Global Health Policy
June 12, 2008
HIV/AIDS Funding and Health Systems: How do AIDS Donors Interact With National Health Systems?
Posted by Steve Rosenzweig at 12:00 PM
A heated debate has emerged in the global health community over whether or not disease-specific funding, particularly the large sums of donor money for HIV/AIDS, is positively affecting health systems in developing countries (my colleagues Ruth Levine, Mead Over, and Danielle Kuczynski have discussed these issues in previous posts on AIDS spending and health systems, vertical health programs, and "diagonal" approaches to health, see here and here).
Is the surge of AIDS money strengthening national health systems? Or is it weakening them by pouring disproportionate funds into systems that target one disease - while neglecting others?
June 02, 2008
We Need a Metaphor for Health Systems. What About the Human Body?
Posted by Ruth Levine at 11:37 AM
Creating a shared metaphor is a powerful way to make an abstract concept tractable. Just think about how the metaphor of "war" dominates and shapes so much of what we do in public health: the war on cancer, the fight against AIDS, the battle against TB. Metaphors also shape and define the boundaries of how we think about problems and how to solve them. We fight diseases with campaigns, with armies of health workers, with magic bullets. In fact, metaphors are often the boxes (metaphor alert!) that we are asked to think outside of.
The contemporary concept of "health systems" desperately needs a better metaphor. Right now, we have a couple of contenders out there. I've seen a puzzle (View image), with five interlocking pieces (financing, human resources, infrastructure, technologies and drugs, and knowledge and information). OK, it gets across the notion of some sort of relationship among the parts, but is static and conveys the (wrong) idea that there's one way to put together the system elements. Health economists occasionally invoke the dominant metaphor in neoclassical economics: The "sides" of demand and supply, and the "invisible hand" of competition. This has a lot of meaning for practitioners of the gloomy science, and leaves just about everyone else glassy-eyed.
I have to admit that neither of these metaphors quite do it for me, nor do the growing numbers of boxes-and-arrows diagrams that are cropping up in journal articles and powerpoint presentations. They just make me think, "Wow. That's complicated….I wonder what software they used to make that diagram?" And I suspect I'm not alone in yearning for a useful metaphor, given the inarticulateness that often overcomes very smart people when faced with the question, "What to do you mean when you say 'health system'?"
Continue reading "We Need a Metaphor for Health Systems. What About the Human Body?"
May 30, 2008
Shining a Light on What Works: Aravind Eye Care System Wins Gates Award
Posted by Danielle Kuczynski at 02:51 PM
Congratulations to the Aravind Eye Care System for winning the Gates 2008 Global Health Award, a $1 million prize that is the largest of its kind given for international health. Presented at the Global Health Council's 35th Annual International Conference last night, the award honors exceptional efforts to improve health in developing countries.
Established in 1976, Aravind is a global health example of 'what works' - one of the biggest eye care clinics in the world, they aim to prevent unnecessary blindness in rural India. Between April 2006 and March 2007, over 2.3 million outpatients were treated and over 270,444 surgeries were preformed through Aravind and Managed Eye Hospitals. See the CGD publication Case Studies in Global Health: Millions Saved which highlights their work in treating cataracts.
May 22, 2008
"AIDS Spending Harms Health Systems" -- Passionately Disputed but Hardly Refuted
Posted by Mead Over at 01:34 PM
Roger England's article on "AIDS exceptionality" in the British Medical Journal argues that AIDS has received a larger share of total health spending than its contribution to the burden of disease would justify and that this large increase is having negative effects on the rest of the health care system in recipient countries. His article has so far generated 17 often passionate and lengthy responses.
Some of the effort of responders is devoted to demonstrating that the effects of AIDS are worse than its burden of disease would indicate. This effort to justify donor spending on AIDS seems futile, since the same is true of many other diseases, including tuberculosis, motor vehicle deaths, smoking caused disease, etc. (In any case, the cost-effectiveness of public spending should play a larger role than the total burden of disease in guiding the allocation of public health spending). Much of the rest of this prodigious rhetorical effort asserts that AIDS spending is really helping, not harming, the rest of the health sector.
If Roger England's assertion that AIDS spending harms the health sector could have been refuted by data, one of those posting would have cited such data and the others would not have felt the need to post. The problem is that we really don't know, in any general way, what the extraordinary scale-up of AIDS spending has done to other parts of the health sector.
[For previous discussion of this issue on our blog, look here, here, and here]
An interview I had last November with the nurse who was responsible for managing a health center in Western Kenya is perhaps revealing. His district health center had tripled in size due to the addition of a clinic, lab, waiting and storage space for treating AIDS patients and for warehousing the fresh produce, cooking oil, flour and other groceries given to supplement the diets of many AIDS patients. The staff nominally reporting to him had increased by several young physicians, who had received special training in AIDS case management.
Continue reading ""AIDS Spending Harms Health Systems" -- Passionately Disputed but Hardly Refuted"
May 19, 2008
Good Drugs are Hard to Come By
Posted by Rachel Nugent at 04:56 PM
It's hard to know what to make of the news about bad malaria drugs in Africa reported in the new study from the team at Africa Fighting Malaria. The team went around to private pharmacies in six African countries and bought samples of all the different malaria drugs on the shelves except chloroquine. They purchased a total of 195 drug packages. They found that about one-third of the drugs were sub-standard, and about one-third were artemisinin monotherapy, produced and sold in violation of WHO standards because of the risk of creating resistance.
The authors sum up their results with this:
Continue reading "Good Drugs are Hard to Come By "
May 14, 2008
PEPFAR Should Be Strengthened, Not Blocked
Posted by Mead Over at 04:59 PM
The "hold" that seven U.S. Senators have placed on PEPFAR reauthorization by Congress (see Michael Gerson's column Moral Scales in the Senate in today's Washington Post and Josh Busby's related blog) literally threatens the lives of over a million people in Africa. In my recent working paper I said that these people whose lives now depend totally on continued U.S. funding have an "entitlement" to U.S. support that is every bit as compelling as U.S. citizens with Social Security pensions. In a recent blog I suggest that our commitment to these patients is just as compelling as our commitment to the people of Iraq. Backing away from either of these commitments would severely damage the reputation of the U.S. in general and the responsible politicians in particular.
So I urge the Senate to work to resolve the impasse and quickly reauthorize PEPFAR.
That said, I believe that the pause engendered by this hold can be used to improve the PEPFAR reauthorization bill. I suggest that the Senate consider the following three improvements:
Continue reading "PEPFAR Should Be Strengthened, Not Blocked"
May 12, 2008
Prevention Failure Redux: Unexpected Tradeoffs in HIV Testing, Prevention and Treatment
Posted by Mead Over at 10:28 AM
Last Monday, CGD posted my working paper entitled, "Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It." In response, I've received a number of e-mail comments on various aspects of the paper. A wonder of cyberspace is that I heard from far flung correspondents within hours after the working paper was posted. But the modern technology hasn't overcome the age-old problem of people interpreting an author differently than he intended. This is a chance to continue the conversation and invite others in.
One person characterizes the paper as saying that donors should "improve our efforts in prevention, and avoid ART financing." Another person feels that the title of the paper places treatment and prevention too much in competition and might lead to slower increases, if not reductions, in AIDS treatment funding. Both seem to feel that the paper exaggerates the trade-off between treatment and prevention - to the disadvantage of treatment.
In fact, I do not argue for the avoidance of ART financing, only for a clear recognition that it entails a permanent, lifetime commitment to the individual patients who receive treatment. I hope that my article helps to assure that donors who start patients on AIDS treatment in 2008 and 2009 never subsequently drop their patients for lack of budget or political will. I also urge that an increasing share of US funding for these patients be routed through multilateral institutions like the Global Fund or the development banks, in order to dilute what is otherwise an extreme form of dependency of patients and their home countries on a single donor country, namely the U.S.
April 30, 2008
"Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease
Posted by Mead Over at 11:22 AM
The front page of the weekend edition of the Financial Times reports a Tanzanian research proposal with the breathless fanfare usually reserved for a medical or scientific breakthrough. In fact, the FT is not announcing a new research finding, but is prematurely publicizing a planned research project which the Tanzanian government has yet to authorize. The researchers propose to offer payments to women who repeatedly test negative for curable sexually transmitted infections, such as gonorrhea and syphilis. The hope is that reductions in unsafe sexual contacts will protect the women not only from the curable STIs but also from contracting or spreading HIV, and the research project will measure whether this happens. To help them achieve these objectives and also to contribute to the womens' success in other dimensions of their lives, the intervention includes substantial gender and life-skills counseling. To measure success in dimensions beyond safe sex, the researchers will collect data on the women's labor force participation and on other economic outcomes. The FT article makes clear that the payments are unrelated to the HIV status of the women in the study.
Since I am a member of the research team, it's not surprising that I think this is a good idea. Although no one knows whether the idea can be shown to work in the proposed Tanzanian location or elsewhere, there are reasons to be optimistic.
First, so-called "conditional cash transfers" have previously been shown to be successful in changing health-related behaviors and improving health. For example, in Mexico's Progresa program (See the CGD evaluation in Millions Saved) cash grants conditional on a poor family's preventive health visits are associated with improved health of the family, adults and children alike.
Continue reading ""Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease"
April 24, 2008
AEI Takes on Demand Forecasting for Malaria
Posted by Jessica Pickett at 10:39 AM
In honor of World Malaria Day tomorrow, AEI research fellow Roger Bate has issued a new policy brief and related magazine feature decrying the state of global demand forecasting for artemisinin-based cominbation therapies (ACTs):
WHO estimates often rely on 'need,' a normative concept of how many people should be treated, rather than on demand, a positive concept of what can and will be bought. In 2004, the WHO projected that the global need for ACTs in 2005 would be over 130 million treatments. This projection proved to be way too high; in 2005, maximum demand was only 25 million treatments. Major suppliers such as Novartis and Sanofi-Aventis relied on WHO estimates and, as a result, were forced to either destroy unused products or declare substantial losses when the anticipated demand never materialized. In December 2006, Novartis temporarily shut down its production facility in Suffern, New York, to prevent the production of too much medicine with a short shelf life; Chinese farmers had begun to complain that they had no buyers for their Artemisia annua. With an excess of supply, prices of Artemisia annua have plummeted, and now the WHO fears that farmers and artemisinin producers may withdraw from the market, reducing the overall supply of drugs and creating a risk of future shortages.
In the short run, unrealistically high demand estimates are costly for companies. In the long run, they are costly for the millions of people afflicted by malaria. If drug companies must weather too many losses as a result of misjudging malaria demand, they may decide to invest in drug development for other diseases. The WHO argues that its forecasts are better today. But to be useful to companies, they have to be provided at least 12 months in advance, and the WHO forecasts are not.
Continue reading "AEI Takes on Demand Forecasting for Malaria"
April 23, 2008
Global Health Geometry
Posted by Danielle Kuczynski at 10:20 AM
The ongoing debate about "vertical" versus "horizontal" approaches to health swings like a pendulum. My colleague Ruth Levine has previously pointed out the rhetorical tendency towards polarizing this debate in favor of practical solutions for resource allocation to health systems; more recently, Mead Over has commented on the alternative concept of “diagonality.” But what does diagonality mean as an approach to health systems strengthening? As spelled out in a recent article by Gorik Ooms and others, this approach avoids the popular dichotomy by promoting harmonization and a focus on health infrastructure through which all vertical programs are ultimately delivered. In addressing this issue, the article looks largely at the role of key institutions such as the IMF, and explicitly recommends transforming the Global Fund to Fight AIDS, Tuberculosis and Malaria into a broader Global Health Fund. Indeed, the Board of the Global Fund has already moved in this direction by adopting diagonal interventions, where funds could be used to strengthen "public private or community health systems" using components of Global Fund grants.
Although Ooms et al. laudably attempt to step out of the "either/or" orthogonality with this suggestion, they seem to advocate for diagonality as a means to fully horizontal integration, rather than as an end in and of itself as a type of sustainable financing. The long-term goal of foreign assistance for health is to achieve a functional and integrated health system at the country-level. However, there will always be vertical pieces that exist within these systems, ranging from the disease-specific programs du jour, to function or context-specific funding targets (read: vertical) such as laboratory capacity building that could serve as "islands of efficiency" around which the broader system could ultimately be strengthened.
