was done using both qualitative and quantitative methodologies. Documents and issuances related to the development of PCB2 including Administrative Orders, Philhealth Circulars, other legal issuances, and reports of key meetings and events were reviewed. Key informant interviews were conducted among an initial list of actors involved in the development of this new benefit package to gain insight into the key decision made, why these decisions were made and how such decisions were arrived at. The snowballing technique was employed to identify other potential interviewees. The study aimed for theoretical saturation. A trend analysis on quantitative data from the Philhealth database on inpatient claims for NCDs was performed to enrich the contextual description of the case.Sampling
A total of 28 key informant Interviews were conducted with actors involved in the development of PCB2, including:
1. Philhealth decision-makers (e.g. the former and current president of Philhealth, technical personnel within the Primary Care Benefit Team);
2. Program managers and decision-makers at the Department of Health specifically those who are concerned with primary care, NCDs, access to medicines and local health systems development;
3. Members of the academe and researchers consulted on PCB2;
4. Representatives of advocacy groups on Universal Health Care and NCDs;
5. Health officers and representatives of local governments selected as pilot sites;
6. Representatives of the private pharmaceutical sector in the Philippines.Analysis
The policy triangle (Walt and Gilson 1994) and Kingdon’s policy window theory (Kingdon 1995; Guldbrandsson 2009) was applied to analyze the case. The researchers reconstructed the story of the development of PCB2 and identified key strategic decision-making points in the development process. We analyzed how the policy was shaped by the interaction between the context, actors and process. We enriched the contextual description with the time trend analyses of Philhealth population coverage, NCD-related inpatient claims, and reserve funds. The study also identified different streams in the discourse around PCB2, including the discussions on Universal Health Care, NCDs, primary care, strengthening local health systems, and analysed how and why this specific policy window emerged. The research approach was iterative. Each set of data analyzed were used to construct and test the theory.
Results We identified four key elements in the new outpatient benefit package of Philhealth: 1) only for sponsored program members or the bottom poor enrolled into the program by the national and local governments, 2) use of the WHO Package of Essential Noncommunicable (PEN) Disease Intervention guidelines for screening and risk scoring, 3) access to full monthly regiments of 8 firstline NCD medications which were 4) made available through contracted private pharmacies.The focus on the bottom poor is consistent with the overall poverty reduction strategy of the government. The strategy is to concentrate poverty alleviation interventions (e.g. Conditional Cash Transfers, enrolment in social health insurance) among the bottom poor (20% of the population) identified through a national household targeting system for poverty reduction.The use of the PEN guideline for screening and risk scoring was a result of consultation with the World Health Organization (WHO) and with the health managers of the City of Pateros where the guidelines were being piloted. Setting risk scores was seen by the insurance managers as a good way to have control over the cost exposure of Philhealth on this new benefit package. This was further validated by expert consultants in Medicine.The first line generic medications included in the list covered by the benefit package was arrived at with the technical team validating the evidence around NCD drugs included in the Philippine National Drug Formulary. By law, all government agencies, including Philhealth, can only pay or procure medicines that are included in the formulary. The position of Philhalth is to promote rational drug use and is directed at the common practice of many physicians who prefer originator drugs. Representatives of pharmaceutical companies, public health centers and specialist doctors actively raised the issue of the "very limited" list of medicines covered by the package.

The decision to make the NCD medicines available through contracted pharmacies is to be consistent with the Pharmacy Law but also largely depoliticizes access to drugs and link it as a clear benefit of being a Philhealth member. Access to medcines made available through public primary care facilities are often politicized.

The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.

Conclusion Health policies, programs and and agendas do not exist in separate silos from each other. PhilHealth’s “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia" or "Primary Care Benefit Package 2" (PCB2) is one such policy whose development was shaped by policy development processes, actors pushing for their specific agenda and by the context. The actual policy is a product of the dynamic interplay of these factors.

Boost the boosters : India

Author(s) Rajesh Gupta,
Affiliation(s) 1Department of Pediatrics, Ruxmaniben Deepchand Gardi medical college, Ujjain, India.
Country - ies of focus India
Relevant to the conference tracks Governance and Policies
Summary This study was undertaken to assess status of Tetanus vaccination in school going children. A survey of the booster vaccination of 1000 children age of 5 to 18 years was done at Pediatric out patient department (OPD) for their routine immunization with DPT booster at age of 5 years and Tetanus Toxoid (TT) at 10 and 16 years of age as per the National Immunization schedule. 69% children were vaccinated for DPT booster at 5 years of age. Only 32% children were immunized with TT at age 10 and 15% at age of 16 years. Integration of Education department with the health system is needed to improve coverage of Tetanus immunization is in the community.
Background Tetanus is an acute, spastic paralytic illness historically called lockjaw that is caused by the neurotoxin produced by Clostridium tetani. Tetanus occurs worldwide and is endemic in approximately 90 developing countries. Tetanus is an entirely preventable disease. A serum antibody titer of ≥0.01 U/mL is considered protective. The active immunization with tetanus toxoid has an estimated failure rate of less than 4 per 100 million immunocompetent persons.
Objectives To assess status of Tetanus vaccination in school going children and to make awareness about booster vaccinations in community as well as health professionals.
Methodology A survey of the booster vaccination of the children age of 5 to 18 years was done at Pediatric out patient department (OPD) of R.D.Gardi medical college, Ujjain, M.P., India. Total of 1000 children were screened during the period of June – September 2013 for their routine immunization with DPT booster at age of 5 years and Tetanus Toxoid (TT) at 10 and 16 years of age as per the National Immunization schedule (NIS). Informed verbal consent from the subjects / attendants was taken to be included for the study. The study has been approved by institutional Ethics committee.
Results 69% children were vaccinated for DPT booster at 5 years of age. Only 32% children were immunized with TT at age 10 and 15% at age of 16 years.
Limitations – Survey was based on asking the children or their attendants to recall by their immunization status. No document viz. immunization card was available to confirm. Subject number may not suffice statistical parameters.
Conclusion In spite of simple preventive measures available, tetanus remains a major cause of child mortality in the developing countries. Mortality has been reported to vary from 10% to 39.3% in various series depending on the age group, grade of tetanus, availability of intensive care, complications, etc. Data released by state Government of Madhya Pradesh, India indicates only 67.57% and 67.77% of children were immunized for TT booster at 10 years and 16 years consecutively.
Conclusion – In a developing country like India, infectious diseases are still major causes of child mortality. In spite of available preventive measures, coverage of Tetanus immunization is less in the community. Tetanus immunization can be improved by making policy to integrate education departments with health systems so that school going children may get this vaccine at their schools and at the right age.

Health governance in Ethiopia: Does systems theory strengthen district health planning and procedural fairness?

Author(s) Kadia Petricca1, Dereje Mamo2, Whitney Berta 3, Clare Pain 4, Jennifer Gibson 5
Affiliation(s) 1Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 2Policy and Planning Directorate, Ministry of Health, Addis Ababa, Ethiopia, 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 4Psychiatry , University of Toronto, Toronto, Canada, 5Joint Centre for Bioethics, University of Toronto, Toronto, Canada.
Country - ies of focus Ethiopia
Relevant to the conference tracks Governance and Policies
Summary Building strong health systems in resource-poor settings involves strengthening good governance. This study explores the ability of a new district-health planning strategy in Ethiopia to strengthen procedural fairness and district-level capacity, while further reflecting on the systemic features that act as barriers and facilitators in this process. Results explore various dimensions of the district-health planning process and in strengthening procedural fairness at all levels. Strengthening mechanisms for building good governance can enhance the  transparency and accountability of health systems.
Background Health planning and priority setting is a complex undertaking in all health systems. Therefore, building strong health systems in resource-poor settings involves strengthening good governance for health planners to assert their local needs, and build capacity for multistakeholder engagement, and transparent and accountable decision-making. In 2008, the Ethiopian government implemented district-based health sector planning; a national strategy to streamline evidence-based planning, harmonize stakeholder agendas and promote democratic decision-making. While evaluations revealed some improvements in these areas, they also revealed a variety of system-level constraints influencing the adoption of such processes. However, conceptual guidance in the use of systems theory and in its ability to guide our understanding of health governance and procedural fairness remains in its infancy. Using a systems analysis and a framework for procedural fairness, this study analyzes challenges and strengths emergent from implementation.
Objectives The overall objectives of this presentation will be to (i) reflect on the experiences of implementing district-based health sector planning in Ethiopia through the views of health planners and non-government partners; (ii) assess its implications on strengthening fair and legitimate decision-making; and (iii) to further reflect on the application of a systems analysis to gain a deeper understanding of important systemic factors influencing health planning and procedural fairness.
Methodology Multiple case studies were conducted in three districts (in three separate regions) of Ethiopia. Methods included: (i) Fifty-eight in-depth interviews with national, regional, and district health planners and non-government partners, (ii) participant observation in health planning meetings; and (iii) policy analysis. Analysis was guided by the Transformative Systems Change Framework (TSCF) and Accountability for reasonableness (A4R).
Results Overall, district-based health sector planning had a strong impact on strengthening both evidence-based planning and democratic decision-making. A new evidence-based planning and budgeting (EBPB) tool guided district health planners to set priorities through generating priority targets. A4R revealed the process upheld principles of fairness based on the inclusion of multistakeholder engagement, disclosure of planning outcomes, evidenced-based planning and an appeals mechanism. Leadership capacity at the district level was still considered weak and varied across districts. To guide our understanding of the system, the TSCF dissects the system structure into four components that may act as barriers or facilitators in district health planning. It identified: (I) System Norms, where strong cultural values were present for strengthening evidence-based practice and promoting participatory dialogue; (II) System Regulations, where policies and national strategies promoted and valued evidence-based planning and stakeholder inclusivity, yet did not highlight explicit mechanisms for promoting transparency; (III) System Resources, where limited technical and environmental capacity hindered the management of the excel-based planning and budgeting tool and the ability to conduct on-going training; and (IV) System operations, where on-going communication delays between district health offices and NGOs and overlapping stakeholder roles impacted the clarity and efficiency of planning. There is clear interconnectedness between each of these system elements that will be further reflected upon, for changes in one domain will yield consequences in another.
Conclusion Strengthening the capacity of district health planners to set health priorities can enhance the transparency and accountability of health systems in low-income settings. District-based health sector planning appears to be a valuable mechanism in strengthening the evidence-based planning and procedural fairness as it guides evidence-based planning through the EBPB tool and promotes democratic decision-making through multistakeholder engagement. A systems lens can reveal unique insights as to the interconnected parts of a system and how they impact the ability of district health planners to set health plans and priorities fairly, legitimately and in accordance with national policies and local health needs.

The integration of health into foreign policy: Health is Global

Author(s) Michelle Gagnon1.
Affiliation(s) 1Norlien Foundation and University of Calgary, Norlien Foundation and University of Calgary, Calgary, Canada.
Country - ies of focus Canada
Relevant to the conference tracks Governance and Policies
Summary This study explored the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. To elucidate a deeper and clearer understanding of this phenomenon, the research used a case study design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13.
Background Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings.
Objectives The main objective of this study was to explore and better understand what global health diplomacy (GHD) is by focusing on the health and foreign policy nexus. Since little empirical research has been undertaken that focuses on GHD this study aimed to break new ground in this area. Specific objectives were to:
• understand how health as a concept is understood and positioned in the diplomatic and policy discourse at the state level.
• build theoretical understanding about global health diplomacy by exploring how and why nations integrate global health into foreign policy (e.g. what factors influence this process and what is the process itself that leads to this integration).
• build understanding about what the connection between health and foreign policy means for the craft of foreign policy and global health diplomacy.
• begin exploring whether whole-of-government strategies that aim to promote this integration make or have the potential to make a relevant difference to government policy, structures and processes and what that difference is or could be as perceived by the stakeholders involved.
• derive policy and decision making lessons for other nations that are potentially interested in developing similar policy coherence mechanisms.
While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health.
The central research question explored was: how and why is global health integrated into foreign policy? Sub-questions include: how is global health defined and understood in the diplomatic and policymaking processes? Which global health issue(s) have the most saliency with state actors and why? Who are the actors involved and what role and influence do they exert in the process? How and why does global health attract the attention of state actors and remain on the policy agenda? How have government diplomatic strategies or practices changed with respect to the adoption of a broad policy framework that embodies GHD? How are state foreign policy interests in global health understood by state actors?
Methodology This research adopted a case study design. The major element of the study consisted of an in-depth investigation and analysis of the UK global health strategy launched in 2008. This UK case was chosen because it represents the first instance in which a G8 country has articulated a national global health strategy that purports to integrate global health into foreign policy. Of the countries presently engaged formally in some form of GHD initiative, the UK global health strategy is also the most detailed and comprehensive. In addition to the UK case, document analysis and interviews were conducted for three other background case reviews, Norway, Switzerland and Brazil. Methodology included literature review, document analysis and semi-structured interviews. Purposive sampling was used to identify and recruit interviewees for semi-structured interviews. In keeping with the objective of the study and to help answer the main research question, state and non-state actors who had been directly involved in the process of the integration of health into foreign policy in each of the four countries were targeted for interviews. A total of twenty interviews were conducted, 14 for the UK case (seven with state actors and seven with non-state actors) and two each for the background cases (Norway: one state, one non-state; Brazil: two state; and Switzerland: one state and one non-state). Interviews took place between August 27, 2009 and March 24, 2010. A general inductive approach was used analyze the data. In this approach, both the research objectives and questions (deductive) and multiple readings and interpretations of the raw data (inductive) guide data analysis. The main mode of analysis is the development of categories from the raw data into a framework or model that captures key themes and processes. Data analysis encompassed three concurrent and iterative flows of activities: data reduction, data display and conclusion drawing/verification.
Results The primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent, though weaker, theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The research elucidated factors that underpin this process as well as lessons for other nations.
Conclusion This study was principally exploratory and as such aimed at advancing understanding of how and why health is integrated into foreign policy. Overall it:
• Helped to fill identified knowledge gaps through rigorous, primary research focused on understanding the global health diplomacy process from the perspectives of those who have been involved in it.
• Provided further empirical support and critical analysis to advance understanding of the key arguments for health in foreign policy, including global health security.
• Used a triangulated theoretical approach that incorporated the Multiple Streams Model of the policy process and Fidler’s three health in foreign policy conceptualizations to advance theoretical understanding of global health diplomacy.
• Proposed a more precise definition of the global health diplomacy process at the state level that is potentially a useful starting point for other countries that may embark on similar global health policymaking processes.
• Contributed to advancing theory about global health diplomacy by elucidating some of the key factors that can lead to a successful global health diplomacy process.
• Contributed some initial perspectives on what constitutes success of state level global health policymaking processes and outcomes.
• Surfaced a number of areas for further in-depth research such as that which compares global health diplomacy processes within the state with those between states and institutions at the international level (e.g. WHO). More specifically, a number of research topics could be pursued in each of the areas that make up the policy analysis circle – context, content, process, actors and impact. Further empirical research into the key arguments that underpin health in foreign policy, how this discourse is potentially shifting in the current world economic environment, and in particular, how and why health diplomats make trade-offs in their advancement of these arguments is another area for further inquiry. Other research topics could include a more in-depth look at the role of researchers and research evidence in the global health diplomacy process at the state level and knowledge translation practices that help facilitate the use of evidence in global health policymaking.
• This study provided significant insight to the global health policymaking process at the state level that could inform similar processes that other countries might be considering embarking on.

The relevance of research evidence in informing vaccination policies in Switzerland.

Author(s) Xavier Bosch-Capblanch1, Christian Auer2, Sylvie Olifson3
Affiliation(s) 1Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 3Division Maladies transmissibles, Office fédéral de la santé publique OFSP, Geneva, Afghanistan, 4
Country - ies of focus Switzerland
Relevant to the conference tracks Governance and Policies
Summary Vaccination in Switzerland may not reach public health targets. The Swiss Federal Office of Public Health is developing a National Immunisation Programme to improve coverage based on an overview of available evidence. 22 studies and 18 systematic reviews were included showing modest effects in general. Interventions included information, vaccine prescription, new vaccination programmes, information and vaccination campaigns, organisational interventions, financial incentives, and combinations of the above. This overview provides evidence to inform a participatory process to interpret and assess its relevance to the specific Swiss policy context.
Background Vaccination is one of the most cost-effective interventions to control disease. For vaccines to show public health effects, high coverage needs to be attained, for example, as high as 95% for measles elimination. However, there are gross differences in vaccination coverage between high- and middle- and low-income countries and within countries. Factors related to poverty and low education level of caregivers have been widely described as determinants of non-vaccination. Surprisingly, though, coverage is still relatively low in some high-income countries even among well-educated populations. Switzerland is not an exception; for example, vaccination coverage for the second dose of measles in children by the age of two was 88% (2011-2012), well below international recommendations.
Cognisant of these issues, the Swiss Federal Office of Public Health has recently launched an initiative to better understand the factors affecting the uptake of vaccinations in the country and to find out which interventions to improve vaccination coverage may be effective and relevant to the Swiss context. A review of these interventions was commissioned to the Swiss TPH (presented here) in order to feed into a national consultation process to translate research evidence into meaningful policies.
Objectives To search, retrieve and synthesise evidence on the effects of interventions to improve vaccination coverage potentially relevant to the Swiss health policy context.
To inform a participatory process to incorporate research evidence, alongside implementation and policy issues, in the elaboration of the Swiss National Immunisation Programme (NIP).
Methodology A systematic literature review (SR) following commonly accepted methods was devised. Two sources of evidence were searched: primary studies assessing the effects of interventions to improve vaccination coverage, carried out in Switzerland or neighbouring countries over the last 10 years; and published systematic reviews of interventions to improve vaccination coverage without any geographical or time limitation. Participants considered were people of any age targeted by routine vaccination programmes or campaigns, any intervention aiming at improving vaccination coverage was considered and tested against any control or without control, and the primary outcomes were changes in vaccination coverage.
A search strategy was produced by a specialist and applied to a wide range of sources including: Medline, EMBASE, PsycInfo, the Cochrane Library, Web of science and CINAHL. Hits from the search strategy were assessed by looking at titles and abstracts. Relevant studies where assessed against the inclusion criteria. At the stage of data extraction, some references were excluded, mainly because there were no quantitative estimates of the primary outcome. Data from included references was extracted by a single reviewer.
Analyses were carried out based on a list of categories of interventions: organisation / governance, human resources, financial resources (health system and users), vaccines management, information (systems and users), way of delivery, education and combination of interventions. The effects of interventions were summarised using standard measures of coverage change. Where possible, results were presented in relative change. Where more than one change of coverage was reported the median relative changes with ranges were presented. We did not attempt to undertake any meta-analyses, due to the large diversity of interventions, outcomes and vaccines. However, we synthesised the findings categorising the estimates in four groups, using arbitrary criteria: (A) effects do not favour the intervention either because the point estimate is below 1 or because the lower precision estimate is below 1; (B) effects favour the intervention with an estimate below 2; (C) effects favour the intervention with an estimate above 2 but with a lower precision estimate below 2; (D) effects favour the interventions with both a point estimate and an existing lower precision level above 2.
Results A total of 10,719 references were retrieved: 4,585 primary research studies and 6,134 SR. A large proportion of these references were judged as irrelevant (e.g. studies of vaccine efficacy, vaccine development or animal studies).
(1) Primary studies
122 references from Switzerland or neighbouring countries were relevant, of which 22 studies were included. Most of the studies showed only modest effects. The most remarkable effect was reported in a study which reported changes in influenza coverage among health care workers between two seasons (relative increase 2.56 and 2.85). Another study assessed information and vaccine prescription for parents and vaccination proposed to parents during hospitalization (absolute changes of +6.63% and +7.11% respectively. The only study which assessed an organisational intervention showed that a vaccination programme introduced in a maternity ward produced a relative increase of BCG coverage by 1.23. The most remarkable study on information provided to users looked at the effects of TV spots, press conferences, information to health professionals, an Internet site, and leaflets and posters upon improved influenza vaccination status in the elderly. Interventions affecting the mode of delivery were more promising in general (e.g. vaccination campaigns).
(2) 93 SR were classified as relevant, of which 36 were excluded in the first round and a further 39 at the stage of data extraction. One review reported on 11 different interventions, showing large effects of regulatory interventions requiring vaccination at school, child care and college entry (+15% change in coverage), use of standing orders (51%), incentives to users (8%) and combined interventions for women, children and infants (9%). An SR assessed a series of interventions to increase adult immunisation. Interventions with significant effects included: organisational interventions (adjusted OR 16), education to providers (3.21), reminders to providers (3.80), reminders to users (2.52) and financial incentives for users (3.42). Interventions targeting human resources showed mixed results. Three SR looked at financial incentives targeting providers with relative changes between 1.26 and 2.22. Financial incentives to users showed positive effects (adjusted OR 3.42). A number of SR looked at information interventions within the system, with heterogeneous results. A review which combined access and user targeted interventions suggested relatively large effects with absolute changes of 14%.
Conclusion The interventions most widely reported are those related to information to users (e.g. reminders) therefore, it is more likely to find studies with positive effects in these interventions. A second group of interventions widely addressed are those with combinations of strategies.
• All types of interventions have examples of modest effects, or no effects or even negative effects on vaccination coverage.
• Information-related interventions have been the most widely reported. At least one review showing promising findings dealt with mass media.
• Educational interventions targeting users showed very modest effects except for a single study (educational intervention involving health care staff).
• The most effective ways of delivering vaccinations were those more proactive, such as campaigns or approaching parents in wards.
• Organisational interventions were the least reported albeit with promising findings.What is the relevance of these findings?
Our overview provides not only evidence on the effects of interventions but also offers a comprehensive menu of interventions tested and allows the identification of interventions which may have been hardly tested or not at all. While there is little dissent on the need to use the best available evidence reported in SR to inform policies, this overview highlights the challenges in translating research evidence into policy, especially on health systems interventions. For example the bias in reporting different types of interventions, the lack of standardised interventions, the fact that organizational/structural interventions were the least reported and the heterogeneity of findings.This overview was carried out in the context of a participatory policy making process to support the contents of the upcoming Swiss NIP, and not as a pure research exercise. The interpretation of this evidence is, therefore, embedded into a deliberative process which extends for several months and which includes immunisation stakeholders of several constituencies. The deliberative process is the backbone of policy making and assesses the relevance evidence through several mechanisms: (a) deciding which interventions are suitable in the Swiss context; and (b) the magnitude of effects that can be expected. The deliberative process will culminate into a series of recommendations which will be based, not only on the best available research evidence, but on implementation and context specific considerations as well.

An Exploration of how Health is Positioned in Canadian Foreign Policy.

Author(s) Ronald Labonte1, Vivien Runnels2, Michelle Gagnon3.
Affiliation(s) 1Institute of Population Health, University of Ottawa, Ottawa, Canada, 2Globalization and Health Equity Unit, University of Ottawa, Ottawa, Canada, 3Institute of Population Health, University of Ottawa, Edmonton, Canada.
Country - ies of focus Canada
Relevant to the conference tracks Governance and Policies
Summary Canada has been regarded as a model global citizen with firm commitments to multilateralism. It has also played important roles in several international health treaties and conventions in recent years. There are now concerns that its interests in health as a foreign policy goal may be diminishing. This study reports on a thematic analysis of key Canadian foreign policy statements issued over the past decade, and interviews with key informants knowledgeable of, or experienced in the interstices of Canadian health and foreign policy.
Background In 2007, the foreign ministers of seven countries (Norway, France, Brazil, Indonesia, Senegal, South Africa and Thailand) issued the Oslo Declaration identifying global health as ‘a pressing foreign policy issue of our time’. A number of government legislative, policy or commentary reports preceded and followed: Sweden’s policy on development, Switzerland’s health foreign policy, Norway’s Policy Coherence Commission and new white paper on global health in foreign and development policy, and the UK’s Health is Global strategy. In 2009, the US Institute of Medicine issued the second of two reports on global health in foreign policy, the same year that the Annual Ministerial Review held by the UN Economic and Social Council devoted itself to global public health. In November 2008 fifty-five nations sponsored a UN General Assembly Resolution on global health and foreign policy, urging member states ‘to consider health issues in the formulation of foreign policy’. Such developments serve to demonstrate a decadal trend in which health has risen to become an integral part of global policy discourse.
Objectives Canada, until recently regarded as a pioneer in health multilateralism through its demonstration of leadership in the Ottawa Agreement to ban the use of anti-personnel landmines and in negotiations over the Framework Convention on Tobacco Control], has yet to produce any formal global health policy or framework. The lack of an explicit governmental policy does not necessarily mean that interest in the intersection of global health with foreign policy is absent. In 2010, for example, Health Canada commissioned two policy reviews to examine the bases for global health as a foreign policy goal. Further, two research projects were undertaken around the same time examining global health diplomacy in Canada, including the study we report on. Most recently, the Canadian Academy of Health Sciences (CAHS) completed an expert panel review of Canada’s strategic role in global health. These scholarly activities provide a base from which to examine the role of global health in Canada’s recent past, present and near-future foreign policy engagements. Our particular study set out to examine how global health has been considered in Canadian foreign policy. We were further interested in how global health is understood by Canadian foreign policy makers; is the perspective one that is narrowly focused only on disease and health/medical care (including drug research or access to essential medicines), or does it incorporate a broad understanding of the importance of social determinants of health? Relatedly, we wanted to explore which global health issues had most policy traction, which state or non-state actors are involved in framing health as a foreign policy goal, and what have been enabling or constraining factors in positioning health (and health equity) more prominently in Canadian foreign policy deliberations. In this study we focus on how health has been framed or defined as a foreign policy concern.
Methodology Two methods were employed in our study. The first method involved a systematic document review and analysis of recent (post-2000) Canadian federal government policy statements on global or international health, or other policies and statements issued by federal Ministries or departments whose activities have strong if indirect bearing on health. Ten such documents were located. A discourse analysis of these documents was conducted searching for specific references to how health was framed as a policy issue. An initial template of policy framings, based upon earlier work by the researchers was used, followed by a thematic coding to ensure that novel rationales were also captured.
The second method was key informant interviews using purposive and snowball sampling. Thirteen (13) interviews were conducted with persons from the government, academic research and civil society sectors. All interviewees were recruited on the basis of their recent and current engagement in global health and foreign policy. Transcripts were returned to interviewees for member-checking if they so requested. Interview data were thematically coded with the assistance of qualitative data analysis software, NVivo.
Results International relations scholars argue that national security and economic interests will often conflict with and inevitably trump that of global development and humanitarian aid, the domains within which most global health issues reside. Our study’s findings offer little evidence to challenge the supposition that health, when it does rise in Canadian foreign policy, does so primarily for instrumental reasons. Moreover, health is primarily and increasingly framed in relation to national security and economic interests. Little attention has been given to human rights obligations relevant to health as a foreign policy issue, and global health is not seen as a priority of the present government. Global health is nonetheless regarded as something with which Canadian foreign policy must engage, if only because of Canada’s membership in many United Nations and other multilateral fora. Development of a single global health strategy or framework is seen as important to improve intersectoral cooperation on health issues, and foreign policy coherence. There remains a cautious optimism that health could become the base from which Canada reasserts its internationalist status.
Conclusion National security and global competitive advantage are playing the dominant roles in Canadian foreign policy. The challenge is how effectively, if at all, global health can find a position within such a framing, and without losing its moral or humanitarian base. Our own study findings are inconclusive on this point; although we found a keen desire for Canada to re-assert its presence in global health. We leave the last word on that count to one of our informants:
"[Health] is a win/win situation … It’s not like a trade issue, it’s not like a natural resources issue, it’s something that all countries can agree on [is] a benefit to their citizens. And I think if we can actually situate global health as a sort of a flagship of a renewed Canada foreign policy, I think that would be perceived extremely well by Canadians as being a reaffirmation of Canada’s engagement, in much the same way that we used to be considered as peace builders and peacekeepers internationally. I think Canadians are looking for that."

How far are the ‘left behind’ left behind? The psychological and physical wellbeing of family members of international labour migrants.

Author(s) Kolitha Wickramage1, Chesmal Siriwardhana2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Institute of Psychiatry, King's College London, United Kingdom, United Kingdom.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Governance and Policies
Summary International labor migration has become a crucial engine in economic development for many countries worldwide. Even though the enormous contribution from international migrant workers to Sri Lanka’s economic development is well documented, politically encouraged, socially accepted and commercially stimulated, little is known on the actual health and social consequences of the ‘left behind’ members of their families. Despite the growing importance on migration for global development, the public health implications for migrants and their families have received little attention and empirical research into measuring impacts have been scarce.
Background ILM from Sri Lanka has grown ten-fold during the past decade, with 23.8% of Sri Lanka’s total labour force currently employed abroad. In what was once a highly feminized labor force, today 49% percent of ILMs are women, and out of these, 86% are ‘domestic housemaids’ with the majority (over 93%) employed in the Middle Eastern countries. ILMs contributed 4.1bn USD to the Sri Lankan economy in 2011 (second highest contributor). Many ILMs also choose continuous cycles of re-migration (‘circular migration’) to increase their savings potential. Even though the enormous contribution from international migrant workers to Sri Lanka’s economic development is well documented, politically encouraged, socially accepted and commercially stimulated, little is known on the actual health status and health consequences of the ‘left behind’ members of their families. The WHA resolution on health of migrants prompted public health attention and called for an evidence-based research agenda on migration health. In the current study, the association of spousal migration with socio-demographic factors and health status of ‘left-behind’ family members (spouse, children and care givers) were compared with families without a history of migration, using standardized instruments with diagnostic values.
Objectives Despite the fact that nearly one-in-ten Sri Lankans are employed abroad as International Labor Migrants, very little is known about the impact of their migration on the health status of the families they ‘leave behind’. The findings from this study will be useful to form an evidence-based approach in the National Migration Health Policy for Sri Lanka. In addressing the social and health impacts and determinants on the reliance for migration for development the challenge for policy makers lies at the nexus of migrant rights and economic gain through remittances and responsibility. In order to advocate for migrant sensitive health policies, empirical evidence is needed to determine the true health consequences of labour migration on families 'left behind'.
Methodology This national study utilized both quantitative and qualitative methods to study associations between the health status of ‘left-behind’ spouses, children and caregivers, and comparative non-migrant families. A cross-sectional study design with multi-stage random sampling was used. We surveyed a total of 1990 persons; 875 adults (from 410 migrant and 410 non-migrant families), 820 children from 410 migrant and 410 non-migrant families matched for both age and sex, and 295 school teachers linked to these children. Socio-demographic and health status data were derived using standardized pre-validated instruments. Univariate and multivariate analyses were used.
Results Nearly one-in-three migrant families were from single-parent households. Forty-four percent of left-behind children had some form of psychopathology, with over a quarter of those under 5-years being underweight or severely underweight (29%). Association of emotional, hyperactivity, conduct problems and having any psychiatric diagnosis was strongest in children from migrant family households [Odds ratio 1.62 (CI: 1.16-2.27)], and was exacerbated in families where the sole parent was the overseas based migrant worker. Significantly high levels of depression were found in caregivers [12.3% (CI: 12.23-12.31)] and spouses from left-behind families [25.5% (CI:25.47-25.60], with physical health status showing similar trends.
Conclusion Findings provide empirical evidence on the health consequences for heavy out-migration for the families ‘left-behind’. These are relevant for many labour ‘sending countries’ in Asia relying on ILM remittances. Whilst cross-sectional studies can only suggest, but not prove a cause–effect relation, this study highlights a number of major challenges for policy makers at the nexus of balancing rights, remittances and health consequences. We advocate the adaptation of migrant sensitive health policy frameworks guided by the 2008 World Health Assembly Health of Migrants Resolution, which promotes safe, healthy and economically beneficial ‘migration for all’.