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Posts Tagged ‘health system strengthening’

The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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The most griping message from Dr. Peter Mugyenyi this week was, of course, his stories about HIV patients in desperate need of treatment being turned away, including pregnant and breastfeeding women who risked passing the deadly virus on to their babies. As director of Uganda’s Joint Clinical Research Center, the largest PEPFAR implementer in East Africa, Dr. Mugyenyi painted a heart-wrenching image of patients who had been promised treatment going from one clinic to another, only to be told there would be no open slots until a currently enrolled patient died.

But another vital perspective that got less attention in Dr. Mugyenyi’s meetings this week with members of Congress, the Executive Branch, and the press, was that the idea of health systems strengthening—at least as its being conceived in Washington today—may actually undermine, rather than bolster, the gains made in fighting AIDS.

Why? Dr. Mugyenyi says we must go back to the 1990s in Africa, before the historic roll out of antiretroviral treatment in the developing world, when HIV was a death sentence.

“In the 1990s, you just couldn’t strengthen health systems because they were clogged … Clogged with AIDS patients,” he said. He recalled serving as the head of a children’s ward in one of Uganda’s main hospitals and he said the entire ward was filled with sick, dying children. When they tested for HIV, 100 percent of the children were found to be positive. 

“If you went to the surgical ward, it was the same. If you went to the medical ward, it was the same,” he said. “What happened to the other diseases? Had they gone into recession? Of course not.” They had simply been displaced by the mayhem and crisis created by AIDS.  

Dr. Mugyenyi and others meet with Rep. McDermott

Today, when he goes to a medical ward in a hospital, patients with those other diseases are there, being successful treated and cured, because the AIDS patients are no longer filling all the beds.

Any effort to strengthen health systems, Dr. Mugyenyi said, “must be focused to the realities on the ground.” Those realities include AIDS being a continuing, consuming crisis that the world cannot afford to turn away from. An effort to strengthen health systems is welcome, he said, but not if it takes away from the focus on combating AIDS.

Dr. Mugyenyi was in Washington this past week for a series of meetings with policymakers, advocates, and the press, in a trip organized by the Center for Global Health Policy and several other groups. This is part of the Global Center’s efforts to make the voices of developing country physicians heard in American policy debates.

Click here to see a video interview with Dr. Mugyenyi or here to read a VOA story highlighting his concerns. This Huffington Post blog also takes a wider view of the messages Dr. Mugyenyi brought to Washington this week.

Dr. Mugyenyi meets with Rep. Henry Waxman on Capitol Hill

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The November issue of the Journal of Acquired Immune Deficiency Syndromes offers something of a roadmap for how best to move forward, more productively and less bitterly, in the decades-old debate that pits diseases-specific health initiatives against broader efforts to strengthen health systems. With nearly 20 articles exploring the relationship between HIV scale up and global health systems, JAIDS is weighing in on the hottest topic du jour in Washington and various academic circles.

But the opening piece, an introduction by Drs. Wafaa El-Sadr and Kevin De Cock, reminds us that this should not be an esoteric debate, disconnected from the health care realities on the ground in the developing world. “Health systems exist to provide services for real people to prevent and treat diseases that have names,” they write. Failure to recognize that could have devastating consequences.

“Perhaps most seriously, the debate fails to take account of the lives saved through PEPFAR and the Global Fund, and the implications for countries and systems if those advances are not sustained or extended,” Drs. El-Sadr and De Cock say. “We cannot forget that it was the unparalleled impact of untreated HIV/AIDS in Africa that launched these major initiatives and that the prevention of death remains a core public health function. At the same time, criticisms such as that HIV/AIDS programs steal health care workers or are sometimes ivory tower initiatives amidst a sea of misery need to be examined seriously.”

Instead of a polarizing and theoretical debate, these questions need to be addressed with strong “global health leadership, clarity of thought, pragmatism, and sound understanding of disease epidemiology.”

And that’s just the JAIDS opener on the topic. Click here to see the table of contents and read the rest.

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For decades, global health experts, policymakers, and others have been debating the merits of disease-specific initiatives versus broader efforts to strengthen health systems. It’s the old the vertical vs. horizontal argument.

No one has settled that debate. But maybe we should stop asking that particular question. Or at least start asking some new ones.

 “It’s not a helpful way to frame the issues,” Peter Berman, a lead economist on the health, nutrition and population team at the World Bank said today at a brown bag lunch exploring what TB and AIDS programs can contribute to health system strengthening in Africa.

He said all health initiatives, whether focused on one disease or on something broader, are aimed at improving results, i.e. health outcomes. So it’s not productive to engage in a debate that pits one approach against another. Instead, Berman suggested, we need to start asking more “why” questions. Why is the quality of a country’s TB program so poor? Why are the primary care clinics in another resource-poor country crumbling?

“We need to think more about the casual analysis,” he said. If we don’t ask the why questions, he said, we’re at risk of introducing “technical solutions” that improve things in the short term, but that fail to make enduring fundamental change.

Berman’s remarks came near the end of the World Bank session, which featured two experts from Family Health International. (more…)

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From antiretroviral drugs to bicycles, one program in Zambia is redefining the notion of integrated health services and care.

The Global Health Council’s Vince Blaser blogged about the program, called RAPIDS, or Reaching HIV and AIDS Affected People with Integrated Development and Support, here.

The program’s main focus in HIV prevention and treatment, but implementers have added a range of additional services–from malaria prevention to food security. And then there are the bikes–offered to caregivers to help them “cover greater distances, use it for personal or economic reasons and transport community members to local clinics,” as Blaser writes. 

This seems like just the kind of innovative program information we’re looking for as we gather hard data and interesting anedcotes about the impact of PEPFAR and other global AIDS programs on developing country health systems for a special report on this topic.  Please feel free to share any similar info or stories!

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As the 5th IAS Conference drew to a close, the society released a broad-brush statement summarizing some of the scientific and policy highlights of the meeting. The bottom line is that money spent treating and preventing HIV in the developing world also helps improve health and strenghten health systems.

This is no small point at a time when the Obama Administration is looking for a cost-effective way to bolster US global health programs and appears to be rethinking the emphasis on global AIDS.

New evidence illustrates “how investments in HIV have contributed to reductions in infant mortality and TB incidence, improved access to health services for women, and expanded health systems capacity,” the IAS wrote on its blog today. “As a result of investments in HIV, clinics and hospitals are being refurbished; laboratory and diagnostic capacity is being strengthened; additional cadres of health workers are being mobilized; and morale among health workers is greatly lifted.”

Click here to read the full IAS statment and here to read the blog. 

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Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that the Fund and PEPFAR are probably the most significant players in efforts to strengthening health systems.

Speaking after an International AIDS Society workshop on the impact of HIV program on health systems, Kazatchkine sought to counter arguments that HIV programs undermine health systems. Click here to read the Aidsmap story on this front-burner issue.

 

 

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