It has been over 30 years since the international community launched the “Safe Motherhood” (SM) strategy to reduce maternal mortality (MMR). The strategy, which advocates increased access to family planning, quality antenatal care, skilled supervised births, access to essential obstetric care, and post-natal care has never really been rigorously evaluated. Part of the problem is that in general the programs tend to get adopted as a whole at the national level, there are many components to the SM approach, and implementation challenges in most settings have always hampered efforts to evaluate impact. So for the most part, we don’t know if the strategy really works, and if it does, which components are most important.

A new study, published this month in Health Economics, attempts to shed some light on this question by evaluating the impact the rollout of a SM program in China during the early 2000s. The program was targeted to some of the counties with the highest levels of MMR as well as those with the greatest capacity to implement the program. Unlike other attempts to reduce MMR through the SM approach, the Chinese program appears to have really focused on getting women into hospitals to give birth. I don’t know much about the Chinese context, but my guess is that access to family planning was already very high – given what I know about Chinese fertility rates. This is a much more aggressive strategy than has been adopted in most developing countries, where the focus has been on “supervised deliveries” whether institutional or not. Therefore, we may not be able to generalize these results too broadly and we may wish to question the belief that ensuring that a birth is supervised is enough.

Admittedly, I am not entirely convinced by the methods used in the paper to address the selection problems among the counties. The authors use a propensity score matching approach but given that one of the selection criteria was ability to implement the program, and the overlap between the treated and controls was less than optimal, this may not fully address the selection problem – but I am still encouraged by this effort to actually evaluate the program.

The authors find that in fact the program was able to increase the proportion of births that took place in hospitals and reduce MMR by about 10%, specifically deaths due to hemorrhaging, which would be consistent with getting more women into hospitals – believed to be very important in reducing such deaths. Whatever effect they found, however, took at least 4 years to become visible, which might suggest that it took a while for the program to affect the behavior of women, or perhaps some other alternative explanation.

So if we believe these findings, what it suggests is that getting women into hospitals is effective at reducing maternal mortality – by a lot. The Chinese program, however, is quite different from the approaches that have been used elsewhere – the focus on institutional delivery and a demand side subsidy which was not well explained – but it does give hope that some of the elements of the SM strategy might be effective if well designed and well implemented. This news comes at a crucial time where once again policy makers are debate what should and should not be included in programs to reduce maternal mortality – let’s just hope it is also taken as rationale for more, and more rigorous evaluation of such efforts.

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Where to find information on global health jobs

On March 20, 2010, in global health, jobs, by Karen Grepin

It is that time of the year again when hundreds of new masters and undergraduate students are actively on the hunt for their first job in global health. I have received emails from dozens of people over the past few weeks asking about good sources for jobs on global health, so I decided to put a post out there for all to see. If you email me again, I apologize, but I may just forward you a link to this blog posting. Here are some sites to get you started:

First, the Global Health Council maintains a great website called the “Global Health Career Network“. This is a great, and free, resources, that should certainly be starting your point for any job search in global health in the United States. Most big global health groups will now advertise through this site and there are some really interesting jobs on there. Also, the global health council will shortly be hosting their annual global health conference in Washington D.C. If you are not too far away, you may also wish attending at least one day of this conference to visit the booths at the expo where there are lots of companies advertising positions or even just about their work. I suspect the Unite for Sight conference coming up in a few weeks at Yale might have a similar component, but I do not know this for sure.

Second, consider searching on non-traditional websites for job announcements, for example Twitter. I try to retweet most global health job announcements I see, so you may wish to consider following me (that is if you can put up with the rest of my ramblings). But twitter is also searchable, and you may wish to search for terms like #globalhealth and #jobs. You might be surprised as to what you will find. Dozens of international health organizations are now on Twitter and many of them are actively using Twitter and other forms of social media to let the world know what is going on inside their walls.

Third, if you are currently a student at a University you should really be thinking about reaching out to the faculty at your University who are involved in work related to your interests. I am amazed at the amount of job announcements I have started to receive since becoming a faculty member. We can be incredibly hooked into what is going on. There is little risk of just reaching out to these people, telling them your interests, with a good version of your resumé and you will never know what might happen. 

My first job in global health came to me this way.

Finally, as of March 19, 2010 I have seen interesting job postings at the following organizations, who generally are big employers of masters and undergraduate students with interests in global and public health:

JSI – including a few interesting jobs at their new San Francisco Office

IntraHealth

USAID’s Global Health Fellows Program

Center for Global Development – Very competitive but perhaps one of the most exciting places I could
think of working right now

PATH

Happy job hunting!

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In the NYTimes today, Nick Kristof argues that the period in US history where life expectancy gains were the greatest were during the 1940s and he argues that these gains can be attributed to increases in access to health services that occurred around this time period. While interesting, and certainly a nice theory, unfortunately, this theory is not supported by the majority of empirical research on this topic. Here are just my two cents on why I think this argument is flawed.

To start, a bit of background to set the stage. From 1900 to 1988, US life expectancy increased from 47 to 75 (Lee and Carter, 1992). Kristof suggests that it is difficult to pin down the biggest gains in life expectancy due to low data reliability, but vital statistics data for the United States have been available in complete form since the early 1930s. Prior to this period, these data were available for only a handful of states for an additional 30 odd years, but for the most part our data on life expectancy, is actually quite good throughout most of the 20th century. Relative to the areas where I work, the data in the United States on Life Expectancy is what I would consider excellent.

Using this data, most demographic studies of life expectancy during the first half of the 20th century have shown tremendous declines, but these declines occurred at a relatively constant rate throughout this time period. The following figure, taken from a paper by Lee and Carter in the Journal of the American Statistical Association (87(419): 659-671) shows this graphically. It would be hard to argue that the 1940s were that much different from other decades.

Also lots of other things were happening during this time period that likely influenced life expectancy, so it is hard to attribute any change to one factor. During the late 1930s we saw the introduction of sulfa drugs and shortly thereafter we also saw the rapid increase in availability of penicillin and other antibiotics, which arguably also had impact on life expectancy. From 1940 to 1946, the price of a dose of penicillin dropped from $20 to $0.55. A new working paper by Seema Jayachandran, Adriana Lleras-Muney, and Kimberly Smith estimates that the increases in life expectancy from sulfa drugs alone accounts for 0.4 to 0.8 years of the gains in life expectancy seen during the late 1930s and early 1940s.

Most of the debate about the rapid declines seen during the early 20th century focus on including rising living standards, better nutrition as the source of life expectancy gains. Rarely is increased access to health services taken too seriously during this time period. Medical innovation is generally not seen as a major contributor until the second half of the 20th century (see for example, Cutler 2004).

Finally, and perhaps the most depressing piece of news to health folks out there, there is actually little evidence that the introduction of health insurance improves health outcomes in the short-run. The biggest benefit from increased financial risk protection against health shocks is generally that – financial risk protection. In an excellent study of the impact of the introduction of Medicare on health and financial outcomes, Amy Finkelstein and Robin McKnight has shown that Medicare had little impact on elderly mortality but it did provide substantial risk protection, which alone is a very important outcome.

I say all of this, not because I am arguing against increased access to health insurance in the United States – I am all for it. But rather, I make this point because I think there should be greater admission that health reforms to increase access to health services may not lead to health improvements. I frequently hear the argument that the health reforms seen in Ghana over the past half decade have done little to improve health outcomes, and I am always amazed at the degree to which people believe that this is a necessary outcome to measure the success of these reforms. Utilization of health services appears to have improved and satisfaction also seems to have increased, but so far we know less about its impact on either health or financial risk protection. It would not surprise me in the least if we cannot measure any discernible impact on health but that is not the only criteria that matters.

The relationship between access and health outcomes is certainly a tricky one, and unfortunately not one that is well understood. But I do know, that simple association does little to help anyone’s case: just providing access is not enough.

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Vaccines save millions of lives every year, yet uptake and coverage of many potentially life saving immunizations remain sub-optimal throughout much of the developing world. Most of the work that has been done to date to better understand why vaccines don’t get into the mouths or arms of those who need them most focus on operational level aspects but little research has been conducted at the global level to understand why some countries adopt particular vaccine policies while others do not.

Despite the availability of an effective vaccines against Haemophilus influenza type b (Hib) – a bacteria that is responsible for causing almost 400,000 deaths in children and significant morbidity globally – over a decade after its introduction only 13 low-income countries were using the vaccine. A few years later over 60 were. What factors influence a country’s decision to adopt a national vaccination policy?

That is the question that is explored in a new PLoS Medicine research article by researchers at the Johns Hopkins School of Public Health and the Hib Initiative. Using a hazard model, they explore the determinants of national level adoption of the Hib vaccine in recent years. They find:

“The receipt of GAVI support speeded the decision to adopt vaccination by 63%, for example, and sharing borders with two or more countries that had adopted the vaccine speeded the decision by 50%. By contrast, for each 1% increase in vaccine costs, the time to decision to adopt vaccination was delayed by 2%. The 1998 and 2006 World Health Organization recommendations on routine Hib vaccination and the existence of local studies on Hib disease had no influence on the time to decision.”

National policies, therefore, seem to be heavily dependent on whether or not an outside organization is willing to fund such introductions – and not just advocate for them. More evidence of how the new Global Health Initiatives – here GAVI – are radically transforming the way in which health care is delivered around the world.

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The potential to markedly reduce childhood mortality from vaccine preventable causes is perhaps higher today than it has been for decades. Progress has been made to scale up existing vaccines in developing countries, thanks in part to GAVI and its partners, but waiting in the wings are a series of new vaccines that target some of the most important causes of childhood death: the pneumococcal and rotavirus vaccines against pneumonia and diarrhea respectively. These should be exciting times for the immunization world, however, not everyone is optimistic about its future.

Despite having shown progress, and despite the potential of the powerful new vaccines, donors have not jumped onto the immunization bandwagon in the way in which they have for other global health priorities. The troubled financial future of GAVI was recently highlighted in a story in the Lancet. GAVI has enjoyed long term financial commitments from the Gates Foundation and a number of bilateral donors, including the US, Norway (by far the largest bilateral donor on a per capita basis for child health and immunization), the Netherlands, my home country Canada, the UK, Sweden and Denmark. But at a time where GAVI actually needs to be scaling up resources, its core donors actually appear poised to scale back funding.

Last week, the conservative government of Canada announced sweeping cost-cutting measures to contain the mounting federal deficit. They explicitly have targeted parts of the budget that will be least felt by Canadians – foreign assistance and military spending. Sweden has also announced cut backs, including cut backs to its commitments to GAVI.

Advocates for universal treatment for HIV have been tremendously vocal against the threat of cutbacks in aid to their cause and so far have been successful at securing commitments to protect these funding flows. This highlights one of the numerous limitations in relying on international donors to provide sustainable financing flows for global health programs – the winners are going to be those with the most vocal and outspoken advocacy groups – not those issues that might most benefit from increased attention.

I am happy to see calls for more attention to these issues from people like Bill Frist and others, but this is an important issue that will need more advocates. Count me among them.

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Despite the fact that protective vaccines are generally available, the regular influenza virus causes upwards of 200,000 hospitalizations and tens of thousands of deaths every year in the United States – mostly among the elderly and immuno-compromised.

Current vaccination policy tends to focus more on people most at risk of death – namely the elderly – despite the fact that children are also prone to illness and are believed to play a big role in the transmission of the disease. While on the face this strategy seems to make a lot of sense – vaccinate those most at risk – it turns out that vaccinating adults tends to be a lot harder than vaccinating children due to a number of factors: they are not accustomed to getting shots, many do not visit the doctor every year, and tend to be less proactive on this front. Children tend to be good captive targets – we frequently require them to be vaccinated before attending school, for example.

Epidemiologists have long discussed the merits of herd immunity and have recognized the role of children in the transmission of influenza in the general population. There has been a great deal of chatter of late about what optimal vaccination policy should be for influenza – in particular whether children should be preferentially targeted in hopes of blocking the transmission of the virus in the population.

A new study conducted in isolated communities on the Canadian prairies suggest that such proposals might have merit. In a randomized trial, the children in treatment communities were vaccinated against the influenza vaccine and the rates of influenza in the non-immunized population was assessed. The researchers found rather substantial reductions in the incidence of influenza among the general population suggesting that such a strategy could in fact be a good idea. The authors even suggest that the “protective effect is likely comparable with or greater than what can be achieved by direct immunization”. Plus, it also protects the kids. Pretty cool.

Roll-up your sleeves kiddies and do your part for your communities!

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