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Ethical Challenges in GH Education: David Bernard
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An Ethics and Human Rights Impact Assessment of Global Health Training; Experiences in Poor Countries: From checklists to indicators

An Ethics and Human Rights Impact Assessment of Global Health Training; Experiences in Poor Countries: From checklists to indicators

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Ethical Challenges in GH Education: David Bernard Ethical Challenges in GH Education: David Bernard Presentation Transcript

  • An Ethics and Human Rights Impact Assessment of Global Health Training Experiences in Poor Countries: From Checklists to Indicators David Barnard, PhD, JD Thuy Bui, MD Global Health Residency Track Division of General Internal Medicine University of Pittsburgh School of Medicine Global Health Education Consortium April 4, 2009
    • When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind, it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.
    • --Lord Kelvin
    • What gets measured gets done.
    • --Douglas N. Daft,
    • CEO of Coca-Cola, 2000
  • Objectives
    • Take note of prior analyses of ethical aspects of global health training experiences
    • Emphasize the importance of measuring the effects of training experiences on host communities
    • Propose two resources for constructing appropriate measures
    • a. The Human Rights Impact Assessment
    • b. Human Rights Indicators:
    • Suggest some elements and indicators for an Ethics and Human Rights Impact Assessment of Global Health Training
  • Prior discussions of the ethical aspects of global health training experiences (1)
    • Andrew D. Pinto & Ross E.G. Upshur, “Global Health Ethics for Students”
    • Proposed principles:
        • Humility
        • Introspection
        • Solidarity
        • Social justice
  • Andrew D. Pinto & Ross E.G. Upshur, “Global Health Ethics for Students”
    • Questions for the student prior to working in global health (selected)
        • What are the benefits and who will receive them, and what are the costs, and who will bear them?
        • In the context of very limited resources for global health needs, is your elective justified?
        • Will it work to undermine disparity, or actually contribute to it?
  • Prior discussions of the ethical aspects of global health training experiences (2)
    • Kelly Anderson & Fadi Hamadani, Canadian Federation of Medical Students, “What is Our Responsibility? Global Health Ethics in Practice”
    • “ Difficult questions”
        • In overseas medical electives, how do we ensure that we are not a drain on the system? Are we impeding the training of local medical students and health professionals?
        • Should we measure the outcome of our students’ overseas activities? How do we ensure that in the long-term we don’t cause harm to the communities we work in?
  • Prior discussions of the ethical aspects of global health training experiences (3)
    • John A. Crump & Jeremy Sugarman, “Ethical Considerations for Short-term Experiences by Trainees in Global Health”
    • Governing norm: “Mutual and reciprocal benefit”
    • Stakeholders:
        • Patients and other intended beneficiaries
        • Trainees
        • Local staff and host institutions
        • Sending institutions
  • John A. Crump & Jeremy Sugarman, “Ethical Considerations for Short-term Experiences by Trainees in Global Health”
    • Concluding admonition:
    • “ Efforts should be directed at developing a means of assessing the potential benefits and harms to patients or intended beneficiaries in the host country and to trainees.”
  • Two crucial distinctions
    • 1) There are at least three potential foci for ethical evaluation of training programs:
        • Individual patients
        • Trainees
        • Host communities and populations
    • Our focus will be at the community and population level .
    • 2) There are at least two broad theoretical frameworks for ethical evaluation:
        • Consequentialism : The ethical evaluation of actions or policies depends on their consequences and net balance of benefits over harms (variously defined).
        • Non-consequentialism (deontology) : The ethical evaluation of actions or policies depends not only on consequences but on characteristics independent of a net balance of benefits or harms (e.g., conformity to a moral rule; respect for rights; expression of a moral virtue)
    • Our focus will be on measurable outcomes (i.e., consequences) . We acknowledge at the outset that the approach we are advocating does not encompass everything that is of ethical significance about global health training programs, even at the community or population level.
  • The two roots of our approach
    • Human Rights Impact Assessment (e.g., Gostin & Mann)
    • Human Rights Indicators (e.g., UNDP, Special Rapporteur for the Right to Health)
  • Human Rights Impact Assessment
    • Gostin & Mann (1994) proposed their impact assessment in the context of government policies in the AIDS epidemic. Core elements of their proposal:
        • Identifying all of the stakeholders
        • Establishing a normative framework
        • Fact-finding
    • The next question: what facts to collect?
    • Criteria for a good indicator:
        • Policy relevant
        • Reliable
        • Valid
        • Consistently measurable over time
        • Possible to disaggregate
        • Separates the monitor from the monitored
    • ( Human Development Report , 2000)
    Human Rights Indicators
  •  
  • Human Development Report 2000
  • A Normative Framework for an Ethics and Human Rights Impact Assessment of Global Health Training Experiences
    • General Comment 14 (2000), The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights) .
  • The “normative content of the right to health” (1)
        • Availability (of health services and facilities)
        • Physical accessibility
        • Economic accessibility (affordability)
        • Information accessibility
        • Acceptability (cultural respect, gender and life-cycle sensitivity, respect for confidentiality)
        • Quality (skilled personnel, approved and unexpired drugs and equipment, safe and potable water, sanitation)
  • The “normative content of the right to health” (2)
    • Special concern for:
        • Non-discrimination
        • Gender perspective
        • Women and the right to health
        • Children and adolescents
        • Older persons
        • Persons with disabilities
        • Indigenous peoples
  • Health systems and the right to health: an assessment of 194 countries Gunilla Backman, Paul Hunt, Rajat Khosla, Camila Jaramillo-Strouss, Belachew Mekuria Fikre, Caroline Rumble, David Pevalin, David Acurio Páez, Mónica Armijos Pineda, Ariel Frisancho, Duniska Tarco, Mitra Motlagh, Dana Farcasanu, Cristian Vladescu Lancet 2008; 372: 2047–85
  • Applying the indicators to Global Health Training (1)
    • Underlying determinants of health
    • 24 What percentage of the rural and urban population has access to clean water?
    • How do trainees/programs contribute to access to clean water for communities?
    • There are some student-initiated programs aimed at fundraising to dig wells. What is the yield of these programs in clean water?
  • Applying the indicators to Global Health Training (2)
    • Underlying determinants of health
    • 26 Prevalence rate of violence against women
    • One of our medical students some years ago did a DV survey in Honduras. This documented the problem and raised awareness but what was the long-term impact of this activity on that community?
        • How many support groups formed?
        • What public awareness campaigns were implemented?
        • How many prosecutions for domestic violence were carried out by legal authorities?
        • What was the impact of increased awareness on the victims?
  • Applying the indicators to Global Health Training (3)
    • Access to health services
    • 27 Proportion of women with a live birth in the last 5 years who, during their last pregnancy, were seen at least 3 times by a healthcare professional, had their BP checked, had a blood sample taken, and were informed of signs of complications
    • How do communities with and without global health trainees perform on these indicators of prenatal care and maternal health?
  • Applying the indicators to Global Health Training (4)
    • Medicines
    • 32, 33 What is the average availability of selected essential medicines in public health facilities? Private health facilities?
    • How do trainees/training programs contribute to availability of selected essential medicines?
        • Donations
        • Fundraising
        • Networking with other non-profits
  • Applying the indicators to Global Health Training (5)
    • Health workers
    • 38 Does the state have a national health-workforce strategy?
    • 39 Does the state law include provision for adequate remuneration for doctors?
    • By compensating the local mentor for supervising our students/residents, we help to retain that mentor in that facility (perhaps) and may elevate the status of this local clinician.
        • How does this practice affect the mentor’s responsibility in other areas, e.g., patient care or administration?
        • How many local physicians are available to staff local clinics?
        • At clinics in communities with and without training programs:
            • What are waiting times for patients?
            • How many patients are seen per day?
  • Challenges and Limitations
        • What indicators to choose
        • How to collect the data
        • What time frame to cover
        • Attribution of causality (If we observe a negative trend, how can we determine that the presence of the training program is a cause)