Gender is an intersectional determinant of health that remains insufficiently integrated in programmes and policies. Sustained processes of dialogue and collaboration, including participatory approaches such as co-design, are needed to effect gender integration. However, the contexts and power dynamics through which co-design may support gender integration are not well understood. This qualitative case study examined a co-design partnership that undertook gender integration within an established adolescent sexual and reproductive health programme in South Africa from 2022-2025, drawing on (n = 37) project documents, (n = 36) post-meeting reflections, (n = 2) annual project group reflections, and (n = 12) key informant interviews. Analysis was deductive-inductive and informed by theories of context, organisational logics, gender, and power. Three interlinked contextual levels influenced the partnership. Macro-level funding arrangements and accountability structures created hierarchical pressures that constrained participatory and gender-responsive work. Meso-level organisational logics differed across partners, creating misalignment with the reflective co-design approach and between partner organisations. At the micro-level, boundary-spanning individuals enabled trust-building and adaptation. Interactions across levels revealed how institutionalised power shaped feasible forms of participation and gender integration. Co-design partnerships can strengthen gender integration in programmes but require macro-level enabling systems, institutional support, and navigation of meso-level organisational logics alongside sustained micro-level action.
Often recognised as a determinant of health and key to health communication, education is an underdeveloped concept in global health. This paper develops a conceptual understanding of how educational processes shape engagement with global health challenges, particularly their role in promoting health equity, capability and sustainability. Using antimicrobial resistance (AMR) as an illustrative case, the paper examines how education shapes understandings of health challenges, supports capability development and enables engagement with health governance. Methodologically, the paper adopts an interpretive conceptual synthesis, drawing on an author-led corpus of peer-reviewed papers on AMR education. Guided by frameworks on social determinants of health, health capability and ‘wicked’ problems, an iterative analysis identifies cross-paper patterns in how education mediates meaning-making, situated capability development and engagement with health governance. A conceptual framework is developed comprising three interrelated contributions: (1) education shapes how global health challenges are understood, valued and problematised, (2) education enables development of capability for situated health action and (3) education constitutes a site for engagement with global health governance. Expected outcomes encompass education as a mediating interface shaping how global health challenges are understood, critically evaluated and addressed, which can inform future research on ways to address global health challenges, including AMR.
Women asylum seekers and refugees face persistent barriers to maternity care (antenatal, intrapartum and postnatal care) across high-income countries, yet the upstream governance shaping access remains under-examined. Although legally distinct, both groups share protection-seeking experiences and are addressed jointly in governance documents. This study examined and synthesised how international (macro), European regional (meso), and United Kingdom (UK, micro) governance documents frame and operationalise maternity service access. Sixty-four documents were analysed using the READ framework. Inductive analysis of macro and meso documents identified six access dimensions: universal coverage; cultural and linguistic adaptation; rights-based approaches; multi-agency collaboration; data, monitoring and accountability; and quality of care. These dimensions structured assessment of UK governance, with jurisdictions rated strong, moderate or weak. Alignment was fragmented: Wales, Scotland and Northern Ireland exempted asylum seekers from charging, whereas England retained charging provisions. Multi-agency collaboration was consistently articulated, yet none of the 35 UK government documents focused on maternity access for this population, and none required outcome monitoring disaggregated by asylum or refugee status. UK governance appears coordinated in form but fragmented in substance. UK-wide minimum standards and routine recording of these data, with safeguards against immigration-related use, could strengthen coherence and accountability and improve visibility of inequities.
Health and politics are intertwined, yet few studies have examined the association between health and protest. This study examined whether population health burdens were associated with protest incidence and whether healthcare access modified these associations. Analysis was based on an unbalanced 2004-2023 country-year panel, combining protest counts from ACLED with rates for 22 GBD causes. Mixed-effects negative-binomial models estimated incidence-rate ratios (IRRs) with interactions for healthcare access (±1 SD). Two-way fixed-effects Poisson models were estimated as a benchmark to distinguish cross-national associations from within-country dynamics. Health burdens were systematically, but heterogeneously, associated with protest. Rates for several non-communicable burdens were associated with protest, notably musculoskeletal disorders (IRR 1.72, 95% CI 1.37-2.15), neoplasms (1.24, 1.06-1.44), substance-use disorders (1.32, 1.12-1.56) and HIV/AIDS and other STIs (1.24, 1.12-1.38). Higher healthcare access generally attenuated health-protest associations. Fixed-effects models confirmed several associations (e.g. HIV/AIDS, neoplasms) but revealed that others (e.g. maternal/neonatal disorders, enteric infections) were driven primarily by cross-national differences. Population health burdens were associated with cross-national variation in protest mobilisation. Chronic, non-communicable burdens were associated with heightened protest, whereas poverty-linked and early-life burdens were associated with lower mobilisation. Healthcare access was associated with attenuation of these relationships.
Migrants living in informal settlements face overlapping health and environmental vulnerabilities shaped by exclusion from formal housing and essential services. Un Nuevo Amanecer, an informal settlement located on a former landfill on the outskirts of Santiago, Chile, illustrates these dynamics. Rising housing costs and precarious labour conditions have pushed migrants to self-construct housing on land with limited state oversight. This qualitative study examines how residents experience and respond to health and infrastructure challenges through community-based strategies. Drawing on long-term, community-engaged research, data were collected through in-depth interviews and a focus group with a total of 19 participants recruited via snowball sampling. Interviews explored settlement trajectories, access to services, waste exposure, food insecurity and coping strategies. Findings reveal persistent challenges, including irregular water access, inadequate sanitation, waste accumulation and power outages, that compromise hygiene and food safety. Despite these constraints, residents developed grassroots responses, including informal water systems and collective waste management. The study highlights migrant communities as active agents whose practices should inform inclusive urban health policies.
For young people living with HIV (YPLHIV) navigating their status since birth, managing onward disclosure of a potentially stigmatising condition in relationships is challenging, and may or may not lead to social support, with implications for wellbeing. In a clinical trial setting in KwaZulu-Natal, South Africa, we investigate how young people living with vertically acquired HIV navigate onward disclosure. Data were from the qualitative component of the BREATHER Plus randomised controlled trial evaluating the efficacy, safety and acceptability of short-cycle dolutegravir/tenofovir-based triple antiretroviral therapy (ART) in young people aged 12-19 years. We analyse data on 35 participants receiving ART engaged in clinical trials at the research site: 29 in longitudinal in-depth interviews (IDIs) and 12 across three focus group discussions (FGDs), including 6 in IDIs and FGDs. The Disclosure Processes Model was applied in the thematic analysis. Pre-disclosure was characterised by social assessments of potential confidants. During disclosure, reciprocal vulnerability and partial information-sharing were employed. Post-disclosure processes entailed linear and non-linear feedback trajectories, impacting future disclosures. The findings show that the study cohort of young people receiving ART navigated many bidirectional disclosure pathways to maintain social connections in relationships, and counselling guidelines need to be responsive to this.
Tuberculosis (TB) is a leading cause of death globally, with most new TB cases notified in the Asia-Pacific region. We aimed to synthesize qualitative research of TB prevention strategies from the region, summarizing reported barriers to and facilitators of practices, and identifying important gaps and opportunities for future research. A scoping review was conducted using the Arksey and O’Malley framework and includes qualitative studies published in the Asia-Pacific region between 2015 and 2025. Six databases were searched to identify qualitative studies (or qualitative components of mixed-methods studies) that focused on TB prevention. Articles were assessed for inclusion by two authors who independently screened articles based on predetermined key words and criteria. Of 1745 articles identified, 40 were included in this review. Most qualitative research addressed secondary rather than primary prevention, such as treatment of TB infection and early detection and treatment of disease. Articles largely focused on healthcare workers, while vulnerable populations—such as pregnant women and people living with HIV—are underrepresented. Key barriers identified included health system weaknesses, TB-related stigma, and unclear infection control policies. Strengthening health systems, decentralizing TB services, and engaging communities were identified as crucial to ensuring accessible and sustainable TB prevention efforts.
Reproductive health monitoring systems typically measure progress through service-coverage indicators, such as contraceptive prevalence and institutional delivery rates. This article argues that treating high coverage as evidence of women's autonomous reproductive choice creates interpretive risks for rights-based accountability, a problem we term metric conflation. Using published tables from India's National Family Health Survey (NFHS-5, 2019-21), we show how national averages obscure structural inequalities across wealth groups. Despite high institutional delivery (90.4%) and modern contraceptive use (56.4%), unmet need remains 9.4% nationally, and 23.3% of women aged 20-24 were married before age 18. The poorest quintile faces higher unmet need (11.4% vs. 8.6%) and far lower secondary education attainment (37.9% vs. 88.7%) than the wealthiest quintile, structural differentials obscured by aggregate reporting. Female sterilisation accounts for 67.2% of modern method use, raising governance-relevant questions about choice that coverage metrics cannot detect. State-level contrasts (Kerala, Bihar and Uttar Pradesh, selected as high-performing, low-performing, and large-population benchmarks, respectively) further illustrate subnational heterogeneity. We propose a minimal reform package: strengthened use of existing wealth-quintile disaggregation, interpretive guidance for SDG dashboards, and piloting of autonomy-sensitive companion indicators to strengthen equity and accountability in reproductive health monitoring.
Global health is driven by concerns for indicators, metrics, and standards, with measures of program ‘success’ intricately linked to counting people reached and services delivered towards improving the health of populations. Within the context of crises, program monitoring takes on a new salience. Based on a collaborative study between the Ukrainian Institute for Social Research after O. Yaremenko and the University of Manitoba, we draw on data exploring monitoring and evaluation during the war in Ukraine from key informants working in organizations responding to HIV and sexually transmitted and blood borne infections. We conducted 26 in-depth interviews with individuals from 24 organizations across the country between May and June 2023. Our findings point towards a burdensome system of reporting documents that do not reflect current program realities and obscure additional ways that programs respond to client needs. Our study highlights the critical need to listen to the perspectives and needs of those on the ground doing the daily work of global health interventions to ensure that monitoring systems are flexible and responsive to their evolving contexts, and gather data that is useful for program improvement, rather than simply accountable to external donors.
Tooth extraction is among the most common dental interventions, particularly in underfunded health systems where preventive, restorative, and rehabilitative dental services remain scarce. Drawing on Jasbir Puar’s concept of ‘maiming’ tooth extraction is reframed from technical/economic inevitability to care that results in structural harm. Extraction-based oral healthcare reflects a transnational logic in which injury is normalised, repair withheld, and debility managed rather than resolved. The analysis shows how tooth extraction becomes an organised response to resource constraints; absence of restoration or rehabilitation produces lasting debility; and how omission of population-level preventive strategies maintains predictable cycles of disease and loss. Stigma and narratives of personal responsibility recast this structural injury as individual failure, extending maiming into psychological dimensions that constrain civic mobilisation. A typology of structural maiming in dental care makes these dynamics explicit. Recognising the global patterns through which oral harm is produced shifts the discourse from clinical shortcomings to systemic governance, aligning with Universal Health Coverage commitments and the right to health. Extraction-based care persists across countries despite vast differences in wealth and infrastructure, calling for renewed scrutiny of the global political, economic, and institutional conditions that continue to render avoidable harm a global routine in dental healthcare.
The COVID-19 pandemic intensified existing social and gender inequalities, disproportionately affecting Black women living in communities like Soweto, South Africa. This paper primarily draws on qualitative data from 25 in-depth interviews conducted in 2021, complemented by descriptive survey data from 204 women collected between 2020 and 2021. We employed inductive thematic analysis guided by the socio-ecological model to examine how intersecting individual, interpersonal, community and societal factors shaped women's experiences during the pandemic. Women played vital caregiving roles, supporting families and communities despite considerable personal stress linked to fears of infection, violence, isolation and economic hardship. On an interpersonal level, stigma related to COVID-19 severely disrupted social bonds, causing mistrust and exclusion within communities. At the societal level, pre-existing distrust in government institutions worsened, contributing to vaccine hesitancy. The widespread looting and unrest observed in Soweto during lockdowns are interpreted as collective resistance reflecting the community's perceived right to survival and fair treatment amid structural neglect. We argue that public health responses must adopt multi-level strategies that recognise women's crucial caregiving roles, address stigma through community engagement, rebuild institutional trust and promote economic justice.
AI is being rapidly integrated across nearly all sectors, including within healthcare and health systems. The prevailing dominant narrative frames AI's impact on health as overwhelmingly positive and destined to improve further. However, this benefit-focused discourse overlooks a growing set of serious risks to human health arising from AI systems already in use or clearly on a path to deployment—termed as near-term AI risks to health. The most prominent near-term AI risks to health are outlined, including algorithmic bias, erroneous clinical diagnoses and recommendations, AI-enabled health disinformation, harms to mental health, AI-driven mass unemployment, lethal autonomous weapons systems, AI-enabled chemical and biological weapons and AI as both a vulnerability and an enabler of cyberattacks on health systems. Each risk is already causing harm, or could plausibly do so soon, to the health of substantial proportions of populations, thereby collectively satisfying the criteria for a public health problem. Recognising near-term AI risks to health as a public health problem rebalances the benefit-centric narrative. The article addresses counterarguments and briefly outlines potential risk management responses: mandatory AI health impact assessments for high-risk systems, public health-oriented surveillance of AI-related harms and systematic embedding of public health expertise within AI governance structures.
The current humanitarian health model frequently, though not universally, establishes temporary parallel systems that undermine local public health infrastructure through brain drain, bypassing local supply chains, and creating data silos, ultimately leaving systems vulnerable post-aid withdrawal. This tendency is most pronounced in sudden-onset disasters and high-visibility emergencies, yet even in protracted crises where humanitarian actors work within existing Ministry of Health structures, poor coordination and absent integration accountability mechanisms perpetuate fragmentation. This viewpoint proposes a transformative approach to humanitarian interventions by mandating a Health System Integration Plan as a prerequisite for funding. This plan prioritizes integration with local staff, procurement, and data systems from the outset, ensuring flexibility to adapt to diverse crisis contexts, reinforcing existing structures in post-disaster settings and rebuilding through community-based strategies in fragile states. It balances immediate life-saving needs with long-term resilience across acute, stable, and recovery phases, embedding integration strategies from day one. Practical guidance for humanitarian actors includes co-designing plans with local stakeholders, transitioning to mentorship roles, and adopting integration-specific metrics for monitoring and evaluation. Aligned with the Humanitarian-Development-Peace (HDP) nexus, this framework leverages multi-sectoral partnerships and flexible funding to enhance feasibility, particularly in conflict-affected regions.
Infertility-related stigma remains a significant yet often overlooked issue in sexual and reproductive health programming, particularly in sub-Saharan Africa. Although awareness of infertility’s prevalence and social, psychological, and health impacts is growing, efforts to address the associated stigma remain insufficient. Drawing on a synthesis of existing evidence, this commentary examines the multi-level nature of infertility-related stigma, highlighting its roots in social norms and structures that undermine the ability of individuals and couples to exercise their sexual and reproductive rights. The commentary provides a framework for understanding and addressing this stigma, borrowing lessons learned from effective social and behavior change approaches to reshape social relationships, shift norms, and empower individuals and couples to make informed reproductive health decisions while advancing rights-based, equitable, sexual and reproductive health programming.
The United States' withdrawal from the World Health Organisation and the defunding of multilateral health programs represent more than a political disruption. Complexity science identifies them as a phase transition in a system that had been losing resilience for decades. This article applies complexity science to global health governance, arguing that the old equilibrium is gone and cannot be restored. Drawing on complexity science's concept of leverage points (places where targeted interventions have disproportionate systemic effects), it identifies four interventions that act on the structure of the system rather than its surface. These are building redundant regional hubs to replace a fragile center; embedding polycentricity so that failure of any single node does not cascade; redesigning the rules and incentives that currently reward dependency over capacity; and restoring civil society as the accountability mechanism that keeps distributed power from becoming unaccountable power. The analysis reframes the governance challenge from crisis management to navigating a phase transition, with implications for multilateral institutions, regional bodies, civil society organisations and donor governments.
The protracted conflict in Yemen has led to profound disruptions in the health system, fundamentally reshaping patterns of healthcare access and utilization. This commentary engages with a recent study that conceptualizes self-medication and informal antibiotic use as forms of coping and agency in constrained settings, and re-examines this interpretation within the context of systemic collapse. Drawing on a structural perspective, the analysis argues that self-directed care practices in Yemen are not temporary responses to episodic constraints but are embedded within enduring structural conditions shaped by infrastructure destruction, workforce depletion, and disruptions in medical supply chains. These conditions have produced overlapping physical, financial, and sociocultural barriers to healthcare access, contributing to the normalization of informal care practices, including self-prescription and reliance on community-based networks. The commentary also examines the role of psychological distress in shaping health-seeking behaviour, highlighting how the absence of accessible mental health services reinforces reliance on self-directed care. By reframing self-medication as an outcome of structural conditions rather than individual choice, this analysis contributes to debates on health system collapse in conflict settings and underscores the limitations of behaviour-focused interventions while emphasizing the need to address structural determinants of healthcare access.
Across low-and-middle income countries, adolescents navigate social environments where norms shape their opportunities and life trajectories. Faith actors are deeply embedded within these systems and often influence expectations related to communication, sexuality, reproductive health, and marriage. While faith engagement is widely recognized as important for sustainable change, empirical evidence on how faith actors contribute to social norm change remains limited. This paper presents findings from a 2024 scoping review of peer-reviewed and grey literature (2014-2024) examining how faith actors contribute to shifting norms and improving health and livelihood outcomes for adolescent girls and young women. Searches of seven bibliographic databases were supplemented by grey literature. Following deduplication, two reviewers independently screened records against predefined eligibility criteria. Seventeen interventions met inclusion criteria. Findings reveal substantial variation in faith actor engagement, alongside consistent gaps in reporting on intervention design, faith-related characteristics, and approaches to addressing resistance. Few studies explicitly measured social norms, limiting comparability. While the body of evidence remains under-reported, and mixed, there are several interventions which demonstrated shifts in attitudes, behaviors, and norms. The review highlights the need for stronger documentation, participatory design, and rigorous measurement to build evidence for ethical, scalable engagement of faith actors in gender-equitable programming.
Since its inclusion in the Sustainable Development Goals in 2015, the global health target of achieving Universal Health Coverage (UHC) has largely stalled. This article contends that one of the reasons for this lacking progress refers to the fact that the current definition of UHC does not sufficiently account for the transnational realities of global health. This article seeks to develop a more conceptually robust understanding of what UHC is, and what is normatively required to achieve it. In this context, the article proposes a novel definition of UHC that is adapted to the transnational realities of global health and advances an understanding of UHC as a global distributive justice norm. This normative theorising draws on literature in global distributive justice, which has largely been neglected in research and policy-led efforts to understand UHC. In this reconceptualisation, the article accentuates three required discursive shifts: from ‘good health’ to ‘fair health’; from ‘assistance’ to ‘duty’; and from ‘cost’ to ‘investment’. To illustrate the conceptual and empirical validity of this reconceptualisation of UHC, it is then empirically applied to the activities of the Drugs for Neglected Diseases initiative (DNDi) in its health system strengthening efforts on Chagas disease in Latin America.
The deterioration of family-based care and rising functional impairment among older adults have led to greater reliance on paid care, which remains sparse in low- and middle-income care economies. The present study aims to explore the demands and dilemmas in paid care as perceived by caregivers, receivers, and service providers. A qualitative exploratory design grounded in an interpretivist approach is used to explore demands and dilemmas in paid care. Twenty older adults (65+), seven caregivers, and eight service providers were selected through purposive sampling and interviewed until data saturation, followed by an inductive thematic analysis. The analysis illuminated the care demand‒choice‒dilemma‒decision framework, which depicts the realities of the care paradox and the pathways to care decisions in migrant households. However, suitability, reliability, risk of discontinuity, unaffordability, and limited person-centered care in paid care are reported as dilemmas in paid care, which is critical in deciding the places where people choose to age in their later years.
Over the last decade, there has been an increase in calls and efforts to change knowledge practices in global health, from within the field, in the fields that intersect with it, and from outside the field. While these calls and efforts are often aimed at rethinking or reimagining the field, they often fall short. Based on interviews with researchers who have participated in change efforts within and around global health, we developed criteria for distinguishing change efforts between first-order change, which seeks to adjust the current system for efficiency and effectiveness while keeping things the same; second-order change, which seeks to reform the current system to meet the needs of stakeholders; and third-order change, which seeks the total transformation of the system. In addition to the schema, our findings illustrate how the desired order of change is not simply a choice but rather dynamically determined in the interaction between change seekers and the institutions and systems they seek to change. This study offers a tool to clearly articulate the nature of a particular change effort, to distinguish and allow for comparison between change efforts, and to think through the kinds and extents of change required to achieve desired transformational change.
