The per diem culture

On July 31, 2009, in aid effectiveness, donor assistance, HIV/AIDS, by Karen Grepin

A few years ago I attended a high level meeting for a large and well respected international health organization (one that I also high respect, so it shall remain nameless) in Africa. I generally sat in the back, mostly because one was likely to secure a power cord back there. Nearly every day I sat next to the same woman, who from her clothing appeared to be from that location. We never really spoke but occasionally we would exchange glances throughout the conference.

One day we ended up in the lunch line next to one another so I decided to strike up a conversation with this woman. Turns out she could not understand a word of English. I tried French, again not a word. I wondered to myself “if she does not understand English or French, what has she been doing in the room with us for the past few days?”. When I told this a colleague who had been to many of these conference he had a quick answer – “she is there for the per diem – her sitting fee.”

I was horrified that this type of behavior was happening at a meeting of this nature. There was a whole section of people in the back of the room, it turns out, who were all there for the sitting fees.

Anyone who has conducted work in Africa has certainly encountered the per diem culture. There are endless meetings and trainings, sometimes it seems they are organized for the sake of the per diems. While certainly one would expect people to get compensated for their travel and their additional expenses, I believe the practice has gotten out of hand.

In Ethiopia where I spent most of the month of June, I recall one health official telling me that they had to put a limit on the practice because donor organizations were out bidding one another with higher and higher per diem rates and in the end they could not control the whereabouts of their employers. The HIV organizations were frequently in violation of the limit, so now they have given a special exemption for HIV.

In a recent essay, Andrew Jack of the Financial Times argues that the per diems are at the root of many of the problems of slow bureaucracy in health services. He calls them:

“..a form of institutionalised, legal time-wasting that is endemic in the region – and an unwelcome global phenomenon legitimised by donors and international organisations alike.”

I challenge those out there who are opposed to funding cuts for HIV in Africa to ask whether existing resources are being used effectively as well. I suspect much of it is wasted and much more could be done within the existing financial envelope if we took a closer look at how money is currently being spent and what impact it is having.

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A few interesting things caught my eye on the internet today:

1. Elizabeth Pisani reviews my friend Amy Nunn‘s book “The Politics and History of AIDS Treatment in Brazil” in the Lancet. She summarizes the main findings of this book – which was largely based on Amy’s dissertation at HSPH – which shows how many of the reasons why Brazil took such a leadership role on expanding access to ARVs has to do political and historical factors specific to that country, suggesting that replicating such successes will be hard.

2. It is now 3:16 p.m. (EST) on Thursday, July 30, 2009. That means that as of right now, it is estimated that 35,172,096 people have died this year – about 10,000,000 from cardiovascular disease. How do I know this? Well, thanks to this nifty clock I can find out lots of great “real time” estimates of cumulative deaths, population, and cases of illness.

3. I sometimes find Nick Kristof’s take on developing countries a bit sensationalized and over the top, but when he is he is good, he is really good. His essay today on maternal mortality in Pakistan is one example of when he is really good. At the end he challenges the Obamas to step up leadership on this issue – would that not be great?

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A few weeks back I wrote about the potential side effects of free bed net programs that rely exclusively upon public distribution channels, which is only one small part of a much larger debate regarding how bed nets should most appropriately be distributed to achieve high levels of coverage and to reduce mortality from malaria.

Other aspects of this debate, highlighted by Bill Brieger in his comments to my blog posting, is on the use of “catch up” vs. “keep up” strategies. In addition, there is also debate regarding whether bed nets should be delivered through standalone campaigns or delivered through as a part of integrated routine health services. Countries are experimenting with different approaches, and as more and more evaluations of these programs are conducted and compared, a better sense of what works where may become clearer in the coming years.

In a recent issue of the BMJ, Kara Hanson and colleagues published the results of one such evaluation. Their paper evaluates the effect of the Tanzanian National Voucher Scheme (TNVS) on the level and equitable distribution of insecticide treated net (ITN) in that country. The program was rolled out progressively across the country starting in 2004 and lasting until 2006. The program design used a voucher to allow people to purchase the nets through private distribution channels. The vouchers themselves were delivered through antenatal clinics and were targeted for pregnant women and for children. In the lingo from the above discussion, this program would likely be qualified as a “keep up” strategy, delivered through routine health services using private distribution channels.

Using a “plausibility” study design, the authors found relatively large and significant increases in net ownership over the time period: from about 44% of all households in 2005 to about 65% in 2007. There were also increases in the proportion of nets that were treated with insecticide, used by infants under the age of 1, and other indicators. While it is difficult to directly attribute all of the observed changes to the TNVS program itself, the “plausibility” design provides ample evidence that such changes were likely the result of the program by collecting changes in indicators along the program delivery pathway.

In addition to the TNVS, many of the districts had also been exposed to other programs, including three that had been exposed to “catch up” free bed net distribution programs. While all of these districts saw sizable increases, about half of the districts without free distribution programs saw increases of the same magnitude. In addition, the authors point out that net ownership actually declined in some of the free bed net regions. Not exactly glowing evidence of the effectiveness of those programs, but I would have liked to have seen more details on those programs to know more.

So while this evaluation showed that the TNVS is probably an effective “keep up” strategy, none of the none of the districts – even those with free bed net programs – achieved coverage levels anywhere near those advocated by the World Health Organization and Roll Back Malaria – even after two years. The distribution of bed nets ownership was highly inequitable, with the lowest levels of ownership among the poor (no data was given on whether the free bed net districts achieved more equitable outcomes). In addition, all changes were based on within district changes in treated areas, so it is not clear how bet net ownership would have improved even without these programs. Just the same, the evaluation points to the important role of ongoing distribution programs delivered through routine health services (95% of women did attend the clinics, and the vast majority did receive the voucher when they were available) and through private channels.

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I’ve been on the road quite a bit the past few weeks, but have finally settled into the South of France in a lovely little town in the Var where my in-laws now live. In addition to great food, a fabulous pool, and lovely views my in-laws also have unblocked high-speed internet. It is great to be connected again. One more week of this and I should be ready to take on the real world again!

Here are some links to things on the net I really liked this week:

1. The BBC asked its readers if we are “Failing HIV/AIDS patients” in Africa in their Have your Say section. Lots of junk in the comments, but so far over 600 comments have been posted. I found some of them quite interesting and to see how much lack of consensus there really is on this issue.

2. I had wondered where the Obama’s would stay on their recent trip to Accra. As it turns out, they chose the brand spanking new Holiday Inn near the airport. Not exactly known as the most luxuriest choice but certainly the newest and most American. I guess that makes sense.

3. Is AIDS exceptionalism defensible? Stephen Lewis, the former UN Advisor on HIV/AIDS in Africa argues that it is. If you have ever seen this guy in person, he is an eloquent speaker and I am sure he was very persuasive. I tend to disagree.

4. Alanna Shaikh argues on her blog why she is against a Global Fund for Maternal Health. I tend to agree.

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The onchocerciasis endgame

On July 23, 2009, in onchocerciasis, public health, research, by Karen Grepin


Most infectious disease control programs have a well defined epidemiological end point target. For polio the goal is eradication, for lymphatic filariasis it is elimination, but for other diseases the goal is simply to control the disease to the point where it is no long a public health problem either because the infectious agent is simply too prevalent or because the costs associated with going the last mile are too great.

Currently the goal of onchocerciasis – or river blindness – control in Africa is to reduce the disease to the point where it is no longer a public health problem. In most of Africa, progress towards this goal is achieved through annual and semi-annual mass treatment of communities with ivermectin using the community directed treatment approach developed and advocated by APOC.

It is therefore really exciting news that research conducted by Jan Remme and colleagues in Mali and Senegal and published this month in PLoS Neglected Tropical Diseases suggests that elimination of the disease might also be possible. In two regions in Mali and Senegal, which have been benefitting from ivermectin treatment for years through vestiges of the former OCP program, treatment was stopped and then about a year and a half later researchers investigated subsequent transmission. They were able to conclude that transmission had been successfully interrupted in the areas.

Of course, what works in one area will not certainly work in a another, but it is exciting news that given the current treatment strategies in use in most onchocerciasis endemic regions an endgame – elimination – might be achievable. Coupled with the news that a new macrofilariacide is in field trials and that doxycycline might also be useful to target the adult worms, this is has been a really good year for onchocerciasis control. Thanks to decades of effort from hardworking entomologists and parasitologists this disease might be on its way out – for good.

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What group of the population is nearly 9 times more vulnerable to HIV infection in many developing countries but that are almost never targeted by HIV prevention activities? According to recent research, and this new editorial from the AIDSTAR portal: men who have sex with men (MSM).

The term is used to describe people who engage in a particular behavior rather than a label for sexual identity, which at times can differ. MSM can also have sex with women, or may do so for only a short period of time, but the key is that they are not always identified as people who engage in sexual relations with other men which can make them difficult to identify. To complicate things further, the behavior is frequently illegal in developing countries making it difficult to launch effective prevention programs.

The AIDSTAR initiative, supported by USAID, seeks to begin to fill the gap in terms of what we know about MSM and what we know works in MSM prevention and control. They have compiled an excellent website which can be found here.

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Amidst the hoopla surrounding his first visit as President to Sub-Saharan Africa, President Obama took time away from his visits to castles, meetings with tribal leaders, and performances from dance troops to address the Ghanaian Parliament today. But before making his speech, he and Michelle stopped at a hospital in Accra to visit with pregnant women and children.

It was no coincidence that he chose a maternity ward to visit before his speech, during his address to Parliament he made it clear that the US will be adopting a new – and broader – strategy to address public health issues in Africa. While the big diseases like HIV got an honorable mention, Obama seems to really take the idea of supporting systems not just addressing single fashionable diseases to heart, or as he called it no more “confronting diseases in isolation“.

He even went so far to acknowledge that donor countries, via some of the single disease programs, are contributing to health worker shortages: “Yet because of incentives – often provided by donor nations – many African doctors and nurses understandably go overseas, or work for programs that focus on a single disease.” Denialism is dead.

While he stopped short of describing in detail how this new strategy operationally would be any different from the existing strategy – he tends to do that – or how he would get any changes to existing programs approved without any new funding – he is already on the hot seat for “slashing” HIV funding despite “increasing” commitments – he did stress a broader approach was on the way, which included investments in “public health systems that promote wellness, and focus on the health of mothers and children”.

For now I am a happy woman, and feel as though his visit has been a good one for global health. I think it is a “change” in the right direction – or “nsakrae” if my Twi dictionary serves me correctly.

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Earlier this week the Global Fund elected a new Chairman of the Board, electing the Minister of Health from Ethiopia – Ato Tedros Adhanom Ghebreyesus. In addition to having served at the Minister of Health in Ethiopia for over 4 years, Ato Ghebreyesus is no stranger to international health bureaucracy having served as the Chair of Roll Back Malaria and holding positions with UNAIDS.

Many of the big health reforms seen in Ethiopia in recent years have been attributed to his leadership. Most notably, Ato Ghebreyesus has overseen the creation, training and deployment of nearly 30,000 paid health extension workers to provide basic primary health services in remote communities, the construction of thousands of new health centers, the distribution of over 20 million insecticide treated bed nets, and one of the most rapid scale-ups of antiretroviral treatment programs in the world. Less well known achievements also include the signing of the first “International Health Partnership”, an agreement among development partners to coordinate aid activities in the health sector in Ethiopia, which if successful could signify a new way to coordinate aid for health in developing countries.

Congratulations to Ato Ghebreyesus and lets hope his leadership skills benefit the Global Fund in the challenging months ahead. An interview with Ato Ghebreyesus was also featured in this month’s Bullentin of the World Health Organization. You can read more about Ato Ghebreyesus here.

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Akwaaba President Obama

On July 9, 2009, in Ghana, health insurance, health reform, by Karen Grepin

Photo credit caitlindd/flickr.

I am terribly sad that I am not in Ghana this week. Later today (Friday), President Obama and his wife Michelle will make their first official visit to a sub-Saharan Africa country making a stop in Accra and Cape Coast, Ghana. I am sure almost everyone in Ghana is preparing for his visit, and even most Africans will be watching his visit carefully. What will he promise Africa? Will he live up to this promises? So much, it seems, is a stake. I had so wanted to be there to see this historic visit first hand.

I’ve been wondering, however, what can Obama learn from Ghana? I think it is interesting that health insurance reform is the top domestic priority of the Obama Administration (that is of course after making sure that the economy recovers) and has also been an important political issue in Ghana for many years. The current opposition party – the NPP – and which was until recently the ruling party, had been elected years ago on a promise to implement national health insurance. It was not easy, it took many years, lots of vocal opposition from the NDC, organized labor, health care providers, but somehow they managed to push it through and make it happen. During the last election national health insurance was once again an important issue, and even the NDC, that has initially opposed the plan, was campaigning on a platform that included important improvements to the national health insurance plan.

So what can Obama learn from the Ghanaian example?

1. Passing health insurance reforms will likely be opposed by just about everyone.

This is perhaps the biggest single reason why the US does not currently have national health insurance. Almost every country has faced the same problem: whenever health insurance reforms are proposed, most groups oppose any sort of change to the status quo, even if it seems that they should benefit from the changes. The way in which policies are passed in the US makes this kind of opposition particularly challenging and as such all previous efforts have failed. When the final vote on health insurance was passed in the Ghana parliament, the opposition party had even left the chambers in protest. But they got the bill passed.

2. You may not get rewarded from your efforts, at least in the short-run.

Sadly, I suspect that this might be the case in many countries. Implementing health insurance is long, costly, and politically taxing. Then to make things worse, you don’t always seen any immediate health benefits, and people like to complain. Passing health insurance is good for the country, but it is not always good for the party that makes the effort. The NPP was ousted in the last election (not just for health insurance of course). But, I hope Obama is the kind of President who is willing to put his beliefs of what is best for the US ahead of his own political needs.

3. But a healthy population is key to economic growth and recovery.

The real benefits from the health insurance reforms for Ghana will likely be realized in the coming years as the country begins to reap the benefits of having a healthy and productive population. It will affect education and the productivity of the labor force. Countries looking to make investments abroad may see health insurance as an asset and will consider more investments in Ghana. All of this means that good health is good for business. The US can learn and from this as well.

So I wish the Obamas all the best on their visit to this little gem of Africa. Enjoy your trip!

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I’ve been around the world in the past few weeks, in and out of about a dozen airports, in half a dozen countries, on 4 continents. Along the way I have been entertained by the public health efforts of the countries I have visited to isolate cases of Swine Flu – or H1N1 – in traveling passengers.

In Cairo, before they upgraded to their new terminal, I was swarmed and nearly crushed by other passengers as were were all channeled down one corridor to have our bodies screened by a heat sensing video camera (3 weeks later when I passed through the same airport they had a new terminal and a proper screening area – progress is possible).

In Ethiopia there were lots of great public health posters saying how we should all work together to stop “this new flu”. Incidentally, after I landed I did end up with flu like symptoms, for about 24 hours. I was too worried I’d be locked up to go and see a doctor, so I sat it out.

On a flight to Frankfurt was given a long letter in German that I was to present to a German doctor explaining how I had traveled on a flight from New York and should be treated as a suspected Swine Flu case should I present with any symptoms.

Upon arrival in Chengdu, China yesterday we were told to remain seated for the quarantine inspection. Three masked men boarded the plane and went through the aisles with little temperature guns which were pointed at each passenger’s head and our temperature taken instantly. This was my favorite.

On the whole I’ve been mighty impressed with the global response to the Swine Flu – far from perfect, and many would argue overblown – but as I have argued before when we did not know, it was better to err on the side of caution. But I was impressed at how even some of the poorest countries in the world dedicated resources to monitoring for this epidemic.

According to a recent KFF report, the WHO is now recommending to countries that have detected cases to give up stepped up efforts to screen for swine flu and just use regular methods to diagnose the flu going forward. It appears that we have little to worry about with this phase of the epidemic. I’m happy to hear. I just hope this does not mean governments will give up all efforts to monitor for the disease because who knows, it may be back in a more harmful mode soon. It is too bad that there is not more regular, low level monitoring, somewhere between what happened before and some of the efforts adopted recently.

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