International Journal of Women's Health Care(IJWHC)
ISSN: 2573-9506 | DOI: 10.33140/IJWHC
Impact Factor: 1.011
Review Article - (2019) Volume 4, Issue 2
Joined-Up Thinking in Global Health Education
Received Date: Jun 10, 2019 / Accepted Date: Jun 19, 2019 / Published Date: Jun 25, 2019
Copyright: ©Roger Worthington. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
The scope of global health is necessarily broad and healthcare professionals need special knowledge and skill to help them work effectively in any multi-cultural, multi-ethnic society. Without some form of training over and above traditional areas of core clinical skill, the healthcare needs of vulnerable populations could be left unmet, whether in low-middle income countries where health infrastructure is poorly developed or in high-income countries where ethnic minorities might struggle accessing the care that they need. Recognising that while healthcare provision is always subject to financial constraint, health is not a commodity to be traded, and nursing and healthcare leaders have a role to play in helping create an environment that is conducive towards enabling patients achieve optimum health. Potential barriers to achieving this include creeping commercialisation, weak systems of governance and lack of recognition for the ethical nature of much healthcare provision. The picture varies greatly between and within countries, between specialism’s and providers and between individuals. Global health education programmes should recognise the moral nature of the enterprise, which creates a need for informed leadership and robust systems of governance. Critical to raising awareness of the interconnected nature of global health is a realisation that 1) Healthcare provision is essentially a form of public service, 2) Systems of governance should be fit for purpose and work to promote patient’s best interests (above those of healthcare providers) and 3) Ethical consideration should be factored into all policy initiatives and programmes for the promotion of global health. Without these elements, policy makers could find it hard finding effective interventions to address global health problems, such as the need to reduce rates of infant mortality. Nursing and global health educators can play their part in helping to create an environment whereby leadership, governance and ethics work together in serving the interests of whole communities.
Background
Good healthcare leadership grounded in moral values supported by effective professional regulation should help to promote quality, safe practice. While the integration of leadership, ethics, and governance should be an integral part of all global health policy, there is little evidence to suggest that this is happening on the ground. Interdependence between leadership, ethics and governance has yet to be widely recognised, and in the case of policy development and implementation, practical benefits ought to ensue from taking a joined-up approach towards these issues.
This analysis indicates a two-fold educational need: a) for leadership training to include both ethics and governance, b) for healthcare professionals to have practical competencies that are relevant to the provision of global health. A doctor or nurse does not have to practise in sub-Saharan Africa or the Indian sub-continent, for instance in order to be faced with situations requiring these so-called ‘soft’ skills. I argue that core training for allied health professionals should include objectives that are specifically linked to delivering care in a global health environment, whether in the context of a walk-in clinic in the East End of London or in a community health centre in any modern, multi-cultural city.
By way of definition, healthcare governance can be taken to mean having properly constituted systems of administration and quality control in place, supported by legal redress able to deal with failures that arise in meeting professional standards. Furthermore, ethics can be said to refer simply to “questions concerning right and wrong conduct” and such issues should be the concern of every healthcare professional [1]. For this reason, on occasions when clinical conduct falls short of agreed normative standards, for example, such as those issued by the General Medical Council (UK), systems need to be in place so that healthcare leaders can respond to challenges by helping to promote safe standards of patient care [2].
The issue of good governance is multi-faceted and often difficult to address because it sometimes requires government intervention and support to help develop the requisite institutions, even if principles of self-regulation are the legal norm. While governance arrangements could be beyond the reach of healthcare educators, the wider point can still be made that effective health policy needs an appropriate degree of ethical compliance as well as effective governance in order for it to work well, whether in a hospital setting or within the wider community.
Methods
The methods used to support this analysis are qualitative, not quantitative, drawing on practical experience of policy development and curriculum design. Using principles of argumentation within the broad context of a right to health, I outline an approach towards the development of global health education designed to bring practical benefits in a range of settings, having particular regard to the healthcare needs of minority patients and people living in multi-ethnic communities [3].
Discussion
Governance, ethics and healthcare leadership form a triangle, and unless all three sides are firmly in place, the structure will be prone to collapse. Governance and ethics without good leadership will be no more effective than leadership without suitable governance arrangements in place to demonstrate respect for core ethical values. As noted in The Lancet (referring back a paper by Donabedian in 1966), ‘‘an ethical approach towards people is the foundation of a health system’s success. Where that ethical commitment is lacking, there can be no high-quality service’’ [4].
It could be argued that ethics and professionalism are most noticeable when they are absent, for instance, when poor clinical performance and/or unprofessional behaviour affect patient care or where healthcare professionals fail to show respect for patient rights and individual autonomy. Conversely, when governance arrangements work well and ethical values are respected, it should not be necessary to shout this from the rooftops because the facts will speak for themselves. When systems do not work well, however, it may be hard to identify the root causes and/or to rectify problems that have been identified. If these are deep-rooted and spread across systems, it could be hard to find effective strategies to put in place to try and address these deficiencies, especially if the will to change is missing and people in positions of power and influence are deriving benefit from unethical or corrupt practice [5, 6].
Healthcare leaders set the tone of the institutions where they work and leadership initiatives should be at their most effective if ethical values are understood and respected, while supported by strong, effective systems of local governance. To an extent, all healthcare leaders have the power to change the environment and culture of healthcare delivery, whether at macro-level or micro-level. Before attitudes and behaviours make a practical difference to healthcare service delivery, systems have to be in place to help ensure that governance arrangements apply equally in all settings to all healthcare professionals.
Weak governance and lack of respect for ethical values can spread like cancer within an organisation, which can only hurt patients. Healthcare governance and ethics should be moral imperatives for anyone working in the healthcare environment, including policymakers, administrators and healthcare leaders. For instance, low-middle income countries such as India, have fragmented healthcare systems, and policy initiatives can fail for any number of reasons, including chronic underfunding, weak systems of governance and ethical codes that are not upheld and do not translate into practice [6,7]. However, this need not be the case and it should be possible to adopt a multi-lateral approach to healthcare regulation and governance, building systems for vertical and horizontal integration into local leadership frameworks.
Even in places where healthcare regulation and governance are bound together in the form of a social contract, the effectiveness of self-regulation in professions such as medicine and dentistry depends on principles of ethics and governance being implemented and respected, which is certainly not always the case. While healthcare everywhere is subject to financial constraint, especially when it comes to the allocation of scarce public funds, weak governance and ineffective regulation combined with deficiencies in local infrastructure and leadership will almost inevitably have a negative impact on patient care.
For example, according to Lui L and Chu Y et al. “Infant mortality in India was 695,852 in 2015 - A rate of 27.7 per 1000 live births” and “India had the largest number of under-5 deaths of all countries in 2015”, well short of targets set by Sustainable Development Goals for 2030 [8]. While causes of this high number of deaths will be multi-factorial, India has long had problems with weak governance combined with low levels of education on medical ethics, and while there is no suggestion that this weakness is a direct cause for the high number of cases of infant mortality, it could be a factor given some of problems in India affecting healthcare regulation and medical education [9].
Conclusion
Healthcare leaders need to be grounded in ethics and governance as well as being in possession of the more traditional areas of knowledge. Leadership training programmes across the healthcare professions need to adopt an integrated approach to help ensure that policies and practices conform to international standards, whilst affording patients adequate protection from unsafe practice. It is hoped that healthcare educators and planners bear this in mind when designing programmes for training future healthcare professionals.
Leaders and educators in global health need to be good at collaborating within organisation, between organisations, within systems, between organisations and if necessary, between countries in order to help reinforce their vision for the future. To this end, respect for human rights should underpin core thinking behind all global health provision, and the integration of leadership, ethics and governance should help to build these values into modern, effective systems of healthcare delivery wherever they are, and particularly where the healthcare needs of minority populations are otherwise left unmet.
References
- Jennings B (2014) Encyclopaedia of Bioethics 4th Ed. (“Ethics, p.1049). Macmillan Reference, Farmington Hills. http://www. bioethics.net/2014/05/encyclopedia-of-bioethics-4th-edition-now-available/
- General Medical Council (2014) Good Medical Practice, GMC. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors#good-medical-practice
- Kruk ME, Gage AD, Catherine Arsenault, Keely Jordan, Hannah H Leslie, et al. (2018) High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health Commission 6: 1196-1252.
- Lancet (2018) Putting quality and people at the centre of health systems. The Lancet 392: 795.
- Nundy S, Keshav D, Nagral S (2018) Healers or Predators?Health care corruption in India, Oxford University Press.
- Rao S (2016) When corruption becomes the norm and ethicalconduct an exception. Indian J. of Med Ethics 13: 54-57.
- Rinshu Dwivedi, Jalandhar Pradhan (2017) Doe’s equity in healthcare spending exists among Indian states? Explaining regional variations from national sample survey data. International Journal for Equity in Health 16: 15.
- Lui L, Chu Y, Shefali Oza, Dan Hogan, Jemie Perin, et al. (2019)National, regional, and state-level all-cause and cause-specific under-5 mortality in India in 2000-15: a systematic analysis with implications for the Sustainable Development Goals. The Lancet Glob Health 7: 721-734.
- Pandya SK (2019) Something is rotten in our medical colleges.Indian J. of Medical Ethics 4: 92-94.