Issue #6 - Tracking Goals - Global Health Magazine

Are We Chasing Goals Rather Than Solving Problems?

Is Universal Access a Realistic Goal?

23 Achieving Maternal Health: Getting Further, Faster 14 20

Issue 06

SPRING 2010 $4.95 U.S.

TRACKING GOALS www.globalhealthmagazine.com —

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issue 06

contents —

In this issue:

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14 Are We Chasing Goals Rather Than Solving Problems?

16 Smallpox: Death of a Disease

COVER STORY: tracking goals

6 A New Angle on Pediatric HIV/AIDS in Swaziland 0 08 From the Ground Up: Rebuilding Haiti 09 With Big $ behind them, ngos seek seat at the table 23 Achieving Maternal Health: Getting Further, Faster

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20 Is Universal Access a Realistic Goal?

stories online: C Global Goals: Read about each mdg on the

blogs at globalhealthmagazine.com

screenshots —

04 Children Who are Suffering from Underweight, Stunting and Wasting 05 How Do Countries Pay for Health?

05 Who Doesn’t Have Access to Drinking Water? www.globalhealthmagazine.com

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Issue 06

Global Health

letter

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from the editor

Executive Editor

Annmarie Christensen Managing Editor

Tina Flores

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Web

Winnie Mutch Liza Nanni Graphic Design

Shawn Braley

goals The word implies an achieved and desired outcome, more specifically, the end of a challenge. In global health, our goal is to improve the lives of people around the world primarily by reducing the burden of disease.

Global Health Council

The Millennium Development Goals, ICPD, Alma Ata, and other targets have guided much of the work in our community in recent years. While we are nowhere close to reaching them, we carry lessons – the need for vaccines, better delivery systems, newer, less expensive, more portable technologies – that accelerate progress.

In addressing the goals, we gain better tools and greater wisdom toward achieving them.

As Linda Fried and Lynn Freedman of the Mailman School of Public Health allude to in their article, goals keep us on track.

They enable resources to be mobilized amid decreases in funding and emerging disease threats. But it begs the question, are we finding sustainable solutions?

Robin Gorna of the International AIDS Society reflects in her article, it’s not the goals that are the problem. Rather, it is a lack of commitment to following through with what needs to be done in order to achieve them. But we all know that lip service is not enough. Resources – money, people, knowledge – have to be invested for real gains to be made.

And then there is smallpox eradication – the gold standard in public health achievements. As Dr. D.A. Henderson shows, through ingenuity and plain stubbornness, it has been eradicated. To think that with a single mindset in the late 1960s, and with an international staff that never numbered more than 150 in the field, the World Health Organization provided the framework within which all countries could constructively work, even during the days of the Cold War. Indeed, there are still many lessons to be learned, and many challenges to be conquered.

The Editors

ISSUE 06 spring 2010

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E-mail:

magazine@globalhealth.org Board of Directors

Susan Dentzer, chair, William Foege, MD, MPH,

chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Joel Lamstein, SM Reeta Roy Jeffrey L. Sturchio, PhD,

President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members.

Learn more about the Council at www.globalhealth.org

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issue 06

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C

online exclusives

go to www.globalhealthmagazine.com for further reading

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C The Blog Universal Health Access: Mali’s Goal

By John Donnelly

GLOBAL HEALTH magazine is featuring blogs on each of the MDGs throughout the spring. Read online at www. globalhealthmagazine.com.

MDG 1: Integration, Food Security and HIV/AIDS MDG 1: One Step Closer: The Role of Micronutrient-Rich Staple Foods

C Hot Escapes

Santo Domingo and the Haiti Border Tina Flores explores a key portal to Haiti.

C Field Notes

Conner Gorry on Cuban-trained doctors working in Haiti for the long haul.

MDG 2: Education for All: Beyond the Numbers MDG 3: Promoting Gender Equity MDG 4: Delivering on the Promise of Immunization Photo by Dominic Chavez

Siribala, Mali - In this village 200 miles north of the capital Bamako, Femakan Sissoko, 64, stands as a symbol of what Mali wants for all its citizens.

Last year, Sissoko joined a cooperative called a “mutuelle,” which for a relatively small fee would provide him and his 14 family members health insurance for the next year. Sissoko couldn’t sign up fast enough.

Reporter John Donnelly will be blogging on health issues in Mali and Sierra Leone throughout the spring for GLOBAL HEALTH.

C Read the blog online at www. globalhealthmagazine.com

MDG 5: Protecting the Sexual and Reproductive Rights and Health of our Daughters MDG 5: The Product Makes the Program: The Importance of Supplies in Improving Maternal Health

© Connor Gorry

C Dim Sum

A collection of book reviews, music picks, and other cultural forays.

MDG 5: 3 Billion Reasons Why the Time is Now for Adolescent Sexual and Reproductive Health MDG 6: Addressing Infectious Diseases MDG 7: The Unbreakable Link: Environmental Sustainability and Human Health MDG 8: Building Public-Private Partnerships

© Cielo Productions www.globalhealthmagazine.com

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Global health statistics

screenshots —

Child Nutrition % of under-fives (2003–2008) suffering from: Wasting

underweight moderate & severe

Africa (total)

Sub-Saharan Africa

Eastern and Southern Africa

West and Central Africa

Middle East and North Africa

Asia (total)

South Asia

East Asia and Pacific

Latin America and Caribbean

World

ISSUE 06 spring 2010

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Source: UNICEF 2009

21

stunting

moderate & severe

10

moderate & severe

40

23

10

42

23

8

45

22

11

40

14

10

32

27

17

36

42

19

48

11

0

22

4

2

14

23

13

34

Click on the source at C www.globalhealthmagazine.com.

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Regional Distribution of the 884 million people not using improved drinking water sources in 2008 in millions Sub-saharan africa 330

southern asia 222

eastern asia 151

South eastern asia 83

latin america & caribbean 38

Western Asia 21

comm. of independent states

17

Northern Africa

13

oceania

5

developed regions

4

Source: World Health Organization 2010

% of total health spending

public (government)

Private

$

$ 72.5 32.8

69.1

52.1

58

77

24.6 14.4 39.6 80.4 51.8 79.2 83.6 40.8 54.2 67.6 53.2

85.6 75.4 67.2

60.4 47.9

42

46.8

45.8 32.4

30.9

27.5

59.2 48.2

23

20.8

19.6

16.4

$

Source: Health Systems 20/20, Health Systems Database.

Accessed April 19, 2010.

zambia

viet nam

united states

tanzania

pakistan

lao pdr

kenya

india

ethiopia

dpr korea

djibouti

cote d’ivoire

china

brazil

azerbaijan

australia

Afghanistan

$

Click on the source at C www.globalhealthmagazine.com.

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A New Angle on Pediatric HIV/AIDS in Swaziland Photos and story By jon hrusa

Jon Hrusa/EPA

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I’ve been taking pictures for the Elizabeth Glaser Pediatric AIDS Foundation since 2004, photographing donor trips in South Africa, Tanzania and Swaziland.

I’ve visited many Foundation-supported health clinics, and I’ve always known that the Foundation’s mission is to eliminate pediatric HIV and AIDS. But it wasn’t until November 2009 that I fully understood how that goal can be achieved.

Jon Hrusa/EPA

In recognition of World AIDS Day (Dec. 1, 2009), I wanted to tell the story of a family living with HIV in Swaziland –- the country with the highest HIV prevalence on earth. Through my relationship with the Foundation, I was introduced to Mfanzile Dlamini (28), his wife Zanele (24), and their 13-month-old daughter Phiwa. Mfanzile and Zanele are both HIV-positive, but Phiwa has thus far tested negative thanks to the Foundation-supported prevention of mother-to-child transmission (PMTCT) services that she and her mother received.

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Living in South Africa, HIV/AIDS has become an accepted fact of daily life. Before I met the Dlaminis, I knew that people with HIV needed antiretroviral medications (ARVs) to stay alive. When it came to prevention, I’d heard a lot about the “ABC” campaign –

Jon Hrusa is a staff photographer for the European Pressphoto Agency, based in Johannesburg, South Africa. He has been partnering with the Elizabeth Glaser Pediatric AIDS Foundation on photography projects since 2004.

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Jon Hrusa/EPA

Jon Hrusa/EPA

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Jon Hrusa/EPA

And if every mother living with HIV had access to the same services that Zanele received, there would be no more pediatric AIDS. It was mindblowing.

Abstinence, Be faithful, Condoms. But I knew very little about preventing mother-to-child transmission of HIV. When I thought of pediatric HIV/AIDS, I usually thought about helping the children who already have it, rather than preventing them from getting it in the first place.

The reality hit me as the Dlaminis were sitting outside their one-room house, with Phiwa crawling around in the dirt: This child’s parents are HIV-positive, and she is HIVnegative. The Foundation’s work helped bring this about.

And if every mother living with HIV had access to the same services that Zanele received, there would be no more pediatric AIDS. It was mind-blowing.

I photographed the Dlaminis for nearly three days and witnessed every aspect of their daily lives. Despite dealing with extreme poverty, life-threatening illness, and social stigma from their HIV status, the Dlaminis are a family just like any other. They work hard and their lives are difficult, but they like to eat and laugh and play with their daughter.

I was particularly struck by the relationship between Mfanzile and his little girl. In the health clinics I’ve visited over the years, I usually see babies with their mothers.

But Phiwa gravitated to her father as well as her mother.

● ●

I’ll never forget the afternoon that Phiwa ran into the hut to wake Mfanzile, who slept during the day because he worked as a night watchman. I was very moved by this intimate moment between father and daughter.

My time with the Dlaminis left me feeling grateful and incredibly humbled. As a photojournalist, I tend to enter a situation, shoot it as I see it, and move on. My camera is a barrier between me and the emotions on the other side of the lens. But since the Dlaminis welcomed me into their home for several days, I had time to put my camera down. I played with Phiwa and talked with her parents. I saw them as people rather than subjects.

On my last day with the Dlaminis, I went with them to the plot of land they farm. While Mfanzile and Zanele toiled planting seeds, Phiwa played next to me in the field.

Mfanzile took a moment away from work to pick up his daughter, and I was there to catch it. There’s so much hope in this photo – Mfanzile looking up at Phiwa as he lifts her toward the sky. It sums up my feelings about this project and the admiration I have for the Foundation’s work. GH —

It is estimated that 26.1 percent of adults (aged 15–49) in Swaziland are HIV positive, UNICEF, 2007 100,000 of the 190,000 people living with HIV/AIDS in Swaziland are women, Population Reference Bureau & UNAIDS

www.globalhealthmagazine.com

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by Nellie bristol

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Photo courtesy of International Medical Corps.

From the Ground Up Rebuilding Haiti’s Health Structure Haiti’s new health system will guarantee access to quality services for all through a performance-based funding system and large investments in human resources, according to rebuilding plans laid out by the Haitian government. The effort will require an investment of $1.5 billion according to a Post Disaster Needs Assessment (PDNA) developed by the Haitian government and international groups. The estimate of funding “needs” in the document takes into account recovery, reconstruction and re-establishment of the Haitian government.

Stakeholders already have begun meeting to develop specific objectives and goals for the system’s

development, said Judith Timyan, health program coordinator for USAID’s Haiti Reconstruction Task Team.

Overall reconstruction initially will be overseen by a Haitian interim commission for recovery led by former U.S. President Bill Clinton in his role as UN special envoy to Haiti and by Haitian Prime Minister Jean-Max Bellerive.

Donor funding will be pooled in trust fund overseen by the World Bank. Auguste Kouame, World Bank sector leader for poverty reduction and economic management and lead economist for the Caribbean, said the Bank will serve as a fiduciary agent for the fund. The trust fund will receive and distribute money largely from major Continued on page 10

ISSUE 06 spring 2010

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Nellie Bristol is a freelance journalist, specializing in health policy.

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by Nellie bristol

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With Big Money Behind Them, NGOs Seek Seat at the Table

International relief and development NGOs working in Haiti are seeking a greater say in how rebuilding progresses as they tally up contributions of more than $2 billion for recovery and reconstruction. The push comes even as the groups come under criticism from some quarters for a history of side stepping the government and failing to support sustainable local systems.

Sam Worthington, president and CEO of the NGO alliance group InterAction, said U.S. NGOs had received more than a billion dollars in donations by the end of March. European Union donations totaled $880 million with an additional $150 million raised in Canada, he said.

“We are committed to investing a tremendous amount of financial and human resources in Haiti, and should be recognized by nation-states as a key partner in the reconstruction effort,” he added. InterAction received $330,000 from USAID to establish a “coordination cell” to help groups connect with UN system activities.

In a recent interview, Lindsay Coates, InterAction vice president for Policy and Communication, called the amount of money raised by NGOs “astounding.” She said the sum changes the relationship the groups have with donors. “We’re more of a partner and less of an implementer,” she said.

International NGOs are seeking a voting position on the interim commission for the reconstruction of Haiti, an entity of donors and Haitian officials established to oversee recovery efforts, and the Haitian development authority that will eventually replace the commission.

“Given both the significant resources NGOs are contributing to the rebuilding effort and their role as the primary implementers of the post-earthquake recovery and reconstruction activities, NGOs should be included as voting members of these institutions,” the groups argued in Principles and Recommendations for International NGO Participation in Haiti Recovery, Reconstruction and Development. The statement was developed by NGO alliances representing groups in Brazil, Canada, Chile, Europe, France, Spain and the U.S. Foreign aid in Haiti historically has been complicated and controversial. Billions of dollars have been donated to the country over several decades with limited results.

Erratic and politically motivated donor support, Haitian government corruption, and lack of coordination by development groups are often cited. With an unprecedented amount in foreign funding now pledged Continued on page 11 www.globalhealthmagazine.com

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haiti - continued from page 8 international donors, keeping with the priorities of the Haitian government. Kouame said the fund is modeled on a similar structure used to distribute international donations related to the 2004 tsunami and included strict oversight to ensure the quality of the work funded through the program. “It worked beautifully,” Kouame said. “If we could replicate and adapt the Aceh model in Haiti it would be great.”

The PDNA indicates that 30 out of 49 hospitals have been damaged or destroyed. On the plus side, it says, 90 percent of health centers are intact or suffered only minor damage, providing a platform to launch a community based health strategy. Priorities for a new system include services in maternal and reproductive health and to combat the spread of HIV/AIDS. The goal is to build a system that is a vast improvement over the pre-earthquake model, which left 47 percent of citizens without access to health care. “The health system is fragmented, highly unfair (6 percent of the poorest women give birth in health-care institutions, compared with 65 percent among the most well-off) and highly inefficient, with expenditure of US$32 per capita per year and poor health outcomes for expenditure of this level,” the PDNA says. It cites fee-for-service arrangements as a major barrier to health-care access.

One of the biggest obstacles to revamping the Haitian health-care system is lack of personnel. “The earthquake has had a major impact on health-care staff, with more than 50 percent living in tents, leading to disorganized service delivery,” the report says. Further, most of the country’s training facilities and universities were located in the earthquake zone leaving a major gap in that sector.

While all concerned are anxious for the government to take charge of reconstruction efforts, many worry it doesn’t have the resources needed. “They’re going to need a lot of help,” said Timyan. Lindsay Coates, vice president of Policy and Communications for the NGO umbrella group InterAction, agrees: “The Haitian government is very thin.”

“There is a very strong desire to work with the government of Haiti in partnership,” she said. “The challenges are around the government’s capacity.”

InterAction received funding from USAID to set up a “coordination cell” that is helping NGOs connect with UN system.

Coordination of UN activities and program implementers

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is being overseen by the UN Office for the Coordination of Humanitarian Affairs and representatives of the Haitian government. Souad Lakhdim, a Pan American Health Organization official helping to coordinate UN health activities, said OCHA, government representatives and NGOs are meeting regularly to exchange information and synchronize activities. Despite the effort, some say more is needed to ensure help is reaching those in greatest need and isn’t duplicative, particularly as the effort moves from relief to reconstruction. “The problem in responding to the earthquake is not lack of material or coordination, but lack of complete and coherent planning that could be implemented without gaps,” said Loris de Filippi, Medecins Sans Frontieres’ Haiti operational coordinator.

Creating the local personnel capacity to take charge of the reconstruction and mobilize the many resources to carry it out is a top priority. In the health sector, USAID is offering technical assistance to train health personnel, particularly allied personnel such as pharmacists’ assistants, nurse midwives and auxiliary nurses, Timyan said.

Many are seeing the involvement of the Haitian diaspora as a key to ensuring that as many indigenous personnel as possible are part of reconstruction, with the hope that the involvement will make new systems sustainable. The Center for Global Development (CGD) is urging development of a mechanism to support the exchange. “Dozens, even hundreds might be willing to return home for up to two years to help jumpstart and expand the school and health systems, replacing the skills of the huge number of Haitian civil servants who lost their lives,” CGD President Nancy Birdsall wrote in a commentary on the group’s website. She suggested that USAID could support a group like the Clinton Foundation or the Peace Corps to manage the program, screen the applicants, and to arrange modest monetary support.

CGD also is urging flexibility in USAID contracting rules to ensure Haitian NGOs receive priority in contracting for work.

Haiti will need all the help it can get to repair not only earthquake damage, but to escape a history rife with instability and hardship. “It is a plan to create a ‘New Haiti,’” UN Secretary-General Ban Ki-moon said of the reconstruction. “A Haiti where the majority of people no longer live in deep poverty, where they can go to school, and enjoy better health, where they have better options than going without jobs or leaving the country all together.” GH —

An estimated 3 million people were affected by the quake. The Haitian government reported that an estimated 230,000 people had died, 300,000 had been injured and 1 million made homeless. They also estimated that 250,000 residences and 30,000 commercial buildings had collapsed or were severely damaged.

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NGOs in haiti - continued from page 9 for the country’s reconstruction, stakeholders are saying they want things done differently. “The old ways in Haiti have never been good enough in the past and they won’t be good enough in the future,” said Peter Bell, senior research fellow at Hauser Center for Nonprofit Organizations at Harvard University. “Everyone is going to have to change, including NGOs.” InterAction’s Coates said NGOs are committed to working more cooperatively and transparently. “We need to work with the government in a partnership,” she said.

The groups support the development of a single country plan through which specific projects can be taken on by different donors and NGOs, she said.

The aid machinery currently at work in Haiti keeps too much for overhead for its operations and still relies overmuch on NGOs or contractors who do not observe the ground rules we would need to follow to build Haiti back better.

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paul farmer

NGO critics say the groups have not supported the government enough in the past. While providing most of Haiti’s health care and education, NGOs “have been accountable neither to users or funders,” Paul Collier, Oxford professor of economics and former UN special advisor on Haiti, wrote on ForeignPolicy.com He also cited lack of quality assurance and coordination.

Long-time Haiti health provider Paul Farmer of Partners in Health, now UN deputy special envoy to Haiti, voiced a similar message. “The fact that there are more NGOs per capita in Haiti than in any other country in this hemisphere is in part a reflection of need, but also in part a reflection of over-reliance on NGOs quite divorced from public health and public education sectors,” he told a Senate panel. “The aid machinery currently at work in Haiti keeps too much for overhead for its operations and still relies overmuch on NGOs or contractors who do not observe the ground rules we would need to follow to build Haiti back better.” New rules should include a demand to create local jobs for Haitians, building infrastructure for sustainable economic growth, and reducing Haiti’s dependence on aid, he said.

Those working on the ground reject attempts at greater government authority over their work. “We’d lose control over some very successful programs,” said Jeremiah Lowney, president of the Haitian Health Foundation (HHF). The group, which started in Haiti in 1982, regularly supports 250,000. It is now providing health, education and food for an additional 50,000 people who fled earthquake-affected areas to the region where his group works. He says the school it runs now offers two shifts a day to accommodate an influx of children displaced by quake-related destruction.

While aid groups resist greater government authority, many say they crave better coordination with the

government and with each other and seek out mechanisms to achieve it. “We really need a leader,” said Dianne Jean-Francois, Haiti country director of the Catholic Medical Mission Board. “The Ministry of Health needs to take leadership to facilitate all of the players that are on the ground.” Coordination of NGOs is being conducted through the U.N. Souad Lakhdim of the Pan American Health Organization is the U.N. contact for health groups. She said about 300 groups are registered with the system and that it helps them coordinate with other NGOs and with the government. But, she said, there are groups that don’t register. “They are not aware of the rules and they just come do whatever they want,” she said.

The U.S. attempted to improve NGO coordination through the USAID funded InterAction office. “Given the magnitude of the disaster, USAID saw a need for supporting critical humanitarian coordination efforts including NGO coordination activities to supplement the intentional coordination architecture in Haiti,” Anna Gohmann, USAID legislative and public affairs special assistant, wrote in an email. “USAID support to InterAction for a NGO coordination cell was intended to provide guidance and an advocacy forum to both international and national NGOs and to facilitate access for new agencies not familiar with existing international coordination structures.” InterAction worked with the Switzerland-based International Council of Voluntary Agencies in the effort to facilitate contact with groups beyond InterAction’s U.S. NGO members. GH —

• International NGOs raised more than $2 billion for Haiti’s recovery and reconstruction efforts.

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Millennium Developm GlobalPla

ICPD+15 toStopT

3 by 5 Initi Integrated Management Childhood Illness Abuja Declaration

Smallpox Target

Zero

of

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Alma Ata

Deliver Now for

Women & Children Campaign

Countdown to 2015: Maternal, Newborn & Child Survival

Global Health In

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ment Goals an

TB

PEPFAR

iative 20

C GLOBAL HEALTH magazine is featuring blogs on each of the MDGs throughout the spring. Read online at www.globalhealthmagazine.com.

MDG 1: Integration, Food Security and HIV/AIDS Gwenelyn O’Donnell-Blake, D.C. Office Director/ Senior Food Security Technical Officer, Project Concern MDG 1: One Step Closer: The Role of Micronutrient-Rich Staple Foods Erick Boy, Head of Nutrition, HarvestPlus MDG 2: Education for All: Beyond the Numbers Elizabeth Leu, Senior Education Advisor, Global Education Center, Academy for Educational Development

Universal

MDG 3: Promoting Gender Equity EngenderHealth

G lo ba l

MDG 5: Protecting the Sexual and Reproductive Rights and Health of our Daughters Gill Greer, Director-General, International Planned Parenthood Federation

Convention Child

Polio Eradication Initiative Roll Bac k

Malaria campaign

nitiative

on the Rights of the

Access10

MDG 4: Delivering on the Promise of Immunization Rebecca Fields, AED and Robert Steinglass, John Snow Inc.

MDG 5: The Product Makes the Program: The Importance of Supplies in Improving Maternal Health Jennifer Bergeson-Lockwood, Project Associate, Population Action International MDG 5: 3 Billion Reasons Why the Time is Now for Adolescent Sexual and Reproductive Health Gwyn Hainsworth, Senior Advisor for Adolescent Sexual and Reproductive Health, Kristy Kade, Program Officer for Advocacy, Pathfinder MDG 5: Promoting Maternal Health EngenderHealth MDG 6: Addressing Infectious Diseases Susan Higman, Director of Research and Analysis, Global Health Council MDG 7: The Unbreakable Link: Environmental Sustainability and Human Health Jade Sasser, Public Health Institute MDG 8: Building Public-Private Partnerships Jeffrey Jordan, Senior Vice President of Programs, Catholic Medical Mission Board

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By Linda P. Fried and Lynn P. Freedman

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Are We Chasing Goals Rather Than Solving Problems?

We stand at an unprecedented moment in global health: advances in public health science enable us to project health trends into the future as never before and to understand how to prevent or effectively treat many of the significant global health concerns – or position us to figure out more effective approaches. We also have global experience in setting goals, deploying resources, and observing outcomes. This is a critical time to be cognizant of the broad changes that are in process and take stock of whether current approaches will serve us well in this changing world. This article seeks to reflect on both of these issues and suggest on how each can inform the other for future success in improving global health.

The new world of global health will be characterized by persistence of our longstanding concerns to mitigate infectious disease and improve maternal and child health, food and water availability and safety. In these areas, there is little doubt that global goals and targets have been critical for redirecting policy attention and mobilizing advocacy. Witness the rise of attention to maternal mortality once it was chosen as an MDG – and the equally striking decline in the fortunes of reproductive health when it was omitted from the original Goals. Yet, even when there is such welcome attention, successive goals and targets have come and gone, largely unmet.

Our poor track record may stem from the reliance on plans that are formulated with an eye trained exclusively on the bar set globally by the goal, while ignoring what science teaches us is needed locally for lasting solutions. In fact, recent analyses by Peters et al, in the 2009 the World Bank’s Improving Health Service Delivery in Developing Countries: From Evidence to Action, clearly demonstrate how global goals and targets have been set without reference to crucial aspects of the country context that influence change, and without acknowledging the varying pace of change that is possible across different settings with different starting points.

Linda P. Fried, MD, MPH, is dean and DeLamar Professor of Public Health at Columbia University Mailman School of Public Health, and professor of Epidemiology and Medicine and senior vice president, Columbia University Medical Center

Lynn P. Freedman, JD, MPH, is director of the Averting Maternal Death and Disability Program (AMDD) at the Mailman School of Public Health, Columbia University

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Too often, global goals and targets that were meant primarily to refocus political attention are mistakenly assumed to dictate appropriate first steps in a plan of action for effective implementation. For example, there is clear consensus that a goal such as MDG 5 on maternal mortality cannot be met without an approach that strengthens district-level health systems. Yet many of the Roadmaps for Reduction of Maternal and Newborn Mortality developed by countries in Sub-Saharan Africa, while aspiring to meet global MDG targets for births attended by skilled health professionals, are devoid of adequately resourced implementation plans to tackle the systemic problems that have repeatedly sabotaged such aspirations.

Insights from the fields of systems science and implementation science would guide us toward a rather different approach to implementation – one that builds from the local level up, starting with a strategically developed understanding of the power dynamics and institutional constraints that currently hamper progress.

Such plans for meeting goals and targets might use results-based financing and management approaches, but they would be deployed using a conceptual framework and monitoring design that can accommodate unintended consequences, policy resistance and emergent, changing properties of the system itself.

Implementation would proceed with focused attention to these dynamics of the system and with a flexible plan to strengthen the capacity for local problem solving.

Ultimately, according to Potter and Brough’s 2004 Health Policy and Planning paper “Systemic Capacity Building: A Hierarchy of Needs,” the pace of progress would depend substantially on the success at strengthening the institutional arrangements – rules, accountability, incentives, organizational structures – on which the health system is built.

Clearly, this evidence-based approach to implementation would argue for a different relationship between aspirational global goals and the metrics that govern action on the ground. When global targets are, nonetheless, used to grade countries as “success” or “failure,” and intense pressure for fast results is allowed to eclipse attention to institution building, or even to justify violation of rights, the damage can go beyond simple failure to meet the goal. Painful experiences with contraceptive targets and coercion in the family planning field teach us that numbers are not neutral: their

operation within a health system is filtered through the wider power dynamics operating in a society.

Now let’s consider the dramatically different epidemiologic and demographic picture of the coming decades that these longstanding health concerns will nest within. The world, over the next 20-30 years, will manifest a number of significant changes. Mortality and morbidity from chronic, noncommunicable diseases will be the dominant causes of ill-health – fueled by worldwide changes in health behaviors and environment.

Already, according to WHO in 2004 and then again in their fact sheet number 310 of October 2008, of the top 10 causes of death in low-income countries, three were noncommunicable disease: coronary heart disease, stroke and cerebrovascular disease, and chronic obstructive pulmonary disease; in middle-income countries, seven of the top 10 were noncommunicable.

(See GLOBAL HEALTH magazine, Issue 4, Fall 2009) Associated with this rise in noncommunicable disease is the aging of all populations, globally. A great success of public health, our increasing life expectancy, this brings a need for a new set of goals for healthy aging and a whole new range of methods to accomplish this.

Global and national goals for prevention of these noncommunicable diseases and health in an aging world are much needed to align global action with these new realities. But at the operational level, new types of solutions that will be effective in prevention on a population level are also needed. The approach and ability to manage the complexity of the problem will matter: for example, consider the picture of a world-wide obesity epidemic coexisting with persisting malnutrition in many developing countries; this will make goal setting and problem solving necessarily complicated, because we must be able to design solutions that don’t take people from starvation to obesity. Further, the most effective methods for accomplishing these goals could bring co-benefits in terms of more effectively addressing many other co-existing health concerns.

Given the massive changes in population health status and needs, and the complexity of real-life challenges, in comparison to the necessary simplicity of goals, we ask if we have all the necessary goals, and whether global health goals serve us well as a guide in shaping our strategies to solve these future scenarios. GH —

C The World Bank’s Improving Health Service Delivery in Developing Countries: From Evidence to Action, http://www.enrecahealth.dk/news/elearning/Improving_Health_Service_Delivery.pdf/ C 2004 Health Policy and Planning paper, “Systemic capacity building: A hierarchy of needs,” http://heapol.oxfordjournals.org/cgi/reprint/19/5/336

C WHO fact sheet number 310, October 2008, www.who.int/mediacentre/ factsheets/fs310/

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By D.A. Henderson, MD, MPH

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The Death of a Disease

Geneva, Switzerland, May 8, 1980 – The 33rd World Health Assembly declares solemnly that the world and all its peoples have won freedom from smallpox…a most devastating disease…since earliest time. In so doing, it demonstrates how nations working together in a common cause may further human progress.”

In May of this year, the World Health Assembly celebrates the 30th anniversary of its historic declaration of global freedom from the ravages of smallpox, the most virulent of all pestilential diseases.

The planned campaign to achieve eradication began in January 1967. That year, 43 countries experienced more than 10 million cases and 2 million deaths. All countries feared the disease and continued long-standing smallpox vaccination programs whether or not they had cases.

International travelers were required to carry certificates showing that they had been recently vaccinated.

Photos courtesy of the Centers for Disease Control and Prevention

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D.A. Henderson, MD, MPH, led the WHO’s Global Smallpox Eradication Campaign. He is currently a distinguished scholar at the Center for Biosecurity and a professor of medicine and public health at the University of Pittsburgh Medical Center. He is also a distinguished professor and the former dean of the Johns Hopkins School of Public Health.

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The planned campaign to achieve eradication began in January 1967. That year, 43 countries experienced more than 10 million cases and 2 million deaths.

However, the decision to undertake the global eradication campaign had not been an easy one. Many doubted its feasibility. No disease had ever been eradicated. A vote was taken in the Assembly to decide whether or not the program should be launched. It was endorsed – by a margin of only two votes. The WHO budget provided an allocation of $2.4 million – not enough even to buy the vaccine required each year. A 10-year target called for the last case to occur by December 1976. The program didn’t quite succeed – it missed the target by 9 months and 26 days.

The strategy was simple, consisting of only two components. First was to protect at least 80 percent of a country’s population by vaccination, thereby limiting the spread of disease. Second was to begin a program called “surveillance and containment” – to detect cases at the earliest possible time, to isolate them in their homes, and to vaccinate neighbors and friends in a large circle around the infecting houses. The virus could not survive unless it infected one person after another in a continuing chain of transmission. When the patient’s contacts were protected by vaccination or previous illness, the virus was blocked and the chain could be broken.

A first, major hurdle for the program was to obtain sufficient heat-stable vaccine. Large, initial donations by the U.S. and Soviet Union provided a basic supply.

However, little of the vaccine produced in developing countries was usable. Emergency meetings were convened of the vaccine producers from the two major donors and experts from Canada, the Netherlands and the U.K. Standard manuals were developed and members from the group worked on-site with the deficient laboratories. Within five years, more than 80 percent of the vaccine was being produced in the developing countries and all were meeting standards.

New vaccination techniques were introduced that Image courtesy of WHO

• Egypt’s Ramses V most likely died of smallpox.

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permitted more rapid and effective vaccinations. Jet injectors that could vaccinate hundreds in an hour were superseded by a newly invented simple two-pronged (bifurcated) needle that required much less vaccine and whose use could be taught in a matter of 15 minutes.

Finding outbreaks quickly was essential for the containment strategy. All health centers and hospitals were asked to provide a report every week; two-person teams responded quickly to confirm the diagnosis, to find other cases and to perform vaccination of the patient’s contacts. This approach proved to be so effective in stopping transmission that it was given priority over mass vaccination.

Progress in the program was more rapid than any had anticipated. The first successes were in a block of 20 countries in West Africa whose programs were supported

by USAID and experts from CDC. These countries had been among the most heavily infected and logistically difficult. Nevertheless, smallpox was on the verge of elimination within three years.

By the sixth year of the program, smallpox had been eliminated from all countries except Ethiopia and four in South Asia – India, Pakistan, Bangladesh and Nepal.

This group of countries proved to be far more difficult than had been expected. In the densely populated Asian countries and in Ethiopia, there was a never-ending array of catastrophes and setbacks that left the staff repeatedly reeling in frustration and fatigue – floods, famine, civil wars, kidnapping of teams, political instability, government suppression of reports, and bureaucratic obstacles of every imaginable type. On several occasions, the ultimate success of the program hovered on the brink of a major, perhaps permanent setback.

However, a dedicated, resourceful array of national and international staff persisted and eventually celebrated the occurrence of the last case on Oct. 26, 1977.

An important legacy of the program was the demonstration of the importance of surveillance in working out strategies in disease control. It depended on weekly reports being submitted promptly by all health centers and hospitals and containment teams to be sent.

The teams were usually on-site within one to two days and this reinforced the fact that the reporting of cases had actionable meaning. It was an approach that was alien to programs throughout the developing world.

Although smallpox vaccination teams had been in use for many years, it was surprising to discover how effective such teams could be when villagers were properly approached and when the teams were well supervised.

In Africa, teams could readily average 500 vaccinations daily per vaccinator. Why not increase the number of Images courtesy of the Centers for Disease Control and Prevention ISSUE 06 spring 2010

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• In the early 1800s, orphans were used to transport the vaccine to Asia and the Americas.

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The achievement of smallpox eradication is a landmark. It is a tribute to an international staff that never numbered more than 150 in the field.

The bifurcated needle – inexpensive, used less vaccine – revolutionized the way smallpox vaccine was delivered.

Image courtesy of the Centers for Disease Control and Prevention

vaccines being given? In the developing countries, there were few vaccines then in regular use. Resources were a problem and international agencies focused primarily on a foundering malaria eradication effort. Some yellow fever vaccine was administered in heavily endemic areas; BCG vaccine was provided to a few countries by UNICEF; but basic vaccines such as DPT, measles and polio were little used.

In 1970, we convened an international WHO meeting to develop recommendations for a program on immunization that would extend beyond smallpox vaccination – that it include DPT, measles, polio and BCG vaccines as routine immunizations for all children – an Expanded Program on Immunization. This was endorsed by the World Health Assembly in 1974. Eventually, UNICEF took this on as a priority and Rotary International volunteered to raise millions of dollars for polio vaccine.

The goal was to reach 80 percent vaccination coverage for all children throughout the world by 1990. And so momentum was established for ever larger-scale

programs to make products for better health conveniently available to villagers. These eventually have included many other vaccines, Vitamin A capsules, bed nets for malaria, and others.

The achievement of smallpox eradication is a landmark.

It is a tribute to an international staff that never numbered more than 150 in the field; to national leaders and staff who capably undertook new tasks; and to the World Health Organization that provided the framework within which all countries could constructively work even during days of the Cold War.

It is the behind-the-scenes drama of this victory that I have endeavored to portray in my book, Smallpox: Death of a Disease (Prometheus Books, 2009) GH —

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By robin gorna

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Is Universal Access to HIV Prevention and Treatment A Realistic Goal?

Photo courtesy of the International AIDS Society

Yes. Universal access to HIV prevention, treatment, care and support is not only realistic, it must be achieved.

Yes, we must do it now. The benefits – in lives saved, HIV infections and other illnesses prevented, families and societies supported, children schooled, economies restored, and futures safeguarded – are worth every dollar and every hour of effort invested. And yes, we have a lot of work ahead of us to make universal access to HIV prevention, treatment, care and support a reality for all.

Skeptics say that the world’s richest nations, the G8, over-promised when they committed in 2005 to ensure access to HIV services for all who need them by 2010.

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Or that 189 United Nations member states did not know what they were doing when they agreed in a unanimous vote to join the universal access pledge.

From my perspective, the problem is not over-promising.

It’s under-achieving. None of us – rich nations, poor nations, policymakers or advocates – have done enough to make universal access a reality. The fact that we will not reach the goal by 2010, however, is no excuse not to act now with more determination than ever to make global access to HIV prevention and treatment a reality as quickly as possible.

Robin Gorna is executive director of the International AIDS Society (IAS), the world’s leading independent association of HIV professionals, with over 14,000 members working in 190 countries.

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Number of people receiving antiretroviral therapy in low- and middle-income countries. By Region. 2002-2008 4.5

North africa and the Middle East Europe and Central Asia

4.0

East, South and South-East Asia 3.5

Latin America and the Caribbean Sub-saharan Africa

millions

3.0 2.5 2.0 1.5 1.0 0.5 0.0

end 2002

end 2003

end 2004

end 2005

end 2006

end 2007

end 2008

Source: WHO/UNAIDS/UNICEF. Towards Universal Access: Scaling up Priority HIV interventions in the Health Sector. Progress Report 2009.

The International AIDS Society (IAS), our partners, and many other organizations of people living with HIV, funders, policymakers and activists are working through the IAS Universal Access Now campaign to remind the world that universal access is a collective commitment, a shared responsibility, and a realistic, achievable goal.

Universal Access Now demands greater action by the G8 and G20 nations, including full funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria, which needs US $20 billion over the next three years to continue and expand its lifesaving work.

With aggressive action, why shouldn’t we deliver universal access to HIV prevention, treatment care and support by 2015? Michel Kazatchkine, head of the Global Fund, has stated that “If countries can continue scaling up their efforts at the pace set in recent years, we could come close to, reach or even exceed the health-related Millennium Development Goals. By 2015, millions more HIV infections may be prevented and lives otherwise lost to AIDS saved, and we may virtually eliminate transmission of HIV from mother to child.”

Is this massive undertaking worth the expense and the effort? Every public health and development indicator says “yes.” Universal access will not only dramatically reduce the HIV epidemic – it will also provide a strong foundation toward achieving Millennium Development Goals (MDGs), including reducing child mortality (MDG 4), improving maternal health (MDG 5), and combating HIV

• Infant mortality in South Africa declined 30 percent between 2001 and 2007 following implementation of ART prophylaxis to prevent vertical transmission.

and AIDS, malaria and other diseases (MDG 6).

The number of people receiving HIV antiretroviral therapy (ART) in low- and middle-income countries increased from 400,000 in 2003 to 4 million in 2008. That’s good progress, but we’re still only reaching about one-third of the people who need HIV therapy today. That number has grown with the introduction of new World Health Organization guidelines, urging earlier treatment for better health outcomes, which include preventing HIV transmission by reducing viral loads in people on therapy, proving once again that treatment and prevention go hand-in-hand.

Globally, coverage of HIV prevention services is improving, but we still have far to go. In 2008, nearly half (45 percent) of pregnant women living with HIV in low- and middle-income countries received ART to prevent vertical transmission and for their own health, up from only 10 percent in 2004. Importantly, an increasing proportion of pregnant women are receiving optimal HAART regimens for their own health, rather than singledose ARVs designed exclusively to prevent vertical transmission.

Worldwide, more people are getting testing and counseling, too. The percentage of people aged 15-49 living with HIV in low- and middle-income countries, who reported having an HIV test and receiving the results, more than doubled in recent years. Still, studies show that only about 40 percent of people worldwide know

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their HIV status: a significant barrier to achieving universal access.

More action is also needed to scale up access to highly-effective prevention interventions such as male circumcision and harm reduction for people who use injection drugs, including needle and syringe programs and opioid substitution therapy. Globally, men who have sex with men often have both the highest HIV prevalence and poorest prevention coverage. Sex workers and migrant populations are also overlooked and discriminated against when it comes to access to effective HIV prevention. Measures to reduce this kind of stigma and discrimination, including the reform of laws that criminalize same sex behavior, drug use and sex work must be scaled up urgently.

As the universal access target comes due, progress toward the goal is mixed. But, in a world of competing priorities, isn’t slow, incremental progress better than nothing? Unfortunately, this epidemic does not work that way. Of course, on an individual level, every person reached with ART or with the tools and information to avoid HIV infection is a victory. Globally, however, the only way to reduce and ultimately end this epidemic is to reach a very high level of people in need. Providing universal access to HIV services would also create dramatic improvements across a number of vital health and development indicators.

Universal access would: n Significantly reduce the impact of other serious diseases, such as tuberculosis, the world’s seventh largest killer. HIV/TB co-infection levels are as high as 80 percent in some sub-Saharan African countries.

Multiple studies show that HIV-positive people on therapy contract and transmit TB at much lower rates than those with no access to treatment. n Strengthen maternal and child health. AIDS is the

leading cause of death among women of reproductive age worldwide, and a major contributor to high maternal death rates. Safe breastfeeding, which is made possible by access to ART, reduces diarrheal diseases (the fifth leading cause of death worldwide) and other serious childhood illnesses. n Strengthen health systems. In many countries, national health policies and programs developed to address HIV are already improving health system capacity to treat and prevent other illnesses. AIDS-related investments in health infrastructure and health-worker employment and training lead to broad health systems’ improvements, and decreases in all-cause mortality. n Foster economic growth and security. The loss of

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skilled workers to AIDS is a major barrier to development in struggling economies. Access to HIV prevention and treatment keeps women and men productive in their families, communities and national economies, while reducing government health-care costs.

Despite successes to date and overwhelming evidence in support of universal access, there are worrying signs that financial and political support for the goal is weakening just as it should be increasing. The Organization for Economic Cooperation and Development confirms what health and outreach workers are seeing in the field: wealthy nations are falling billions short of their commitments to universal access, and the gap between the resources committed and the resources required is growing. Médecins Sans Frontières (MSF) already reports ART stock-outs in many countries as HIV treatment budgets are cut.

We all have work to do to ensure that world leaders build on the progress to date to keep the universal access promise. IAS’s Universal Access Now campaign demands that: n Donors fully fund the Global Fund, one of the most successful public health funding mechanisms ever developed. US$20 billion is needed to keep the countrylevel programs the fund supports on an aggressive course to achieve universal access. n G8 nations, the world’s richest and most powerful, increase funding and political support for universal access and national programs such as PEPFAR scale-up to build on successes to date. n G20 nations increase their commitments to the universal access effort at home and abroad. n African nations keep the promise of the 2001 Abuja Declaration commitment to dedicate at least 15 percent of their national budgets to health. n All nations increase national funding and political support for universal access, and support innovative financing mechanisms, such as the proposed Financial Transactions Tax, a tiny surchage on financial transactions that would raise billions for global health, including universal access.

The bailout given to global financial institutions produced more than US$ 1 trillion in a matter of weeks. For a fraction of that, we could end HIV, tuberculosis, malaria and other diseases and create benefits for global wellbeing that we cannot even imagine. GH —

C Visit the IAS “Universal Access Now” webpage at http://www.iasociety. org/universalaccessnow.aspx for tools and information that can help you add your voice to the demand for Universal Access to HIV prevention, treatment, care and support.

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By adrienne germain

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Achieving Maternal Health Getting Further, Faster

Photo courtesy of the International Women’s Health Coalition

This month, a study published in the The Lancet reported a decline in maternal mortality. While this is cause for optimism, we cannot afford to be complacent: more than 300,000 women still die senseless deaths and suffer disabilities each year due to preventable causes related to pregnancy and childbirth, and in some countries, maternal deaths are on the rise. Many of these girls and women give birth and die at home, often alone, in fear and agony. Or, they die in substandard medical facilities ill-equipped to deal with problems that are routinely managed for women in rich countries and for rich women in their own countries. Saving women’s lives in childbirth requires relatively inexpensive and known interventions at the clinical level – not fancy hospitals, new technologies

Adrienne Germain is president of the International Women’s Health Coalition.

or scientific breakthroughs. This decline does give us reason to be optimistic, but with political will, we can and should continue to make maternal health a global priority.

And we must also make it easier for women and girls to decide to use, and actually reach, these services.

With impetus from the Millennium Development Goals (MDGs), specifically MDG 5, priorities are starting to shift and nations are beginning to pay more attention to women. Our mission, however, is not simply to reduce maternal deaths, but to achieve maternal health. Maternal health is a state of being. It cannot be achieved through a simple technical fix, nor through maternity care alone.

Rather, we must also equip women with the information,

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skills and services to make informed decisions whether to become pregnant and to give birth. They must have access to safe, affordable contraceptives, including emergency contraception, and male and female condoms, especially where HIV and other sexually transmitted infections (STIs) are prevalent. They must also have the choice of safe abortion. And they need prevention and treatment for the myriad of STIs that jeopardize not only their own health and lives, but those of the children they choose to bear.

Maternity care, contraception, safe abortion, prevention and treatment of STIs including HIV – these four, together with comprehensive sexuality education form the core sexual and reproductive rights and health (SRRH) package, which is required to ensure that women and young people can live just and healthy lives. Each of the five main elements of the package relies on the others to reach peak effectiveness. Focusing only on one element of this package without the others in concert is not only shortsighted, but a failure to respect women’s realities. As we look at the function of each element, the justification for providing the complete package is clear, not only in terms of girls’ and women’s needs, but in terms of efficacy.

Knowledge is power – and a key element of the SRRH package. In Nicaragua, almost 90 percent of sexually active adolescents did not use contraception the first time they had sex simply because they were unaware that they could. Early, comprehensive sexuality education for girls and boys can help fill gaps in knowledge, empower young people to make healthy decisions, prevent unwanted pregnancies, reduce the risk of STIs, and encourage equal and balanced relationships based on respect for human rights and for consent.

The second element of the package is access to contraception. More than 200 million women who want to delay or prevent pregnancies lack the information or contraceptives needed to do so; and nearly half of the 205 million pregnancies that occur each year are unplanned. By making effective contraception affordable and accessible, we can help ensure that every pregnancy is wanted and reduce the need for abortion.

Contraception helps reduce unwanted pregnancies, but will not eliminate them. More than half of the 80 million unwanted pregnancies that occur each year end in abortion – and half of those are performed in unsafe conditions. About 67,000 women die annually from complications of unsafe abortion, and thousands more are severely injured. Preventing these deaths and injuries would reduce maternal mortality by approximately 13 percent globally. Yet, even where abortion is legal, access

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is often limited by barriers imposed by health institutions; a shortage of skilled providers; and lack of information.

When women give birth, skilled birth attendance with ready referral to facilities that can provide good quality emergency obstetric care could reduce maternal mortality by over 50 percent. The absence of these services remains a major problem especially where populations are widely dispersed. Only two out of every three women living in the developing world today give birth with skilled assistance, and even fewer have access to essential obstetric care.

Finally, prevention and treatment of STIs, including HIV, is vital for both maternal and neonatal health. Women with pelvic inflammatory disease (PID) from untreated STIs are at higher risk of infertility and ectopic pregnancy, a condition that is fatal without skilled care. A recent study showed that HIV-positive women in South Africa were up to five times more likely to die of pregnancyrelated causes than pregnant women not living with HIV. Educating women and men on preventing STIs through the use of male and female condoms and other safer sex practices, as well as diagnosis and treatment, would save lives and transform communities.

The integrated SRRH package I’ve just outlined is not simply a concept. It has proved to be an effective strategy for the improvement of maternal health. In Bangladesh, one of the poorest countries with high rates of maternal mortality, the success of a comprehensive SRRH initiative in the 1990s provides inspiration. Within five years of initiation, the percentage of women receiving check-ups and care prior to childbirth doubled from 26 percent to 56 percent. Use of emergency obstetric care rose by nearly 25 percent. Female life expectancy increased by two years. Maternal mortality dropped by 26 percent.

Fifteen years after the United Nations International Conference on Population and Development (ICPD), the Obama administration announced a Global Health Initiative that mirrors the ICPD SRRH approach which was adopted by Bangladesh. They, other donors, the U.N. Secretary General, and many nations are now increasing attention to MDG 5. But we must not try to play with only half the deck available. We must fully fund and implement the comprehensive sexual and reproductive health package, not only maternity care or only family planning or HIV prevention and treatment.

Together, the elements of the SRRH package add up to far more than the sum of its parts. Its full implementation will not only achieve maternal health, but also secure health and human rights for generations. GH —

In Nicaragua, almost 90 percent of sexually active adolescents did not use contraception the first time they had sex simply because they were unaware that they could.

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