A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?
Health systems strengthening: a common classification and framework for investment analysis
The impact of medical insurance for the poor in Georgia: a regression discontinuity approach
The Role of Executive Time Horizons in State Response to AIDS in AfricaPages
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© 2011 Karen Grepin's Global Health Blog
Since I am expecting the arrival of my baby any week (day?) now, I am way beyond the point where people are afraid to ask if I am pregnant or not. I am now at the point where complete strangers will come up to me on the subway and ask if they can touch “it”. Unsurprisingly, these strangers almost always also ask if it is a boy or a girl (it is a boy) and whether it is my first one or not (it is not).
Surprisingly, however, many will also ask me where I plan to deliver. When I say where I plan to deliver, some acutally look surprised or even make an expression of disgust. It turns out that in NYC, where you deliver says a lot about who you are and where you stand in society. Unfortunately, not everyone can rent out the entire labor and delivery floor at Lenox Hill. Next time.
Fortunately, even the most basic facility available to me here in NYC is infinitely better staffed and better equipped than essentially any public hospital available to people in most developing countries. If you are like me and track global health data, you might have noticed that Measure DHS project, the organization that helps with the collection and dissemination of the Demographic and Health Surveys recently began releasing for the first time a set of surveys known as the Service Provision Assessments (SPAs), which collects information on a nationally representative set of health facilities in small number of developing countries. So far these surveys have been under-exploited for research.
Using this data, a recently published paper in Health Policy and Planning by Renee Hsia, Naboth Mbembati, Sarah Macfarlane and Margaret Kruk paints a pretty grim picture of the status of emergency and surgical facilities in Sub-Saharan African hospitals. They find:
The percentage of hospitals with dependable running water and electricity ranged from 22% to 46%. In countries analysed, only 19–50% of hospitals had the ability to provide 24-hour emergency care. For storage of medication, only 18% to 41% of facilities had unexpired drugs and current inventories. Availability of supplies to control infection and safely dispose of hazardous waste was generally poor (less than 50%) across all facilities. As few as 14% of hospitals (and as high as 76%) among those surveyed had training and supervision in place.
They conclude that not a single surveyed hospital in the entire sample of 2000+ facilities had “enough infrastructure to follow minimum standards and practices that the World Health Organization has deemed essential for the provision of emergency and surgical care”. I’ll think twice about complaining about the hospital food this time around.
Share on FacebookFew countries represent such a challenge when it comes to the scale up of immunizations than Nigeria. Consistently immunization rates have trailed behind neighboring countries. It is where we hear stories of whole communities rejecting immunization due to a misunderstanding about the purpose of these programs and mistaken belief about those running the programs.
At the same time, few countries stand to benefit as much from rapid scale up of these programs than Nigeria: child mortality rates are abysmal – on the order of twice as high as nearby neighboring countries such as Ghana. Barriers to immunization adoption have also stymied efforts to eradicate polio: it is one of the three countries in the world where the virus remains endemic. Even India – another vaccine basket case by historical standards – has managed to go polio free.
So I was not terribly surprised to hear that “Vaccine Summit” has been organized this week in Nigeria to bring together national and international leaders and experts to put increased emphasis on immunization in this country. This is what national and international leaders and experts do when things don’t seem to be working well.
What I was surprised to learn about, however, is new project that the Gates Foundation has launched in this country to help incentivize uptake of immunization. Called the Governor’s Immunization Challenge, the new program will reward a cash prize to the Governor that demonstrates the greatest leadership in improving both routine and polio immunization by the end of the year. This is not what the Foundation, which admits that it has a bias towards technological solutions to global health challenges, does. It seems like a departure from their regular business model of focusing on technical and operational barriers and an admission that things like leadership of health officials might matter a lot.
I wonder if this represents a new new direction for the Foundation in general? I sure hope so, as I believe it could be a very fruitful avenue to explore.
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I heard some rather surprising news this afternoon (on Twitter, where else?): after 40 years, the Global Health Council has decided to cancel its 2012 Global Health Conference in Washington, DC. In an email circulated this afternoon, the reason the organization gave was:
We appreciate that during tight budget times many members need to prioritize conferences they intend to attend and/or support. The same choices would need to be made by panelists, sponsors and participants. Rather than compete with other health causes and organizations whose missions we support, the Global Health Council Board has decided to cancel our 2012 Conference.
As most people know, the International AIDS conference is going to be held in Washington this summer, which is kind of a big deal. But with all of the global health types descending onto DC at the same time, one might have expected that enrollment at the GHC conference could have been even higher this year than in years past. Clearly not. The conference has been announced for nearly 2 years, so canceling with just under 3 months to go suggests that the situation must be pretty dire.
So what is going on? Are fiscal constraints really making people choose among conferences? Is this a sign that this particular organization, which has been facing some leadership challenges lately, has lost its relevance? Or is it a sign that HIV is the only real issue that most people care about? Or is it something more profound: might broad interest in global health issues be declining? Regardless, this is a worrying sign.
Share on FacebookIt is that time of the year again. No, I don’t mean that absolutely wonderful time of the year when the sun starts to shine, the birds are singing, the buds are forming on the trees, and the grass turns green (which basically describes this entire week in CT). It is that time of the year again when students start (in earnest) to look for summer internship opportunities in global health. My inbox has been full of inquiries from my current and past students as well as from students from around the world. As much as I would love to reply to all of your emails, there are just too many of them to give personalized responses to all of them (I probably received 30 this week alone), and in general my response is usually the same. So instead, this year I will put some thoughts up here on my blog, and I will share this with you when you write (or save yourself the email).
First off: what kind of opportunities are out there? Yes, it is true that many global health organizations have summer internships. What is not necessarily true is that there are a lot of them, that they are well paying, that they are in developing countries, and that they are easy to find. Many summer internships opportunities are quite informal in nature, which makes them hard to find. Most summer internships that I know of are usually with the US-based outfit of the organization, so your dreams of spending the summers in Kenya or China, while possible, should not be the norm. That is OK, you can still learn a lot and gain lots of experience. This should be the goal of an internships.
If you are a graduate student, I would encourage you to think about taking a summer internship even if it does not pay to help you gain experience that will help you land a job after your graduate. Yes, I know many of you are broke, and being paid seems essential, but honestly, in the grand scheme of things, once you have factored in the opportunity cost of going back to school, paying tuition, paying rent (especially if you live in New York), and other factors, the difference of a few thousands dollars (which is about as much as you can expect to make during the summer in a paid internship) is not as important as the opportunity to gain real experience and to network with organizations that might be able to hire you someday. Easy for me to say, I know, but if you were to ask me whether you should take an unpaid internship, my answer would likely be yes, if it is a good opportunity with a good organization.
Where can you find information on summer internships? That is a harder question. By now, most organizations that have formal internship programs likely have their internship positions posted on their websites. I would start there. Come up with a list of organizations that you know of, ideally in your area, and see what they have available. A lot of organizations, in particular organizations in New York send me links to postings. I send all of those to my google groups jobs list, which you can sign up for here, and I usually tweet about it as well.
Many organizations don’t have formal internships, but they might be open to accepting students informally for unpaid internships. If that is the case, I would contact the organizations directly, with a short, but well written email that describes who you are, your area of interests, and some short background information on your skills (including software languages if looking for a research internship) and experiences. I would also attach a cover letter and your resume to this email. Don’t be surprised if you don’t get a response, but there is very little cost to you of sending out these emails. Some academics also hire in this way, so if you have interests in gaining some research experience (again, likely unpaid) you can try this out as well. Try all of your personal connections. My first internship in global health was an informal and unpaid internship with the Global Fund in Geneva. I set it up through a friend, no one knew who I was or what I was doing there, it cost me a fortune to be there, I worked night and day – but it was one of the best experiences of my life.
If you are part of a University, more than likely there will be some sort of on campus career expo or session. I would encourage you to go to these. There is also likely some sort of job posting board on campus. It can’t hurt to try there as well. I would also encourage you to go to your favorite professor’s office hours, if you have not done so yet, and talk to them about your areas of interest so that if they see internships come their way, they may be likely to send them your way. If they don’t know you, they won’t know what you are looking for, and they won’t be able to recommend you for any opportunities.
Some universities also provide some financial support to students who undertake unpaid summer internships that help advance their careers. Wagner, where I work, has recently started the Wagner Experience Fund, which provides $5,000 grant to students who are interested in taking unpaid internships with non-profit organizations. Again: get the right internship first and worry about the finances later.
Should you accept any internship? Probably not. For some organizations, summer interns are code for slave labor. If they are looking for slaves to work on real projects that require you to apply some of the skills you have been learning in school, then by all means say yes. But if they are really looking for people to do menial tasks, it might not be worth your time. When you talk to the organization offering the internship, be clear about the types of opportunities you are looking to find, what kinds of skills you currently have that can be exploited, and be clear on what your role will be and what deliverables will be obtained. If it sounds like something you could have done out of high school, you might want to keep looking, but otherwise, paid or not, it might be a great opportunity. I would also say going to work for a good organization, that is an organization with a good reputation in the global health world, might be worth sacrificing a bit on roles, since it might still look good on your resume down the road and if you put in a lot of effort, small roles might become big ones.
Finding a summer internship in global health is never easy. But rarely do opportunities fall out of the sky and land at your door. You won’t find one without effort, and it takes time and effort to find a good internship. Good luck!
Share on FacebookAs many of you know, I have done some work over the years with the Neglected Tropical Diseases (NTDs) including some work with the African Programme on Onchocerciasis Control (APOC). Although I have not been actively involved with much research in the area, I love keeping up to date with what has been going on in the field.
A new study, published by some former colleagues this month in Parasites and Vectors (c’mon, I know you all read it too) suggests that not only might the models adopted by APOC for the control of River Blindness be effective at achieving control but that they might also be able to achieve something even more impressive: elimination.
APOC has now been supporting programs in some countries for over 15 years, which is an eternity by global health standards. In some of these distribution communities researchers have been able to go in and measure the prevalence of onchocerciasis and found that it is in fact zero…not close to zero…but actually zero cases. Period. This is exciting stuff.
At the outset of these programs, no one really knew what would be achievable, how long it would take to achieve results, and whether something like elimination was really in fact possible from drug distribution alone. Long-term commitment to the program from donors and implementing countries, realistic goals and a governance structure commitment to re-evaluation, strong regional leadership from the APOC program (especially under Uche Amazigo, one of the authors of this paper) and a commitment to ongoing monitoring and evaluation were really what were key.
I think that is the lesson here: results don’t happen over night, but when the programs are given time to achieve them and the right systems are in place to monitor and measure them, great things can happen.
Share on FacebookA big debate in the aid circles these days is whether conditioning financial support on performance actually improves performance relative to just providing resources (or even giving aid in the first place!). Though there has been a lot of discussion and debate about this issue, there have actually been few large scale evaluations of such programs, this paper being perhaps the best known exception.
New evidence – in the form of an NBER working paper – out of Indonesia, the country that some say every villager is studied and surveyed a few times a year, provides some more evidence that this appears to be the case. As I am working under a series of deadlines this week, I did not have time to give a deep review, so I will leave you with the abstract for you to decide for yourself.
Share on FacebookThis paper reports an experiment in over 3,000 Indonesian villages designed to test the role of performance incentives in improving the efficacy of aid programs. Villages in a randomly-chosen one-third of subdistricts received a block grant to improve 12 maternal and child health and education indicators, with the size of the subsequent year’s block grant depending on performance relative to other villages in the subdistrict. Villages in remaining subdistricts were randomly assigned to either an otherwise identical block grant program with no financial link to performance, or to a pure control group. We find that the incentivized villages performed better on health than the non-incentivized villages, particularly in less developed areas, but found no impact of incentives on education. We find no evidence of negative spillovers from the incentives to untargeted outcomes, and no evidence that villagers manipulated scores. The relative performance design was crucial in ensuring that incentives did not result in a net transfer of funds toward richer areas. Incentives led to what appear to be more efficient spending of block grants, and led to an increase in labor from health providers, who are partially paid fee-for-service, but not teachers. On net, between 50-75% of the total impact of the block grant program on health indicators can be attributed to the performance incentives.
It is not uncommon – it is perhaps even the norm – that whenever a former African head of state needs surgery or another health care procedure, they are flown to Paris, or London, or even New York for care. Last week, however, John Kufour, the former president of Ghana bucked the trend and elected to have a spinal procedure at Korle Bu medical center in Ghana.
Kufuor was largely responsible for bringing national health insurance to Ghana so it is particularly notable that he has made this decision. Kudos to him for showing faith and confidence in the excellent medical staff at Korle Bu. Last summer, I visited surgical wards at Korle Bu and was amazed at the level of care provided. I wish President Kufuor a swift recovery and a safe – and very short – trip home.
Share on FacebookEarlier this week, I was fortunate to attend the launch of a report by Save the Children on the state of malnutrition globally. Their report, entitled “A Life Free from Hunger” rightly draws global attention on one the most important, yet perhaps most neglected causes of child mortality and ill health – malnutrition. According to their estimates, malnutrition is an underlying cause in 2.6 million child deaths every year. And of course mortality is only the most extreme manifestation of this problem, it leaves children less able to learn and to grow into productive members of society.
What I disagree with is the message among advocates of child health that the we already know what works and that “simple” interventions simply need to be implemented. If the solutions are so simple, why are they not adopted or implemented?
The report states:
Simple solutions delivered to children who are at risk of malnutrition and their families are well known and well supported by nutrition experts. In 2008 the Lancet medical journal identified a package of 13 direct interventions – such as vitamin A and zinc supplements, iodized salt, and the promotion of healthy behavior, including hand washing, exclusive breastfeeding, and complementary feeding practices – that were proven to have an impact on the nutrition and health of children and mothers.
[Emphasis mine]
I agree, many of these interventions are relatively inexpensive and straightforward, but in particular with regards to the behavior change components, I don’t think the solutions are so simple. I believe that we have not even begun to understand why these practices are so hard to put into practice. One prime example of this is breastfeeding.
Honestly, if I hear another public health official (frequently male) allude to the fact that breastfeeding is among the simplest interventions available I think I am going to lose it. I can tell you from first hand experience, breastfeeding was among the most physically and emotionally challenging aspects of raising my own son.
My son was born a week early by cesarean section due to the fact that he was breeched. This delivery likely delayed my own milk production and I spent four very distressed and agonizing days watching my son shrivel up because I was so hell bent on making breastfeeding work. The simple solution would have beee to supplement his feeding. The advice and support I received from the breastfeeding experts usually took the form of one counsellor telling me to only do Y and whatever I do don’t do X only to be followed up by another counsellor telling me to only to X and never to do Y. Oh, and I did I mention how painful it was? Picture cracked, bleeding and infected nipples and a whirlwind of hormones. Yeah.
Most public health experts recommend mothers to “exclusively” breastfeed their children for 6 months. But that means that the mother can never very far from their baby this entire time. The fact that this might negatively impact a mother’s labor force participation or productivity seems completely ignored in these cost-effectiveness calculations. Simple in this case is leaving a bottle so that fathers, grandparents, and other care givers can share in the feeding of children.
This of course is just one of these interventions, and this is just my own personal reflections on the process – many women love and adore breastfeeding – I even started to enjoy it after a month or two and before my son decided he had enough and decided to communicate this to me by biting during feeding sessions – but it points to what I believe is a very important and overlooked issue in global health, that of why some healthy behaviors and technologies are adopted while others are not. That is not so simple and we have only begun to scratch the surface being able to influence these behaviors through policy.
Share on FacebookThe March issue of BMJ-STI is devoted to the topic of HIV and health systems, which was edited by Alan Whiteside, Gary Brook, Till Bärnighausen, John Imrie and William Wong. By all accounts, the global response to the epidemic is entering into a new phase. The funding landscape is changing, the sense of urgency has changed, and yet there is still a lot to be done. The articles in this issue are all devoted to challenges facing the global response from the perspective of heath systems as it enters into this new phase of the response.
Among the collection of papers, is an article I wrote on this topic which investigates the implications of what I can “donor fatigue” for HIV and the implications this might have on health systems and treatment programs. I argue that if funding remains relatively flat, which I believe it will for a while, then donor sponsored programs will have to focus more on getting more “bang for the buck” by making efficiency improvements. My argument, however, is that most of the gains that people think of when they think of efficiency gains, namely productive efficiencies, will not alone be enough. While most everyone can agree to make productive efficiency improvements (i.e. waste less), more challenging efficiency considerations must also be made, which may mean making tradeoffs between the types of HIV activities supported (e.g. prevention vs. treatment), to which populations, and in which ways. Those types of tradeoffs are less easy to make, but may be more important in the long run.
Lots of other interesting papers here too, including one by Allison Goldberg, Ashley Fox, Radhika Gore, and Till Bärnighausen on measures of political support for HIV programs and a series of articles that look at clinical models. I encourage you to have a look.
Share on FacebookThe position of Managing Director of Health programs at the Rockefeller Foundation has been vacant for over half a year since Ariel Pablos-Mendez left the Foundation to become the Assistant Administrator of Global Health at USAID last summer. The Director is responsible for overseeing the Transforming Health Systems Initiative among other programs. The THSI initiative is in my view one of the few initiatives among the big global health Foundations that has dared to think outside the box in terms of how to build and strengthen health systems globally. For better or for worse, we have them to thank for the buzz word “Universal Health Coverage”.
Over the weekend I learned that that the Foundation has found Ariel’s replacement. Jeannette Vega, a Chilean medical doctor and a Ph.D. in Epidemiology, will be joining the Foundation in a few months to head the health programs. I don’t know much about her, other than what I learned from reading her bio from Judith Rodin, which is impressive, but look forward to the opportunity to meet with her. I spent a month in Chile a few years back studying its health system and its health system reform process, so that credential alone means a lot to me. To read more about Jeanettte, please see below.
Share on FacebookJeanette brings to the Foundation in-depth experience in public health. She started her renowned career as a medical doctor in Chile where she specialized in Family Medicine. Jeanette then went on to earn a master’s degree in Public Health from the Universidad de Chile and a Ph.D. in Public Health from the University of Illinois at Chicago. After practicing family medicine, Jeanette became a national consultant for Epidemiology and Chronic Diseases with the Pan American Health organization. In 2000 – 2003 Jeanette served as Director of the National Institute of Public Health in Chile and was a member of Chile’s National Health Reform Committee. Jeanette then took her expertise in health reform to the World Health Organization in Geneva, where she was a Director leading the equity in health agenda, looking at the social determinants of health and health systems. With her team at WHO she set up several ‘knowledge networks’ that focused on, among other themes, work conditions, health systems, and health and gender, running demonstrations in a number of countries. In 2008 Jeanette left WHO at the invitation of the President of Chile, Michelle Bachelet, to join her in leading Chile’s 13-step agenda for equity in health. As Vice Minister of Health, Jeanette transformed Chile’s health system from a vertical structure to an insectoral approach.
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