Kufuor elects for health care at home

On February 29, 2012, in Ghana, by Karen Grepin

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.

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Earlier 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.

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HIV, health systems, and donor fatigue

On February 17, 2012, in health systems, HIV/AIDS, research, by Karen Grepin

The 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.

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The 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.

Jeanette 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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I could not resist tweeting about this one…(H/T @cdsamii and @matt_blackwell).

A couple of months ago I got into a long conversation with a group of very senior health economists about the value of young researchers engaging in social media activities (or as they saw it, wasting your time on Twitter). I have *long* (I’ve been in Twitter for 3 years, eons by Twitter standards) been a proponent of the benefits of engaging in these networks believe that I get a lot of benefits from the time I spend on twitter (which believe it or not, is not actually that much time each day). One of my arguments is that it is a great tool for research, in particular in keeping me abreast of what is new and exciting in the academic fields in which I dabble (broadly defined as #healtheconomics #healthpolicy and #globalhealth).

Earlier today I saw this paper (where else, on Twitter) that correlated the tweets a medical paper received and the subsequent number of citations that paper received 1-2 years later – the Holy Grail measure of impact in academia. It turns out that Tweets received in essentially the first few days after publication were strong predictors of the subsequent citation counts of that paper. Of course, it is totally possible that this correlation only reflects the underlying quality of the papers (or authors!) – meaning that good papers get tweeted and cited – but it might also be the case that when papers are tweeted this causes them to be read more and subsequently more highly cited.

Regardless, it is an interesting piece of research. If you follow me on Twitter, don’t be surprised if you see me tweeting about my papers soon!

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