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Health Systems

Born Too Soon: Landmark report & new data on global pre-term births

May 2, 2012
Aid, Global Health, Health Systems, Women's Health
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Each year, 15 million babies around the world are born prematurely, and 1 million of those die as a result of their preterm birth  New findings highlight how even in countries like the US – where we often hear about “million dollar babies” – preterm birth is a huge challenge as public health and clinical experts work to help every child reach his or her fifth birthday and beyond.

Born Too Soon: The Global Action Report on Preterm Birth provides the first-ever national, regional and global estimates of preterm birth. The report shows the extent to which preterm birth is on the rise in most countries, and is now the second leading cause of death globally for children under five, after pneumonia.

Addressing preterm birth is now an urgent priority for reaching Millennium Development Goal 4, calling for the reduction of child deaths by two-thirds by 2015. This report shows that rapid change is possible and identifies priority actions for everyone.

The report is a joint effort of almost 50 international, regional and national organizations, led by the March of Dimes, The Partnership for Maternal, Newborn & Child Health, Save the Children and the World Health Organization in support of the Every Woman Every Child effort, launched by UN Secretary-General Ban Ki-moon. 

You can access the report and other key resources on the following sites:

“If you give a country a dollar…”: Subadditionality in Global Health Financing

January 25, 2012
Aid, Health Financing, Health Systems
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Two themes in global health programming make the question of how countries change their spending on health in response to receiving donor funding (substitutability or subadditionality*, if you’re being fancy or technical) particularly important today.

  1. As global health budgets have become more uncertain in recent years (though, globally, have not decreased) contemplating how countries will respond if donor funding shrinks becomes more of a necessity than a fleeting consideration, and
  2. Emphasis on country ownership begs the question: how can countries respond with appropriate funds from their own coffers as donor budgets are drawn down over time and countries take responsibility for financing their own health programs.

Michael Herman addressed the issue of subadditionality at the recent Global Health Council event highlighting findings of the IHME Financing Global Health 2011 report.  Literature from the past 30 years conducted by economists has “concluded that sector-specific foreign assistance to governments.” More recent studies have also found that receiving sector-specific aid money (i.e. donor dollars tied to a specific area like health) causes recipient countries to shift their own spending away from the sector that receives the aid. But at what levels? How much spending shifts away for each dollar invested?

The research question to be tackled: Do governments replace grants for health at the same rate or a slower rate when assistance funding is lost?

The overall findings: Preliminary research indicates replacement happens at a slower rate. “Subadditionality persists,” said Herman. When countries receive development assistance for health (DAH) from donors, they spend less of their own financial resources on health.  The complete findings are fleshed out in Chapter 4 of the IHME report.

I think technical terms can be intimidating, so I’ve created an infographic of an example (with simple numbers) presented by Herman, highlighting three scenarios: no donor funding & funds increase as expected year by year, an injection of donor funding where the country decreases the amount it plans to spend on health, and an injection of donor funding where the country does not decrease the amount it plans to spend on health.


How this plays out in real terms varies by region, country, and DAH recipient. The report provides an example from East Africa, showing what happens in 2006-2007 and 2008-2009 in response to fluctuations in donor funding. First, we see that in 2006-07 DAH to the government (DAH-G) appears to have decreased government health expenditure as a source of funds (GHE-S), while DAH to NGOs (DAH-NG) appears to have sparked an increase in GHE-S by $57 million.

The following two year period (2008-09), a decrease in DAH-G sparked an increase in GHE-S though.

Because of the complexities of the financial flows, researchers found it difficult to understand how the different flows of DAH (government and NGO) ultimately affect health outcomes in a country. As such, you cannot generalize that giving to an NGO is more effective than giving to governments, and you need to ask the harder questions around what happens when you provide donor dollars to cover health expenditures. Do you increase the cost of doing business in a country due to rules and regulations? Provide investment to underscore the importance of spending on health? The list could go on.

What does all of this financial back-and-forth mean for populations living in developing countries, who often rely on health services funded jointly by the government and donor resources though? Herman suggested the following:

  • the impact on health outcomes remains important, and having resources available to finance health programs is essential improve outcomes;
  • don’t lose sight of the context in which all of the financial data is being crunched; just because on the surface it appears assistance to NGOs creates a positive response (more government spending on health) and assistance to governments creates a negative one (less government spending on health) does not mean it’s necessarily better to give money to NGOs;
  • in 2012, continued progress on the Millennium Development Goals for health depends on the trajectory of DAH growth and the response of Ministries of Finance in recipient countries;
  • And finally, from what we’ve seen in the past, when budgets are cut, child mortality ultimately increases, which is something none of us want to see.

*IHME’s quick summary of subadditionality: “Last year, we studied the relationship between DAH and public domestic health spending. We found that for every $1 of DAH channeled through government (DAH-G) that flowed to a country, governments on average took $0.43 to $1.14 of their own money away from the health sector. We call this phenomenon “subadditionality,” which occurs when DAH to government partially or fully substitutes for public domestic health spending. The opposite phenomenon, or “additionality,” happens when DAH-G fully supplements [government health expenditure as the source].”

More on the general findings of the report in this post  from last week. This post is the second of four on the IHME Financing Global Health in 2011 report and a related event at the Global Health Council.

Community Health Workers: Champions in the Fight against Child Pneumonia

November 11, 2011
Aid, Health Systems
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While the social media sphere has been abuzz with updates and tweets about 11/11/11 – and rightly so, given that it’s Veteran’s Day – the global health community has its eye on the day after.

November 12th marks the annual World Pneumonia Day  for advocacy about the leading cause of death for children under five around the globe.  1.4 million children die each year as a result of pneumonia, and most of those deaths could be averted through simple treatment.

In remote areas, though, families often don’t have the time, money or other resources to access facility-based care. Choosing between taking a child 30 kilometers to a health facility when they show signs of illness and putting food on the table is a reality for many families throughout the developing world. According to Dr. Elizabeth Mason from the World Health Organization, only 30% of children in need of treatment for pneumonia actually receive it. A solution to that challenge of access comes in a form familiar to those in global health sphere:  community-based treatment.

By training health workers to provide simple interventions at the community level, famliies with no immediate access to a health facility could receive care without an undue burden of cost or time.  Well-timed with World Pneumonia Day, The Lancet published a study supported by USAID and conducted by Save the Children, the Boston University Center for Global Health and Development, and the World Health Organization clearly documenting the success of community-based treatment of child pneumonia in Pakistan. Researchers found that the risk of discontinuing or failing to receive treatment was significantly lower for those in the intervention group (receiving community-based care) compared to the control group (only received facility-based care).

New data supporting a promising practice to save lives are wonderful, but will raise questions around the next steps for the global health community, such as:

How does research like this translate into practice? The next challenge will be for WHO to consider revisions to its recommendations for treatment of child pneumonia and include home-based administration of oral antibiotics. Recommendations are made and revised based on large bodies of evidence, including studies like the one noted earlier. To act on any new recommendations will then require global health organizations leverage existing resources to support training community health workers  (CHWs)– either existing cadres or new ones – in this specific treatment protocol.  Notably, numerous organizations and donor agencies are already supporting many community-based programs; the USAID Child Survival and Health Grants Program has some great examples.

What needs to happen as recommendations are being considered and programs designed?  Any number of items, depending on who you are. Two important priorities should be better counting and mapping of existing CHWs and advocacy around why this approach is important – whether programs are implemented today or next year, they will require resources.

Why is mapping and counting CHWs so important? In order to identify where CHWs have already been trained and could be taught additional skills, updated data on the number and location of CHWs around the world is needed. Information is power, particularly when you’re working to deliver services in remote and underserved areas. The most recent data on how many CHWs work in various regions is outdated (more than 6 years old), particularly for an informal work sector with high turnover. That data indicated that more than half of the 100 million trained health workers documented were informal, rather than physicians, nurses, and midwives, according to Dr. Arial Pablo-Mendez, Assistant Administrator for Global Health at USAID. Efforts to document existing cadres of CHWs are moving forward though, which will hopefully provide much needed data on existing human resources for health and their distribution.

What kind of data do we have to advocate for community-based care? From a financial perspective, Mary Beth Powers from Save the Children, indicated it only cost around $300 per health worker for all of the required training around community case management of child pneumonia.  With funding for global health under attack, low-cost/high-impact interventions like these are essential to continue and scale up programs to maximize the number of lives saved.  In addition to saving children’s lives, the community health workers feel empowered, receive increased respect from the community after demonstrating how lives can be saved through their simple actions, and projects build local capacity that will live on beyond the life of the project.

Leaders in the global health community are supporting increases in community –based care for child pneumonia, and have the data to illustrate the potential in these programs. Next up: advocating for integrated community case management of childhood illness (iCCM), which has also been demonstrated to be highly effective and financially smart. On this World Pneumonia Day, consider lending your voice to help combat some of the 1.4 million child deaths that happen each year as a result of this disease.

#socialgood day 2: Community Health Works

September 21, 2011
Events, Health Systems
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Today was star-studded. They brought out the big guns, from Serena Williams to Lance Armstrong to Mandy Moore to Jeff Sachs (perhaps only a celebrity to wonky aid types like me). Presentations were filled with interesting questions and conversations, but at the end of the day there are a few things that stuck with me. At the forfront of my mind: just how important community health workers (CHWs) and a community health approach are to the success of global health programs, and the amazing ways these individuals are using new technology.

Dr. Len (Deputy Chief Medical Officer, ACS) responded with a resounding “Yes, yes, yes!” when I asked him if there was a place for CHWs in behavior change, education, and screening around noncommunicable diseases (NCDs). Jeff Sachs mentioned the work done by CHWs as part of the Millennium Villages Project. One of Ericsson’s Technology for Good projects provides CHWs with mobile handsets loaded with the ChildCount+ app, allowing them to enter basic data and autogenerate medical records for clients. Mandy Moore talked about how community health workers are distributing bed nets and providing education around how to use them. And the list goes one.

The importance of taking a community health approach is not new.  The Child Survival and Health Grants Program has been working in communities for decades, and the CORE Group was founded to provide a place for NGOs working on community-based service delivery to network and work together.  Community health systems have received increased attention as an important item for consideration in health systems strengthening programs, and I’ll be curious to see how all of the rhetoric around that importance translates into action.

The presenters today, though, highlighted how they’re emphasizing the importance of and empowering CHWs through their projects, which I found exceptionally interesting and admirable. While questions around who pays for incentives or salaries for CHW cadres, or what services they will be trained to provide still persist, I love that their role and importance has made it on the agenda for both private industry and social good organizations.

For immediate action: international affairs funding

August 9, 2011
Aid, Health Systems, US Policy
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If you believe the cuts being made to the international affairs budget are shortsighted like many of us who work in international affairs, please consider printing, signing, and mailing this letter to Chairman Leahy and your Congressperson. Foreign assistance – excluding military spending – accounts for less than one percent of the federal budget, and while these cuts will have devastating effects on individuals, families, and communities, they will hardly make a dent in the cuts that need to happen to resolve the spending/debt crisis we’ve created.

If you need domestic – and not just doing-good – justification for why foreign affairs spending is essential to domestic growth, please see my previous post where a few kids will tell you what you need to know.

I’m not lucky enough to have representation who can vote in the House or Senate, thanks to the fact that I live in DC. I still plan on signing & sending this off to the reps from my childhood homes, though, and to Chairman Leahy.

Special thanks to CORE Group and PATH  for drafting and circulating this letter. You can also cute and paste the letter into this form, with your name, and send it electronically.

—

ACTION: PLEASE SIGN ON TO THE LETTER BELOW (also attached) AND EXPRESS YOUR CONCERN ABOUT PROPOSED FUNDING CUTS BY FRIDAY AUGUST 19.

August xx, 2011

The Honorable Patrick Leahy

Chair,

Subcommittee on State/Foreign Operations

Committee on Appropriations

U.S. Senate

Washington, DC 20510

Dear Mr. Chair:

We are writing to express our extreme concern about the potentially devastating effects of the deep and disproportionate cuts in the House of Representative’s International Affairs Budget. As you continue work on the Fiscal Year 2012 (FY12) Appropriations bills we, the undersigned organizations, urge you to defend long-standing US commitments to meet critical health and development needs by fully funding the International Affairs account, including global health programs, within the State, Foreign Operations and Related Programs Appropriation bill.

The bill being considered in the House would cut 9% from current global health funding levels. This means that

    • 24,074 more infants will be infected with HIV
    • 345,559 orphans and vulnerable children will potentially lose their food, education, and livelihood assistance
    • AIDS treatment will be eliminated for 332,216 people;
    • 3.8 million fewer people will be treated for malaria
    • 37,292 fewer people with tuberculosis (TB) and 375 fewer people with multidrug-resistant TB would receive lifesaving treatment, seriously endangering their lives as well as others’ due to the highly contagious nature of this illness.
    • 640,000 mothers and newborns would not be reached with life-saving interventions during pregnancy, childbirth and soon after birth.
    • Over 1 million (1,028,330) fewer children could receive low-cost antibiotics to treat pneumonia – the leading killer of kids under five
    • 1.6 (1,623,165) million fewer children could receive oral rehydration salts that can help save many of the 1.2 million who die needlessly from diarrhea.
    • More than 900,000 (910,158)children could not be immunized against measles, tetanus, and pertussis.
    • Thousands of health workers could not receive the midwifery training needed to help ensure that mothers deliver with a skilled health worker present – seriously endangering the life of the mother and newborn.

This is not the time for the United States to retreat from global leadership on health and development assistance programs.  In a world where health, development and economic growth are inextricably linked, it is in the best interest of our economy and national security to ensure the creation of strong and healthy nations. It is important that U.S. efforts to defend our national security be augmented by health and development policies and programs that prevent inequity and unrest. The U.S. must remain committed to battling conditions that lead to extreme deprivation – such as lack of access to food, safe water, adequate health care – and infringement of basic human rights, which create environments conducive to fostering threats against the security of our nation.

Although the U.S. budget for global health comprises less than one percent of the total federal budget, these programs are high-impact and cost-effective. U.S. support for global health – has provided funding that has enabled the U.S. to

  • treat more than 3 million people living with HIV and prevent HIV transmission among millions more;
  • cut  the number of malaria cases by more than 50% in 43 countries in the last 10 years;
  • immunize more than 100 million children each year;
  • treat 10 million people with tuberculosis;
  •  treat more than 168 million people for neglected tropical diseases;
  • help millions of women prevent unintended pregnancies;
  • increased the number of skilled birth attendants present during

deliveries; and support research to develop and deliver new vaccines,drugs, and other critical health tools.

These resources allocated to global health are critical to advancing U.S. interests and other international development targets and objectives, mitigating the effects of the global financial crisis and securing a healthier, safer world. Now is not the time to roll back progress.

We recognize and understand the difficult fiscal environment facing this country. We are also concerned about the costs of disproportionate cuts on programs that have proven their value and effectiveness.  Heedlessly slashing US global health programs will reverse the gains we have seen worldwide, and ultimately cost us more in the long run.  An overwhelming majority of Americans across the political spectrum have supported U.S. assistance for global health and development programs. We urge you to support full funding for the International Affairs budget and American commitments to global health in the FY 12 .

Sincerely,

[your name here]

My other blog activities

June 15, 2011
Aid, Aid Work, Health Systems, Water and Sanitation, Women's Health
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I’ve been neglecting my personal blog over the past couple months for two main reasons:

1. My schedule has been nothing less than crazy between work with One Home Many Hopes, my full time job at MCHIP, and a good number of personal commitments (serving as the maid of honor in a wedding is a delight and an honor, but takes time!).

2. I’ve been blogging at MCHIP.net! (Content on this site remains mine, though, and my opinions do not necessarily represent the views of MCHIP, USAID, or my employer.)

If you follow me on Twitter or have managed to track me down on Facebook, you’ve probably seen me cross-posting a number of items from MCHIP.  In case you missed them, below are links to some posts I’ve written over the past couple months. If you’re interested in maternal, newborn, and child health, I hope you’ll considering following MCHIP on twitter and liking us on Facebook - the project does amazing work, and the best way to stay up to date on our activities at headquarters and in the field is to connect through social networks.

Thinking of Poverty Like a Bathtub

Three Themes: Collaboration, Men, and the Power of Girls

WHO Officially Endorses the Use of Misoprostol 

New National Data from Kenya on Service Readiness and Quality

Water: A limited resource essential to life and health

mHealth: Not just for techies

Reducing Newborn Deaths with Handwashing

Investing in Opportunity

May 11, 2011
Aid, Aid Work, Health Systems, Reflections
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In the opening presentation at the CORE Group’s spring meeting, one of the interesting findings from the research that went into One Illness Away was how common it was for youth living in poverty to create their own glass ceilings. They often don’t believe they have the ability to obtain the education or other necessary skills to become a software developer or university professor, instead aspiring to simply have employment.

While Dr. Krishna, the book’s author, said if he had money to invest in poverty reduction he would first put it toward universal health care, his second major investment would be in career training for impoverished youth. Many don’t even know what channels they would need to go through to obtain proper skills and training; until that happens, they will continue to impose their own glass ceiling.

In sharp contrast, here in America many youth have education, opportunity and promise handed to them without a second thought. They complete elementary and secondary schools, many go on to university, and we have the luxury of delaying choices like marriage, childbirth, and other rites of passage into “adulthood” until we’ve deemed ourselves ready. Thus the invention of emerging adulthood as a distinct phase in developmental psychology, and the rising average age of marriage in America.

Krishna’s research also showed found the most common paths out of poverty were through success in agriculture or in urban employment, not in a regular, salaried job. Can we not work to provide opportunities for children from Kibera and other slums to move up through skills, education, and sound employment? Or at lease help them believe in that possibility?  He argued, and provided supporting evidence, that people do not choose to be poor, contrary to the beliefs of some who preach about the laziness or tendencies towards drinking among the poor (myths debunked in Krishna’s research). The poor are often remarkably resourceful, and, given the proper training and circumstances, can move themselves up.

You can purchase Krishna’s book on Amazon or wait until the paperback comes out in July 2011. To my technical friends:  you can also read more about his methodology (“Stages of Progress”).

Seven key ideas from GHME

March 18, 2011
Aid, Aid Work, Data, Health Systems, Women's Health
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As I listened through three days of information-dense sessions at the GHME conference in Seattle, a few major themes stuck with me. My short list of seven key takeaways, some of which I’ll be breaking down in longer, more in-depth posts next week:

7. Desire for data sharing. There is a strong need for data sharing across institutions, countries, and projects, but no well-maintained central repository for those data nor an organization taking responsibility for organizing the files.  While the GHDx steps in and fills this role to a degree, the catalogue of datasets will only be as complete as what is submitted by researchers or sought out by IHME. A representative from the Gates Foundation spoke to their new data exchange policy, to be released in the coming months, which should be interesting.

6. A focus on developing country needs and wants. “Indicators should be owned by countries, but no one ever asks countries.” Country-recipients of donor funds should have a greater say in determining what data is collected about their respective nations and programs. Collecting and reporting data on indicators determined by outside actors (funders, academics, etc.) can be a huge burden for some developing country statistics agencies, program managers, and other stakeholders; many times, the data collected is not used in-country at all. It will be interesting to see how the arena of indicator selection evolves after the 2015 deadline for the Millennium Development Goals has passed: I am hopeful that the next round will be less donor-centric and more focused on developing realistic development targets on meaningful indicators. And, with the focus on noncommunicable diseases throughout the conference & the fall meeting focused on that exact topic, new targets and goals should include NCDs as well.

5. Women are more than mothers. The MDGs and other development programs have focused almost exclusively on maternal health, rather than women’s health, in many cases. Women are worth more than their uteruses, and women also die from many other illnesses and problems outside of childbirth.  Despite the efforts of Women Deliver, we continue to see “woman as mother” and not “woman as citizen,” which is a paradigm shift that needs to happen. The MDGs were focused on maternal health, not women’s health, and neglected important items like family planning.

4. Strengthening country information systems is key. Sometimes research focuses so much on national surveys and other data collection done by external actors (i.e. the demographic and health surveys), developing in-country statistical capacity and strengthening the local health information system is neglected, noted Fatima Marinho de Souza from PAHO. In order to ensure sustainability of programs and provide opportunities for countries to measure and monitor the indicators that matter to them, we must emphasize local HIS strengthening as part of our global health and HSS aims.

3. Inequalities are important to know about. Multiple presenters spoke to the “tyranny of averages,” and even more highlighted the importance of identifying inequalities and inequities in wealth, gender, geographic, and other groups. Focusing only on country-level data – while useful for cross-national comparisons – is limiting, often missing the more nuanced story of health outcomes in rural districts or among the poor.  The draft of the next set of global indicators includes stratification by six different factors, not just wealth, in order to better address the inequality question.

2. Health system strengthening is still sexy. Raj Shah spoke those immortal words at a CSIS address a few months back, and they still ring true. Measuring health systems strengthening and developing new performance metrics are even sexier.  Julio Frenk, Chris Murray, and Martin McKee spoke over a lunch session on the importance of continuing to evolve a new generation of tools for measuring HSS: these are not to replace existing measures, but to evolve existing measures further and add new tools. We’ve come a long way in conceptualizing a health system since the 2000 World Health Report, but there is still much work to be done.

Global Health Academia is the new black. - Richard Horton1. Global health metrics is changing. And according to Richard Horton, global health academia is the new black. Results-based programs, reliant on good data and metrics, are a central focus for today’s aid agencies, operating with more limited funding. A meeting like GHME happened (with over 600 attendees) because of the interest in global health metrics. Academic institutions are stepping into the roles filled in the past by large multilateral agencies and institutions, though there is still a need for those multilateral spaces for collaboration and goal-setting. Organizations like IHME and strong academic institutions are conducting pioneering, forward-thinking research on a wide range of global health topics. And there are some pretty incredible people working in global health today, which I found very inspiring.

 

Also cross-posted on PSI’s Healthy Dose Blog

Virtual Poster Presentation: Measuring Health System Strengthening

March 16, 2011
Aid Work, Data, Health Financing, Health Systems
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Our team has a poster at today’s morning session at GHME, which is the reason I had the opportunity to come to the conference. The poster focuses on our work investigating the use of a deviance analysis of health system performance, including development of a health system effort index (HSEI).

You can view a full PDF of the poster here. The work was collaborative across our team at AIM, with the support of USAID health systems experts; if you have comments or questions, please don’t hesitate to e-mail me or post a comment. You can read the abstracts for the other poster presentations on the GHME website, and I’d encourage you to take a look at the interesting work being presented.

More on the thought-provoking questions and ideas that have come out of the conference proceedings so far will be in a post later today.

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