A theoretical exploration of the implementation of antimicrobial stewardship programmes in the United Arab Emirates.

Antimicrobial resistance (AMR) is considered a global health threat and one of the most pressing public health issues. The World Health Organization (WHO) outlined actions to combat the AMR risk including optimising the use of antimicrobials through the introduction of Antimicrobial Stewardship Programmes (ASP). Many collaborative groups have produced bundles of actions that can guide ASP implementation. The Center for Disease Prevention and Control (CDC) have produced a framework of seven core elements driven from key ASP studies demonstrating effectiveness in antimicrobial use. The Gulf Cooperation Council (GCC) states responded to the global health threat of AMR by issuing a five pillars strategic plan. In United Arab Emirates (UAE), local healthcare authorities detected the increased prevalence of resistant microbial strains and responded by issuing mandates demanding hospitals to establish ASP teams and actions tailored to their available resources. The overall aim of the doctoral research was to explore ASP implementation in acute care hospitals in UAE. A number of systematic reviews have been published providing evidence on the effectiveness of ASP interventions and its impact on patient and microbiological outcomes, yet none have explored ASP implementation in relation to international standards. Since it is well recognised that ASP interventions can vary greatly across geographical regions, the need for a systematic review exploring ASP implementation in the GCC region has emerged. The first phase of this doctoral research was a systematic review of 17 studies that aimed to critically appraise and synthesise the evidence of ASP implementation in GCC hospitals in comparison to the CDC framework and identify key facilitators and barriers. The CDC framework was the international standard of choice given its value as a reference point for many GCC hospitals and based on multiple effectiveness studies that used it to identify gaps in ASP implementation in acute care hospitals. Mapping to the CDC framework identified key areas of strengths and weaknesses in reporting implementation where infrastructure elements reporting was heterogeneous and insufficient. It also identified the need for rigorous qualitative in-depth research that utilises implementation frameworks to facilitate identification and understanding of factors that influence the translation of ASP research findings into practice within the healthcare sector in GCC states. The second phase of this doctoral research aimed to explore key stakeholders' perspectives of ASP implementation in UAE hospitals, with a focus on facilitators and barriers. A qualitative study was conducted underpinned by the Consolidated Framework for Implementation Research (CFIR) and involving semi-structured interviews with ASP key stakeholders from UAE hospitals. Data saturation was achieved at the completion of 31 interviews. Multiple CFIR constructs emerged as facilitators (such as stakeholders' engagement and effective communication) or barriers (such as perceived ASP complexity and blame culture) for ASP implementation, which highlighted the value of employing theory as an underpinning in comparison to studies without any theoretical underpinning. Coronavirus Disease 2019 (COVID-19) highly impacted data collection during phase two. Participants' perspectives on the impact of COVID-19 on ASP implementation were separately analysed and presented. The study identified the complexity of ASP implementation which led to initial disruption of the service, yet successful evolvement and restoration of ASP services reflects the high value and adaptability of ASP implementation in UAE hospitals. Future research should focus on obtaining consensus agreement of ASP key stakeholders on recommendations for ASP implementation based on findings of the systematic review and the qualitative study

Advancing the Right to Health: The Vital Role of Law

Effective laws and an enabling legal environment are essential to a healthy society. Most public health challenges – from infectious and non-communicable diseases to injuries, from mental illness to universal health coverage – have a legal component. At global, national and local levels, law is a powerful tool for advancing the right to health. This tool is, however, often underutilized. This report aims to raise awareness about the role that public health laws can play in advancing the right to health and in creating the conditions for all people to live healthy lives. The report provides guidance about issues and requirements to be addressed during the process of developing or reforming public health laws, with case studies drawn from countries around the world to illustrate effective practices and critical features of effective public health legislation. Advancing the right to health: the vital role of law is the result of a collaboration between the World Health Organisation, the International Development Law Organisation (IDLO), the O’Neill Institute for National and Global Health Law, Washington D.C., USA, and Sydney Law School, University of Sydney. The Project Directors were: Professor Lawrence O. Gostin, Linda D. and Timothy J. O’Neill Professor of Global Health Law and University Professor, Georgetown University; Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University; Mr David Patterson, Senior Legal Expert – Health; Department of Research & Learning, International Development Law Organization; Professor Roger Magnusson, Professor of Health Law & Governance, Sydney Law School, University of Sydney; Mr Oscar Cabrera, Executive Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center; Ms Helena Nygren-Krug (2011–2013), Senior Advisor, Human Rights & Law, UNAIDS. The content and structure of the report reflect the consensus reached at the second of two international consultations in public health law that preceded the preparation of the report, hosted by WHO and IDLO in Cairo, Egypt, 26-28 April 2010. Part 1 introduces the human right to health and its role in guiding and evaluating law reform efforts, including efforts to achieve the goal of universal health coverage. Part 2 discusses the process of public health law reform. The law reform process refers to the practical steps involved in advancing the political goal of law reform, and the kinds of issues and obstacles that may be encountered along the way. Part 2 identifies some of the actors who may initiate or lead the public health law reform process, discusses principles of good governance during that process, and ways of building a consensus around the need for public health law reform. Part 3 turns from the process of reforming public health laws to the substance or content of those laws. It identifies a number of core areas of public health practice where regulation is essential in order to ensure that governments (at different levels) discharge their basic public health functions. Traditionally, these core areas of public health practice have included: the provision of clean water and sanitation, monitoring and surveillance of public health threats, the management of communicable diseases, and emergency powers. Building on these core public health functions, Part 3 goes on to consider a range of other public health priorities where law has a critical role to play. These priorities include tobacco control, access to essential medicines, the migration of health care workers, nutrition, maternal, reproductive and child health, and the role of law in advancing universal access to quality health services for all members of the population. The report includes many examples that illustrate the ways in which different countries have used law to protect the health of their populations in ways that are consistent with their human rights obligations. Countries vary widely in terms of their constitutional structure, size, history and political culture. For these reasons, the examples given are not intended to be prescriptive, but to provide useful comparisons for countries involved in the process of legislative review

Department of Health annual report 2012.

In 2012, there were eight Divisions in the Department. Each Division is headed up by an Assistant Secretary (or equivalent). Together with the Secretary General, who heads up the Department, they form the Management Advisory Committee (MAC). Each Division is comprised of a number of Units. Each Unit has a specific area of responsibility. Primary Care, Drugs Programmes Unit, Drugs Policy Unit, Eligibility, Medicines, Controlled Drugs & Pharmacy Legislation: The Division’s role is to promote the development of primary care services, to secure enhanced value for money in the GMS, community drug schemes, dental and optical schemes, and to ensure implementation of legislation and policies in relation to medicine and cosmetics safety, pharmacy services, medical devices, control of illegal drugs as well as lead on the strategic development of policies relating to Eligibility. The Division also oversees the implementation of the National Drugs Strategy, service provision and expenditure in relation to the Drugs Initiative allocation, and monitors the work of the Local and Regional Drugs Task Forces

The Global Risks Report 2016, 11th Edition

Now in its 11th edition, The Global Risks Report 2016 draws attention to ways that global risks could evolve and interact in the next decade. The year 2016 marks a forceful departure from past findings, as the risks about which the Report has been warning over the past decade are starting to manifest themselves in new, sometimes unexpected ways and harm people, institutions and economies. Warming climate is likely to raise this year's temperature to 1° Celsius above the pre-industrial era, 60 million people, equivalent to the world's 24th largest country and largest number in recent history, are forcibly displaced, and crimes in cyberspace cost the global economy an estimated US$445 billion, higher than many economies' national incomes. In this context, the Reportcalls for action to build resilience – the "resilience imperative" – and identifies practical examples of how it could be done.The Report also steps back and explores how emerging global risks and major trends, such as climate change, the rise of cyber dependence and income and wealth disparity are impacting already-strained societies by highlighting three clusters of risks as Risks in Focus. As resilience building is helped by the ability to analyse global risks from the perspective of specific stakeholders, the Report also analyses the significance of global risks to the business community at a regional and country-level

Malta: health system review

Maltese life expectancy is high, and Maltese people spend on average close to 90% of their lifespan in good health, longer than in any other EU country. Malta has recently increased the proportion of GDP spent on health to above the EU average, though the private part of that remains higher than in many EU countries. The total number of doctors and GPs per capita is at the EU average, but the number of specialists remains relatively low; education and training are being further strengthened in order to retain more specialist skills in Malta. The health care system offers universal coverage to a comprehensive set of services that are free at the point of use for people entitled to statutory provision. The historical pattern of integrated financing and provision is shifting towards a more pluralist approach; people already often choose to visit private primary care providers, and in 2016 a new public-private partnership contract for three existing hospitals was agreed. Important priorities for the coming years include further strengthening of the primary and mental health sectors, as well as strengthening the health information system in order to support improved monitoring and evaluation. The priorities of Malta during its Presidency of the Council of the EU in 2017 include childhood obesity, and Structured Cooperation to enhance access to highly specialized and innovative services, medicines and technologies. Overall, the Maltese health system has made remarkable progress, with improvements in avoidable mortality and low levels of unmet need. The main outstanding challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope with a growing population; redistributing resources and activity from hospitals to primary care; ensuring access to expensive new medicines whilst still making efficiency improvements; and addressing medium-term financial sustainability challenges from demographic ageing

A mixed-methods study of antibiotics use and prescribing dynamics in Indonesian hospitals: implications for antimicrobial stewardship

Antimicrobial resistance (AMR) is an accelerating public health problem, with antimicrobial agents, including their inappropriate use, being one of the key drivers. In Indonesian hospitals, there is a fragmented picture of antibiotic use and of the drivers of prescribing patterns. This thesis aimed to fill this knowledge gap by assessing patterns and quality indicators of antibiotic prescribing for hospitalised patients, mapping their drivers and dynamics, and exploring the factors influencing the implementation of antimicrobial stewardship (AMS) programmes. Using an explanatory sequential mixed-method approach, data collection was conducted in six hospitals in Jakarta, between March 2019 and October 2020. A quantitative survey found high proportions of hospitalised patients receiving systemic antibiotics, that guideline compliance was poor, use of blood cultures was low, and that prolonged surgical prophylaxis was common. The qualitative findings revealed multidimensional social-cultural factors influenced antibiotic prescribing, such as disjunctions between drivers of AMR and day-to-day clinical practice, antibiotic prescribing as risk aversion vis-à-vis concerns of poor clinical outcomes, the ‘pull’ of conformity to normative, suboptimal group prescribing practices, and suboptimal operations of microbiology and surgical facilities. Effective AMS programme implementation was challenged by ineffective resourcing and institutional buy-in, cost-prohibitive culture testing, entangled hospital priorities to generate profits, and a non-collegial communication approach to AMS execution. Three identified areas of improvement are addressing hierarchical cultural norms in the medical profession, encouraging ownership of the AMR problem and solution among all stakeholders, and developing sustainable context-specific AMS strategies. Based on the complex adaptive system (CAS) concept, I formulated four recommendations: 1) identifying the agents of influence; 2) evaluating the problem using a CAS lens; 3) developing health system resilience; and 4) identifying leverage points. In conclusion, this thesis contributed to the development of a conceptual framework showing how multilevel and multidimensional social-cultural factors interact to influence antibiotic prescribing and AMS implementation