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Cur(e)ated: A Monthly Guide on Access

May 31, 2018

Burundi.  Photo by Kristy Carlson | longmilescoffeeproject.com

At the end of every month, we highlight key readings—and other information sources such as podcasts and videos—that during the month have provided us with new knowledge about efforts to improve access to health technologies in low- and middle-income countries (LMICs). Though we are always eager to learn about exciting new technologies for health improvement, what really matters, in our view, is the process of getting these technologies to the people who need them. Therefore, the knowledge sources that we highlight here are not about the characteristics and uses of health technologies, but instead are about the people and systems that make access happen. When we talk about access, we mean “people’s ability to obtain and appropriately use good quality health technologies when they are needed” and we conceive of the access process in terms of four sets of activities—related to architecture, availability, affordability, and adoption—that occur simultaneously at the global-level and within national health systems (click here for more about this access definition and framework). In curating these readings every month, we hope to spotlight emerging knowledge about new and ongoing efforts to address persistent barriers to access, the consequences (both intended and unintended) of these efforts, and information gaps in the access to health technologies field.

–Our starting point is WHO’s publication this month of the Essential Diagnostics List (EDL). This list includes 113 diagnostics and will be expanded and updated regularly. The next steps are the development of national EDLs (this has started in countries like India, South Africa, and Ethiopia) and the strengthening of laboratory networks in countries.

–We can learn as much from our failures as from our successes, and in that spirit, the access story of miltefosine, the only oral drug approved for leishmaniasis, is a must-read. Product development of miltefosine is a successful story of a partnership between WHO, a private company, and clinical researchers in leishmaniasis-endemic countries; this partnership demonstrated the viability of the product development partnership (PDP) model. In 2002, India approved miltefosine and a visceral leishmaniasis elimination campaign was launched in 2005. But access efforts stumbled, due to a range of factors including insufficient supply chains leading to shortages and difficulties in managing adverse events. Lessons learned from the miltefosine story include the need for PDP agreements to contain detailed provisions for sustained access, and the importance of competition and/or generic producers and ongoing political commitment from national and global actors.

–Milk banks provide pasteurized, donor breast milk for newborns when a mother’s own milk is unavailable. This article describes the work of Joao Aprigio Guerrade Almeida and his colleagues to improve Brazil’s milk bank system through the provision of more affordable and locally sourced equipment, marketing campaigns, and supportive national policies. Today this system feeds thousands of vulnerable newborns, especially premature babies, and through South-South partnerships, Brazil has helped other countries (such as Cuba) establish similar systems.

–Many countries confront the difficult question of how to pay for and provide access to new, high-cost medicines for their citizens. This paper describes a pilot project, conducted at the central level in China between March and July 2017, to conduct pricing negotiations with pharmaceutical companies on innovative, high-cost medicines that are not on the national formulary (ie for oncology). The pilot project reached an overall agreement rate of 81% and the authors present six suggestions for future development. Brazil and Thailand have attempted a different strategy to address the challenge of providing access to high-cost medicines—compulsory licensing. This type of licensing permits the production or purchasing of generic medicines during the patent term in order to make medicines more affordable. This study compares the two countries’ experiences of compulsory licensing in order to draw out implications for other middle-income countries (unfortunately, this paper is not open access).

–The US FDA since 2004 has established a dedicated drug review process in support of PEPFAR to ensure safety, effectiveness, and quality of antiretrovirals (ARVs). Through the “one-way reliance” process, WHO and the Global Fund can include the products reviewed by the US FDA on their ARV drug lists. An assessment of the number of ARVs that have been made available due to the US FDA review process found that many of the ARVs originally reviewed by the US FDA were on both the WHO and Global Fund lists. The authors found additional room for improvement and called for a more coordinated approach and information sharing between the three agencies in order to reduce duplication, save resources, and expand ARV access.

–This commentary calls for building on the experiences of market-based approaches to addressing global health access challenges (such as ceiling price agreements and advanced purchase commitments) where appropriate, in the context of declining donor funds.

–One way to improve access to health technologies in LMICs is to strengthen local production of pharmaceuticals. This study of pharmaceutical production in Africa calls for a “local health” policy perspective to generate linkages between and strengthen the health and industry sectors—often treated as separate silos. The authors point out that a “local health” perspective may require a paradigm shift and will challenge some of the underlying assumptions of “global health” frameworks.

–An important vaccination effort for cholera commenced this month. “The biggest cholera vaccination drive in human history,” supported by Gavi and WHO, began in five African countries (Nigeria, Malawi, Uganda, Zambia, and South Sudan) and in Yemen, aided by two recently approved oral cholera vaccines which are more affordable, have better packaging for transport, distribution, and waste management, and remain stable at higher temperatures.

–Ebola is back in DR Congo. This is the country’s ninth Ebola outbreak, and the Congolese have a wealth of experience in outbreak containment. In addition to drawing on this experience, the Congolese are also incorporating lessons learned from the 2014 West Africa Ebola outbreak into their response (such as studying burial practices and modes of communication). The experimental Ebola vaccine rVSV-ZEBOV is also being deployed through a ring vaccination strategy, aided by the Arktek (“the coolest cooler on Earth”) which keeps the vaccine cold enough in the field. These exciting new technologies, however, are not in themselves sufficient to address Ebola; previous experiences in DR Congo as well as Liberia, Sierra Leone, and Guinea show that community buy-in remains essential.

–And staying in DR Congo…several years ago, I had the extraordinary opportunity to hear one of my heroes, Dr. Denis Mukwege, speak at a screening of a film about his life. This month, Bill Gates spotlights Dr. Mukwege in his blog series about “Heroes in the Field” and describes how, with his staff at Panzi Hospital, Dr. Mukwege has helped more than 50,000 survivors of sexual violence. His work and optimism remind us that together “we can change hate by love.”

Do you have a knowledge source that you think should be included? Great! Please send suggestions to Laura at laurajfrost@glohi.org or tweet to us @laurajfrost.

Cur(e)ated: A Monthly Guide on Access

April 30, 2018

Burundi. Photo by Kristy Carlson | longmilescoffeeproject.com

At the end of every month, we highlight key readings—and other information sources such as podcasts and videos—that during the month have provided us with new knowledge about efforts to improve access to health technologies in low- and middle-income countries (LMICs). Though we are always eager to learn about exciting new technologies for health improvement, what really matters, in our view, is the process of getting these technologies to the people who need them. Therefore, the knowledge sources that we highlight here are not about the characteristics of health technologies or the processes behind their research and development, but instead are about the people and systems that make access happen. When we talk about access, we mean “people’s ability to obtain and appropriately use good quality health technologies when they are needed” and we conceive of the access process in terms of four sets of activities—related to architecture, availability, affordability, and adoption—that occur simultaneously at the global-level and within national health systems (click here for more about this access definition and framework). In curating these readings every month, we hope to spotlight emerging knowledge about new and ongoing efforts to address persistent barriers to access, the consequences (both intended and unintended) of these efforts, and information gaps in the access to health technologies field.

–World Immunization Week was this month (24-30 April) and this feature story highlights the current status of global efforts to eradicate polio. It describes how migrants and refugees from Afghanistan and Pakistan are a key focus of the final push towards eradication and how the Global Polio Eradication Initiative with the two governments have set up vaccine “transit stations” on roads where migrants and refugees travel, as well as in bus and train stations and in airports.

–Pakistan’s Lady Health Workers deliver primary healthcare to women and immunization campaigns to children—in so doing, they play a critical role in polio eradication efforts. Many of these workers, however, face difficult work conditions including threats of physical violence, sexual harassment, and irregular payment of salaries. Their experiences are a stark reminder of the personal sacrifices made by many health workers to keep services functioning and the necessity of providing adequate protection and support.

Efforts to improve access to contraceptives and family planning services in conflict-affected areas of eastern DRC found the importance of several program strategies—clinical coaching and supervision of providers to improve skills and attitudes, training and supporting providers in immediate postpartum insertion of the IUD, introduction of the levonorgestrel-releasing intrauterine system to expand client choice, and behavior change communications campaigns to raise awareness about family planning. The authors argue that women and their partners in conflict areas want family planning and that delivery of these services is feasible as long as programs are adapted and sensitive to local context.

–And on the subject of context…while many of us working in global health agree that “context matters,” the authors of this PLOS blog post argue that context is insufficiently accounted for or examined in our approaches, and call for the inclusion of local values and local expertise as a routine practice in global health institutions and interventions.

A qualitative study of a syphilis/yaws point of care diagnostic test in the Solomon Islands sought to understand broader issues in the health system that might influence the test’s rollout. The study identified four themes related to healthcare worker and patient perceptions—training and ease of use, time taken for test and ability to fit into the clinical workflow, perceived reliability of the test results, and access to the test in lower levels of the health system.

–Local pharmaceutical production is one access strategy that can improve the affordability and availability of medicines. An examination of Brazil’s experiences highlights the conditions necessary for building local production as an access-to-medicines strategy (unfortunately, this article is not open access).

–On World Malaria Day (April 25), the African Development Bank released a report about the financing of malaria control efforts, with a focus on the role of foreign aid. In the report, the AfDB notes that in September 2016, Sri Lanka was declared malaria free, and examines this country’s experiences to extract lessons learned for African countries. Related, a case study of a public-private partnership in Sri Lanka for malaria elimination, established at the end of the separatist conflict in 2009, shows how collaboration with the private sector from 2010-2014 in war-affected districts with weak health systems contributed to Sri Lanka’s achievements.

–In this podcast, Dr. Allan Pamba shares his story of his personal experiences with malaria as a child in Kenya, his medical training during the HIV/AIDS epidemic at a time when no treatment was available, his subsequent establishment of the first HIV care clinic on Kenya’s coast at a time when ARVs had become available but not affordable, and then taking a job with a pharmaceutical company as way to “get to the heart of the problem” and learn more about how to make these treatments more broadly available.

Do you have a knowledge source that you think should be included? Great! Please send suggestions to Laura at laurajfrost@glohi.org or tweet to @laurajfrost.

 

Cur(e)ated: A Monthly Guide to Access

March 31, 2018

Burundi. Photo by Kristy Carlson | longmilescoffeeproject.com

At the end of every month, we highlight key readings—and other information sources such as podcasts and videos—that during the month have provided us with new knowledge about efforts to improve access to health technologies in low- and middle-income countries (LMICs). Though we are always eager to learn about exciting new technologies for health improvement, what really matters, in our view, is the process of getting these technologies to the people who need them. Therefore, the knowledge sources that we highlight here are not about the characteristics of health technologies or the processes behind their research and development, but instead are about the people and systems that make access happen. When we talk about access, we mean “people’s ability to obtain and appropriately use good quality health technologies when they are needed” and we conceive of the access process in terms of four sets of activities—related to architecture, availability, affordability, and adoption—that occur simultaneously at the global-level and within national health systems (click here for more about this access definition and framework). In curating these readings every month, we hope to spotlight emerging knowledge about new and ongoing efforts to address persistent barriers to access, the consequences (both intended and unintended) of these efforts, and information gaps in the access to health technologies field.

–It was World TB Day on March 24 and we highlight two papers this month about efforts in India to provide access to Xpert MTB/RIF for the diagnosis of pediatric TB and drug resistance. The Foundation for Innovation in New Diagnostics (FIND) and the Revised National TB Control Program in India (RNTCP) undertook a USAID-funded project in four cities that rolled out free, rapid Xpert testing for all presumptive pediatric TB patients. The project is described here, and this paper presents findings from the project’s qualitative study of Xpert practices and barriers to use. The authors report that for those who diagnose and treat pediatric TB, improved access to Xpert helped raise awareness about drug resistant TB in children, assisted in antibiotic stewardship, and reduced clinical diagnosis. The study also found a diversity of Xpert utilization practices among providers and emphasizes the importance of placing Xpert early in diagnostic algorithms, conducting intensive and continued advocacy with providers, and ensuring a system of ongoing access to affordable Xpert as well as rapid diagnostic turnaround time.

–Last month, we posted this call for an essential diagnostics list similar to the WHO Model List of Essential Medicines (WHO EML). This article explains how India is taking the lead in consultations with WHO and national stakeholders about the process for creating an essential diagnostics list.

–The TRIPS (Trade-Related Aspects of Intellectual Property Rights) flexibilities are a set of measures that WTO Member States can take to improve access to medicines. This paper documents the use of TRIPS flexibilities between 2001 and 2016 to access lower priced generic medicines and finds that TRIPS flexibilities were invoked more frequently than commonly believed, and that the majority of these were successfully implemented.

–The Farmácia Popular Program (FPP) in Brazil is a government subsidy program for essential medicines launched in 2004 with the objective of improving medicine access and decreasing the financial burden of households. An analysis of the FPP documents its implementation and finds that it has promoted access to medicines for hypertension and diabetes, and has also led to the establishment of a pharmaceutical information system in Brazil.

–WHO in 2013 released a framework for decision-making about how to prioritize vaccinations in acute humanitarian emergencies. MSF shares its experiences of using this framework in a displacement setting in South Sudan. MSF used the framework to prioritize vaccinations and then successfully conduct a series of mass vaccination campaigns against epidemic-prone diseases. However, the organization was not able to gain authorization from the MoH to implement the full package of priority vaccines. The authors suggest that for the framework to reach its full potential it should be adapted for field use and also be introduced to national decision-makers as to its importance and practical relevance.

–The spirometer is a medical device that has been used for more than a century to measure lung function. Spirometers come outfitted with “race correction” in which lung function values are reduced for patients who are identified by their doctors as black; this design was based on the flawed assumption of inferior lung capacity of non-whites. Professor Lundy Braun has won this year’s Ludwik Fleck Prize for her book Breathing Race Into the Machine: the Surprising Career of the Spirometer from Plantation to Genetics in which she documents the spirometer’s history and traces the processes through which racial and ethnic differences became normalized in medical, public health, and insurance fields.

Do you have a knowledge source that you think should be included? Great! Please send suggestions to Laura at laurajfrost@glohi.org or tweet to @laurajfrost.

10 Case Studies of Multisectoral Action for Health

A current trend in global health research papers and commentaries is for authors to conclude with a call for a “multisectoral approach.” These calls have increased in the era of the Sustainable Development Goals with its emphasis on policy coherence and collaboration across sectors for reaching national and global targets.

Indeed, many of the determinants of health lie outside of the health sector, and collaboration with sectors such as transport, energy, housing, education, agriculture, water, and others is essential for improving health. But what do we know about how stakeholders in different sectors can best work together, given the many barriers to effective and sustained action?

While there have been myriad attempts to implement multisectoral approaches for health, in many different settings, the literature on the how of multisectoral implementation remains limited. These papers detailing 10 case studies are the exception, and provide valuable information about what works, and what does not, in working across sectors to improve health.

Bhalla K, Bump JB, Frost L, Glassman A, McQueston K, Pratt BA, Pierre Louis AM, Harman N, Meiro-Lorenzo M (2014). Building the Foundation for Healthy Societies: Influencing Multisectoral Action for Health. Phase One, Volume II: Case Studies on Multisectoral Action. Washington, DC: World Bank.

  • This World Bank knowledge product provides four case studies on multisectoral action for health: road safety in Argentina, conditional cash transfers in Latin America, multisectoral HIV/AIDS responses, and tobacco tax reform in the Philippines. The cases highlight constraints to working effectively and mechanisms for addressing them.

Chandra-Mouli V, Gibbs S, Badiani R, Quinhas F, Svanemyr J (2015). Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reproductive Health. 12:12.

  • This paper discusses the nationwide scale up of a multisectoral initiative, Programa Geração Biz, to improve the sexual and reproductive health of adolescents in Mozambique. This initiative involved the Ministries of Health, Education, and Youth & Sports, with technical support from Pathfinder and UNFPA.

Cole DC, Levin C, Loechl C, Thiele G, Grant F, Girard AW, Sindi K, Low J (2016). Planning an integrated agriculture and health program and designing its evaluation: Experience from Western Kenya. Evaluation and Program Planning. 56: 11-22.

  • This paper describes the program development process and evaluation design of the multisectoral MAMA SASHA project for health, nutrition, and agriculture in Western Kenya. This project was undertaken by the International Potato Center and PATH with the ministries of health and agriculture, and funded by the Bill & Melinda Gates Foundation.

Garrett J, Natalicchio M (eds). 2011. Working Multisectorally in Nutrition: Principles, Practices and Case Studies. Washington, DC: IFPRI.

  • This IFPRI book provides lessons for engaging in a multisectoral approach for the improvement of nutrition. It presents case studies of two multisectoral efforts: the Nutrition Enhancement Program in Senegal and the Food and Nutrition Improvement Plan of Antioquia, Colombia.

Lencucha R, Drope J, Chavez JJ (2015). Whole-of-government approaches to NCDs: the case of the Philippines Interagency Committee—Tobacco. Health Policy and Planning. 30 (7): 844-52.

  • This paper is a case study of the interagency mechanism in the Philippines to govern tobacco control and provides lessons learned for multisectoral approaches to NCDs.

 Puvanachandra P, Kulanthayan S, Hyder AA. (2012). A game of Chinese whispers in Malaysia: contextual analysis of child road safety education. Qualitative Health Research. 22 (11): 1476-85.

  • This paper describes the Malaysian government’s initiative to implement road safety education programs in primary schools, involving the Ministries of Education, Transport, and Health.

Cur(e)ated: A Monthly Guide to Access

February 28, 2018

A nurse in Burundi using a pregnancy wheel. Photo by Kristy Carlson | longmilescoffeeproject.com

At the end of every month, we highlight key readings—and other information sources such as podcasts and videos—that during the month have provided us with new knowledge about efforts to improve access to health technologies in low- and middle-income countries (LMICs). Though we are always eager to learn about exciting new technologies for health improvement, what really matters, in our view, is the process of getting these technologies to the people who need them. Therefore, the knowledge sources that we highlight here are not about the characteristics and uses of health technologies, but instead are about the people and systems that make access happen. When we talk about access, we mean “people’s ability to obtain and appropriately use good quality health technologies when they are needed” and we conceive of the access process in terms of four sets of activities—related to architecture, availability, affordability, and adoption—that occur simultaneously at the global-level and within national health systems (click here for more about this access definition and framework). In curating these readings every month, we hope to spotlight emerging knowledge about new and ongoing efforts to address persistent barriers to access, the consequences (both intended and unintended) of these efforts, and information gaps in the access to health technologies field.

— Sofosbuvir is a much needed treatment for hepatitis C but its high price means it is unaffordable to many patients around the world. This is the story of how a group of doctors, government officials, generic drug makers, and activists in India drove down the cost of sofosbuvir through various strategies including addressing IP barriers, regulatory barriers, and utilizing patient pooling.

— Though it’s critical to access, the process of procurement is relatively understudied in the academic literature. This paper examines procurement work processes in Tanzania and Kenya, as experienced by front line staff, and warns that the increased globalization of procurement systems has had the effect of weakening linkages within countries between health sector procurement and the local pharmaceutical and health supply industry.

Partners in Health (PIH) shares its experiences of setting up laboratory networks, with a particular focus on pathology and TB diagnostics, in Haiti and Rwanda. The authors discuss how PIH addressed access obstacles related to “staff, stuff, space, and systems,” and argue that a strong commitment to the building of laboratory capacity in partnership with national health authorities will lead to better patient care while also strengthening the public health sector.

— The Health Intervention and Technology Assessment Program (HITAP), Thailand, and the National Institute for Health and Care Excellence (NICE), UK are two institutes that have conducted capacity building for health technology assessment (HTA) throughout LMICs. In this paper, they share their lessons learned from HTA capacity building efforts in India, Colombia, Myanmar, the Philippines, and Vietnam. Key challenges include fostering of political commitment, stakeholder participation, and technical integrity of HTA in order to sustain the use of evidence in policymaking.

— The WHO Model List of Essential Medicines (WHO EML) is a guide for the development of national and institutional essential medicines list, and contributes to improving access to essential medicines. Anyone can petition for a medicine to be added to the WHO EML, and in this paper, the authors describe and assess their efforts over the last decade to modernize, through biennial petitions, the WHO EML for medications for preventing and controlling cardiovascular diseases. Unfortunately the paper is not open access but here is a (less compelling) audio summary.

— Related, a call for an essential diagnostics list similar to the WHO’s EML.

Dr. Tedros’ remarks on 26 February at the WHO-WIPO-WTO Technical Symposium on Sustainable Development Goals: “…access to health technologies—vaccines, diagnostics, medicines, medical devices and assistive technologies—is a key pillar of universal health coverage…We must not tolerate systems that put the protection of intellectual property ahead of the protection of health. Patients must always come before patents…We’re committed to working with all partners, including WIPO and WTO, and other relevant agencies such as UNCTAD and UNDP, to help countries increase access and make progress towards universal health coverage.”

–And if you haven’t seen it yet, check out this tool put together by the Medicines Patent Pool for finding out the patent status of essential medicines for HIV, TB, hepatitis C ,and cancer in LMICs, as well as licences and data exclusivity: http://www.medspal.org/

— In the Lancet this month, editor Richard Horton writes that public health science needs to give greater attention to the “lived experiences of people in societies” and to “recognize the importance of identity, reasoning, and voice.” We agree and recommend Ramah McKay’s new book Medicine in the Meantime, an ethnographic account of two global health projects in Mozambique, told through the lens of the lives of patients and health care providers.

— And finally, for my fellow podcast lovers…in this episode of the Future of Healthcare, Fred Ochieng shares his powerful story of growing up in Lwala, Kenya including memories of malaria illnesses and treatments, and his family’s reliance on Where There is No Doctor for health information; moving away to the Nairobi area and the US for his secondary schooling and graduate education in medicine; losing his mother and then his father to HIV/AIDS; and returning home with his brother to set up a health clinic in Lwala.

 

Do you have a knowledge source that you think should be included? Great! Please send suggestions to Laura at laurajfrost@glohi.org or tweet to us @glohi4access.

Ensuring access to quality health technologies and services requires a people- and systems-centered approach

The BBC recently featured the “backpack midwife”— Margaret, a community health worker in Kenya who carries a backpack full of technologies that support the provision of health care within communities, particularly for women and children. Margaret makes home visits twice per week, in an area north of Nairobi with approximately 120 households. Though she says the work can be difficult, “…this is what I must do, and it makes me feel happy to be useful and known in the community.”

[1] The “hi-tech gadgets” she carries in the backpack include a wind-up fetal doppler for detecting a baby’s heartbeat during prenatal care; a small light powered by solar charged batteries; a light-weight, battery powered portable ultrasound for OB/GYN or abdominal imaging; an in-ear thermometer; a blood pressure and heart monitor; a monitor which assesses respiratory rate in children; and a pulse oximeter that measures blood oxygen levels in both children and adults. All of these portable technologies are made by the company Philips Healthcare. The backpack is a key part of the Philips-supported Community Life Centers (CLCs) which seek to strengthen community health in Africa through the provision of infrastructure, power, medical technologies, training and maintenance, community outreach, information systems, and referral to other parts of the health system. More information about these CLCs can be found here.

The innovations in this backpack address real needs in communities with insufficient access to quality health services. But we would like to emphasize that it is not the technologies that reach people in these underserved, and often remote, areas. It is a person—often a community health worker (CHW) like Margaret—who transports and uses these technologies during their interactions with members of the community, considers when to employ them and how to act upon results, and decides what to do when batteries run out or maintenance is required. In many countries, national health strategies recognize that health begins at the household and community level. As such, CHWs are often best placed to perform important outreach services in communities and act as a vital link in the chain of referral to other parts of the health system. For this reason, development partners often design initiatives that either recruit a specialized cadre of CHWs or draw upon an existing national pool of CHWs. However, questions remain as to how such CHW initiatives can best be structured. What is CHW’s relationship to the wider health system? To whom are they responsible and to whom are they accountable? How are they selected, trained, retrained, and incentivized?

One key issue that has long been debated both within countries and at the global level is compensation for CHWs. This is important because in most settings, there are high attrition rates amongst CHWs who have been recruited and trained, but who do not receive financial payment. The BBC article points out that Margaret is an unpaid volunteer. This is not unusual in Kenya, or indeed many other countries in Africa, where the majority of CHWs are unpaid.

Efforts to change this are ongoing and a campaign was launched at the Africa Health Agenda International Conference in Nairobi last year that advocates for integrating and renumerating CHWs like other civil servants in the health workforce. A recent report by six organizations implementing CHW programs around the world underscores the importance of some sort of financial payment for CHWs (e.g. salaries, performance-based rewards, etc.). Based on a review of their own experiences, these implementing organizations identified eight minimum elements needed for CHW programs to succeed, one of which is that CHWs must receive financial payment, and that non-monetary incentivization is insufficient. In addition to being paid, the report argues that CHWs should be accredited, accessible, proactive, continually trained, supported by a dedicated supervisor, part of a strong health system, and part of data feedback loops.

These design principles raise important questions about CHWs in Kenya like the “backpack midwife.” How can CHWs like Margaret be trained, supervised, renumerated, and given a career path forward as part of the country’s formal health system? Who finances CHW programs—district government or national government or international agencies? How much should communities themselves contribute to CHW remuneration? How should other potential non-monetary public service incentives be handled (for example, housing, pensions, access to banking facilities)? How can such a large financial undertaking be sustained in light of existing human resources crises across primary, secondary, and tertiary health facilities?

These are critical questions for Kenya’s President Uhuru Kenyatta, as he embarks upon his strategy of affordable healthcare for all by 2022, announced in December 2017, as one of four pillars of his final term. They are also important questions for global health professionals seeking to roll out new health technologies in countries such as Kenya. A backpack (and the life saving health technologies within) is only as good as the person who carries it. And the person who carries it is only as good as the health system allows her to be. So, when rolling out new health innovations, let’s not forget that our focus should be on the systems and the people—like Margaret—whose work is essential to improving access to quality health care. A technology-centric approach will not suffice.

[1] Munford, M. (2018; January 23). Meet the ‘backpack midwife’ bringing healthcare for all. BBC News. Retrieved from www.bbc.com.

What We’re Reading: A History of Global Health

In A History of Global Health (Johns Hopkins University Press, 2016), historian Randall M. Packard examines why initiatives to prioritize and implement comprehensive approaches to health, as opposed to narrow technological ones, have failed to be sustained over time. This book centers on a tension that most of us working in global health have long felt—between the urgency (and perceived efficiency) of addressing health problems through technological fixes/vertical programs and the critical yet painstaking work of supporting health systems and addressing underlying structural determinants of health.

Some years back, this was a central theme in my own doctoral research studying efforts to eliminate trachoma through the SAFE strategy (Surgery, Antibiotics, Face-Washing, and Environmental Improvements) via the Alliance for the Global Elimination of Trachoma by the Year 2020, a partnership launched by WHO in 1997. Though the SAFE strategy was a well designed, comprehensive approach to the elimination of the world’s leading infectious cause of blindness, I questioned whether equal or greater financing and attention would ever be given to the F and E components— strategies that address the underlying causes of trachoma and require a longer-term commitment from, and collaboration between, donors, governments, and implementing agencies. Indeed, throughout the almost 20 years of the global trachoma elimination initiative, the administration of antibiotics has, in practice, remained at the center of trachoma programs (Freeman et al, 2013). And despite impressive progress in countries like Morocco (Levine, 2007), recent analysis suggests that annual antibiotic administration alone is unlikely to achieve sustained elimination of infections, particularly in highly endemic communities, without concomitant improvements to the environment (Jimenez et al, 2015). Renewed efforts are thus underway for increased collaboration between the WASH and neglected tropical disease sectors and more funding for the F and E components of the SAFE strategy.

What makes A History of Global Health an essential read for students and practitioners of global health is the detail that Packard provides, beginning with colonial settings and ending with the West African Ebola outbreak, to demonstrate why efforts to broaden global health’s frame have failed to gain momentum. Packard begins by showing us how a focus on disease elimination campaigns began during the colonial era and became central in subsequent international health efforts which were, in many instances, led by former colonial medical officers. Efforts to go beyond such disease elimination campaigns in order to strengthen health systems and address the structural determinants of health have periodically been attempted —notably in the 1930s and 1940s with the emergence of social medicine and universal health care systems in Europe, and later with attempts within international health to build a primary health care (PHC) movement in the 1970s – however, public health paradigms persistently returned time and time again to vertical, disease-based approaches. These more comprehensive efforts have not taken hold in global health for a number of intersecting and mutually reinforcing reasons.

For example, following WWII, crises due to epidemics and food shortages among war-affected populations in Europe and Asia required rapid responses that could not wait for longer-term, integrated strategies. At the same time, new technologies and innovations emerged during the war years and inspired optimism amongst international health actors that these innovations could be used to rapidly improve health. For example, the discovery of DDT offered the possibility of addressing malaria, yellow fever, the plague, and typhus. Furthermore, political contexts in some settings meant that broader approaches to health and development were distrusted. This was particularly the case in the U.S. amongst right-wing politicians during the McCarthy era who were isolationists and had misgivings about the UN, and were suspicious of any program that looked to be “socialist” (such as national health insurance).

Packard also traces the barriers to implementing the PHC model. Advocates failed to provide successful examples of programs that had gone to scale for countries to learn from. There was also unanticipated resistance in some countries to redirecting investments in health that were necessary for implementing the PHC model. In addition, the successes of the disease eradication campaign for smallpox refocused attention on the potential of technological strategies to solve health problems, while the feasibility of PHC was questioned in terms of expense and human resource requirements, leading to the adoption of “selective PHC” delivered through targeted programs. Furthermore, changing economic environments marked by the global recession of the 1980s made it difficult for governments to invest broadly in development and address inequalities. Countries borrowing from the IMF were faced with structural adjustment policies that forced them to reduce spending, particularly for social sectors like health, with negative effects on the availability and accessibility of health services.

In the 1990s and 2000s, the field of “global health” emerged as “a set of practices, organizations, and ideas (p. 273). A diverse array of organizations and partnerships involved in planning and implementing health programs were established, and vastly more funding became available for the global health sector. Such initiatives often recognized the need to address the structural determinants of health; however, this recognition was rarely translated into operationalizable, well-financed policies and programs. This period was also marked by conditionalities set by funding organizations because of concerns about the ineffectiveness and inefficiency of development aid. Selective approaches were encouraged by donors. NGOs were prioritized over national government and the private sector’s role was increased. Finally, public sector accountability was emphasized.

The focus on accountability led to an emphasis on prioritizing evidence-based interventions in global health, often via randomized controlled trials (RCTs) which became the gold standard for generating evidence on interventions. Such evidence-based interventions tended to favor interventions focused on technologies, as these are easier to study in trials than broader, comprehensive approaches. Parallel to the growth of the focus on RCTs, an increasing reliance within schools of public health on research funding meant that in many schools, students were trained to conduct research on health problems and interventions rather than to build and sustain health systems and collaborate across sectors.

Packard demonstrates how all of these trends led to an increased commodification/ medicalization of global health, and to a situation where health systems in poor settings remain unsupported and unable to fully address the health needs of their populations. This medicalization and commodification, Packard argues, has undermined ministries of health to plan and manage health programs, and led to the weakening of health services in many countries.

Finally, Packard stresses that decisions in global health have always, and continue to be made, by people and in locations far from those affected by these decisions. Increasingly, he argues, organizations that do not represent a consensus of nations on the receiving end of global health aid are making decisions about policies and programs for the improvement of population health in these nations. As anthropologists Joao Biehl and Adriana Petryna (2014) state, “we find ourselves face-to-face with profound disconnections between campaign designs and intentions and the complex ways in which those campaigns are actually received and critiqued” (p. 380). The consequences for the health of the poorest are grave. Disease is never just one thing, requiring a single solution. An individual’s health is influenced by biology as well as social, economic, and political factors. Until we seek to understand and engage with the complexities within which people’s lives are experienced and the systems within which interventions are implemented, sustained improvements in the health of the world’s poorest will remain elusive.

In global health, we are continually confronted with difficult decisions, particularly in times of crisis when we need to act with urgency. This book reminds us that our choices are not made in isolation—instead, we operate within a global health system that is governed by history. Moreover, the decisions we make may have collateral effects and unintended consequences. In this SDG era, we are increasingly committed—at least in our discourse—to working multisectorally in health and supporting countries to provide universal health coverage. To ensure that the pendulum does not swing back, once again, to an overwhelming focus on technical, vertical approaches, we must do better than before. We must put people in the center of our endeavors and make a concerted effort to better understand and confront the forces, some of which are listed above, that over time have limited actual and sustained achievements in comprehensively and collaboratively improving population health around the world.

 

References

Biehl J, Petryna A. (2014). Peopling global health. Saúde e Sociedade. 23(2): 376-89.

Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, Amnie AG, Beckwith C, Cairncross S, Callejas R, Colford Jr JM, Emerson PM. (2013). Integration of water, sanitation, and hygiene for the prevention and control of neglected tropical diseases: a rationale for inter-sectoral collaboration. PLoS Negl Trop Dis. 26; 7(9): e2439.

Jimenez V, Gelderblom HC, Flueckiger RM, Emerson PM, Haddad D. (2015). Mass drug administration for trachoma: how long is not long enough? PLoS Negl Trop Dis. 23; 9(3): e0003610.

Levine, R. (2007). Case 10: Controlling Trachoma in Morocco. In Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett Publishers. Pages 73-80.

Packard, Randall M. (2016). A History of Global Health. Johns Hopkins University Press.

 

Harnessing Data for the SDGs Requires a Human-Centered Approach

All you have to do is walk into a primary health center or health post and eyeball the record-keeping and you know that health statistics in Africa need serious “enhancement.” On September 25, 2015, the Global Partnership for Sustainable Development Data was launched—the partnership is a multi-stakeholder group seeking to harness the power of data and technologies to drive implementation, measure progress, encourage accountability, and achieve the Global Goals. In a recent CGD blog post, Amanda Glassman asks the new partnership for more clarity on how partners’ commitments to the initiative will meet the need and will within low-income countries to produce and use better data. How will these commitments, she asks, work together at the country level where limited capacity requires coordination rather than siloed approaches?

We agree. But we also want to emphasize that data collection is not just about funding and developing data systems in countries—it is about funding and developing health systems more broadly.

Because, after all, who will collect this data? In most African countries, isn’t it (mostly) primary health workers? And how does health service delivery work at the primary level? Doesn’t it typically take place in under-staffed, over-worked rural health centers, in which two to three health workers (tops) oversee the daily clinical care of upwards of a hundred patients on very low and often inconsistently paid out salaries, while simultaneously being responsible for all the record keeping and data collection on behalf of: a) the Ministry of Health; b) parallel vertical programs; and c) assorted clinical and operational research projects, all without a dedicated data manager on site? Health workers not infrequently end up entering or phoning in data on their own time (and sometimes on their own mobile phones using their own airtime). And sometimes they don’t find the time at all.

As an example, Yassi et al (2014) provide insight into the human resources barriers to data management when describing a joint South African-Canadian Occupational Health RCT in South Africa.

[1] They note that the research team “continues to seek the most convenient way for busy occupational health practitioners to systematically collect the data needed for operational purposes, as well as for our RCT, without adding burden.” Our experience suggests that this dilemma is shared not only by many operational research projects, but also by national information systems more broadly. Yet too often the human resource-related problems encountered during data collection get swept under the rug during “data cleaning.”

Likewise, Lesley-Anne Long of mPowering Frontline Health Workers notes that frontline health workers are frequently burdened with “unfeasible workloads [and] under-valued by their communities, other health workers and Ministries of Health. Add to these challenges the fragmented activities of the global health development players – where collaboration is vital but consistently fails to move from rhetoric to reality, and where funding so often ring-fences aspiration for impact.”[2] Long argues that failure to support frontline health workers, in particular community health workers, is one contributing factor as to why so many projects have failed to go to scale.  But the same argument can be applied to countries’ struggles with information systems in general, especially those relying on data collected at the primary or community level.

Improved data collection and management, then, is a human issue as much as it is a data systems issue. It is a labor issue. It is a workplace quality issue. It is a service delivery issue. And if new systems of collecting statistics put an unfair time and resource burden on health facility staff at the lowest levels of the health system, then the only thing that has been enhanced is the implementing/research/financing partner’s program portfolio.

We argue that at the forefront of efforts to improve data systems in African countries, the relevant questions are:

  • How can we create data systems that are realistic to the environment and human resources restrictions that exist in the real world?
  • How can we make data collection systems health worker-friendly and patient-friendly?
  • How can we achieve maximum data collection with minimum human resources burden?
  • How can we ensure data collection does not result in less time spent on patient care?

Let’s fund efforts to address these questions along with new data systems. Because without people, new data systems can’t possibly succeed.

 

[1] Yassi A, O’Hara LM, Engelbrecht MC, et al. Considerations for preparing a randomized population health intervention trial: lessons from a South African–Canadian partnership to improve the health of health workers. Global Health Action. 2014; 7: 10.

[2] http://1millionhealthworkers.org/2015/05/18/data-for-decision-making-series-the-importance-of-chw-data-collection-by-lesley-anne-long/

We’re Blogging!

Years ago, I was engaged in my first study of innovation and access, working with the Harvard School of Public Health on a case study of the Mectizan Donation Program (MDP). MDP is a groundbreaking donation program established by Merck and partners to get ivermectin for the treatment of onchocerciasis out to the people who needed it. During a presentation of our findings at a conference on the outskirts of Boston, a fellow researcher asked, “But it sounds like you found that the MDP was a success because of the people. That seems to me problematic because what lessons can the global health community learn from this finding? Weren’t they just lucky to have the right people in the right place at the right time?”

As a researcher with a background in both public health and social sciences, this comment still manages to both surprise and alarm me. Access to technology and services is both a technical issue and a human issue. Technological solutions for health cannot occur without people. Ensuring access to technologies and services requires advanced planning, sufficient resources, and a lot of persistence and hard work by people. Most importantly, developing appropriate innovations and achieving access cannot occur without understanding people’s lived experiences of illness. While we love geeking out about new innovations, what we are really passionate about are the people that develop technologies and ensure they get to those who need them, along with the people who plan for, implement, and utilize such technologies in their daily lives. And we think the global health community has much to learn from their stories and experiences.

So was the MDP lucky because it had “the right people in the right place at the right time”? The short answer is “yes.” But there is nothing problematic about this finding. It simply illuminates the importance of prioritizing human solutions to critical health problems over technical ones, and placing people—program managers, practitioners, and, most vitally, patients—at the forefront of global health.

In 2008, we, the partners at Global Health Insights, wrote a book with Professor Michael R. Reich called Access. Since that time, we have been living throughout Africa (Burundi, Democratic Republic of Congo, Egypt, Uganda, and Zambia). We have become increasingly focused on the intersection of innovation, access, context, and health systems in middle- and low-income countries – as well as the social experience of disease and the people that make innovation and access happen. These are the topics that we look forward to exploring and debating on this blog with all of you!