tag:theconversation.com,2011:/us/topics/healthcare-access-28807/articlesHealthcare access – The Conversation2021-12-01T13:28:14Ztag:theconversation.com,2011:article/1710862021-12-01T13:28:14Z2021-12-01T13:28:14ZHIV prevention pill PrEP is now free under most insurance plans – but the latest challenge to the Affordable Care Act puts this benefit at risk<figure><img src="https://images.theconversation.com/files/434560/original/file-20211129-13-1w51j99.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C700&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The FDA approved the first PrEP drug, Truvada, in 2012.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/FDAHIVDrug/dd94b9ab97d14c6f9ec04661c8e81c86">AP Photo/Jeff Chiu</a></span></figcaption></figure><p>Since the start of the HIV epidemic in 1981, <a href="https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-the-basics/">over 700,000 Americans</a> have lost their lives to AIDS. Being infected used to be a death sentence. But now, 40 years later, the U.S. is on the precipice of eradicating HIV.</p>
<p>The U.S. <a href="https://www.cdc.gov/endhiv/index.html">Ending the HIV Epidemic</a> initiative provides a road map to reduce new HIV infections by 90% by 2030. A key preventive strategy in this plan is preexposure prophylaxis, or PrEP, medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">almost 100% effective</a> in preventing HIV infection when taken as prescribed.</p>
<p>Today, Medicaid and Medicare <a href="https://www.cdc.gov/hiv/basics/prep/paying-for-prep/index.html">cover PrEP at zero or low cost</a>, and there are assistance programs as a backstop. Just this year, PrEP was designated a <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/prep-hiv-prevention-pill-must-now-totally-free-almost-insurance-plans-rcna1470">required preventive service</a> under the Affordable Care Act that almost all insurers must cover at no cost. </p>
<p>But the latest challenge to the ACA has put these gains at risk.</p>
<p>We are public health researchers who study the <a href="https://www.bu.edu/sph/profile/paul-shafer/">ACA’s effects on preventive health usage and costs</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">HIV prevention and LGBTQ health</a>. Because PrEP was only recently included as a required preventive service, there is limited evidence on how expanding PrEP coverage has affected access. But given that removing financial barriers has been shown to significantly increase access to <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">other types of preventive care</a>, eliminating free HIV prevention would be a big step backward in the goal to eradicate HIV.</p>
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<h2>Barriers to PrEP access</h2>
<p>Although the Food and Drug Administration <a href="https://www.fda.gov/media/83586/download">approved the use of PrEP</a> to prevent HIV in 2012, insurance coverage was slow to build and faced regional disparities, primarily in the South. PrEP often required <a href="https://doi.org/10.1001/jamanetworkopen.2020.7445">prior approval</a> before it could be prescribed by a health care provider and is often documented in medical records with stigmatizing terms like “<a href="http://publichealth.lacounty.gov/dhsp/Providers/PrEP-PEPBillingCodes.pdf">high-risk sexual behavior</a>.” Some states also have public insurance policies like restrictive HIV testing requirements that <a href="https://www.kff.org/hivaids/issue-brief/state-medicaid-management-of-prescription-drugs-for-hiv-treatment-and-prevention/">create more barriers to PrEP access</a>.</p>
<p>People who are socially and economically vulnerable face <a href="https://dx.doi.org/10.1007%2Fs12325-020-01295-0">additional access barriers</a>, like limited knowledge and awareness of PrEP, concerns about costs and provider unwillingness to write a prescription. Fear of stigma from the health care system and personal relationships further diminish its use.</p>
<p>People who face higher financial burdens <a href="https://labblog.uofmhealth.org/industry-dx/what-happens-when-preventive-care-becomes-free-to-patients">benefit the most</a> from making preventive care free. For example, low-income Medicare patients showed the <a href="https://doi.org/10.1002/cncr.29494">greatest increase</a> in colorectal cancer screening rates once it was made free compared with higher-income privately insured patients.</p>
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<a href="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=1000&fit=clip"><img alt="Person holding red ribbon." src="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434526/original/file-20211129-25-spcyg6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">PrEP, or preexposure prophylaxis, is highly effective at preventing HIV infection when taken consistently as prescribed.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-holding-red-ribbon-for-hiv-illness-awareness-1-royalty-free-image/1185494323">klebercordeiro/iStock via Getty Images Plus</a></span>
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<p>These same trends apply to PrEP. A <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">recent study</a> in a large California health system found that younger patients, people of color and those with lower incomes face significant disparities in obtaining and continuing PrEP. Removing the financial barrier for PrEP through the ACA was a huge win for HIV prevention and the <a href="https://www.aidsmap.com/news/oct-2021/stark-disparities-seen-all-along-us-prep-continuum">marginalized populations</a> that stand to benefit most.</p>
<h2>The Affordable Care Act and PrEP</h2>
<p>A popular piece of the Affordable Care Act is its requirement that <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">preventive care services</a> be covered at no cost in most commercial health insurance plans. Though it <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few. </p>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the law lays out a few ways a preventive service can qualify for full coverage. Immunizations, like COVID-19 vaccines, require a recommendation from the <a href="https://www.cdc.gov/vaccines/acip/index.html">Advisory Committee on Immunization Practices</a> of the Centers for Disease Control and Prevention, while women’s health services require approval from the <a href="https://www.hrsa.gov/womens-guidelines/index.html">Health Resources and Services Administration</a>. Most other preventive services require an A or B rating from the <a href="https://uspreventiveservicestaskforce.org/uspstf/home">U.S. Preventive Services Task Force</a>, an independent body of experts trained in research methods, statistics and medicine, and supported by the <a href="https://www.ahrq.gov/cpi/about/otherwebsites/uspstf/index.html">Agency for Healthcare Research and Quality</a>.</p>
<p>The U.S. Preventive Services Task Force assigns <a href="https://www.uspreventiveservicestaskforce.org/uspstf/us-preventive-services-task-force-ratings">letter grades</a> to preventive services through a <a href="https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/uspstf-recommendations-development-process-graphic-overview">five-step review process</a> that evaluates the strength of the <a href="https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">scientific evidence</a> supporting a service’s net health benefit. An A or B grade indicates “moderate” or “substantial net benefit” supporting the service’s being provided to patients when appropriate. C grades mean there is likely only a small benefit and the service should be considered on a case-by-case basis, while D indicates a recommendation against use. An I grade means there is insufficient evidence to make a recommendation.</p>
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<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
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<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> in June 2019. This paved the way for both PrEP and related services like clinic visits and lab tests to be covered at no cost for millions of commercially insured Americans.</p>
<p>[<em>More than 140,000 readers get one of The Conversation’s informative newsletters.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140K">Join the list today</a>.]</p>
<h2>What is at stake?</h2>
<p>This preventive health benefit has become the latest front in the seemingly unending <a href="https://www.theatlantic.com/ideas/archive/2021/06/next-major-challenge-affordable-care-act/619159/">legal battle</a> over the ACA. The plaintiffs in <a href="https://www.vox.com/2021/4/2/22360341/obamacare-lawsuit-supreme-court-little-sisters-kelley-becerra-reed-oconnor-nondelegation">Kelley v. Becerra</a> are arguing for the inclusion of religious and moral objections that would directly affect contraception and PrEP coverage. Kelley v. Becerra, which is currently <a href="https://www.healthaffairs.org/do/10.1377/hblog20211109.807537/full/">pending at a Texas district court</a> with Judge Reed O'Connor, may also strike out Section 2713 of the ACA altogether, eliminating other free preventive services. A decision is expected early next year.</p>
<p>The case rests on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">two legal technicalities</a> that have nothing to do with whether PrEP or contraception deserves to be considered on equal footing with cancer screenings and childhood immunizations. It focuses on whether Congress needed to be more specific about what services could be covered under the law, and whether the power to select covered services could be delegated to groups like the U.S. Preventive Services Task Force.</p>
<p>There are well <a href="https://doi.org/10.1016/j.annepidem.2018.05.003">over a million people</a> in the U.S. who could benefit from PrEP. But if Kelley v. Becerra eliminates free preventive care, over <a href="https://dx.doi.org/10.1016%2Fj.annepidem.2018.06.009">170,000 current PrEP users</a> and a million others who need it could be severely affected. Access to PrEP for Americans with commercial insurance – <a href="https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202108-508.pdf">nearly two-thirds of the population</a> under age 65 – was made easier with the removal of financial barriers. Now those barriers are at risk of being put back in place.</p>
<p>A future without HIV is possible and within reach for the U.S. But widely accessible PrEP is a big part of how the nation can get there. Losing preventive coverage through Kelley v. Becerra would be a huge setback to the goal of ending the HIV epidemic in the U.S.</p><img src="https://counter.theconversation.com/content/171086/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, Starbucks Coffee Company, and Renova Health. He also previously worked in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality, which provides support to the US Preventive Services Task Force.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski has been supported by funding from the Robert Wood Johnson Foundation, the National Institutes of Health, and the Centers for Disease Control and Prevention.</span></em></p>World AIDS Day on Dec. 1 this year comes at a time when a key step to removing financial barriers to PrEP access in the U.S. faces legal challenges.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1459332020-09-20T07:47:47Z2020-09-20T07:47:47ZCan COVID-19 inspire a new way of planning African cities?<figure><img src="https://images.theconversation.com/files/357703/original/file-20200911-24-76vj2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Makoko neighbourhood in Lagos, initially founded as a fishing village.</span> <span class="attribution"><span class="source">Frédéric Soltan/Corbis via Getty Images</span></span></figcaption></figure><p>Health crises are not new in Africa. The continent has grappled with infectious diseases on all levels, from local (such as <a href="https://theconversation.com/what-115-years-of-data-tells-us-about-africas-battle-with-malaria-past-and-present-85482">malaria</a>) to regional (<a href="https://theconversation.com/ebola-in-the-drc-the-race-is-on-between-research-and-the-virus-112537">Ebola</a>) to global (<a href="https://theconversation.com/africa/covid-19">COVID-19</a>). The region has often carried a disproportionately high <a href="https://theconversation.com/african-health-research-needs-support-heres-one-programme-thats-working-144611">burden</a> of global infectious outbreaks. </p>
<p>How cities are planned is critical for managing infectious diseases. Historically, many urban planning innovations emerged in response to health crises. The global <a href="https://www.history.com/topics/inventions/history-of-cholera">cholera epidemic</a> in the 1800s led to improved urban sanitation systems. Respiratory infections in overcrowded slums in Europe <a href="https://thecityfix.com/blog/will-covid-19-affect-urban-planning-rogier-van-den-berg/">inspired</a> modern housing regulations during the industrial era. </p>
<p>Urban planning in Africa during colonisation followed a similar <a href="https://theconversation.com/how-the-legacy-of-apartheid-design-is-making-students-lives-unsafe-64770">pattern</a>. In Anglophone Africa, cholera and bubonic plague outbreaks in Nairobi (Kenya) and Lagos (Nigeria) led to new <a href="https://www.tandfonline.com/doi/abs/10.1080/02665430902933960">urban planning strategies</a>. These included slum clearance and urban infrastructure upgrades. Urban planning in <a href="https://www.tandfonline.com/doi/abs/10.1080/19376812.2016.1208770">French colonial Africa</a> similarly focused on health and hygiene issues, but also safety and security. </p>
<p>Unfortunately regional experiences with cholera, malaria and even Ebola in African cities provide little evidence that they have triggered a new urban planning ethic that prioritises infectious outbreaks. </p>
<p>References are often made to <a href="https://www.tandfonline.com/doi/abs/10.1080/19376812.2016.1208770">historical successes</a> of urban planning in Africa. But colonial use of planning for cultural and structural isolation, as well as for socio-economic and spatial segregation, limited its capacity to respond to health emergencies. With the widespread nature of COVID-19, is it reasonable to argue that it could possibly be the pandemic that inspires a new way of “doing” urban planning in Africa? </p>
<p>Our recent research <a href="https://www.tandfonline.com/doi/full/10.1080/23748834.2020.1812329">paper</a> discusses three areas that can transform urban planning in the continent to prepare for future infectious outbreaks, using lessons from COVID-19.</p>
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<a href="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An aerial view shows a mass of shacks on one side and a green, spread out suburb on the other, divided by a wall." src="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Spatial inequality in Johannesburg, South Africa.</span>
<span class="attribution"><span class="source">Per-Anders Pettersson/Getty Images</span></span>
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<h2>Integrating the informal</h2>
<p>The first relates to the integration of the city’s informal sector into the formal planning process. This is reflected in two ways. The first is the non-inclusion of informal settlements (mostly slums) in urban planning practice. The second is the lack of planning focus on the informal economy that results in <a href="https://theconversation.com/african-cities-must-address-social-and-economic-issues-when-upgrading-slums-97471">exclusion</a>. Yet this is a sector that constitutes more than 80% of Africa’s <a href="https://www.researchgate.net/publication/259331356_The_Informal_Economy_Worldwide_Trends_and_Characteristics">urban economy</a>. </p>
<p>In a time of COVID-19, <a href="https://theconversation.com/lagos-makes-it-hard-for-people-living-in-slums-to-cope-with-shocks-like-covid-19-138234">slums</a> and <a href="https://theconversation.com/covid-19-how-the-lockdown-has-affected-the-health-of-the-poor-in-south-africa-144374">informality</a> are critical due to the sector’s vulnerability to transmission. It is challenging to deploy testing and contact tracing , as well as adhering to social distancing rules. Many slum residents in African cities lack access to basic essential services such as water, sanitation, housing and healthcare. </p>
<p>And, given that the informal sector is characterised by unregulated <a href="https://theconversation.com/why-brutalising-food-vendors-hits-africas-growing-cities-where-it-hurts-76339">economic activities</a> including uncontrolled hawking and unplanned open markets, overcrowding is impeding social and physical distancing rules in African cities. </p>
<p>Change is needed. Perhaps COVID-19 will be the wake-up call to spur the consolidation of existing and formal structures to becoming more responsive to managing health crises in slums and the informal sector.</p>
<h2>Geographic and economic imbalances</h2>
<p>Second, there are geographical and economic imbalances in urban planning in Africa. <a href="https://theconversation.com/megaprojects-in-addis-ababa-raise-questions-about-spatial-justice-141067">Investment</a> patterns and development mostly focus on the major cities with limited focus on its adjoining districts and regions. Yet what happens in cities does not stay in cities. </p>
<p>Infectious diseases often have <a href="https://theconversation.com/why-its-hard-to-stop-ebola-spreading-between-people-and-across-borders-118851">cascading effects</a> on adjoining districts and regions with functional relationships to major cities. COVID-19 has affected both cities and their adjoining regions. However, adjoining districts continue to receive limited investment in critical infrastructures such as health, housing and other essential social services. </p>
<p>Given the disruptions to the supply chain between major cities and the adjoining districts due to the pandemic, it’s about time that planning practitioners and educators learn to prioritise urban planning to reflect these imbalances. A poorly managed relationship between cities and adjoining regions can create inequality that may lead to unhealthy city-regional inter-dependencies, environmental damage and unmanaged waves of health crises. These can have ripple effects across the urban-rural spectrum. </p>
<p>Planning in Africa should ensure city-regions are more resilient by addressing imbalances to produce a more integrated city-regional planning around health, economies, transport networks and food production.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A rusty signboard for Nairobi city in the foreground with a vast green park with trees behind it and the cityscape in the distance with high-rise buildings." src="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">View over the city park towards the Nairobi skyline in Kenya. Green spaces are crucial to healthier urban planning.</span>
<span class="attribution"><span class="source">Ian Forsyth/Getty Images</span></span>
</figcaption>
</figure>
<h2>Open spaces</h2>
<p>Third, public health matters should be considered in urban planning. Health outcomes traditionally do not drive urban planning practice in Africa. In our study, urban green spaces are used as an example because the COVID-19 pandemic has highlighted their importance in managing emergencies. Literature evidence <a href="https://www.tandfonline.com/doi/full/10.1080/23748834.2020.1812329?af=R">suggests</a> that African cities are rapidly losing their green spaces. This is due to, among other things, poor urban planning. </p>
<p>A new approach should bring open spaces into the heart of how African cities are planned, and management systems for local green space must improve. Integrating larger open spaces within the urban fabric allows cities to implement emergency services and evacuation protocols during health crises. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/urban-planning-needs-to-look-back-first-three-cities-in-ghana-show-why-144913">Urban planning needs to look back first: three cities in Ghana show why</a>
</strong>
</em>
</p>
<hr>
<p>What frequently seems to be effective in advancing responses to health crises is an urban planning approach that integrates a range of infrastructure. This includes grey (such as treatment facilities and sewers), green (trees, lawns and parks) and blue (wetlands, rivers and flood plains) systems.</p>
<p>Although COVID-19 has profoundly transformed urban life globally, this article provides cautious optimism of its potential in managing future health crises in Africa. Going forward, urban planning in Africa needs to reflect the aspirations of urban residents and address multiple spatial inequalities, including access to better spaces in times of a pandemic.</p><img src="https://counter.theconversation.com/content/145933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Brandful Cobbinah has previously received funding from the Lincoln Institute of Land Policy.</span></em></p><p class="fine-print"><em><span>Ellis Adjei Adams has previously received funding from the US National Science Foundation.</span></em></p><p class="fine-print"><em><span>Michael Odei Erdiaw-Kwasie works for Transparency International Australia. </span></em></p>If we learn from COVID-19, there are three key areas to tackle to make cities safer from outbreaks of future infectious diseases.Patrick Brandful Cobbinah, Lecturer, The University of MelbourneEllis Adjei Adams, Assistant professor, University of Notre DameMichael Odei Erdiaw-Kwasie, Research fellow, University of Southern QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111022019-02-21T14:17:27Z2019-02-21T14:17:27ZCancer drug pricing gets in the way of treatment in developing countries<figure><img src="https://images.theconversation.com/files/257024/original/file-20190204-193226-1kwfkjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to affordable medical treatment can save lives.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Most cancers can now be detected early. This hasn’t always been the case. The first big breakthrough came 80 years ago when the <a href="https://www.mayoclinic.org/tests-procedures/pap-smear/about/pac-20394841">pap smear</a> was introduced. Ten years later the <a href="https://www.pinkdrive.co.za/breast-health-info/mammograms/">mammogram</a> was created and then nearly half a century ago the <a href="https://www.mayoclinic.org/tests-procedures/fecal-occult-blood-test/about/pac-20394112">fecal occult blood test</a> was developed. </p>
<p>Advances in diagnosis have made a huge difference. When cancer is detected at an <a href="https://www.who.int/news-room/detail/03-02-2017-early-cancer-diagnosis-saves-lives-cuts-treatment-costs">early stage</a> – and when coupled with appropriate treatment – the chance of survival beyond five years is dramatically higher. Early diagnosis can also reduce the cost of treatment. </p>
<p>Despite this, millions of cancer cases are found late. This results in expensive and complex treatment options, diminished quality of life, and avoidable deaths. </p>
<p>The <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">global cancer burden</a> is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018 up from 12.7 million new cases and 7.6 million deaths in <a href="http://governance.iarc.fr/SC/SC50/Biennial%20Report%202012-2013.pdf">2008</a>. One in 5 men and one in 6 women <a href="https://www.uicc.org/new-global-cancer-data-globocan-2018">worldwide</a> develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease. </p>
<p>Unless greater effort is placed into altering the course of the disease, this number is expected to rise to close to 30 million <a href="https://gco.iarc.fr/tomorrow/home">new cases</a> by 2040. </p>
<p>More than <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">70%</a> of the world’s total new annual cases occur in Africa, Asia, and Central and South America. These regions account for more than 60% of the world’s cancer deaths. Yet treatment for cancer is not widely available in these regions. Health systems are often not equipped to deal with detection and treatment of cancers. Prevention and early detection programmes are often weak or non-existent. </p>
<p>This situation is exacerbated by the <a href="https://www.healthpolicy-watch.org/cancer-drugs-unaffordable-for-millions-treatment-costs-exceed-other-diseases-who-reports/">high cost</a> of treatment and, in particular, the high cost of newer cancer medication. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834140/pdf/mdx521.pdf">Cancer medication pricing</a> has increasingly become a global issue creating access challenges in low-and middle-income countries. Death rates from cancer in wealthy countries are <a href="http://cebp.aacrjournals.org/content/cebp/early/2015/12/10/1055-9965.EPI-15-0578.full.pdf">declining slightly</a> because of early diagnosis and the availability of treatment.</p>
<p>But this isn’t the case in low- and middle-income countries. For example, over 80% of children diagnosed with cancer in high-income countries will be <a href="https://www.who.int/news-room/fact-sheets/detail/cancer-in-children">cured</a>. In low and middle-income countries the rate is as low as 10%. </p>
<h2>Massive disparities</h2>
<p>Only <a href="https://academic.oup.com/annonc/article/21/4/680/156750">5%</a> of global resources for cancer are spent in the developing world. Yet these countries account for almost <a href="https://www.sciencedirect.com/science/article/pii/S014067361061152X?via%3Dihub">80%</a> of disability-adjusted years of life lost to cancer globally. And developing countries, governments and individuals struggle to pay for products that are priced at several times the level of their per capita GDP. Buyers are at the mercy of a single provider, often the patent holder of the product, particularly where the product has no competitors. </p>
<p>In 2018 the <a href="http://apps.who.int/medicinedocs/en/m/abstract/Js21758en/">World Health Organisation</a> found that pricing of cancer drugs was disproportionately higher than other types of pharmaceuticals and therapies.</p>
<p>Nor is it just a question of price. Efficacy comes into the picture too. In 2017, estimated global expenditure on medicines for cancer and related supportive care amounted to <a href="https://www.iqvia.com/institute/reports/global-oncology-trends-2018">US$ 133 billion</a>. Despite these huge costs, a systematic evaluation of 68 cancer medicines approved by the European Medicines Agency in 2009–2013 showed that only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627352/">35%</a> had established evidence of prolonged survival at the time of approval. Similarly, only 10% of the 68 medicines had evidence of improvement in the quality of life at the time of approval.</p>
<p>In addition, some medicines may present higher risk of toxicities to patients, with <a href="https://apps.who.int/iris/handle/10665/272962">evidence</a> of high rates of deaths related to treatment (toxic deaths) and high chances of patients discontinuing treatment due to intolerance. </p>
<h2>Some answers</h2>
<p>We often hear that efforts to expand cancer care aren’t affordable and will divert resources from higher priorities. A similar view was once held about HIV/AIDS. Yet we have seen remarkable success expanding access to services. Many lessons can be learnt from this experience. For example, generic drug competition in the HIV market has been essential in bringing the price of antiretroviral medicines down dramatically. </p>
<p>Developing countries should be encouraging the use of generic and biosimilar cancer medicines with a view to enhancing competition. This will certainly drive down cancer drug prices. <a href="http://ascopubs.org/doi/10.1200/JGO.2016.008607">For example</a>, in Norway, an infliximab biosimilar was discounted by nearly 70% and now represents more than 50% of drug sales. Similarly, in India and Peru, a rituximab biosimilar was introduced at a 50% lower price compared to the originator, illustrating the value they bring into oncology care.</p>
<p>In addition, governments must ensure that the application of patent law and rights for market exclusivity are not over compensating innovators and becoming barriers to access. Such activism has been found resonance in many countries as has been the case in <a href="https://www.fixthepatentlaws.org/wp-content/uploads/2016/09/MSF-FTPL-report-FINAL-VERSION.pdf">South Africa</a>.</p>
<p>These approaches are important to create platforms for engagement and the political momentum to strengthen health care for cancer patients at national level and take action globally to provide guidance for treatment and care, share knowledge about treatment cost and provide a legal framework to ensure treatment is available. </p>
<p>The cost of new drug development as an explanation for the high prices of new medicines is doubtful. Yet when it comes to health care and certainly in the case of potentially fatal diseases such as cancer, people are willing to bear a heavy burden even if the health benefits in reality turn out to be limited.</p>
<p>What’s important is that biomedical and technological advancements don’t introduce greater disparities and inequities when it comes to access to care and outcomes. The watch word must be affordability, not profitability.</p><img src="https://counter.theconversation.com/content/111102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vikash Sewram does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The global cancer burden especially in developing countries is exacerbated by the high cost of treatment.Vikash Sewram, Director of the African Cancer Institute, Faculty of Medicine and Health Sciences , Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921352018-02-28T13:47:50Z2018-02-28T13:47:50ZHealthy outrage: the story of a pioneer of community healthcare in South Africa<figure><img src="https://images.theconversation.com/files/207736/original/file-20180224-108125-15qi4hz.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A younger Dr Trudy Thomas engaging with a community in St Mathews en route to visit a clinic. </span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p><em>Healthy Outrage</em> is an apt title for a story that describes the journey Dr Trudy Thomas travelled during the various stages of her life. Thomas was the pioneer of community health programmes in South Africa. Her work spanned more than half a century, stretching through the dark years of apartheid and into the democratic era when she was asked to run the department of health in the Eastern Cape province after the 1994 elections.</p>
<p>Thomas entered the public health arena at a time when <a href="http://www.sajbl.org.za/index.php/sajbl/article/view/216/194">health services were heavily skewed</a> towards white people under the apartheid government. This meant that resources were disproportionately allocated by the state and the vast majority of black South Africans received poor quality and inferior services. </p>
<p>In 1994 the dawn of democracy brought the constitutional promise of healthcare for all. But the optimism of the time was soon to wear thin: for Thomas too. Even before the new government’s first term was up, she had begun to express her disdain at the deterioration of healthcare.</p>
<p>And two decades later the public health care system remains in shambles. In the Eastern Cape, the health care system has collapsed. A report <a href="https://www.timeslive.co.za/news/south-africa/2013-09-12-health-report-brings-tears-to-judges-eyes/">released by the human rights lobby group Section 27</a> revealed severe doctor shortages, a lack of ambulances and hospitals without water or essential equipment. Thomas contributed to the report when it was researched. </p>
<p>In <em>Healthy Outrage</em>, she describes how many of her experiences, particularly as a doctor dealing largely with children, provoked outrage. But her response was a “healthy” and constructive one. When faced with a problem she would sum up the key issues and then to go about addressing them, often with very limited resources. </p>
<p>The book is well written and is a fascinating read about one of the relatively unsung South African heroes of the past half-century. One of its main messages is how, with relatively few resources, a few people with integrity, commitment and hard work can achieve so much.</p>
<h2>Her story</h2>
<p>Thomas was born in 1936 and describes her early life of growing up in a working class family in Krugersdorp where her father was a miner on the gold mines. She excelled at school and went on to study medicine at the University of the Witwatersrand.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=882&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=882&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=882&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1108&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1108&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1108&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Receiving an honorary doctorate from Rhodes University.</span>
</figcaption>
</figure>
<p>She soon struck up a relationship with Ian Harris. After they’d completed their studies they got married and went on to do their internships at what is now Chris Hani Baragwanath Academic Hospital in Johannesburg. </p>
<p>This proved to be a valuable preparation for the next phase of their lives as they learned practical skills in most areas of medicine. Thomas was struck by the enormous burden of preventable diseases that she saw in children, both infectious and nutrition related. </p>
<p>During this time <a href="http://www.sahistory.org.za/topic/sharpeville-massacre-21-march-1960">the Sharpeville massacre</a> took place and many of the injured were brought to Baragwanath Hospital where she was part of the team treating them. This had an important influence on her political outlook.</p>
<p>She and her husband moved to a remote health facility called St Matthews Mission in the Eastern Cape where they took over as the medical team. Thomas concentrated on the children’s ward; her training at Baragwanath Hospital stood her in good stead.</p>
<h2>Serving the community</h2>
<p>Thomas put enormous energy into travelling throughout the community providing primary health care. </p>
<p>She had very limited resources but used them to maximum effect with the full buy-in of the community. As she states in her book, this was community outreach long before the term was coined. It was only in 1978 that an International Conference on Primary Health Care in the Soviet Union led to the well known <a href="http://www.who.int/social_determinants/tools/multimedia/alma_ata/en/">Declaration of Alma Ata</a> which emphasised that effective primary care is fundamental to the health and well-being of any community. Thomas was well ahead of her time.</p>
<p>In 1974, the family moved to East London and it was here that Thomas’s political profile developed further. She got involved with the human rights organisation, the <a href="https://www.blacksash.org.za/index.php/our-legacy/our-history">Black Sash</a>, and also struck up a solid relationship with the charismatic black consciousness leader <a href="http://www.sahistory.org.za/people/stephen-bantu-biko">Steve Biko</a> and his immediate family and associates. </p>
<p>I first met Thomas in 1976 while working at Cecilia Makiwane Hospital in what was then the Ciskei homeland. As a young doctor, I was enormously impressed with her clear views on how primary healthcare and community health complemented curative hospital care.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=823&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=823&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=823&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1035&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1035&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1035&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
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<p>Thomas was put in charge of community health at the hospital and its 14 clinics. Despite her political opposition to the homeland policy she typically decided to make the most of the situation. For example, she coordinated an immunisation campaign that virtually eliminated measles in the region in the early 1980s, something the country hasn’t managed to achieve 35 years later.</p>
<h2>At the helm</h2>
<p>Thomas was full of hope and optimism when the first democratically elected government took over in 1994 and, somewhat to her surprise, was appointed to run the provincial health department in the Eastern Cape.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=482&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=482&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=482&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eastern Cape Health MEC Dr Trudy Thomas with then president Nelson Mandela at the opening of the Umtata Academic Hospital.</span>
</figcaption>
</figure>
<p>As one of the poorest provinces in the country, the challenge of developing an integrated and effective health system was enormous. She travelled the length and breadth of the province and achieved a great deal. </p>
<p>But her honesty and inability to toe the party line eventually led her into political disfavour and she was not appointed to a second term in 1999.</p>
<p>This didn’t stop her. She took up the fight against HIV and AIDS. She resigned from the African National Congress because of the government’s <a href="https://www.timeslive.co.za/sunday-times/opinion-and-analysis/2016-05-08-dear-mbeki-now-is-the-time-to-apologise-for-aids-denialism/">attitude</a> to HIV and AIDS but continued to set up structures to assist and support AIDS orphans.</p><img src="https://counter.theconversation.com/content/92135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Cooper received funding in the past for contract research from companies for research on nutrition and antibiotics. He also received funding from the SA Medical Research Council. None are related to this review.</span></em></p>The tale of an unsung South African hero in the field of community health.Peter Cooper, Professor Emeritusin the Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/886822017-12-11T11:51:15Z2017-12-11T11:51:15ZThere’s more to evidence-based policies than data: why it matters for healthcare<figure><img src="https://images.theconversation.com/files/197968/original/file-20171206-926-sjv2uv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse weighs a baby at a clinic in Accra, Ghana. </span> <span class="attribution"><span class="source">Kate Holt/MCSP</span></span></figcaption></figure><p>A critical part of reaching the <a href="https://sustainabledevelopment.un.org/sdg3">United Nation’s Sustainable Development Goals</a> in 13 years’ time is to ensure that everyone can access equitable and affordable healthcare – more commonly known as universal health coverage.</p>
<p>The idea of “Health for All” was first put on the global agenda in 1978 at the <a href="http://www.who.int/publications/almaata_declaration_en.pdf">International Conference on Primary Health Care at Alma Ata</a>. It called for primary health care to be introduced as the first step to making sure that everyone has access to health care.</p>
<p>Since then, primary healthcare has been a feature of health systems across the world. But 40 years later, universal health coverage remains a challenge. About 400 million people <a href="http://www.who.int/mediacentre/factsheets/fs395/en/">do not have access to one or more essential health services</a>. This is because they are too far, too expensive, of low quality or non-responsive to patient needs. </p>
<p>The big question is: how can countries strengthen their health systems to deliver accessible, affordable and equitable care when they are often under-financed and governed in complex ways? </p>
<p>One answer lies in governments developing policies and programmes that are informed by evidence of what works or doesn’t. This should include what we would call “traditional data”, but should also include a broader definition of evidence. This would mean including, for example, information from citizens and stakeholders as well as programme evaluations. In this way, policies can be made more relevant for the people they affect. </p>
<p>Globally there is an increasing appreciation for this sort of policymaking that relies of a broader definition of evidence. Countries such as South Africa, Ghana and Thailand provide good examples.</p>
<h2>What is evidence?</h2>
<p>Using evidence to inform the development of health care has grown out of the use of science to choose the best decisions. It is based on data being collected in a methodical way. This approach is useful but it can’t always be neatly applied to policymaking. There are several reasons for this.</p>
<p>The first is that there are many different types of evidence. Evidence is more than data, even though the terms are often used to mean the same thing. For example, there is statistical and administrative data, research evidence, citizen and stakeholder information as well as programme evaluations. </p>
<p>The challenge is that some of these are valued more than others. More often than not, statistical data is more valued in policymaking. But both researchers and policymakers must acknowledge that for policies to be sound and comprehensive, different phases of policymaking process would require different types of evidence. </p>
<p>Secondly, data-as-evidence is only one input into policymaking. Policymakers face a long list of pressures they must respond to, including time, resources, political obligations and unplanned events.</p>
<p>Researchers may push technically excellent solutions designed in research environments. But policymakers may have other priorities in mind: are the solutions being put to them <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12475/pdf">practical and affordable?</a> Policymakers also face the limitations of having to balance various constituents while <a href="https://www.nature.com/articles/s41599-017-0046-8">straddling the constraints of the bureaucracies they work in</a>. </p>
<p>Researchers must recognise that policymakers themselves are a source of evidence of what works or doesn’t. They are able to draw on their own experiences, those of their constituents, history and their contextual knowledge of the terrain. </p>
<p>What this boils down to is that for policies that are based on evidence to be effective, fewer ‘push/pull’ models of evidence need to be used. Instead the models where evidence is jointly fashioned should be employed.</p>
<p>This means that policymakers, researchers and other key actors (like health managers or communities) must come together as soon as a problem is identified. They must first understand each other’s ideas of evidence and come to a joint conclusion of what evidence would be appropriate for the solution. </p>
<p>In South Africa, for example, <a href="https://www.odi.org/publications/10603-evidence-and-policy-south-africa-s-department-environmental-affairs">the Department of Environmental Affairs</a> has developed a four-phase process to policymaking. In the first phase, researchers and policymakers come together to set the agenda and agree on the needed solution. Their joint decision is then reviewed before research is undertaken and interpreted together. </p>
<h2>Joint efforts</h2>
<p>Integrating research into government policies and programmes can result in meaningful engagement between policymakers, researchers and other actors. </p>
<p>Increasingly, governments and researchers are partnering in various ways to ensure that research can feed into the policymaking process as results emerge. In this way, policymakers are part of the research design as well as the actual research and its interpretation, – known as embedded research. </p>
<p>Ghana’s <a href="http://www.ghanahealthservice.org/chps/category.php?chpscid=98">community-based Health Planning and Services</a> is a good example. By embedding the research in the Ghana Health Service, what started as a pilot in one part of Northern Ghana became national policy in 2005 to improve primary health care. </p>
<p>As part of scale-up efforts, policymakers, health managers and academic researchers worked hand-in-hand to design studies and analyse routine data to improve the programme. </p>
<p>Today the service is a key part of Ghana’s universal health coverage strategy. And importantly the primarily rural model is being adapted for urban areas. </p>
<h2>The journey to accessible health care</h2>
<p>As the Ghana example shows, when there is collaboration between governments and researchers, good results are achievable. This means focusing on long-term engagement and building a comprehensive view of evidence. </p>
<p>When evidence is better sourced and better understood, it can be deployed more effectively. This means that there should be investment in people who are at the front line of finding solutions and implementing change.</p>
<p>Policymakers, researchers, practitioners and communities need to come together to share their understanding of what evidence means, and how it can be used to strengthen health systems. This will help us chart a course to achieving universal health coverage.</p><img src="https://counter.theconversation.com/content/88682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aku Kwamie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For healthcare to be accessible, affordable and equal, policies and programmes that promote universal health coverage need to be based on evidence.Aku Kwamie, Health systems researcher, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/613422016-06-27T22:56:48Z2016-06-27T22:56:48ZUn-Trapped: Supreme Court strikes down Texas law limiting abortion<p>The U. S. Supreme Court on Monday invalidated two Texas provisions that <a href="http://www.nytimes.com/2015/08/20/upshot/how-texas-could-set-national-template-for-limiting-abortion-access.html?_r=0">would have closed at least seven of 17</a> abortion clinics in the state, saying that neither provision had a positive effect on women’s health, and that both existed primarily for the unconstitutional purpose of restricting access to abortion. <a href="http://www.cnn.com/2016/06/27/politics/supreme-court-abortion-texas/index.html">Some</a> are calling the 5-3 ruling one of the most important Supreme Court rulings on the right to abortion in almost 25 years. </p>
<p>Both provisions were part of a new body of legislation known generally as <a href="https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_TRAP.pdf">TRAP laws</a>: Targeted Regulation of Abortion Providers.</p>
<p>The ruling in Whole Woman’s Health v. Hellerstadt will affect states’ powers generally to limit women’s access to <a href="http://www.collinsdictionary.com/dictionary/english/previable">pre-viability abortion:</a> it <a href="http://www.nytimes.com/2016/06/28/us/supreme-court-texas-abortion.html">throws into question</a> the validity of laws in at least <a href="https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers">24 other states</a> with similar requirements. </p>
<h2>What the provisions mandated</h2>
<p>At issue in the case were two requirements in Texas Law HB 2. </p>
<p>First, the law required that doctors working at abortion clinics have admitting privileges (be considered on-staff with a right to admit a patient) at local hospitals. Second, the law required that buildings housing the clinics meet the standards of ambulatory, or outpatient, surgery centers in the state. These standards include a specified width of hallways, temperature controls, and staffing requirements. </p>
<p>Both provisions are difficult and expensive for clinics to meet and, advocates of abortion access successfully claimed, unnecessary for the health and welfare of women seeking care. </p>
<p>Whole Woman’s Health, a privately owned company that offers gynecologic health care to women in several states, provides abortions. According to its website, the <a href="http://wholewomanshealth.com/about-us.html">company</a> had to close two clinics in Texas – one in Austin, the second in Beaumont – as a result of HB2. </p>
<h2>An important win for those who support choice</h2>
<p>The decision to invalidate Texas law was not entirely unexpected. Justice Kennedy – <a href="http://www.vox.com/mischiefs-of-faction/2016/6/26/12031874/justice-kennedy-abortion-politics">thought to be the potential swing vote</a> – has frequently sided on behalf of abortion rights when examining state restrictions on pre-viability access, and asked questions at oral argument that indicated he was suspicious of Texas’ intent in passing HB2. </p>
<p>The decision is important. In fact, many are calling it <a href="http://www.pbs.org/independentlens/blog/whole-womans-health-vs-hellerstedt-what-the-supreme-court-is-deciding-in-most-important-abortion-ruling-in-decades/">the most significant case </a>on abortion access since 1992’s <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a> –- a ruling that is instrumental here. </p>
<p>Certainly, the Texas case has been in the spotlight ever since <a href="http://www.rollingstone.com/politics/news/abortion-rights-under-fire-why-wendy-davis-filibuster-matters-20130626">Wendy Davis’ failed filibuster</a> on the floor of the Texas House opposing HB2, the law overturned with today’s decision. </p>
<p>But even though those interested in abortion rights and abortion restrictions were holding their breath this morning, the decision is not much of a surprise. Although <a href="http://www.wsj.com/articles/supreme-court-voids-texas-abortion-regulations-1467036610?mod=e2tw">Justice Alito</a> argues otherwise in his spirited dissent, today’s decision is in keeping with a long line of Supreme Court decisions regarding access to reproductive health care and abortion.</p>
<h2>The historical record</h2>
<p>In its 1973 landmark decision, <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a>, the Court balanced the legitimate interests of the state in the health and welfare of its citizens against the legitimate interests of women and their physicians, in private decision-making regarding abortion.</p>
<p>Following on the heels of decisions that expanded women’s access to birth control (<a href="https://www.oyez.org/cases/1964/496">Griswold v. Connecticut</a> and <a href="https://www.oyez.org/cases/1971/70-17">Eisenstadt v. Baird</a>), the Court in Roe established a jurisprudence that gave women more rights to decision making regarding termination in the first trimester of pregnancy, and the state more power to regulate abortion in the final trimester – leaving the middle 12 weeks of pregnancy in a relative muddle, in terms of regulatory power.</p>
<p>Since then, anti-abortion activists have focused energy on enacting state level restrictions on abortion, while also using direct action to interrupt women’s access to clinics. As Joshua Wilson, assistant political science professor at the University of Denver, has <a href="http://www.sup.org/books/title/?id=22575">chronicled</a>, efforts to restrict front-of-clinic protests have been largely successful, as pro-choice advocates framed abortion access as part of a right to health care and argued successfully that clinic entrances cannot be blocked. </p>
<p>In the absence of powerful avenues for direct action protest, state legislatures have been aggressive in passing laws that limit women’s access. These laws have, since the 1980s, been frequently at issue before the Supreme Court. </p>
<p>Among the provisions upheld by the Court are extended waiting periods prior to termination and laws requiring that minors have either parental or judicial consent prior to abortion. The Court has also upheld laws restricting both state and federal funds for the procedure.</p>
<p>The Court has rejected, however, several other provisions limiting women’s access to abortion. In particular, the Court has held that spousal consent and notification requirements constitutes, in the words of Justice O’Connor in Planned Parenthood v. Casey, “an undue burden” on the right to abortion established by Roe.<br>
The question before the Court Monday was whether the Texas laws constituted an undue burden or legitimate state protections on women’s health. </p>
<h2>Court didn’t agree that law protected women’s health</h2>
<p>Justice Breyer’s opinion makes clear that the Court was not swayed by Texas’ argument that these laws were passed in order to protect women’s health.</p>
<p>TRAP laws, which were skewered by <a href="https://www.youtube.com/watch?v=DRauXXz6t0Y">John Oliver in an episode</a>, fared only a little better with the Court. TRAP laws, Breyer wrote, provide “few, if any, health benefits for women.” Breyer’s opinion notes that most pre-viability abortions are not surgical. Ginsburg’s concurrence further specifies that complications from non-surgical abortion are quite rare in comparison to complications from childbirth or from surgeries not related to reproductive capacity.</p>
<p>Abortion rights advocates have been concerned, and both global and historical experience bears them out, that when clinics close, women do not decide not to abort. Rather, they choose, by necessity, <a href="http://prospect.org/article/what-happens-when-abortion-outlawed">less safe options for abortion</a>. Ruth Bader Ginsburg’s <a href="http://blogs.wsj.com/law/2016/06/27/scotus-abortion-ruling-highlights-from-the-majority-and-dissenting-opinions/">concurring opinion</a> in Whole Woman’s Health makes it clear that she found this argument persuasive. </p>
<p>Ginsburg writes, </p>
<blockquote>
<p>When a State severely limits access to safe and legal procedures, women in desperate circumstances may resort to unlicensed rogue practitioners … at great risk to their health and safety. </p>
</blockquote>
<p>Ginsburg’s concurring opinion also makes clear the scope of today’s ruling. Had the conservative justices been in the majority, the TRAP laws in the Fifth Circuit would have withstood constitutional scrutiny. But a conservative majority would only have impacted Fifth Circuit jurisdictions. </p>
<p>Today’s holding on behalf of Whole Woman’s Health – striking down these Texas laws – has wider impact. It has the potential to touch all states with TRAP laws in place or pending. As Ginsburg makes clear, Roe lives another day – TRAP laws do not.</p><img src="https://counter.theconversation.com/content/61342/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Renee Cramer receives funding from the National Science Foundation for her work on the regulation of out-of-hospital birth in the United States.</span></em></p>TRAP laws – targeted regulation of abortion providers – have been a way for states to limit abortions. The Supreme Court Monday struck down a Texas TRAP law, saying it did not protect women.Renee Cramer, Professor of Law, Politics and Society, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.