There is growing concern that short-term experiences in global health experiences (STEGH), undertaken by healthcare providers, trainees, and volunteers from high income countries in lower and middle income countries, risk harming the community by creating a parallel system of care separate from established community development efforts. At the same time, the inclusion of non-traditional actors in health planning has been the basis of the development of many Healthy Community Partnerships (HCP) being rolled out in Canada and the United States. These partnerships aim to bring all stakeholders with a role to play in health to the table to align efforts, goals and programs towards broad community health goals.This methodology paper reports on the process used in La Romana, Dominican Republic, in applying a modified HCP framework. This project succeeded at bringing visiting STEGH organizations into a coalition with key community partners and supported attempts to embed the work of STEGH within longer-term, established development plans.In presenting the work and process and lessons learned, the hope is that other communities that encounter significant investment from STEGH groups, and will gain the same benefits that were seen in La Romana with regards to improved information exchange, increased cross-communication between silos, and the integration of STEGH into the work of community partners. Recent increases in short-term experiences in global health (STEGH) participation has occurred both within and outside of broader development efforts . The risAnother contemporary trend has been the establishment of Healthy Community Partnerships (HCPs) in many jurisdictions. These are community coalitions that connect traditional health and healthcare stakeholders with non-traditional partners that influence community health, such as government, private sector (e.g. chamber of commerce), and community services  . DevelopCoalicion de Salud Comunitaria or COSACO. The key modification to the COSACO HCP framework was the inclusion of visiting STEGH groups, to integrate STEGH into broader community planning with the hopes of minimizing potential harms STEGH might have on the community. The wider goal imagined STEGH groups operating not in isolation or in parallel, but rather, within the local health system together with guidance and direction from key local stakeholders, especially local government and health authorities.To address some of the controversy around STEGH, a novel process linking these two concepts was used to create a modified HCP framework in La Romana, Dominican Republic, entitled the This review describes the process around the development of COSACO from initial problem formulation and the formation of a steering committee, followed by identification and invitation of stakeholders, and the timeline of work leading up to an inaugural HCP meeting attended by key stakeholders. Lessons learned in this process will help other communities use HCPs to better incorporate STEGH teams into established community plans for health and development.First developed in Canada in the late 1980s and formalized at the international level by the World Health Organization’s “Healthy City” project in 1986, HCPs have broadly achieved results in various community settings. At the heart of this framework is a priority on capacity building and empowering individuals, organizations, and communities to contribute to community health . ReviewsOver the same time period, the growing popularity of STEGH, particularly among health care trainees and young providers, has raised questions around disparities in benefits and harms assumed by different stakeholders. Literature documents clear benefits for visiting participants and their sending institutions, but for host communities, STEGH benefits remain less clear. These communities also bear a notable risk of harm arising from poorly conducted STEGH. At best, visitors represent an opportunity cost that consumes scarce local resources in providing culturally incongruent programs, but at worst, they may create parallel systems operating independent of local context, needs, or programming, resulting in competition for scarce resources and giving rise to conflict, redundancy and unsustainability .Literature has increasingly attempted to describe factors that improve the conduct of STEGH to mitigate the potential risks on receiving communities. Principles include greater reciprocity, appropriate selection and preparation of volunteers, and a focus on visitor learning, humility and cultural sensitivity , 10. LitImproved partnership and collaboration thus represent a potential strategy to better integrate STEGH into the local developmental context, encouraging resource and data pooling among stakeholders, improved continuity, and joint project planning around locally described priorities , 12. As The applied HCP model aimed to minimize harms and optimize community outcomes related to STEGH in two ways: at minimum, an HCP could encourage communication between local stakeholders and STEGH groups, allowing them to operate with a basic understanding of local context and priorities. The broader hope, however, was that an HCP would align the activities of various STEGH with specific local efforts, breaking down silos between stakeholders towards incorporating STEGH into broader community health plans arising from the local community health ecosystem.bateyes, which are rural settlements traditionally inhabited by Haitian migrant workers employed by the sugarcane industry, though in recent times other marginalized groups call these settlements home.La Romana is the third-largest community in the Dominican Republic, with a population of 130,000 in a census conducted in 2010. With sugarcane as a significant economic driver, the city is home to numerous batey population, limiting the access of these residents to health and social services. Since the mid-1980s, a number of faith-based groups in the United States and Canada have been engaged with a local partner to provide various charity services in the community, notably around healthcare, construction, and education. The number of health-focused visiting groups has continued to grow in both number and diversity, and today, faith-based groups have been joined by groups from academic institutions, non-profit organizations, and community service organizations.Decades of systematic discrimination has led to the disenfranchisement of the The present context in La Romana involves a large mass of groups from abroad conducting health-related STEGH in the bateyes, usually operating with the assistance of a number of local partners. In discussions on the ground, described further in this paper, various groups identified concerns around redundancy and waste between STEGH, which in turn limited their overall impact on community health. Initial interest in collaboration arose from a small group of visiting organizations operating through a local mission hospital; discussions focused on the development of a partnership model to address identified issues.The development of COSACO was preceded by the development of a collaborative model between the local mission hospital and associated STEGH groups in 2008. Initial partners were a North American based non-profit organization, whose strategic goal at the time was to foster collaboration between groups, and a U.S.-based academic institution. An initial meeting arose from a request made to the local partner around contact information for other STEGH groups that volunteered in the community.Initial discussions focused on improving continuity of care between 10-day long mobile medical clinic experiences conducted by visiting STEGH groups in partnership with the mission hospital. Targeted for inclusion were dozens of visiting STEGH groups with different skillsets, values, and goals, with the common thread being their partnership with the mission hospital. Over the next 4 years, the initial members of this collaborative partnership launched two different web platforms to encourage information sharing, with varying degrees of success, and also hosted annual symposia which brought together representatives from the local hospital and any and all STEGH organizations that worked with this partner in La Romana, to foster greater information sharing.By 2012, this collaboration enabled participant groups to pool clinical encounter data from mobile medical clinics to inform a chart review of basic epidemiological trends observed in the work of STEGH medical clinics. The annual symposia grew to include presentations and discussions on standards, guidelines, and joint projects to be undertaken collectively. Growing interest in research and evaluation allowed many of these groups to jointly bring their results to major global health conferences, which in turn provided further opportunities to reach out to other potential collaborators working in La Romana.During the development of the initial collaboration, networking efforts quickly revealed that other local partners hosted STEGH groups in La Romana. Outreach at various global health conference identified a diversity of visiting STEGH groups that worked with different local partners in the La Romana area on various health-related topics ranging from direct service provision and health research to health policy and advocacy. A common thread was that many of these groups undertook their work independent of formal connections to local government or public health.With this growing awareness, members from the initial collaboration reached out to new contacts from conferences in mid-2014 and identified a shared desire for a central data repository to help address various issues with the impact of STEGH within the La Romana community. Specifically, groups expressed concerns around a lack of clarity as to how or even whether STEGH fit into local health and development plans. Similar to the impetus for the first collaboration around the mission hospital, concerns were also expressed around the actual community impacts of STEGH work, redundancy and duplication around research and programming.As a result of these discussions, summer 2014 saw the initial steps towards the development of COSACO which aimed to employ a HCP framework to better represent the view of local community leaders and stakeholders. A steering committee was formed, which consisted of 1–2 representatives from the leadership structures of six North American institutions and non-profits that worked in Romana and the three specific local non-profit partners and the local mission hospital they worked in partnership with. Selected by consensus, the chair of this process represented one of the U.S.-based non-profits, and representatives from two of the local non-profits agreed to provide on-the-ground logistic support. Initial discussions focused on the format of an HCP for La Romana and an assessment of the feasibility of implementation. This required identification of other stakeholders of interest that would be invited to join, discussions on potential manifestations for the HCP , and identifying potential funding sources to support the process.The steering committee agreed on launching the HCP at a major symposium held locally within the next year , which would involve key players described in Table Table In September, another visit by an academic partner on the steering committee obtained additional buy-in from community leaders. At this time, the decision was also made to proceed with a planned meeting, tentatively set for March 2015. In keeping with local community practices the steering committee agreed that the language employed in coalition meetings would be Spanish.Bilingual invitations to the pre-meeting were subsequently issued to partners in January 2015, and a final visit by one of the steering committee members allowed the provision of last minute invites in person, with many key face-to-face meetings  undertaken to emphasize their importance to the process.March 2015 saw a 2-day meeting in La Romana attended by representatives of the steering committee institutions and other invited participants from the local community .Initial discussions laid out the concept and form of an HCP in La Romana, with subsequent small group work focused on developing options for a name, vision, and goals, all of which were subsequently voted on by the wider group. The selected goals Table  reflecteSmall group work then aimed to develop rough work plans towards achieving these goals, which were then endorsed by the larger group. At the close of the meeting, partners agreed to formalize the steering committee, structured with one representative from each organization and a chair selected by consensus. The chair ultimately selected was the incumbent from the steering committee that planned the meeting, and the steering committee was tasked with overseeing the work of various working committees that would achieve the identified goals ahead of the next meeting. Two follow-up meetings were identified as milestones: a June meeting between the local partners alone, and another annual meeting of the wider group to be held in spring 2016. With that, a coalition for community health was officially forged.The application of a modified HCP framework in La Romana subjectively provided several benefits, some immediately realized, and others with future potential. Initial planning discussions between STEGH-conducting institutions quickly revealed a similarity of activities: shared in common were local partners, locales of work, and shared areas of interest applied to various research and projects.One immediate benefit was the establishment of a community of practice that otherwise did not exist, allowing stakeholders to understand that their work did not occur in a vacuum, fostering information exchange, and providing a forum for ideas, all while allowing constituent groups to explore potential new collaborative strategies to achieving community health goals.Value was also observed in the initial consultations with local partners; the repeated invitations and check-ins highlighted a desire on the part of visiting institutions to shift the paradigm of STEGH in the community towards privileging local input. Many community partners quickly understood the desire to focus on the root causes of ill-health instead of providing temporary assistance and appreciated the push for greater community leadership, guidance, and oversight of coordinated STEGH.bateyes. Interestingly, many of the local stakeholders that had been working long-term with STEGH groups discovered that a long-term external focus had often prevented them from investing into relationships with other community groups in the coalition that worked on similar issues. Many groups expressed initial concerns that a direct import and application of the HCP model would not be successful, notably concerning competition between local stakeholders for scarce resources and also the conflicting motives of stakeholders, particularly those that did not attend the initial meeting. However, these partners were more than happy to offer advice on how to better adapt the model to the local Dominican context.COSACO’s first meeting thus stood as a sentinel example of the power of communication arising from the formation of a partnership. Informal evaluation following the meeting suggested that simply bringing the charter stakeholders into discussions allowed sharing of information about each other’s activities, identification of jointly-held opportunities, and examination of more lasting solutions to existing health and health systems issues in the bateyes would be difficult. It was also noted that the existence of the HCP had the potential to provided scale to reduce barriers and create solutions, be it around a critical mass of partners for broader, more systems-level changes, or in adding voices together in advocating as a coalition.In addressing specific concerns around the conduct of STEGH, the discussion provided value in securing agreement among all concerned that the conduct of unsustainable, service-focused STEGH was not in the best interests of the community. Like other HCPs initiated elsewhere, stakeholders easily understood and agreed with the concept that “health is more than just health care”, though many acknowledged that addressing root causes of health problems in the A diverse, well-connected steering committee that employed its broad network to influence other stakeholders to participate, led by individuals with complementary skills .Repeated invitations and follow-up from the initial steering committee to a broad group of stakeholders with some coherence of values, vision, and programming for the community in question.Easy to understand issues  and engaged local community stakeholders to assist with framework adaptation.Willingness on the part of all stakeholders to collaborate and consider their work as part of a greater whole; important for broad discussions on a shared vision and purpose.In evaluating the process during the steering committee de-brief, four critical factors were identified as having contributed to the successful recruitment and involvement of stakeholder representatives in this initial HCP meeting in a STEGH setting:bateyes). This will help to broaden discussions by allowing these stakeholders to contribute to a shared vision for health in the batey community. Of note, the local governor had been invited by one of the visiting STEGH groups a month ahead of the meeting and had agreed to come, but was unable to attend in the end due to a conflict in his schedule.The next step will be for COSACO to build on the identified goals from the preliminary meeting and recruit other key local stakeholders, such as the local government, health authorities, and the private sector (specifically, the largest sugar cane company, which employs the workers in the Regardless of outcome, the very existence of COSACO has the potential to disrupt the current means by which STEGH occur in La Romana. COSACO now serves as a forum for visiting organizations on STEGH to obtain broad community guidance on a number of initiatives. Local organizations that previously targeted their community work to a select number of visiting STEGH teams can now work together towards a common goal. The potential is immense, and continued conversation will undoubtedly result in greater collaboration, opportunities for joint advocacy, and greater integration of the work of STEGH teams into established community health and development projects in La Romana.There is enormous potential for a properly applied modified Healthy Community Partnership framework to integrate visiting STEGH that would otherwise exist outside the formal health system of host communities. These partnerships have the potential to break down silos within both visiting and local stakeholder groups, enable information exchange, and provide locally relevant guidance and direction in integrating STEGH into broader community health plans.


Marine spatial planning (MSP) is often considered as a pragmatic approach to implement an ecosystem based management in order to manage marine space in a sustainable way. This requires the involvement of multiple actors and stakeholders at various governmental and societal levels. Several factors affect how well the integrated management of marine waters will be achieved, such as different governance settings , economic activities (and related priorities), external drivers, spatial scales, incentives and objectives, varying approaches to legislation and political will. We compared MSP in Belgium, Norway and the US to illustrate how the integration of stakeholders and governmental levels differs among these countries along the factors mentioned above. Horizontal integration (between sectors) is successful in all three countries, achieved through the use of neutral ‘round-table’ meeting places for all actors. Vertical integration between government levels varies, with Belgium and Norway having achieved full integration while the US lacks integration of the legislature due to sharp disagreements among stakeholders and unsuccessful partisan leadership. Success factors include political will and leadership, process transparency and stakeholder participation, and should be considered in all MSP development processes. The management of marine ecosystems and their human activities underwent dramatic changes since the 1992 Rio Declaration on Environment and Development. Today sustainable development is still a fundamental principle, but following the 2002 Johannesburg Declaration, sustainable management has been expanded to encompass not only single species or sectors, but the whole ecosystems through the “ecosystem approach to management” (EBM) Because ecosystems are spatially explicit, area-based management approaches offer a suitable and efficient way of implementing EBM into practice i.e. within specific sectors). Successful MSP means getting all these actors to communicate and work together in an integrated way. Therefore, integration means crossing boundaries at professional, physical, institutional or administrative level Because MSP by definition is multi-sectoral, a potentially large number of managers, stakeholders and policy-makers are involved, each accustomed to operate on his own . MSP in Belgium is the result of a long process, going back to initial attempts to implement the 1999 Marine Environmental Protection Act (MEPA), followed by the so-called “Masterplan for the BPNS” in 2003–2005. Since 2012 an explicit legal basis for MSP in Belgium is embedded in the MEPA, which clearly indicates the environmental roots of MSP. Therefore, governments and users of the sea in Belgium have to take into account several legal principles, namely the principle of prevention, the precautionary principle, the polluter pays principle and the restoration principle (art. 5 MEPA).In March 2014, Belgium approved a legally binding Marine Spatial Plan  for the Belgian part of the North Sea (BPNS), a small area of ca. 3500 kmBelgium functions as a multi-level government with authorities divided among local, regional, federal (and European) levels. The marine competences are divided between the federal state and the Flemish region, and within each level, competences are fragmented over several departments It took until 2003, with the appointment of a federal Minister for the North Sea, to set a major step forward in the Belgian MSP process. This Minister was mandated to spatially co-ordinate all activities and competences at sea, except for fisheries which is a regional (Flemish) competence. He initiated a more strategic approach to the  conflicting claims between users of the BPNS which emerged between 1999 and 2003. He developed the BPNS Masterplan, which actually combined several political decisions concerning marine matters that were taken by the federal Council of Ministers and implemented by a number of Royal decrees. The plan was further adopted in two phases: in 2003 with an agreement on the delimitation of several zones for two economic activities- aggregate extraction and offshore renewable energy - and later in 2005 with the delimitation of nature conservation areas for birds and habitat protection. However, it remained essentially a zoning plan, without a legal basis for a planning process or an integrated policy approach, nor a clear and transparent process for stakeholder involvement and public participation In Belgium, there is strong vertical integration between the highest levels (Ministers) and their public administrations. Moreover, each governmental level has its own advisory bodies , represead hoc’ basis, taking into account the individual and selective demands of sectoral organizations and individual stakeholders. As a consequence, consultation with other sea users than the ones in the focus of the Masterplan was not deemed necessary. After 2006, the Masterplan has been adjusted a few times, in particular to take into account shipping interests and to designate a new marine protected area (2008–2010). However, these developments were once again dealt with at sectoral level.Stakeholders have been involved in the MSP process since the Masterplan was presented in 2003, but this happened only on a sectoral basis and mostly through bilateral consultations behind closed doors In 2012, the newly elected federal government re-appointed the same Minister for the North Sea, and a second phase of MSP started. The new marine spatial plan departed from the BPNS Masterplan, but with a clear aim to establish a ‘legally binding’ marine spatial plan and process. The draft spatial plan, which was again based on informal and formal consultations with stakeholders, was subjected to a series of administrative consultations and advice from a new Advisory Commission on MSP. The latter was formally established by a Royal Decree in November 2012 and involves all federal authorities with competences at sea, next to ‘invited’ Flemish authorities. As such, an integration between all federal governmental departments concerning MSP became formally embedded in the new MSP legislation.Next to the MSP Advisory Commission, experts were consulted, stakeholder participation was organized and a strategic environmental assessment (SEA) of the spatial plan was conducted. In July 2013, an updated plan was approved by the Council of Ministers, followed by consultation with the public and neighboring countries and advice from advisory bodies and regional authorities. The Ministry of Environment took into account 140 remarks and finally the Council of Ministers approved the MSP by Royal Decree on 20 March 2014.The new Belgian marine spatial plan comprises the coordinates of all delimitated zones for the activities that are allowed and limited or prohibited in the BPNS, including some new zones for future activities . The Royal Decree also contains several annexes outlining the spatial context and explaining the policy choices that have been made. The long term vision to implement MSP in Belgium foresees concrete objectives for the period 2014–2020 and a revision of the spatial plan every six years, although in between adaptation of the plan is not excluded.A major shortcoming of the Belgian MSP might be that fisheries is only partly included in the MSP, as this is a not a competence of the federal government (Flemish competence). Nevertheless, consultations took place at the highest political  level, and certain limitations for fisheries are included in the new MSP, such as the prohibition of fisheries in the offshore renewable energy concession zones, and a limitation for certain fishing techniques (mainly classic bottom disturbing trawling techniques) in specific parts of the Natura 2000 area ‘Vlaamse Banken’ in order to achieve a good environmental status for the BPNS.As a response to the international to allow for sustainable use while ensuring continued ecosystem health” An inter-ministerial steering group led by the Ministry of Environment was set up to coordinate the development and implementation of these IMPs. The steering group had members from all relevant sector-ministries . This strong political (top-down) steering group tasked the different institutions and directorates under each ministry to contribute to the development and implementation of the plan. Each plan was customized for the particular ecosystem, but with a similar overarching strategic objective: “Integration of different interests and concerns is central to the Norwegian MSP process, and already commenced at the start of the planning process in 2002. The various sectors and levels (of government) have been integrated by jointly developing the knowledge base and management measures across sectors and between levels of government . Joint gThe Norwegian planning process is centralized, where decisions are made by the government and subjected to parliamentary approval. As such, all IMPs have been passed with broad political approval in the Parliament. Involvement of local government levels (e.g. counties) has been poor, mainly because ocean management is a national issue in Norway, with only limited local control over marine resources or management of marine space.The overarching conflict of industrial use versus nature protection has been a central issue for debate at all levels, in particular in the management and risk forums . In thesImposing consensus between the sectoral government institutions was instrumental to develop and implement the Lofoten-Barents Sea plan in a 4-year time frame. This first IMP spearheaded the development of the other plans and created much of the structure and methods to allow the two later plans to be created in 3-year processes. However, seeking consensus could also lead to suppression of substantial and value-based differences. It can be questioned whether the decision-makers would be better served if the differing views and options in the central conflict  would have been clearly presented as different choices rather than hidden in a compromise. A consensus approach limits the options for the decision-makers, who normally prefer a range of options which allows them more room to govern.The existing sectoral legislation and management structures have been the main barrier for integration. Using soft-law in processes like the development of IMP’s, is a tradition in Norway, and is fast, pragmatic and efficient. Also, by implementing through existing legislation and institutional structures, the policy is rapidly and effectively translated into practice without spending much time on developing new legislation or governance structures. However, this approach does little to integrate concerns across the existing sectoral legislation. Nevertheless, many new sectoral laws passed since 2002, took the integrated management approach into consideration and specifically required integration between sectors.Influenced by international MSP developments and strongly promoted by major environmental organizations, the US started a process towards developing an Ocean Policy http://oceanpolicy.com) advocated against MSP. Therefore, MSP implementation has ended up in the middle of the partisan battlefield, even though the first steps were taken by the Bush Administration with bipartisan support. As a result, the federal support for the Ocean Policy has decreased compared to what was anticipated in 2010. Currently, the Ocean Policy implementation is totally dependent on support from the State and regional levels, who are leading the way while the federal level lags behind. Substantial financial support has however been provided by private donors to MSP efforts in the Northeast and Mid-Atlantic regions. It is critically important that top-down and bottom-up processes are linked in the implementation of the US Ocean Policy The Ocean Policy can be seen as a MSP process, although the term ‘marine spatial planning’ is not used in the most recent documents as it has become politicized to the point that the US Congress in 2012 and 2013 refused to fund any MSP related activities. The majority in the House of Representatives see MSP as an unnecessary layer of government, hampering the development of business activities at sea. Also industrial  lobby groups  had a state plan under development when the Ocean Policy was being put forward. The greatest challenge in the Pacific region is distance, as it includes Hawaii and all US Pacific Islands, spanning seven time-zones and the international date-line. Finding time, place and funding to bring regional representatives together, is logistically very demanding. The Pacific RPB may ultimately adopt a more archipelagic approach as has been done for fisheries management in casu ecosystems, based on the regional administrative capacity. However, it is recognized that the desire for standard approaches across the nation may not be accommodated at the regional level. Therefore, a flexible structure of Federal agency engagement with States and local governments is required. All current RPBs have wide participation of federal, state and tribal governmental institutions that have formal mandates for ocean management  and directives . Belgium has a strong formal division of power between the federal and regional levels, although integration between both governmental levels is assured through formal agreements and informal consultations. This is also reflected in the protracted Belgian MSP process: after more than 10 years, the MSP plan and process are firmly embedded in environmentally driven legislation.Norway is not a member of the EU and has an ethnically homogenous population. The government is well integrated across sectors both at central and regional levels. The Norwegian Integrated Management Plans (IMPs) were passed through the Parliament, but are not embedded in Norwegian legislation. They are rather government reports with MSP objectives and a vision on how they will achieve these objectives through a range of management options, including spatial zoning.In the US the independency of the states led to a geographic division in marine management at the border between federal and state waters, mostly three nautical miles offshore. The US Ocean Policy process, based on a Presidential Executive Order, does not have backing in the Congress, which led to funding restrictions to develop or continue the MSP process. The US Ocean Policy became heavily politicized in 2010 and has since been drawn into a struggle among stakeholders largely along commercial users of ocean space and biodiversity conservation, spilling over into the partisan debates in Congress. Even though embedding MSP in legislation creates a more stable solution in heterogeneous societies like Belgium and the US, achieving overall trust and buy-in is instrumental for a successful implementation (and funding) of the MSP process and plan.In contrast to Norway and Belgium, broad political support for implementation of MSP has not been reached in the US, due to the lack of strong stakeholder support for MSP by commercial and non-commercial users. Strong political leadership was instrumental to achieve that bipartisan support for MSP in both Belgium and Norway. In Belgium the personal charisma, tenacity and clout of the Minister of the North Sea was pivotal to lead the planning process and persuade the different parties of the necessity of MSP. In Norway it was the tenacity and clout of the Ministry of Environment, strongly supported by the Ministries of Fisheries and Foreign Affairs that pushed the MSP process. Moreover, achieving broad political buy-in was relatively easy in Norway, as the MSP process was partly driven by Norway’s foreign policy. Foreign priorities are very stable in Norway and do not change with changing governments. In the US leadership has certainly been shown at the Executive level but it is not sufficient to carry through to the legislative leadership.Leaving aside political and ethnic differences between the countries, socio-economics, i.e. the importance of certain marine industries in the national economy of each country, help to explain some of the differences in their governance approach to MSP. In Belgium, maritime infrastructure (shipping and ports) is very important, next to aggregate extraction and to a lesser extent fisheries. Since 2003 offshore renewable energy (wind-farms) developments have been the main driver for MSP in Belgium. However, adherence to EU environmental directives  has created a second driver in MSP in order to identify areas of high biological value (Natura2000 sites) and to achieve a “good environmental status” of the ecosystem. In Norway, the marine natural resources (oil and fish) form the basis for the country’s welfare, and sea-based industries  are of fundamental socio-economic importance. It is a high priority for all governmental levels to create (sustainable) marine value in Norway. The health of the marine ecosystem is understood as an important prerequisite for sustainable value creation, but this is not seen as an absolute hindrance to human uses. Therefore, protecting areas by excluding economic activities is not common in Norway.In the US, sea-based industries, shipping and fishing are of great socio-economic importance, but the country is not as dependent on the exploitation of marine resources (oil/gas and fish) as Norway. The importance and political power of the different sectors vary regionally, e.g., in the Gulf of Mexico the petroleum industry is given priority, while in the Northeast region offshore renewable wind energy has been a driver for MSP. The US has a strong terrestrial tradition of using protection  as a management measure. This has been transferred to the marine environment with the establishment of several MPAs with a high protection level like the Papahānaumokuākea Marine National Monument (MNM) in the north-western Hawaiian islands, the Marianas Trench MNM and the Pacific Remote Islands MNM.The economic incentives have led to different objectives in the respective MSP processes. Although all three countries try to combine ecosystem health with economic use, they differ in their approach. While Norway has a clearly stated dual goal of sustainable use while ensuring a healthy ecosystem, Belgium is focusing on protection of valuable habitats and ecosystem components while finding room for new uses and minimizing conflicts. The US objectives are complex and not prioritized in terms of trade-offs between economic use and nature conservation.Integrating stakeholders in the planning process has been important, but done in different ways in the three countries. In Norway and Belgium, stakeholders were brought early on board, which led to acceptance of the MSP process, although with much debate about specific details of the plan. In the US, stakeholders were invited to comment during the 18 month process leading up to the federal Ocean Policy Executive Order. This process built on many years of responding to the US Commission on Ocean Policy and the non-governmental Pew Oceans Commission processes. However, there was considerable surprise that MSP was the most tangible action required by the Executive Order. This shift in approach resulted in several industrial stakeholder groups forming lobby-groups against MSP implementation, which blocked necessary incremental funding of the MSP process. The resultant stakeholder skepticism conveniently fed into the partisan political battle in Washington D.C. In the meantime, stakeholder involvement and transparency is much more effective at the state and regional level in the US. Threats and opportunities are tackled depending on one’s perspective from existing spatial conflicts, and through new drivers primarily associated with both non-renewable (import/export) and renewable (offshore) energy. A credible threat to established interest adds to the acceptance and continuation of the MSP process in most US regions. Full transparency, open meetings, public documents and active solicitation of stakeholder opinions, make the US stand out compared to Belgium and Norway, where transparency was more limited and controlled.Ecosystem-based management in general and MSP in particular is a multifaceted management approach that combines the management of multiple sectors and goals under one roof through integration. Integration can be measured both in relation to geographic scale and governance scope Horizontally, all three processes are similarly well-integrated, but it has been achieved through different governance approaches. In Belgium a “Minister for the North Sea” was appointed to lead the process, Norway set one ministry (Environment) in charge to lead a multi-ministerial steering group in which the existing ministries were tasked to cooperate, while the US set down an Executive (Ocean Policy) Task Force, directly reporting to the Council on Environmental Quality in the White House and operating through government agencies on a (eco)regional basis. Both the Belgian and Norwegian processes are integrated on a national level, while the US proposed to integrate on a regional level (which is sensible as US regions are much larger than most European states). Horizontal integration across sectors relies strongly on each sector perceiving it to be treated in a fair and equitable manner. Therefore, meeting places and forums should be neutral – amalgamating the Arthurian ‘round table’ of Camelot that created peace among the noble but imperious knights closest to the king (in our examples the relevant ministers or president).Vertically, Belgium and Norway are well-integrated from parliament (through the executive government levels) to stakeholders, while the US is well integrated from the Executive level downwards, but lacks integration (acceptance) from the law-makers (Congress).Next to informal consultations with sectoral stakeholder groups, stakeholders also have a formalized role in some planning forums in Belgium. In Norway and the US, stakeholder participation remains informal and voluntary or self-selected (through consultations), although in the US stakeholder involvement is more comprehensive, reflected in the strong lobbying work of stakeholder groups to the government and the ability to file lawsuits based on administrative procedures and environmental compliance. Planning meetings are open to the public in the US, in contrast to Norway where meetings in governmental steering groups are held behind closed doors. The latter was also true for Belgium in the first MSP (2003–2005), but changed with the adoption process of the second MSP (2013–2014) when stakeholder participation and public consultation were included in the process. Although the current political situations may be regarded as challenging, the three cases illustrate the benefit of having a wide political backing to efficiently implement broad management processes like MSP. Where the MSP process tends to be top-down, formally defined processes and leadership are deemed necessary, while also bottom-up processes are highly valuable when it comes to integrating across vertical and horizontal scales.In Belgium and Norway the process has led to effective and practical implementation of MSP, while in the US implementation is still pending. Our analysis shows that all three planning efforts can be regarded as well-integrated in intent, and that integration is important for a successful MSP. In addition to seeking and supporting political leadership, planners should keep in mind that processes and structures that facilitate effective integration are needed. Transparency and openness of access to stakeholders to make their perspectives be heard and analysed in the total process is a large part of what is required to ensure fair and equitable treatment, in relation to both horizontal and vertical integration.


Large carnivores are decreasing in number due to growing pressure from an expanding human population. It is increasingly recognised that state-protected conservation areas are unlikely to be sufficient to protect viable populations of large carnivores, and that private land will be central to conservation efforts. In 2000, a fast-track land reform programme (FTLRP) was initiated in Zimbabwe, ostensibly to redress the racial imbalance in land ownership, but which also had the potential to break up large areas of carnivore habitat on private land. To date, research has focused on the impact of the FTLRP process on the different human communities, while impacts on wildlife have been overlooked. Here we provide the first systematic assessment of the impact of the FTLRP on the status of large carnivores. Spoor counts were conducted across private, resettled and communal land use types in order to estimate the abundance of large carnivores, and to determine how this had been affected by land reform. The density of carnivore spoor differed significantly between land use types, and was lower on resettlement land than on private land, suggesting that the resettlement process has resulted in a substantial decline in carnivore abundance. Habitat loss and high levels of poaching in and around resettlement areas are the most likely causes. The FTLRP resulted in the large-scale conversion of land that was used sustainably and productively for wildlife into unsustainable, unproductive agricultural land uses. We recommended that models of land reform should consider the type of land available, that existing expertise in land management should be retained where possible, and that resettlement programmes should be carefully planned in order to minimise the impacts on wildlife and on people. Large-bodied mammals of the order Carnivora (hereafter referred to as large carnivores) are culturally important to humans; their body parts are used in ceremonies and traditional medicine and they feature in storytelling, mythology and witchcraft . Large cDespite their value, large carnivores across the world are in decline  in Zimbabwe (Lycaon pictus) and brown hyaena (Parahyaena brunnea), which, like cheetahs, are outcompeted by larger carnivores in national parks , lion (Panthera leo), wild dog, brown hyaena, and spotted hyaena (Crocuta crocuta). The impact that land reform had on the status of large carnivores in SVC between 2000 and 2008 is then evaluated through an assessment of the population sizes of large carnivores in private, fast-track resettlement (hereafter referred to as resettlement) and communal land use types (LUTs).This study uses the partial resettlement of Savé Valley Conservancy SVC;  in south2 (Diceros bicornis) as part of the government’s conservation strategy, the difficulties of farming livestock in such a drought-prone area and the greater profitability of wildlife in relation to cattle in semi-arid environments : private, resettlement and communal. The private LUT study area was the Savé Valley Conservancy (SVC), a private game reserve that originally covered approximately 3,490 km2 , constit2 , a proceronments . Trophy ronments , as prevronments .2 was resettled as part of the FTLRP, reducing the area of SVC to 2,530 km2. The criteria for selection of the properties for resettlement were not transparent  and sampling effort (the number of spoor recorded) was investigated through bootstrap analyses on inter-spoor intervals . This was conducted by calculating 95% confidence intervals from two randomly sampled inter-spoor intervals with replacement, then progressively increasing the sample size and calculating fresh confidence intervals with each sample after  using R Carnivore spoor density is correlated with population density . Spoor dThe raw data analysed in this study is available in 2)) for most LUTs was close to the value of 7 recommended for these techniques  to survey area (kmchniques  Table 22) for mochniques . These sχ2 = 14.087, df = 2, P = 0.01), and were greater in the private LUT than the resettlement and communal LUTs (Spoor from all large carnivore species were recorded in the private LUT, while only spoor from spotted hyaenas were detected in the resettlement LUT, and no large carnivore spoor were recorded in the communal LUT . Spoor dnal LUTs . The prinal LUTs . In contnal LUTs .In 2000 and 2001, approximately 40% of SVC was resettled as part of the FTLRP. In 2008, large carnivore densities in the remaining private LUT were comparable to those found in protected areas elsewhere . In contAlthough there are no comparable density estimates from before resettlement, it seems unlikely that the patterns we report were due to low population densities in the resettlement areas prior to resettlement. Sighting frequencies of cheetah on Senuko ranch declined markedly following the onset of the FTLRP and resettlement on other properties in SVC , and carThe absence or low densities of large carnivores in the resettlement and communal LUTs can be explained by high human densities, which led to pressure for land to grow crops and graze livestock, resulting in a loss of habitat and prey base. In the private LUT human population density was low, habitat was still comparatively intact and prey was relatively abundant. Even so, carnivore population sizes appear to have been below carrying capacity estimates based on prey availability and rainfall , althougThe low carnivore densities in the resettlement LUT are most likely the result of a population decline in response to the resettlement process, rather than migration of animals out of resettlement areas. If this were the case, we would expect to find greater densities of wildlife on private land near to resettlement areas, but the opposite trend was observed . No evidThe extremely high levels of poaching in SVC were the result of a large human population being settled on private land with large wildlife populations, and were exacerbated by Zimbabwe’s economic crisis and food shortages arising from the FTLRP , limitinWithin SVC land resettlement has thus had a large impact on large carnivore populations. Land resettlement was widespread in Zimbabwe, however, and most of the other large-scale conservancies including Gwayi, Bubiana and Chiredzi River have also been severely affected by the FTLRP , with veA key factor that enabled the wildlife industry to become so important and the wildlife populations to become so abundant on private land in Zimbabwe and other countries in southern Africa, was the introduction of legislation devolving rights to utilise wildlife on private land to the landowners . This alThe negative impacts of land reform on the status of large carnivores documented here could be reduced by modifying the way in which land reform programmes are implemented. Firstly, the model of land reform that was applied under Zimbabwe’s FTLRP considered agricultural models at the expense of a wildlife-based model. The agricultural land reform models applied were poorly suited to the arid and semi-arid areas in which many private wildlife and livestock ranches were located , and whePlanning is critical to minimising the impact of land reform on wildlife and human-wildlife conflict. Many problems could be avoided by considering wildlife when planning land reform, such as by maintaining connectivity between wildlife populations  and reduAllowing local communities to benefit economically from the wildlife in SVC, for example through schemes like CAMPFIRE , would c2 of cattle grazing land was set aside and became part of the conservancy (Other innovative mechanisms for involving communities in conservation on private land have been explored in South Africa. For example, game reserves such as Phinda and Mala Mala were claimed by communities, who then leased the land back to the reserve mangement, maintaining wildlife as the land use and retaining the expertise and capital of the former owners, but bringing revenue to the community . Similarservancy . Partnerservancy , which cservancy .We suggest that further research is conducted to determine that the trends observed at the study site are representative at national and international levels, and whether carnivore populations in Zimbabwe are continuing to decrease further. Land reform initiatives are also underway in other countries that had extensive areas of private land such as South Africa and Namibia. Before land reform programmes were initiated , privateLand reform appears to have significantly reduced the population size of large carnivores in SVC. Very high levels of poaching and a decline in prey base associated with land reform are thought to be responsible for these declines. This case study could be indicative of broader trends across Zimbabwe. We recommended that care is taken to carefully plan land reform programmes in other countries in order to minimise the negative effects on wildlife populations and maintain linkages where possible. Retaining wildlife as a land use, while employing innovative models that retaining existing expertise and capital, would go a long way towards allowing both wildlife and people to benefit from land reform.10.7717/peerj.1537/supp-1Supplemental Information 1Click here for additional data file.


Schizophrenia is a serious mental illness that levies a heavy medical toll and cost burden throughout the world. Scientific collaborations are necessary for progress in psychiatric research. However, there have been few publications on scientific collaborations in schizophrenia. The aim of this study was to investigate the extent of author collaborations in schizophrenia research.This study used 58,107 records on schizophrenia from 2003 to 2012 which were downloaded from Science Citation Index Expanded (SCI Expanded) via Web of Science. CiteSpace III, an information visualization and analysis software, was used to make a visual analysis.Collaborative author networks within the field of schizophrenia were determined using published documents. We found that external author collaboration networks were more scattered while potential author collaboration networks were more compact. Results from hierarchical clustering analysis showed that the main collaborative field was genetic research in schizophrenia.Based on the results, authors belonging to different institutions and in different countries should be encouraged to collaborate in schizophrenia research. This will help researchers focus their studies on key issues, and allow each other to offer reasonable suggestions for making polices and providing scientific evidence to effectively diagnose, prevent, and cure schizophrenia. Schizophrenia is a serious mental disorder with a lifetime prevalence rate of 1% in the general population worldwide. It is characterized by abnormal mental functions and disturbed behaviors, which characteristically appear as a series of clinical features, such as positive and negative symptoms, and disturbances in basic cognitive functions . AccordiHowever, there have been very few studies on scientific collaborations in schizophrenia research. In this study we analyzed author collaboration relationships as a way to help researchers focus their studies on key issues in schizophrenia, in the hopes of helping them prevent and treat this disease. An analysis of this sort can help clinical and research departments select experts in the field of schizophrenia, thus allowing research groups to improve the efficiency of their research work and provide scientific evidence and guidance for making policy.The dates for this study were taken from Science Citation Index Expanded (SCI-Expanded) via the Web of Science. The dates contained all documents which have the word “schizophrenia” in the title, abstract, or keywords, from January 1st, 2003 to December 31st, 2012. These documents included reviews, meeting abstracts, and manuscripts. There were a total of 58,107 records, each of which contained a title, abstract, author names, institutions, sources, and key words.Authors’ collaboration relationships were usually researched by using software such as SPSS and Pajek mainly through dimension-reduced simplified algorithms which were basically simple static first-generation InfoVis techniques constrained by traditional tools and methods and simple graphic processing and drawing. This study used the most recent citation analysis and visualization software called CiteSpace III (Edition 3.7), which is based on a JAVA application. CiteSpace was invented by Dr. Chaomei Chen . Dr. Chen is an international expert in the field of information visualization. With the advantage of solid background of theoretical mathematics, computer science and computer software and conversance with library literature information, he firstly introduced Pathfinder—a kind of algorithm that seeks the key path—into network analysis and developed the CiteSpace series of application software employing the second-generation InfoVis technique which are adapted to multivariate, time-sharing and dynamic complex network analysis. By combining InfoVis technique and scientometrics creatively, Chen pioneered the comprehensive academic and applied field of visualization with knowledge management to a new stage of decision-making marked by the assistance of domain mapping and knowledge visualization. The CiteSpace series of utility software developed by Chen has 10,000 users in more than 36 countries and has become a popular tool in scientometrics . In CiteFirstly, the datasets for the analysis of schizophrenia covering the time period from 2003 to 2012 were developed as a test bed for CiteSpace III. The lengths of time were sliced into five parts, each of which was 2 years. The three sets of threshold levels for citation counts, co-citation counts, and co-citation coefficients were , , and , respectively. Then, we selected an algorithm (Pathfinder) to determine the path into the network analysis. In the end, we chose corresponding nodes of networks and formed a citation network of authors in the field of schizophrenia , , and , respectively. Then Pathfinder was used to determine the key path into the network analysis. We chose corresponding nodes of networks and formed a co-citation network of authors in the field of schizophrenia (Figure , 20, (42We have listed the top 10 authors of co-citation frequency in Table In order to further detect the potential author collaboration relationships, we found 12 sub-networks through hierarchal clustering. Figure In this study, we developed an author collaboration network for schizophrenia studies during dates ranging from 2003 to 2012 by using visualization technology. Our findings indicated that genetic research for schizophrenia was a very active and intense area of collaborative research. Schizophrenia is a complex mental disease , and genIn the authors’ external collaborative network, we found that the structure of the network was looser and there were fewer relationships among authors who belonged to different institutions in different countries. This indicated that collaborative networks typically tended to be within the same institution or in the same country or region. Because the level of scientific research is closely related with the rate of economic development, different countries have different scientific research levels. If the development of scientific collaborations among authors is confined to their own country, it is no surprise that polarization occurs, such that scientific research is higher in economically developed countries and lower in economically less-developed countries. This can prevent scientific research on schizophrenia to some extent. Thus, we should encourage collaboration among institutions and countries in order to promote coordinated development of international scientific research in schizophrenia.In the authors’ potential collaborative network, we found that the structure of the network was more compact, which indicated that the research theme was relatively centralized and the collaborative relationship is stronger, allowing for collaborative publications focused on genetics, cognitive symptoms, and brain imaging for schizophrenia. However, researchers in the same field have a disincentive to collaborate and exchange knowledge because they are unable to know and communicate directly each other. Thus, the purpose of this study was to help with the exchange of ideas and strengthen communication between schizophrenia researchers to bolster research in this area.The fact that Weinberger and Lieberman appeared in both the external collaboration network and potential collaboration network showed that these two researchers were not only prolific authors, but also published classical works which had great influence amongst their peers. They had made outstanding contributions in the field of schizophrenia research in the past 10 years.In recent years, schizophrenia research has become one of the most popular areas in the field of psychiatry. With the coming of biological information time, more and more researchers begin to find the necessity of scientific collaboration which not only is beneficial to sharing of ability and technology but also spreading of new knowledge, ability and technology and the production of new ideas, especially improved research production and influence of researchers. In this study we chose visualization technology to analyze author collaboration relationships in the field of schizophrenia so that leaders in the field can produce effective research groups, improve the efficiency of research work, and provide a basis for making policy. Furthermore, our findings may help in developing strategies for finding the etiology and pathogenesis of schizophrenia and help with clinical diagnosis and treatment.Future studies from our groups will use visualization technology to track other branches in schizophrenia research, such as genome association studies, in order to acquire more valuable information and promote rapid development of this area.


This article provided an analysis of gender inequality, health expenditure and its relationship to maternal mortality.The objective of this article was to explore gender inequality and its relationship with health expenditure and maternal mortality in sub-Saharan Africa (SSA). A unique analysis was used to correlate the Gender Inequality Index (GII), Health Expenditure and Maternal Mortality Ratio (MMR). The GII captured inequalities across three dimensions – Reproductive health, Women empowerment and Labour force participation between men and women. The GII is a composite index introduced by the UNDP in 2010 and corrects for the disadavanatges of the other gender indices. Although the GII incorporates MMR in its calculation, it should not be taken as a substitute for, but rather as complementary to, the MMR.An exploratory and descriptive design to a secondary documentary review using quantitative data and qualitative information was used. The article referred to sub-Saharan Africa, but seven countries were purposively selected for an in-depth analysis based on the availability of data. The countries selected were Angola, Botswana, Malawi, Mozambique, South Africa, Zambia and Zimbabwe.Countries with high gender inequality captured by the gender inequality index were associated with high maternal mortality ratios as compared with countries with lower gender inequality, whilst countries that spend less on health were associated with higher maternal deaths than countries that spend more.A potential relationship exists between gender inequality, health expenditure, and maternal mortality. Gender inequalities are systematic and occur at the macro, societal and household levels. No cost can substitute ‘mother's care’ for the children and home, which is a heavy loss when women die from avoidable causes. Empirical evidence highlights that the death of a mother harms the overall wellbeing of her children. In Bangladesh, surviving children of a deceased mother are 3–10 times more likely to die prematurely; whilst in Tanzania, children who have lost their mother spend half as much time in school as other children.2 In society, women build binding and bridging social capital structures to assist each other, which translate to societal development.3The death of a mother is a heavy loss to the family, society and the economy. Women play very important roles including non-paid activities, such as caring for the family and maintaining a healthy home environment. Women's work contributes indirectly to the economic growth of a country and can be likened to investment in health and economic growth.4 Women are dying needless deaths because of their unavoidable reproductive role coupled by gender-biased allocation of health resources. In Afghanistan, the shortage of health services for safe delivery has resulted in pregnancy being likened to a death sentence.5Many women have had their lives cut short because of avoidable deaths during pregnancy. Excess mortality of women in Africa has been socially generated as a result of gender bias in the distribution of health care and other necessities.6 and the latest 2010 estimate is 287 000 deaths.7 The global estimates for the year 2008 showed a 34% decline compared with the 2005 estimate (539 358 deaths)8, whilst the 2010 estimates show a 20% decline from the 2008 estimates. Despite this decline, SSA still constitutes 58% of all maternal deaths in developing countries. One in every six pregnant women dies in SSA as compared with one in 30 000 in western countries.9 These statistics suggest that women's health issues are not being taken seriously in developing countries. Although the situation shows a steady decline, SSA still faces problems that can be attributed to gender inequality and lack of women's empowerment, resulting in troublesome death rates.Though the number of maternal deaths has been declining globally, sub-Saharan Africa (SSA) has shown little or no progress. Approximately 358 000 women were dying each year globally as a result of pregnancy according to 2008 estimates10. Although the GII incorporates MMR in its calculation, it should not be taken as a substitute for, but rather as complementary to, the MMR. Hence, the relationship between health expenditure and MMR will be analysed separately from the GII in order to establish a potential relationship. The research area of maternal mortality in SSA has received wide attention. However, no study has considered a gender dimension with regard to this problem.The objective of this article is to explore gender inequality and its relationship with health expenditure and maternal mortality in SSA. The analysis used in this article is a unique dimension which tries to correlate the Gender Inequality Index (GII), Health Expenditure and Maternal Mortality Ratio (MMR). The GII will capture inequalities across the three dimensions – Reproductive health, Women empowerment and Labour force participation between men and women. The GII is a composite index introduced by the UNDP in 2010 and corrects for the disadavanatges of the other gender indices11 A target of reducing maternal deaths by 50% by the year 2000 was set, but this failed because many developing countries had little access to reproductive health services for women, yet the focus was almost exclusively on skilled attendants at birth and access to emergency obstetric care.12 The International Conference on Population Development (ICPD) in 1994 gave prominence to reproductive health and empowering women in the definition of population policy13, aiming to reduce the number of adolescent pregnancies by making reproductive health accessible to this group. Women empowerment in reproductive health and control over their body emanated from the ICPD, but gender-biased roles and the lack of financial power kept women as subordinates who are unable to make reproductive health decisions without consulting their husbands.14 By 1995, it became clear that inequalities and inadequate expenditure on women's health needs hindered development. These conclusions came up at the World Women's Conference held in Beijing in 1995.15 With the intention to improve development for developing nations, heads of state met in New York in September 2000 and drafted the Millennium Development Goals (MDGs). Goal number 5 of the MDGs aims to improve maternal health, setting out two Targets, namely 5a, to reduce maternal mortality ratio by three-quarters by 2015, and 5b, which targets universal access to reproductive health by 2015.16 Some aspects of universal access to reproductive health that empowered women as agreed at the ICPD were not fully incorporated in goal number 5. Following strong pressure from developing countries and civic society, access to reproductive health was incorporated in the year 2007 as target 5b (previously discussed) in the MDGs goal number 5.17 Gender bias is systematic and occurs at all levels, namely the macro, societal and household levels. The allocation of resources at macro level and household level suffer from gender bias. This adds on to roles we play as a result of our biological differences which put both men and women at risk, affecting their health. The distribution of resources at the household level is based on the contribution to income generation in monetary terms, and as a result, very often more food and resources are made available for men.18 Women in SSA constitute 80% of the poor and account for most of the unpaid work.19 The nature of work includes taking care of the children at home, preparing the fields, farming, producing vegetables in small gardens, fetching water, collecting firewood, washing clothes, and cooking whilst they get food of fewer calories as compared to men, since women's work is usually not rewarded monetarily.18In 1981, the Convention on the Elimination of Discrimination against Women (CEDAW) came into force with efforts to address all forms of discrimination against women. Discrimination in education, employment, decision making, gender-based violence and economic empowerment widens the gender gap and impacts negatively on women's health. The safe motherhood initiative was one of the first actions in response to the CEDAW following a meeting held in Nairobi, Kenya in 1987. The intention of the safe motherhood initiative was to address emergency pregnancy complications in developing countries.20 Governments fail to address the issue of making reproductive health accessible through their responsible ministries. Their expenditures prioritise other issues that do not directly benefit women and save them from needless deaths. High unmet needs in contraceptive usage in Africa signal lack of funds in the field of reproductive health.7 Social exclusion and lack of female agency has been the leading cause of poor health states for women. In his paper, ‘Missing Women’, Sen highlights the fact that the lack of work outside the home, lack of education and lack of participation in household distribution of resources has resulted in high fertility and high infant mortality rates.21 A study by Hobcraft22 on the effect of women education on child health found that women with more than seven years of education have on average fewer children in Africa than women with no education. Access to good quality reproductive health care, women education and other interventions may reduce maternal deaths.Women lack the financial resources to allow them to use modern methods of contraception, and lack the ability to negotiate for contraception or safe sex, which increases the chances of dying during pregnancy, because of increased fertility or their contracting HIV.24 Income should be spent equitably on better nutrition, food production capacity, access to affordable reproductive health, transport, water and sanitation, all of which have an impact on women's health. Failure to spend income equitably could manifest as maternal death.25 The GII has three dimensions which capture inequality between men and women in a country and is interpreted as a percentage loss in human development as a result of inequality. The three dimensions captured by the GII are the reproductive health, empowerment and labour market components. A descriptive analysis of secondary data was used for the quantitative data whilst content analysis of secondary information was used for the qualitative information. The article focused on SSA, but for in-depth data analysis, Angola, Botswana, Malawi, Mozambique, South Africa, Zambia and Zimbabwe were purposively selected based on the availability of data to compare the relationship between health expenditure, gender inequality and maternal mortality. The quantitative data was obtained from the WHO data base26 , whilst the GII was obtained from the UNDP data base.27An exploratory and descriptive design to a secondary documentary review using quantitative data and qualitative information was used for an in-depth analysis of gender inequality captured by the GII, MMR and government health expenditure. Documentary reviews involve the analysis of documents that contain information about the phenomena that the researcher wants to study.The GII, which captures disparities between men and women across three dimensions  is shown in 19 Thus efforts to reduce fertility rates and maternal deaths reduce the GII, whilst at the same time reducing the MMR.Countries with a high GII also had a high MMR as compared with countries with lower GIIs. Malawi, Mozambique, Zambia and Zimbabwe had a higher MMR and GII than Botswana and South Africa. An explanation for this association could be because Botswana and South Africa invested in data for decision-making approaches in order to investigate causes of maternal deaths and identify possible solutions. This enabled them to address health problems and to reduce fertility and maternal mortality rates. Fertility and maternal mortality rates are indicators of the reproductive health component, which constitutes about 73% of the GII in SSA.28 This will result in a high GII for such countries and, since some of the inequalities hinder the health-seeking behaviour of women, maternal deaths are likely to increase. The patriarchal system which is prevalent in Africa and SSA in particular feeds in to the high GII. Women have low decision-making power, low education compared with men and own less resources than men. The failure of women to participate in decision making goes beyond the household level to a macro decision-making level. This is reflected in government policies that do not favour women's needs. Lack of access to water and sanitation, reproductive health needs and girls’ education reflect a lack of gender-sensitive national policies, with an end result of high GII and high MMR.Gender inequality and discrimination impede women's access to health, thus limiting their ability to respond to the consequences of ill-health.The variable Total Health Expenditure per capita in purchasing power parity terms (THE/PPP) captures preventative care, curative care, nutrition and reproductive health per person. This indicator shows how much a country spends on one person and this figure is adjusted for purchasing power differences using the international dollar to enable the figures to be comparable across countries. In Botswana and South Africa have the highest health expenditure per capita as compared against Angola, Malawi, Mozambique, Zambia and Zimbabwe. Botswana has the highest expenditure (close to $1400 per person) whilst South Africa spent slightly above $800 per person. As shown in Ethical concerns are waived for review studies and the documents incorporated in this study were screened based on their authenticity, credibility and representativeness in covering gender inequality, maternal mortality and health expenditure. Furthermore, secondary data that was used for analysis came from credible sources that have met ethical requirements.The findings indicate a potential relationship between gender inequality as captured by the GII, maternal mortality and health expenditure per capita. The article showed that countries that had higher expenditure on health had lower GII and lower maternal deaths. Lower expenditure and discrimination against women, which were captured by the GII, affect the health of women, with the worst-case scenario being maternal deaths. However, it is acknowledged that the potential relationships were based on the findings of seven purposively selected countries only.Hypotheses on potential relationships will require further research in order to accept or reject established eventual associations. Further caution needs to be observed in the interpretation of findings since this review was not able to obtain direct expenditures on reproductive health and other factors affecting women's health in the analysis of the gender implication of these expenditures.It is also acknowledged that important other factors may affect women and contribute to maternal deaths, such as distance to health centres, lack of health insurance, unaffordable user fees, poverty, and lack of commitment by African governments to place maternal mortality onto the policy agenda. All of these factors fall into the category of systematic gender problems, which could be at a household, societal and/or macro level. Increasing financial resources for education, reproductive health, water and sanitation, transport, and increasing access to reproductive health may reduce maternal deaths and improve gender equity. African governments can scale up their efforts to increase enrolments of girls in primary and secondary education, and completion of these educational milestones, in order to improve the girls’ decision making skills, allowing for the likelihood of lowering the pregnancy rate and reducing the risk of maternal deaths. In summary, countries with high GII and MMR had lower expenditure on health as contrasted against countries that spent more on health.


As a field, surgery has generated some of the leading innovators in history . AdvanceRandomized controlled trials (RCTs) represent the gold standard for evaluation of the safety and efficacy of surgical interventions. There are several factors that make conduct of RCTs of surgical procedures particularly difficult. Therefore in the past the majority of surgical innovations were accepted on the basis of non-randomized trials .That was highlighted, in particular, by the reaction to the introduction of laparoscopic cholecystectomy, which was greeted by Sir Alfred Cushieri as the “greatest unaudited procedure in the history of surgery” .The first minimally invasive gallbladder-removal procedure was performed by Mühe in Germany in 1985 using a galloscope he himself had designed , and theThe first report on a prospective randomized trial comparing laparoscopic with open cholecystectomy were published in 1992, attesting to the benefits of the minimally invasive technique . HoweverThe authors thus concluded that “these results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.”It thus took 20 years from the initial introduction of video-endoscopic cholecystectomy until scientific proof of its benefits to the patients could be demonstrated. That proof, of the highest level of evidence according to the Oxford criteria, was obtained from the RCT gold standard and meta-analysis. By that time, laparoscopic cholecystectomy had already become established as the gold standard in all hospitals worldwide.As a reaction to the analysis of how innovations were taking place in surgery, an expert group was set up within the framework of the Balliol Collaboration to compile recommendations for scientific evaluation of surgical innovations. In that spirit, McCulloch  stated tIn addition, the Balliol Collaboration highlighted the special features of this surgical innovation process: “By contrast with the formalized approach for drug developments, the process in surgery has been unregulated, unstructured, and variable. Surgery and other invasive therapies are complex interventions, the assessment of which is challenged by factors that depend on operator, team, and setting, such as learning curves, quality variations, and perception of equipoise” .To take account of how surgical innovations take place in reality, the Balliol Collaboration recommends that details of patients treated with the new technique be recorded in prospective development studies, prospective research databases, or prospective registries. These prospectively recorded data will provide for a better power calculation for RCTs, indications can be formulated for this new technique and quality criteria identified . As suchAnnals of Surgery  can be entered into the registry for Natural Orifice Transluminal Endoscopic Surgery. The national NOTES registry was set up by the German Society of General and Visceral Surgery to collect data on implementation of the new technique. The aim is to draw on past experiences gathered at the time of introducing minimally invasive surgery and identify any problems at an early stage. By the end of February 2014, data on 3,211 NOTES operations had been entered into the registry. The initial results of 551 procedures were published in 2010 in Another example is the various hernia registries . Hernia surgery, in particular, has experienced rapid progress in recent years. By virtue of the ever-expanding number of medical devices used in hernia surgery , the surgical techniques are of such a broad variety that they can scarcely be evaluated in a RCT. But by consistently recording details of the different surgical techniques in a prospective registry, any problems or complications related to particular variants of the technique can be identified at an early stage .The voluntary recall of a metal-on-metal hip implant from the market around the world is an excellent example for the validity of registries in the early identification of complications with a specific surgical procedure. The reason that the company has done this was due to the analysis of data from the Australian National Joint Replacement Registry demonstrating that the rate of early revision surgery for these implants was higher relative to other hip replacements. Additionally, there are concerns about metal-on-metal hip implants and the possibility of adverse health consequences of metal particles and metal ions that may generated by wear of the components of these implants .In summary, the innovation process in surgery is essentially more unstructured, unregulated, and variable than in conservative medicine. Scientific evaluation of surgical innovations must be adapted to take account of that. In addition to the gold standard of evidence-based medicine, i.e., the RCT, surgical innovations should in parallel involve prospective recording of data on patients in a database, i.e., a registry. This will provide for early identification of any problems or complications on the basis of outcome analysis. In the surgical innovation process, registries constitute an important scientific tool that affords insights from the outset and accordingly merits evaluation. All scientists engaged in surgical innovations are called upon to support and promote the development of such registries. Surgeons who themselves create innovations should enter data into a registry on patients treated as per the innovative technique. The challenge is getting surgeons to be more critical about the outcomes of their innovations.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although in literature few successful claims have been shown in comparison with other medical specialties such as gynaecology and orthopaedics, vascular surgery is included among high-risk specialties. The high-risk of receiving medical claims may lead vascular surgeons to practice defensive medicine, as is normal in several other areas of clinical practice. No studies are available to our knowledge of the incidence of defensive medicine in the field of vascular surgery. Taking into consideration the scarce amount of information, the authors provide a critical discussion regarding the application of defensive medicine behaviour among vascular surgeons. Defensive medicine has been defined as the practice of ordering tests, procedures, and visits or the practice of avoiding treatments for patients considered at high-risk, in order to prevent medical malpractice claims , 2. In tAlthough in literature a low incidence of successful claims has been shown in comparison with other medical specialties such as gynaecology and orthopaedics, vascular surgery is included among the high-risk specialties. A high-risk of receiving medical claims may lead vascular surgeons to practice defensive medicine, as in every other area of clinical practice. Nevertheless, to our knowledge, no studies are available in literature about the practice of defensive medicine in vascular surgery. The aim of this paper is to examine the defensive approach, not only in its current application, but also in the field of vascular surgery, discussing how being sued can affect medical treatment therefore highlighting the need to assess the real incidence of certain defensive behaviours among vascular surgeons.The following databases (from 1978 to January 2015) Medline, Cochrane Central, Scopus, Web of Science, and Science Direct were used, searching with the following key words: vascular surgery, defensive medicine, medical negligence, and misdiagnosis. The main key word “vascular surgery” was searched for singularly and then associated individually with each of the other keywords.Of the 446 sources found, only 22 were considered appropriate for the purpose of this paper. All sources have been screened independently by three physicians and in order to be included they had to be selected by at least two of them.The phenomenon of defensive medicine adds 5% to 9% to the cost of US medical care and the annual medical liability system costs along with defensive practice have been estimated in 2008 as $55.6 billion of dollars equal to 2.4% of total health care spending . DefensiThe exposure to medical malpractice litigation has also increased in the field of vascular surgery, where physicians are called to cure disorders affecting arteries, veins, and lymph vessels. As for every other area of clinical practice, vascular surgeons tend to be sued for failing to deliver safe and appropriate care to patients . PhysiciThe probability of defensive performances, among physicians, is directly proportional to the specific risk level. Among surgical specialties, vascular surgery is considered to be a high-risk of litigation as confirmed by Jena et al.  in a stuFurther aspects should be considered in the occurrence of mistakes in surgical procedures. An interesting approach is the evaluation of “time factor” in vascular surgery, carried out by Sirignano et al, who highlighted, between 2009 and 2011, 63 claims involving vascular procedures and how the erroneous timing in surgical, medical, or diagnostic intervention may generate errors and how even more frequently errors occur in cases treated electively rather than in urgent or emergency cases .An “emblematic” question may arise in the evaluation of erroneous timing in vascular surgery: which factors can affect the timing of elective procedures? In this perspective a useful support in the attempt to provide a valid answer is to underline the role of “defensive medicine,” which still remains controversial. A “positive” defensive medicine approach can occur in the assessment of “cardiac risk stratification” for vascular surgery, which is considered a very high-risk category, associated with cardiac morbidity rates greater than 5% in many reports. Examples include aortic and other major vascular surgeries, as well as peripheral vascular surgery .For this reason, in order to avoid underestimation of the cardiac risk, vascular surgeons may assume an “assurance behavior,” which increases the time of preoperative investigation with economic repercussions.With the aim of reducing this phenomenon, the guidelines of the American Association College of Cardiology and the American Heart Association recommend preoperative cardiac testing only when the results may influence patients' management. Moreover, they individuated four high-risk conditions, showing how to assess and treat them preoperatively; they include unstable coronary syndromes, decompensated heart failure, significant cardiac arrhythmias, and severe valvular disease. Applying these guidelines in an appropriate manner could help in reducing the risks of incurring in medical defensive procedures.avoidance behaviors” only with the aim of reducing the risk of litigation in certain medical activities. However, according to data reported below, this attitude may sometimes increase the number of claims. The authors of the same study [If, on the one hand, the application of positive defense medicine in vascular surgery can impact on the consequences above reported, on the other hand, the effects of negative defense medicine can be even more dangerous, as it is based on “me study  have alsIn a paper of 2012  five casOther important issues worthy of attention, which should be evaluated, are the different medico-legal implications of endovascular versus open surgery and the peculiar features of vascular surgery from the perspective of defensive medicine and the consequent medico-legal problems that may result. Regarding the first aspect, over the past 30 years, vascular surgery has undergone a significant evolution process: all has changed with the advent of endovascular procedures and, thanks to the rapid evolution of available grafts, everything is still changing. The approach to patients has varied as well as indications. Critically impaired patients, in poor general condition, can be subjected to effective treatments that were not first to be proposed for the high-risks associated with open surgery . The avaFinally, in considering the fields of application of vascular surgery from the perspective of defensive medicine and the consequent medico-legal problems that may result, three key aspects have to be carefully evaluated: the indication, the timing, and the technique used; in avoidance behaviors,” but also on reporting and reevaluating any suspicious case with a team of specialist surgeons, who can evaluate all diagnostic and surgical procedures undertaken together with the compliance to the guidelines and runtimes. Only in this way will it be possible to have a true picture of this phenomenon and therefore be able to correct the negative impact it has in terms of cost and quality on the health service.In conclusion, the little literature available about defensive medicine related to vascular surgery leads us to take seriously into consideration the need to assess the real incidence of defensive medicine in this area. In order to assess the current trend of defensive medicine (positive and negative) in vascular surgery, we suggest focusing not only on the personal perceptions of vascular surgeons practicing it, which however could be underestimated taking into account “


Intensive care is expensive, and thus a body of research has focused on strategies to reduce its costs. However, efforts to reduce the total cost of intensive care have met with limited success, partly because of the challenges of calculating how much a day in the ICU actually costs. We discuss these challenges and introduce the concept of total cost savings as an outcome of critical care trials, assuming statistically negative effects on mortality and quality of life. Healthcare is expensive, and intensive care is very expensive. ICUs are estimated to consume up to one-third of hospital costs and approximately 0.5 % of the US gross domestic product . It is tTime magazine article infuriated readers by reporting that hospitals charged US$18 for a glucose test strip that could be purchased at Amazon for US$0.55 [There are two common accounting formulas for healthcare costing, conveniently termed top down and bottom up. The top-down method takes the overall cost of care for an ICU divided by the number of patient-days of care delivered to calculate the average cost per day. Similarly, the bill that a hospital sends to a payer for an ICU day can be adjusted by some estimate of hospital overheads to obtain an idea of the average cost for that day. This method provides convenient numbers that are used frequently in the literature. For example, the cost-effectiveness study of antimicrobial-coated catheters used this approach to estimate that an ICU day cost US$1,152 in 1999, or roughly three times the cost of a hospital day [ US$0.55 . Unlike  US$0.55 . ImportaClinicians, researchers and policy-makers have found top-down numbers useful despite their limitations. For example, if catheter-related bloodstream infections extend the ICU length of stay by 4 days, then eliminating each infection should save the healthcare system US$4,608  in ICU costs. If a new sedative drug reduces the ICU length of stay by 0.5 days and the ICU treats 300 patients, the ICU should see an additional US$172,800  in the budget, minus the cost of the drug. However, while these average ICU costs and cost savings are easy to calculate and impressively large, they are deeply misleading. In this article we discuss some of the reasons why and explore the methods and rationale for studying total cost savings as a surrogate endpoint in critical care.Reducing the total cost of hospital care is hard because most hospital costs are fixed, rather than variable. A detailed study of hospital costs at Cook County Hospital in the United States found that the majority of the costs were fixed and related to buildings, equipment, salaried labor and overheads . In addiThere are three important reasons why reducing the length of stay in the ICU may not necessarily lead to overall cost savings. The first reason is that the variable costs of the days or hours that are saved at the end of the ICU stay are small compared with the first days . In factCritical Care, Turunen and colleagues explore the economic benefits of dexmedetomidine compared with standard sedatives in reducing days of mechanical ventilation [Journal of the American Medical Association because they thought that midazolam was an inappropriate comparator will be equally skeptical of this analysis. Careful readers will note that this study finds a statistically significant reduction in ICU length of stay whereas the parent trials did not, because it used different assumptions in counting the length of stay for patients who died [In a recent issue of tilation . The phawho died .However, there are some strengths to Turunen and colleagues’ study that can serve as a guide for future investigations. First, the authors account for the fact that different days in the ICU cost different amounts. They used a hybrid of activity-based bottom-up cost accounting to measure nursing activity using the Therapeutic Intervention Scoring System to estimate, for example, that a day on invasive mechanical ventilation cost 33 % more than a day not ventilated. Second, several sensitivity analyses were performed to see whether costing assumptions changed the results. Dexmedetomidine saved money in all of the scenarios; but in some, particularly in comparison with propofol, the savings are quite small and must be considered against the increased rates of bradycardia and hypotension.The real question for intensivists to consider is posed by the article’s claim that if dexmedetomidine reduces the ICU length of stay by 30 h, then the same ICU staff could care for 19 extra patients for every 100 patients treated with the drug. If true, this important effect might let you treat an additional 80 patients per year in a typical 10-bed ICU. The problem with this conclusion is that you could do it with the same staff. In most ICUs, the last 30 h of an 8-day stay is provided by fewer nurses, but in this example 80 of those last days will be traded for new high-acuity first days of care. Unless the ICU uses a fixed staffing ratio for patients regardless of acuity, it is unlikely that the same staff could deliver this additional care, because it is different care.Critical care has struggled with meaningful surrogate endpoints for trials . Cost-miRegardless of the technique, we believe that the research question posed by this study is fundamental to critical care. In the absence of compelling effects on mortality or long-term quality of life, the only valuable surrogate outcome in critical care might be safe and significant reductions in total cost. This outcome will capture much of what we already look for in our surrogate outcomes of duration of mechanical ventilation, organ failure, rescue therapies and length of stay, and will present them in a persuasive form to society and patients. Critical care is a long way from adopting this outcome. We need to develop understandable methods to express the uncertainty in safety and outcomes, reliable techniques to address informative censoring by death, and accurate accounting that includes post-ICU costs, international variations in labor and resource costs, and adequately addresses the issue of declining variable costs over time. Finally, and, most importantly, we need to see whether these modeled cost savings result in efficiencies that benefit our patients.