Archive for PhD

If somebody had a crystal ball: The paradox of a self-defeating health policy.

When I was a new graduate student of health policy, I was once asked by a professor whose class I took, why I had left clinical practice to study health policy. I replied naively, ‘I migrated from clinical practice because I don’t like the idea of working in a place where I can make one mistake and kill a person.’

‘I see,’ he said, ‘so you decided to come over to policy and kill thousands?’

His response, delivered in jest, was tacitly instructive about the importance of getting health policy right, because of the scale at which the impact can be felt. Indeed, one of the central tenets of governance in healthcare is the identification and rectification of problematic policies (WHO, 2017).

Even after learning at graduate school that policy work tends to be an arduous, convoluted and often contentious process, I still intuitively considered policy work to be safer, more elegant and less stressful than clinical work. It was experiences ‘from the trenches’ that revealed otherwise. Within a year of completing my masters, I was battling to pilot an intervention aimed at mitigating the undesirable effects of a well-intentioned health policy that has outlived its relevance in its context; a process which was the diametric opposite of ‘elegant and less stressful’!


When a health policy endangers health

Pharmacies in Zimbabwe, a low income country in Sub-Saharan Africa plagued by a protracted economic recession and a dilapidated health system (Meldrum, 2008), are prohibited by law from advertising their inventory to the general public unfettered like conventional businesses do (Health Professions Act, 2004; Medicines and Allied Substances Control Act, 2001; Pharmaceutical Professional Conduct Regulations, 1989). Given the information asymmetry characteristic of a typical healthcare market, and the potential severity of the consequences of such asymmetry, advertising restrictions are rightly intended to protect members of the public from product claims they are unequipped to evaluate objectively. However, to the extent that advertising restrictions interfere with information provision and transparency when accessing health care, they themselves are a health hazard and this is what the medicine advertising regulations in Zimbabwe have become. The fine line between availing information about care and protecting the public from exaggerated claims should be carefully navigated. Interventions which mitigate the deleterious effects of health information control policies can and should be developed.

In well-served health systems, restricting advertising in and of itself does not constitute a problem because a patient can reasonably expect to find the medicine(s) s/he requires after only one stop or at most few stops at pharmacies in his/her vicinity. However, in Zimbabwe today, systemic economic challenges are causing generalised medicine shortages. These challenges are, in the main, beyond the control of the pharmaceutical sector. As a result, the largest referral hospitals suspended elective surgeries (United Bulawayo Hospitals, 2016; Harare Hospital, 2016). Pharmacies that happen to have a particular medicine that is in short supply everywhere else, are precluded from overtly advertising this fact. Patients therefore have to rely on door-to-door enquiries at multiple pharmacies, serendipitous coincidences, intuition and the benevolence of some pharmacists who sometimes offer to help by contacting colleagues within their professional networks on behalf of patients. Electronic prescribing is not yet widely used in Zimbabwe so patients or their carers are the ones tasked with transmitting prescriptions between prescribers and the pharmacies that will ultimately dispense them. They therefore bear the transaction cost of this process and have to trudge from one pharmacy to the next until they eventually get to a pharmacy that can fill their prescriptions. When pharmacists turn away prescriptions but offer no additional information about where patients can get those prescriptions filled, they become the human face of a system that seems unresponsive to the plight of the ill. Once, I remarked to my colleagues, ‘If somebody had a crystal ball, they would be the oracle that informs patients where exactly to go to get their prescriptions filled and reduce the burden of medicine access.’


The intervention: Controlled democratisation of pharmaceutical inventory information

Accessing medicines should not depend on unsystematic methods of search and we most certainly shouldn’t have to look to clairvoyance to make health systems more efficient and transparent – especially when advances in health informatics and Web 2.0 coupled with the ubiquity of portable information and communication devices have increased the interconnectedness of actors and rendered faster sharing of information across large networks possible. After a content analysis of the statutory instruments governing the practice of pharmacy in Zimbabwe, with the view to finding a legal workaround for the advertising rules, I discovered a loophole. While advertising inventory to the general public is prohibited in Zimbabwe, advertising to another health professional is not. Therefore, if a vertical search engine that is populated by real-time crowdsourced inventory data from retail pharmacies all over the country was set up, and if the back-end of that search engine was managed by a pharmacist, then it could be used by that pharmacist to advise patients, on a case by case basis, even remotely via the internet, about the exact locations of pharmacies stocking specified medicines. A prototype meant to achieve this was designed and the three statutory bodies that regulate healthcare practice in Zimbabwe were approached for approval before launch.

The unfavourable response received from them, was unexpected. An email communication was circulated to all the registered practitioners, cautioning them against what the chief regulatory institution considered an ‘illegal project’ that was tantamount to advertising. I was explicitly informed that I was risking censure by setting the ball rolling with it and was sufficiently intimidated. Of all the illegal things a health professional in Zimbabwe can do, outside of malpractice, experimenting with advertising is considered the most negligent because it is so easy to avoid. It is seared onto our minds right from pre-qualification training that advertising by health professionals is simply not acceptable, so it is almost a reflex response for healthcare providers to stonewall anything that bears advertising connotations.

Regulators were re-engaged because their endorsement is crucial. Without this it is not possible to persuade pharmacies to volunteer the essential crowdsourced data needed to populate the vertical search engine that drives the intervention. Although they acknowledged unreservedly the existence of the problem that the advertising policy has given rise to, regulators remained steadfast in their position that the proposed vertical search platform solution was illegal and ‘was not in the best interests of the public’. The judiciary arm of the state was therefore invoked in the hope that it could rule on the legality of the proposed intervention.

The intermediate goal became to obtain a court judgement that would compel the regulatory bodies to allow this intervention to be tried. A High Court application (Herald, 2016a) citing the health minister and all three relevant regulatory entities as respondents, was filed. We currently await a judgement pronouncement but continue to keep the discussion about the matter alive, for example through the press (Herald, 2016b). Meanwhile, one of the regulatory bodies has responded to our court application with a counter-suit for costs because according to it, we ‘brought a case before the Court prematurely.’


The Future

Towards the end of 2016 a press announcement notified the public of the healthcare regulators’ intention to relax draconian advertising policies (Herald, 2016c), having recognised the need for the public to access information about healthcare providers and services. I count this a small victory and look forward to the green light to implement the ‘Crystal ball’ project with much optimism. Lessons from its implementation could bode well for health systems facing similar governance problems.

Determined to build my credibility with policymakers and take forward my academic studies, I enrolled for a PhD with the Global eHealth research group at the University of Edinburgh and am now 10 months into a three-year programme. Taking this parallel pathway, whilst continuing to fight the case for better information sharing about community pharmacy stocks in Zimbabwe, has forced me to critically examine my assumptions and proposition and to mentally separate my personas as an objective researcher of eHealth innovation and as an innovator/entrepreneur. It has provided an opportunity take an in-depth look at the technical and legal feasibility of alternative approaches, and their ethical, legal and governance implications, as well as to study a wider range of innovative digital approaches for supporting pharmacy practice and strengthening health systems. This transition has been guided and encouraged by my PhD supervisors Dr Claudia Pagliari and Dr Raluca Bunduchi, who have kept my feet on the ground and combine expertise in health technology assessment, health policy and innovation studies. Our new opinion piece in BMJ Global Health (June, 2017), aims to draw wider attention to the challenges facing Zimbabwe and seeks ideas and opinions from researchers, policymakers and practitioners facing similar problems elsewhere in the world.


By Dudzai Mureyi, Global eHealth PhD student

Dudzai Mureyi is a first year PhD student on the Global eHealth programme at the University of Edinburgh, supervised by Dr Claudia Pagliari (eHealth Research Group) and Dr Raluca Bunduchi (Entrepreneurship and Innovation Group).


  1. Harare Central Hospital (2016). Internal memo: Suspension of Elective Lists-Drug Shortages. Harare. [WWW] Available from Accessed 06 February 2017.
  2. Meldrum A, (2008). Zimbabwe’s health-care system struggles on. Lancet 371(9615); 1059-1060.
  3. Parliament of Zimbabwe (2001) Medicines and Allied Substances Control Act [15:03]. Harare. Parliament of Zimbabwe.
  4. Parliament of Zimbabwe (2004) Health Professions Act [27:19]. Harare. Parliament of Zimbabwe.
  5. Parliament of Zimbabwe (1989) Statutory instrument 232 Pharmaceutical Professional Conduct Regulations. Harare. Parliament of Zimbabwe.
  6. The Herald (2016a). Pharmacist Seeks Court Order for private pharmacy stocks database. [WWW] Available from  Accessed 06 February 2017.
  7. The Herald (2016b). When regulation is outpaced by technology. [WWW] Available from Accessed on 06 February 2017.
  8. The Herald (2016c). Zimbabwe: Govt relaxes Medical advertising rules. [WWW] Available from Accessed 06 February 2017
  9. United Bulawayo Hospitals (2016). Internal memo: Cancellation of Elective Surgical Operations. [WWW] Available from Accessed 06 February 2017.
  10. WHO (2017) Governance. [WWW] Available from Accessed 06 February 2017.
  11. Mureyi D, Pagliari C, Bunduchi R (2017) Drug advertising riles and the patient safety paradoc in Zimbabwe. BMJ Global Health (Opinions), June 8th 2017 Accessed on 10 June 2017

Building Resilience Against Depression

Everyone feels down from time to time but depression is more than sadness or feeling ‘blue’. It is a common mental disorder which affects males and females, young and old, rich and poor. It is a treatable health condition that is found across cultures.

Depression can affect the way you think, move and speak. It can affect your physical health. It can also affect your ability to care for yourself, relate to others and enjoy life. Young people with depression can fall behind with schoolwork, miss out on friendships and struggle to find the energy to keep up with sports and leisure activities. In adults of working age, depression can make it difficult to concentrate at work, keep on top of finances, care for children, and maintain homes in order. Older people who are depressed may become socially isolated, forget important appointments and lose interest in work and hobbies. Some people with depression experience severe loss of appetite or thoughts of suicide and self-harm which can occasionally lead to death.

It is important to recognise and treat depression early to reduce suffering and prevent worsening of the illness. Despite advances in depression care, many people cannot or do not access help and they continue to suffer quietly and alone, hoping and praying the depression will one day disappear. Without additional support, some suffer for much longer than is necessary and later look back on their lives with regret over the lost months and years. This should not happen anywhere in the world.

Today we have a holistic understanding of health and this means people with depression can be helped by a combination of: medication, social support, psychological therapy, exercise, nutritional therapy and spiritual care, depending on the severity of depression and the individual’s needs and preferences. These treatment options address the multiple factors which are associated with depression, such as resilience. While being highly resilient does not eliminate all risk of depression, research findings from both higher and lower income countries show that building resilience can help prevent and treat depression.

Depression causes suffering and loss for those who live with it and for their family and friends. Depression can also cause death. With modern, evidence-based approaches to tackle depression, no one should suffer in silence without hope. Depression care can be tailored to the individual who should expect to make a good recovery, build resilience against future episodes of depression, have better physical health and enjoy a fulfilling life.


Dr Anne Aboaja MPH MRCPsych , University of Edinburgh, Global Health PhD Network

Health in the Eastern Mediterranean Region

The vast complexities of the Middle East and surrounding regions cannot be understood without bringing health into the battleground of analysis. In this context, the Global Health PhD Network organised the event “Health in the Eastern Mediterranean Region” on 28th of October, 2016 with the funding of the University of Edinburgh’s Global Health Academy. The event was framed as a series of four short conferences on diverse topics related to Health in the region, and two networking recesses at the venue’s foyer at 7 Bristo Square, where delicious kenafa was served by the University’s Middle Eastern Society.

The first speaker was Dr Runa MacKay. She studied medicine at the University of Edinburgh at a time where it was not usual for women to go this further in their studies. In 1955 after qualifying in medicine, Dr Mackay arrived at the Edinburgh Medical Missionary Society Hospital in Nazareth, now in Israel, which has served the Arab population there for more than 150 years. Dr Runa Mackay spent around fifty years working across Lebanon, Palestine, and Israel for the betterment of health conditions among the Palestinian population who live within Israel, either in health policy or as a practitioner in war torn Beirut and West Bank. Today, back in Edinburgh, she has written the book “Exile in Israel”, where she tells her personal experience throughout those years which have taken her to state, as she did in the event, that she feels more Palestinian than British.

As the second speaker, Khuloud Alsaba, researcher from the Syrian Center for Policy Research and a final-year PhD candidate in International Public Health Policy talked about part of her research project: “War in Syria: Political Determinants of Health”. In a very critical and insightful way she explained how within the discourse of “The War on Terror” health facilities and health care workers have become a legitimate target. However, turning access to health into a weapon of war has brought unexpected hardships for the population. Khuloud argued that polio, once an eradicated disease, has reappeared in Syria as a consequence of a thrashed and weakened public health system. She concluded by stating that these war tactics are not only militarily and economically inefficient, but also (and most importantly) a violation of the human rights of Syrians.

After a short networking recess, the event carried on with the third talk. Via videoconferencing, Ben Clavey, a young medical student and the co-coordinator at Medact Arms and Militarisation Group, gave a concise explanation about this NGO and its work in the Middle East. Medact is an organisation where health professionals can go beyond the clinic and actively engage with the search for solutions to the most pressing global health issues. Through analysis, lobbying, and education, it aims at having an impact in policy on four main areas: peace and security, climate and ecology, economic justice, and health and human rights. Regarding the Middle East, he added that Medact’s activity in the region has been extensive. It has worked in Iraq and Palestine performing in ground analysis and campaigning for the respect of human rights and adequate health policy for the victims of armed conflict in both countries. Recently, it has worked on warning and lobbying against airstrikes by the British military in Syria and also against UK arms sales to Saudi Arabia, who has been involved in the destruction of Yemen’s health system and the targeting of its hospitals and other healthcare facilities. Finally, Ben invited us to become part of Medact’s effort in taking health as a human right into policy either by donating or joining the organisation. A stand with further information for those interested in participating was set on the venue’s lobby as well.

The fourth and last speaker was Parisa Mansoori, a PhD candidate at the Centre for Global Health Research at The University of Edinburgh, who presented her research project on Iranian health sciences and academic literature production. According to recent data, Iran has had a dramatic increase in the amount of health related academic publications in the past few years. This stands out as a unique situation among the emergent economies, due to the quality of the articles produced in Iran, which have found their way into high impact international journals. Moreover, Parisa pointed out that practically a large proportion of this new literature has been produced by a small group of academics in Tehran University of Medical Sciences and few other Tehran-based institutions. By providing a thorough characterisation of this phenomenon, she expects to lay ground for further progress and development of Iran’s health sciences and their contribution to the global scientific arena.

In conclusion, the event managed to assemble in a couple of hours a wide range of experiences related to health in the Eastern Mediterranean region. Just as this region has been traditionally associated with armed conflict and violent political struggle, health has also been a very pressing issue both then and now, as Dr MacKay and Khuloud Alsaba exemplified. However, as Ben Clavey from Medact and Dr MacKay let us see, there are still spaces for hope and resistance, as well as moments for empathy and sharing. Furthermore, in spite of these difficulties, the region hasn’t stopped creating new knowledge. As Parisa Mansoori portrayed, the region is home for highly qualified and capable academics who contribute to the development of science and knowledge around the world. Lastly, thanks to the networking sessions and kenafa tasting we were reminded that, as in any other place, there are people living everyday lives in this region, where the creation and recreation of very rich cultures has made of it a quite unique and special place.


Bernardo Moreno-Peniche, MSc Medical Anthropology, University of Edinburgh


Images taken by: Clàudia Serra Vinardell

The world is changing – will your PhD matter?

At the dawn of the Sustainable Development Goals (SDGs) – which ushers in 17 new goals in a global agenda to “end poverty, protect the planet, and ensure prosperity for all”, most countries will be realigning their national development goals to be in tune with these global goals to realize specific targets over the next 15 years. As a researcher, one thing will soon become obvious in the midst of this global effort to bring about change – that is future research grants will be awarded primarily around these 17 SDG goals. An important question – “how your research fits in this global agenda?” arises for you and other PhD researchers who will soon be applying for these grants to drive your respective fields forward with whatever piece of the bigger science puzzle you will be solving.

It will not be an easy task to find one’s footing in the fast changing terrain of global goals and priorities, and Dr Liz Grant of the Global Health Academy at Edinburgh University is not shy to point this out. But, thankfully, not without some pointers to a way forward. Dr Grant has had extensive research experience at the level of Global Health with her many years of research in palliative care around the globe. In her talk on the ‘Impact of PhD Researchers on Global Health’ which she delivered at the Global Health PhD Network event in October 2015, she had a lot to share.

In a talk that was neatly supplemented with real life examples of her own research, Dr Grant carefully led the thoughts of the PhD researchers in the room on a number of issues, which in her opinion will soon become important in their researching career in the light of the new SDGs.

Top of her list was the need for PhD researchers to start thinking of where to find other pieces of evidence for their research. “What matters in your PhD”, she said, “is pulling materials from connected disciplines and connected areas and making sure you draw them in – use the materials out there…network pieces of information together”. In truth, that is how science works in our day through extensive bridge building across multiple disciplines and you probably have come across this a number of times already in your field. The rewards of this approach is long term and may not be immediate which in the little time space of a PhD makes it appear impractical. But in Dr Grant’s view, your research questions are still questions because there have not been enough conversations around them for others before you to have answered them. This is a brilliant way to look at things because in a way it challenges you to start expanding the discourse around your research to span more than just the area of your interest, to generate interest in other relevant fields.

But what good might all that knowledge you obtain as a result be, if not for the good of mankind. “Knowledge for knowledge sake is wonderful”, she says, “but knowledge to make a difference is why you are here and why I am here and why the university is here”. The message here is pretty simple – don’t let your PhD be only just another addition to the vast collection of information sitting on shelves around the world and only collecting dust. But it should be one that works and makes a difference. And she thinks you can achieve this by starting to think about your PhD research in terms of who the constituents are (i.e. those directly affected by what you are doing), how you will engage the public on important issues like the burden of the problem you are dealing with or trying to help solve, and also the economics involved and equally importantly why your research needs to be prioritised in the face of other competing research.

Huge task, but is it beyond you? Of course not. A big step forward in making any of the impact that would make your PhD research matter is through advocacy. Because the impact is kind of often seen through advocacy, she said, in doing things like, writing blogs, getting local workshops, and communicating what you are studying to people who have the connections to make things work. “People built systems and people can take it down,” she says in reference to the perpetual ‘brick walls’ of resistance that bureaucracies will mount on your path. Keep talking to as many people as possible and never ever underestimate the power of networking because you can change things in partnerships.

In bringing all this home, Dr Grant urges PhD researchers to think once again about their PhD and ask themselves what are the core components of what they are doing. For instance in her own research in palliative care then this would be about the core components of a health care system. Ask yourself if your research is around the core components. If not, what can you do to create the conditions necessary for change? Are you getting the right materials at the right time to create these conditions? And will these conditions support a sustainable system? Also what is the national architecture like in your country that will mean your piece of research can fit in. Answers to these questions and a lot more which couldn’t fit in this piece are what in Dr Grant’s expert opinion would make your PhD make an impact.

“Never forget why we research, you and I – it’s our communities, it’s our families, it’s people.” Dr Liz Grant

Dr Grant’s talk was preceded by a lively PhD poster session that saw four PhD students from the University of Edinburgh present their research work from four different regions around the globe. The first poster by Sara Valencia looked at vaccine trials in Southern and Central America (Colombia, Brazil and Mexico). A second poster that looked at the prevalence of Non-communicable Diseases and the entitlement to and the use of health services in the Gaza strip was presented by Majdi Ashour. Mkululi Wami presented the findings of a research work he carried out in Sub Saharan Africa in Zimbabwe which used antibody responses based on parasite egg counts to estimate infection prevalence of schistosomiasis in young children. The last poster was presented by Ai Oishi on a research that sort to identify patients for palliative care approach in primary care settings in Japan.

The Global Health PhD Network started, in October 2014, as a student-driven interest group within the Global Health Society, University of Edinburgh, with the express aim of bringing together like-minded postgraduate researchers from the three colleges in the university for research sharing, knowledge and skills exchange, networking and shared global health career development. The Network has hosted a series of events during the past year to bring together PhD researchers in the university to listen to and to share thoughts on important issues surrounding global health. And their most recent event (the one I just described) was yet another opportunity for the Network to reiterate its vision of creating an environment that supports and promotes cross-disciplinary networking by inviting PhD poster presenters from all three colleges of the university.

Again, looking back at some of the key points in Liz’s talk on the importance of networking and advocacy for PhD researchers, you realise that the Global Health PhD Network has its priorities well placed, doing things right as it should be and is already on the right bus into the future.

Richard F Oppong, Institute of Evolutionary Biology, University of Edinburgh