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Questions and concerns involving creatine supplementation and kidney damage/renal dysfunction are common. In terms of pervasive misinformation in the sport nutrition arena, the notion that creatine supplementation leads to kidney damage/renal dysfunction is perhaps second only to the myth that protein supplementation and high habitual protein intake causes kidney damage. Today, after > 20 years of research which demonstrates no adverse effects from recommended dosages of creatine supplements on kidney health, unfortunately, this concern persists. While the origin is unknown, the connection between creatine supplementation and kidney damage/renal dysfunction could be traced back to two things: a poor understanding of creatine and creatinine metabolism and a case study published in 1998.
The study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically.
The disconnection between modest service needs (constrained by financial factors) and vigorous supply of health professionals was recognisable in all settings. Despite the underlying uncertainties about the true size of each workforce, time series pointed unambiguously towards a sustained growth, particularly in relation to the DR Congo and the Occupied Palestinian Territories, both endowed with large health training capacity. This trend has been recognised also in other healthcare arenas, such as in Angola . Counter-intuitively, an expanding workforce looks like a recurring feature of the diminished state, which relinquishes its grip on supply, employment and professional practice. The profit prospects of healthcare activities, within a suffering domestic economy, attract both workers and entrepreneurs.
In the six healthcare arenas examined, professional associations were found to exist to differing degrees, sometimes if only to demand a tax from new entrants to the market but rarely, if ever, to provide professional support.
Strengthening the role of any putative state to take on its enabling role and establish governance mechanisms will be a protracted, incremental exercise, one likely to take decades to reach a basic level of functioning [46-49], with no guarantee that it will happen . In each of the case studies, the fragility of governance structures is not new; rather, it is chronic and stubborn to international interventions. Even if a state-based governance structure registers progress, it will relate only to a modest portion of the healthcare market. And publicly employed health workers will remain subject to market pressures determined outside the public sphere. Thus, a focus on building the capacity of the state on its own is unlikely to result in tangible improvements. Our analysis suggests that conceptualising the HRH arena at the national level and focussing on the public health sector is, to an extent, misleading and provides a parody of reality. A more useful conceptualisation may be to look at local healthcare provision arrangements in their diversity including formal and informal as well as private and public elements . This would provide a more holistic understanding of the HRH resources available to enhance the quality of health care and enable a piecing together of a system from the reality of what is, rather than on the illusion of what is not, drawn from a focus on idealised patterns [5,38,40,50-52]. This more comprehensive analysis of HRH will allow for the development of strategies to support and develop existing resources, promoting adaptive responses to existing dynamics .
The challenge, then, for the international community is to find ways to effectively engage with the system as a whole , essentially looking afresh at the healthcare arena and searching out all actors, working out new ways to engage with them. In other w