Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project

BACKGROUND: The 4-year (2007 2011) Revitalizing Health for All international research program (http://www. globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 lowand middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacityenhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSION: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include: 1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities 2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures) 3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation) 4. Support for community advocacy and engagement in health and social systems decision making These characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.IS

Neoliberalism 4.0: The Rise of Illiberal Capitalism; Comment on “How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention”

Neoliberal logic and institutional lethargy may well explain part of the reason why governments pay little attention to how their economic and development policies negatively affect health outcomes associated with the global diffusion of unhealthy commodities. In calling attention to this the authors encourage health advocates to consider strategies other than just regulation to curb both the supply and demand for these commodities, by better understanding how neoliberal logic suffuses institutional regimes, and how it might be coopted to alternative ends. The argument is compelling as possible mid-level reform, but it omits the history of the development of neoliberalism, from its founding in liberal philosophy and ethics in the transition from feudalism to capitalism, to its hegemonic rise in global economics over the past four decades. This rise was as much due to elites (the 1% and now 0.001%) wanting to reverse the progressive compression in income and wealth distribution during the first three decades that followed World War Two. Through three phases of neoliberal policy (structural adjustment, financialization, austerity) wealth ceased trickling downwards, and spiralled upwards. Citizen discontent with stagnating or declining livelihoods became the fuel for illiberal leaders to take power in many countries, heralding a new, autocratic and nationalistic form of neoliberalism. With climate crises mounting and ecological limits rendering mid-level reform of coopting the neoliberal logic to incentivize production of healthier commodities, health advocates need to consider more profound idea of how to tame or erode (increasingly predatory) capitalism itself

Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals (Migration Policy Series No. 65)

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%

Longitudinal study on the association between problematic Internet use and alcohol and cannabis use among teenagers from Quebec

CONTEXTE : L’utilisation problématique d’Internet (UPI) est un problème de santé publique émergent. Il entraîne de nombreuses conséquences sur la santé physique, psychologique et psychosociale des jeunes. En raison de l’association fréquente chez les jeunes entre différents comportements à risque (ex. : consommation de substances psychoactives) et en présence d’hypothèses divergentes quant au sens de l’association entre l’UPI et la consommation de substances psychoactives, il importe de questionner ces liens. Cette étude longitudinale vise à déterminer l’association entre l’UPI en troisième secondaire et la consommation d’alcool et de cannabis un an plus tard chez les jeunes Québécois. MÉTHODOLOGIE : Un échantillon de convenance de six écoles publiques et privées de trois régions du Québec a été étudié. Tous les étudiants de troisième secondaire (n=719) ont complété un questionnaire autoadministré comprenant des questionnaires validés sur l’UPI, l’anxiété, la dépression et l’impulsivité, ainsi que des questions sur le nombre moyen d’heures passées chaque semaine sur Internet pour des loisirs et sur la consommation d’alcool et de cannabis. Un an plus tard, les étudiants ont rempli le même questionnaire (n=593). Des modèles de régression logistique mettant en relation l’UPI au temps zéro et la consommation d’alcool ou de cannabis un an plus tard ont été réalisés en contrôlant pour le sexe, l’anxiété, la dépression, l’impulsivité et la consommation au temps zéro. RÉSULTATS : L’étude n’a révélé aucune association entre l’UPI et la consommation excessive d’alcool (RC=0,994 IC 95 % 0,976-1,012), la consommation fréquente d’alcool (1.000 IC 95 % 0.981-1.019), la consommation de cannabis dans la dernière année (1,001 IC 95% 0,978-1,024) et la consommation fréquente de cannabis (1,012 IC 95% 0,984-1,041). Aussi, aucune association n’a pu être démontrée entre le temps moyen passé sur Internet et la consommation excessive d’alcool (0,992 IC 95 % 0,979-1,005), la consommation fréquente d’alcool (0,990 IC 95 % 0,976-1,003), la consommation de cannabis dans la dernière année (1,008 IC 95% 0,993-1,023) et la consommation fréquente de cannabis (0,998 IC 95 % 0,979-1,018). CONCLUSION : Cette étude n’a pas révélée d’association entre l’UPI chez les étudiants de troisième secondaire et leur consommation d’alcool et de cannabis un an plus tard. En raison de l’émergence des problèmes liés à l’utilisation d’Internet, davantage d’études doivent se pencher sur les liens entre l'UPI et les comportements de consommation chez les jeunes.Abstract: BACKGROUND: A public health problem has emerged over the past few years: problematic Internet use (PIU). It has many consequences on the physical, psychological and psychosocial health of young people. Because of the frequent association among young people between different risk behaviours (e.g., use of psychoactive substances) and in the presence of divergent assumptions about the direction of the association between PIU and the use of psychoactive substances, it is important to question these links. This longitudinal study aims to determine the association between PIU in grade nine and alcohol and cannabis use one year later among Quebec youth. METHODS: A convenience sample of six public and private schools from three regions of Quebec was studied. All grade nine students (n=719) completed a self-administered questionnaire including validated questionnaires on PIU, anxiety, depression and impulsivity as well as questions on the average number of hours spent on the Internet each week for leisure, and on alcohol and cannabis use. One year later, the students completed the same questionnaire (n=593). Logistic regression models fitted to problematic Internet use at time zero and alcohol or cannabis use one year later, were performed by controlling for sex, anxiety, depression, impulsivity and substance use at time zero. RESULTS: The study found no association between PIU and binge drinking (AOR=0.994 95%CI 0.976-1.012), frequent alcohol use (1.000 95%CI 0.981-1.019), cannabis use in the last year (1.001 95%CI 0.978-1.024) and frequent cannabis use (1.012 95%CI 0.984-1.041). Also, no association could be demonstrated between average time spent on the Internet and binge drinking (0.992 95%CI 0.979-1.005), frequent alcohol use (0.990 95%CI 0.976-1.003), cannabis use in the last year (1.008 95%CI 0,993-1,023) and cannabis use (0.998 95%CI 0.979-1.018). CONCLUSION: This study did not reveal any association between PIU among grade nine students and their alcohol and cannabis use a year later. With the emergence of problems related to Internet use, more research is needed on the links between PIU and substances consumption among youth

No. 65: Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%