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Do countries rely on the World Health Organization for translating research findings into clinical guidelines? A case study.
Globalization and Health. 2016 Oct 6; 12(1):58.BACKGROUND: The World Health Organization's (WHO) antiretroviral therapy (ART) guidelines have generally been adopted rapidly and with high fidelity by countries in sub-Saharan Africa. Thus far, however, WHO has not published specific guidance on nutritional care and support for (non-pregnant) adults living with HIV despite a solid evidence base for some interventions. This offers an opportunity for a case study on whether national clinical guidelines in sub-Saharan Africa provide concrete recommendations in the face of limited guidance by WHO. This study, therefore, aims to determine if national HIV treatment guidelines in sub-Saharan Africa contain specific guidance on nutritional care and support for non-pregnant adults living with HIV. METHODS: We identified the most recent national HIV treatment guidelines in sub-Saharan African countries with English as an official language. Using pre-specified criteria, we determined for each guideline whether it provides guidance to clinicians on each of five components of nutritional care and support for adults living with HIV: assessment of nutritional status, dietary counseling, micronutrient supplementation, ready-to-use therapeutic or supplementary foods, and food subsidies. RESULTS: We found that national HIV treatment guidelines in sub-Saharan Africa generally do not contain concrete recommendations on nutritional care and support for non-pregnant adults living with HIV. CONCLUSIONS: Given that decisions on nutritional care and support are inevitably being made at the clinician-patient level, and that clinicians have a relative disadvantage in systematically identifying, summarizing, and weighing up research evidence compared to WHO and national governments, there is a need for more specific clinical guidance. In our view, such guidance should at a minimum recommend daily micronutrient supplements for adults living with HIV who are in pre-ART stages, regular dietary counseling, periodic assessment of anthropometric status, and additional nutritional management of undernourished patients. More broadly, our findings suggest that countries in sub-Saharan Africa look to WHO for guidance in translating evidence into clinical guidelines. It is, thus, likely that the development of concrete recommendations by WHO on nutritional interventions for people living with HIV would lead to more specific guidelines at the country-level and, ultimately, better clinical decisions and treatment outcomes.
2016 Nov; New York, New York, UN Women, 2016 Nov. 2 p.Violence against women and girls is one of the most universal and pervasive human rights violations in the world, of pandemic proportions, with country data showing that about one third of women in the world report experiencing physical or sexual violence at some point in their lifetime, mainly by their partners. UN Women provides knowledge-based policy and programming guidance to a diverse array of stakeholders at international, regional and country levels often partnering with other UN agencies and stakeholders. UN Women’s work is broadly focused on a comprehensive approach to ending violence against women and girls that addresses legislation and policies, prevention, services for survivors, research and data. The briefs included in this package aim to summarize in a concise and friendly way, for advocates, programmers and policy makers, the essential strategies for addressing violence against women in general, for preventing violence and providing services to survivors in particular.
Female genital mutilation/cutting and violence against women and girls strengthening the policy linkages between different forms of violence.
2017 Feb; New York, New York, UN Women, 2017 Feb. 20 p.Violence against women and girls (VAWG) manifests in different forms. These include intimate partner violence, non-partner sexual violence, sexual exploitation and trafficking, and harmful practices such as female genital mutilation/cutting (FGM/C) and child, early and forced marriage, among others. Programmes to end harmful practices and programmes to end intimate partner violence and non-partner sexual violence are often planned and implemented separately, despite all being rooted in gender inequality and gender-based discrimination against women and girls. While this is intended so that programmes can be tailored accordingly, it can result in isolation of initiatives that would otherwise benefit from sharing of knowledge and good practices and from strategic, coordinated efforts. This policy note explores policy and programming interlinkages and considers entry points in the areas of (i) national legislation, (ii) prevention strategies, (iii) response for survivors, and (iv) data and evidence, for increased coordination and collaboration to advance the objectives of ending FGM/C and other forms of VAWG, in particular intimate partner violence and non-partner sexual violence. The note builds on the background paper “Finding convergence in policy frameworks: A background paper on the policy links between gender, violence against women and girls, and female genital mutilation/cutting” (available below). This policy note is intended for multiple audiences, including those directly involved in policy development, planning and implementing initiatives, those providing technical support, and advocates for ending all forms of VAWG, including FGM/C. This work is the result of a collaboration of UN Women with the UNFPA–UNICEF Joint Programme on FGM/C.
Reproductive Health. 2015; 12:46.In September, the World Health Organization released a statement on preventing and eliminating disrespect and abuse during facility-based childbirth. In addition to this important agenda, attention is also needed for the dignified care of newborns, who also deserve basic human rights and dignified care. In this commentary, we provide examples from the literature and other sources of where respectful care for newborns has been lacking and we give examples of opportunities for integration of maternal and newborn health care going forward. We illustrate the need for respectful treatment and consideration across the continuum of care: for mothers, stillbirths, and all newborns, including those born too soon and those who die in infancy. We explain the need to document cases of neglect and abuse, count all births and deaths, and to include newborns and stillbirths in the respectful care agenda and the post-2015 global reproductive care frameworks.
Strength of recommendations in WHO guidelines using GRADE was associated with uptake in national policy.
Journal of Clinical Epidemiology. 2015;  p.Objectives: This study assesses the extent to which the strength of a recommendation in a World Health Organization (WHO) guideline affects uptake of the recommendation in national guidelines. Study Design and Setting: The uptake of recommendations included in HIV and TB guidelines issued by WHO from 2009 to 2013 was assessed across guidelines from 20 low- and middle-income countries in Africa and Southeast Asia. Associations between characteristics of recommendations (strength, quality of the evidence, type) and uptake were assessed using logistic regression. Results: Eight WHO guidelines consisting of 109 strong recommendations and 49 conditional ecommendations were included, and uptake assessed across 44 national guidelines (1,255 recommendations) from 20 countries. Uptake of WHO recommendations in national guidelines was 82% for strong recommendations and 61% for conditional recommendations. The odds of uptake comparing strong recommendations and conditional recommendations was 1.9 (95% confidence interval: 1.4, 2.7), after adjustment for quality of evidence. Higher levels of evidence quality were associated with greater uptake, independent of recommendation strength. Conclusion: Guideline developers should be confident that conditional recommendations are frequently adopted. The fact that strong recommendations are more frequently adopted than conditional recommendations underscores the importance of ensuring that such recommendations are justified.
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach.
Geneva, Switzerland, WHO, 2013.  p.The 2013 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection provide new guidance on the diagnosis of human immunodeficiency virus (HIV) infection, the care of people living with HIV and the use of antiretroviral (ARV) drugs for treating and preventing HIV infection.
Journal of Human Lactation. 2012 Aug; 28(3):272-5.The BFHI provides a framework for addressing the major factors that have contributed to the erosion of breastfeeding, that is, maternity care practices that interfere with breastfeeding. Until practices improve, attempts to promote breastfeeding outside the health service will be impeded. Although inappropriate maternity care cannot be held solely responsible for low exclusive breastfeeding rates and short breastfeeding duration, appropriate care may be a prerequisite for raising them. In many industrialized countries, BFHI activities were slow to start. Over the past 10 years and as the evidence was becoming increasingly solid and the commitment of health workers and decision makers has become stronger, considerable efforts are being made in most industrialized countries to implement the BFHI. However, coordinators of the BFHI in industrialized countries face obstacles to successful implementation that appear unique to these countries. Problems reported include opposition from the health care establishment, lack of support from national authorities, and lack of awareness or acceptance of the need for the initiative among government departments, the health care system, and parents. It is worth highlighting these facts to enable the BFHI coordinators in these countries to make well-designed and targeted plans with achievable objectives. Strengthening and scaling up the BFHI is an undisputed way to reduce infant mortality and improve quality of care for mothers and children. The BFHI has had great impact on breastfeeding practices. Reflecting new infant feeding research findings and recommendations, the tools and courses used to change hospital practices in line with Baby-Friendly criteria are available and ready to be used and implemented. Governments should ensure that all personnel who are involved in health, nutrition, child survival, or maternal health are fully informed and energized to take advantage of an environment that is conducive to revitalizing the BFHI; incorporate the basic competencies for protection, promotion, and support of optimal infant and young child feeding, including the BFHI, into all health-worker curricula, whether facility- or community-based health workers; and recognize that the BFHI has a major role to play in child survival and more so in the context of HIV/AIDS. The World Health Organization and UNICEF strongly recommend using this new set of materials to ensure solid and full implementation of the BFHI global criteria and sustain progress already made. It is one way of improving child health and survival, and it is moving ahead to put the Global Strategy for Infant and Young Child Feeding in place, thus moving steadily to achieving the Millennium Development Goals.
Positive learning: Meeting the needs of young people living with HIV (YPLHIV) in the education sector.
Paris, France, UNESCO, 2012.  p.This document outlines roles and responsibilities for the education sector in supporting young people living with HIV to realize their personal, social and educational potential. It provides practical recommendations for all those involved in the education sector, and further suggested actions for those in the health sector and for civil society. It is a tool for networks of people living with HIV and specifically young people living with HIV to advocate for more appropriate, conducive and supportive education systems.
Reproductive Health Matters. 2011 Nov; 19(38):197-207.In March 2009, UN member states met at the 53rd Commission on the Status of Women (CSW) to discuss the priority theme of "the equal sharing of responsibilities between women and men, including caregiving in the context of HIV/AIDS". This meeting focused the international community's attention on care issues and generated Agreed Conclusions that aimed to lay out a roadmap for care policy. I examine how the frame of "care" - a contested concept that has long divided feminist researchers and activists - operated in this site. Research involved a review of documentation related to the meeting and interviews with 18 participants. Using this research I argue that the frame of care united a range of groups, including conservative faith-based actors who have mobilized within the UN to roll back sexual and reproductive rights. This policy alliance led to important advances in the Agreed Conclusions, including strong arguments about the global significance of care, especially in relation to HIV; the need for a strong state role; and the value of caregivers' participation in policy debates. However, the care frame also constrained debate at the CSW, particularly about disability rights and variations in family formation. Those seeking to reassert sexual and reproductive rights are grappling with such limitations in a range of ways, and attention to their efforts and concerns can help us better understand the potentials and dangers for feminist intervention within global policy spaces. Copyright (c) 2010 UNRISD. Published by Elsevier Ltd. All rights reserved.
Geneva, Switzerland, UNAIDS, 2011 Oct.  p. (UNAIDS Issues Brief; UNAIDS Policy Document; UNAIDS/JC2244E)Over the past 30 years there have been tremendous gains in the global HIV response, but until now there has been only limited systematic effort to match needs with investments. The result is often a mismatch of the two, and valuable resources are stretched inefficiently across many objectives. To achieve an optimal HIV response, countries and their international partners must adopt a more strategic approach to investments. In June 2011 a policy paper was published in The Lancet (Schwartländer et al) that laid out a new framework for investment for the global HIV response. The new framework is based on existing evidence of what works in HIV prevention, treatment, care and support. It is intended to facilitate more focused and strategic use of scarce resources. Modelling of the framework’s impact shows that its implementation would avert 12.2 million new infections and 7.4 million AIDS-related deaths between 2011 and 2020. This modelling also indicates that implementation of the investment framework is highly cost-effective, with additional investment largely offset by savings in treatment costs alone, and enabling the HIV response to reach an inflection point in both investments and rates of HIV infection. (Excerpts)
Geneva, Switzerland, UNAIDS, 2010 Dec.  p. (UNAIDS/10.12E/JC2034E)This Strategy has been developed through wide consultation, informed by the best evidence and driven by a moral imperative to achieve universal access to HIV prevention, treatment, care and support and the Millennium Development Goals.
Geneva, Switzerland, UNAIDS, 2010.  p. (UNAIDS/10.11E ; JC1958E)The 2010 edition of the UNAIDS Report on the global AIDS epidemic includes new country by country scorecards on key issues facing the AIDS response. Based on the latest data from 182 countries, this global reference book provides comprehensive analysis on the AIDS epidemic and response. For the first time the report includes trend data on incidence from more than 60 countries.
Geneva, Switzerland, WHO, 2011.  p.In June 2010, the UNAIDS Secretariat and WHO launched Treatment 2.0, an initiative designed to achieve and sustain universal access and maximize the preventive benefits of antiretroviral therapy (ART). Treatment 2.0 builds on '3 by 5' and the programmatic and clinical evidence and experience over the last 10 years to expand access to HIV diagnosis, treatment and care through a series of innovations in five priority work areas: drugs, diagnostics, costs, service delivery and community mobilization. The principles and priorities of Treatment 2.0 address the need for innovation and efficiency gains in HIV programmes, in greater effectiveness, intervention coverage and impact in terms of both HIV-specific and broader health outcomes. Since the launch of Treatment 2.0, the UNAIDS Secretariat and WHO have worked with other UNAIDS co-sponsoring organizations, technical experts and global partners to further elaborate and begin implementing Treatment 2.0. The Treatment 2.0 Framework for Action outlines the five priority work areas which comprise the core elements of the initiative and establishes a strategic framework to guide action within each of them over the next decade. The Framework for Action reflects commitments outlined in Getting to Zero: 2011 - 2015 Strategy, UNAIDS and the WHO Global Health-Sector Strategy on HIV, 2011 - 2015, the guiding strategies for the multi-sectoral and health-sector responses to the HIV pandemic. (Excerpt)
[London, United Kingdom], Partnership for Child Development [PCD], 2009 Sep. 80 p.This document describes a review of HIV and AIDS indicators for the UNAIDS Inter-Agency Task Team on Education. The goal of the review was to help develop user-friendly guidance to measure the coverage, outcomes, and impact of education programs on HIV and AIDS in low-income countries.
Strategic considerations for strengthening the linkages between family planning and HIV / AIDS policies, programs, and services.
Geneva, Switzerland, WHO, 2009. 31 p.Many governmental and nongovernmental public health agencies are pursuing and, in some cases, scaling up programs that integrate family planning (FP) and HIV services. In response to calls from public-health decision makers for guidance on FP / HIV integration, the World Health Organization, the U.S. Agency for International Development, and Family Health International developed Strategic Considerations for Strengthening the Linkages between Family Planning and HIV / AIDS Policies, Programs, and Services. The partners drew from publications, the recommendations of more than 100 experts in FP and HIV / AIDS, and lessons learned from field experience. The document is designed to help program planners, implementers, and managers -- including government officials and other country-level stakeholders -- make appropriate decisions about whether to pursue the integration of FP and HIV services. It also explains how to pursue integration in a strategic and systematic manner, in order to achieve maximum public health benefit.
The WHO/PEPFAR collaboration to prepare an operations manual for HIV prevention, care, and treatment at primary health centers in high-prevalence, resource-constrained settings: defining laboratory services.
American Journal of Clinical Pathology. 2009 Jun; 131(6):887-94.The expansion of HIV/AIDS care and treatment in resource-constrained countries, especially in sub-Saharan Africa, has generally developed in a top-down manner. Further expansion will involve primary health centers where human and other resources are limited. This article describes the World Health Organization/President's Emergency Plan for AIDS Relief collaboration formed to help scale up HIV services in primary health centers in high-prevalence, resource-constrained settings. It reviews the contents of the Operations Manual developed, with emphasis on the Laboratory Services chapter, which discusses essential laboratory services, both at the center and the district hospital level, laboratory safety, laboratory testing, specimen transport, how to set up a laboratory, human resources, equipment maintenance, training materials, and references. The chapter provides specific information on essential tests and generic job aids for them. It also includes annexes containing a list of laboratory supplies for the health center and sample forms.
New York, New York, IPPF, WHR, 2005.  p.Moving beyond its solid foundation of family planning services, IPPF/WHR's work has increasingly supported a comprehensive vision of sexual and reproductive health that includes human rights, sensitivity to gender, and a focus on quality care. The advent of the HIV/AIDS epidemic, which has been particularly devastating in the Caribbean region, has made urgent the need to integrate HIV/AIDS into the spectrum of education and services offered by IPPF/WHR's member associations. The IPPF Western Hemisphere Regional Office made great strides in its HIV/AIDS/STI work through 2004 and 2005, both at the Regional Office (RO) and member association level. During these two years, the HIV team has done much strategic planning, taken measures to increase RO capacity and partnerships, and promoted a significant increase in the number of HIV/AIDS and other STI (sexually transmitted infection) programs among member associations. This update provides an overview of the current HIV/AIDS/STI program unit and activities in the field. (author's)
New York, New York, UNICEF, 2008 Apr. 48 p.This report will focus on three major themes. First, strengthening communities and families is crucial to every aspect of a child-centred approach to AIDS. Support by governments, NGOs and other actors should therefore be complementary to and supportive of these family and community efforts, through, for example, ensuring access to basic services. Second, interventions to support children affected by HIV and AIDS are most effective when they form part of strong health, education and social welfare systems. Unfortunately, because maternal and child health programmes are weak in many countries, millions of children, HIV-positive and -negative alike, go without immunization, mosquito nets and other interventions that contribute to the overall goal of HIV-free child survival. A final theme of this report is the challenge of measurement. Documenting advances and shortfalls strengthens commitment and guides progress. A number of countries have data available on the 'Four Ps', and targeted studies are being developed to assess the situation of the marginalized young people who are most at risk but often missed in routine surveys. (excerpt)
Bulletin of the World Health Organization. 2007 Nov; 85(11):822.Armed conflicts and natural disasters cause substantial psychological and social suffering to affected populations. Despite a long history of disagreements, international agencies have now agreed on how to provide such support. The Inter-Agency Standing Committee (IASC), established in response to United Nations General Assembly Resolution 46/182, is a committee of executive heads of United Nations agencies, intergovernmental organizations, Red Cross and Red Crescent agencies and consortia of nongovernmental organizations responsible for global humanitarian policy. In 2005, the IASC established a task force to develop guidelines on mental health and psychosocial support in emergencies. The guidelines use the term "mental health and psychosocial support" to describe any type of local or outside support that aims to protect or promote psychosocial well being or to prevent or treat mental disorders. Although "mental health" and "psychosocial support" are closely related and overlap, in the humanitarian world they reflect different approaches. Aid agencies working outside of the health sector have tended to speak of supporting psychosocial well being. Health sector agencies have used the term mental health, yet historically also use "psychosocial rehabilitation" and "psychosocial treatment" to describe nonbiological interventions for people with mental disorders. Exact definitions of these terms vary between and within aid organizations, disciplines and countries, and these variations fuel confusion. The guidelines' reference to mental health and psychosocial support serves to unite a broad group of actors and communicates the need for complementary supports. (excerpt)
Lancet. 2007 Dec 1; 370(9602):1821.One Sunday morning last year, an elderly Zambian woman, four grandchildren in tow, showed up at Elizabeth Mataka's door. "I'm looking for Mrs Mataka-people said she will help me. She's the one who helps grandmothers", the woman said. She had found exactly the right person. Mataka, herself a grandmother of three, heads the Zambia National AIDS Network (ZNAN) and helps coordinate funds fl owing in from donors. And earlier this year she was elevated to the highest levels of the global response to the pandemic. In April, 61-year-old Mataka was elected Vice Chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The next month, she got a surprise midnight call from New York with the news that she had been chosen to replace the outgoing United Nations Special Envoy for HIV/AIDS in Africa, Canadian diplomat Stephen Lewis. (excerpt)
Towards universal access by 2010. How WHO is working with countries to scale-up HIV prevention, treatment, care and support.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2006. 32 p.In 2005, leaders of the G8 countries agreed to «work with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010». This goal was endorsed by United Nations Member States at the High-Level Plenary Meeting of the 60th Session of the United Nations General Assembly in September 2005. At the June 2006 General Assembly High Level Meeting on AIDS, United Nations Member States agreed to work towards the broad goal of "universal access to comprehensive prevention programmes, treatment, care and support" by 2010. Working towards universal access is a very ambitious challenge for the international community, and will require the commitment and involvement of all stakeholders, including governments, donors, international agencies, researchers and affected communities. Among the most important priorities is the strengthening of health services so that they are able to provide a comprehensive range of HIV/AIDS services to all those who need them. This document describes the contribution that the World Health Organization (WHO) will make, as the United Nations agency responsible for health, in working towards universal access to HIV prevention, treatment, care and support in the period 2006-2010. It proposes an evidence-based Model Essential Package of integrated health sector interventions for HIV/AIDS that WHO recommends be scaled up in countries, using a public health approach, and provides an overview of the strategic directions and priority intervention areas that will guide WHO's technical work and support to its Member States as they work towards universal access over the next four years. (excerpt)
Journal of the Association of Nurses in AIDS Care. 2007 Jan-Feb; 18(1):60-62.The XVI International AIDS Conference had its own essence that differentiated it from previous meetings. This meeting was characterized by the presence of well-known individuals from foundations, international organizations, the media, pharmaceutical companies, nongovernmental organizations, activists, HIV-positive persons, health care professionals, researchers, and others concerned with HIV/ AIDS. Absent as notable exceptions were politicians currently in office. Melinda Gates and the two Bills (Gates and Clinton) and United Nations envoy Stephen Lewis gave stirring speeches. The impact of HIV/AIDS on women was recognized, with more than 100 sessions devoted to women. And although the conference organizers are to be congratulated for so much that was right about the conference, there are some areas requiring further attention. In the conference summaries, one never saw addressed issues of primary concern to nurses. For example, symptom management is given short shrift. Truth in advertising requires that I mention that this is an area of my research. I am not saying that my research should have been mentioned. I am stating that none of the studies in this area seemed on the radar screen of those completing the summaries. This contributes to the invisibility of nursing. (excerpt)
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 2006 Jul. 67 p. (UNAIDS Best Practice Collection; UNAIDS/06.23E)Global Reach: how trade unions are responding to AIDS is a set of 11 case studies which illustrate the wide range of responses by trade unions to the HIV epidemic. It is now well known that the workplace has vast potential for limiting the damaging effects of the HIV epidemic. Workplace programmes that protect rights, support prevention, and provide access to care and treatment can help mitigate the impact of the virus. Yet though the importance of the workplace and the role of employers is generally recognized, the contribution of working people and their organizations has often been overlooked. This report shows that trade unions, assisted by global union federations, have adopted a wide range of workplace responses to AIDS. These include challenging stigma and discrimination, addressing the factors that facilitate the spread of HIV, providing care and treatment, educating their members on prevention, and building worldwide coalitions that campaign for more to be done to tackle the disease. The case studies, based on the experiences of working people in Africa, Asia, Central America and the Caribbean, show that the massive memberships and well-structured networks of trade unions are a powerful tool in the response to HIV. Extensive networks of working people in different countries have been spurred into action by the crisis, and are involved in the development of national policy, global framework agreements, community projects, sectoral alliances and worldwide collaboration between governments, employers and trade unions. (excerpt)
The development of programme strategies for integration of HIV, food and nutrition activities in refugee settings.
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 2006 May. 34 p. (UNAIDS Best Practice Collection; UNAIDS/06.21E)2003, The United Nations High Commissioner for Refugees (UNHCR), United Nations World Food Programme (WFP) and United Nations Children's Fund (UNICEF) launched a joint effort to develop, through multi-site field research in refugee communities in Africa, a set of strategies for using food and nutrition-based interventions to support HIV prevention, care, treatment and support for people living with HIV. That initiative deliberately embodied a very high degree of collaboration, both among the agencies involved, but also with refugees themselves, to best capture lessons about how these sectors can be better integrated under the unique circumstances of refugee settings. This document discusses the process and findings of that initiative, whose value for best practices is found in the collaborative, field-driven methodology as well as in the findings and output. (excerpt)
SAfAIDS News. 2005 Sep; 11(3):11-12.The AIDS epidemic has become a genuine global emergency with rising numbers of new infections, increasing numbers of deaths and the impact of the epidemic increasingly being felt particularly by the rising numbers of children made orphans or vulnerable by AIDS. The scale of the emergency has resulted in an unprecedented response by African countries, civil society and the international community. Today, there are more resources for HIV prevention, care, support and treatment than ever before. This increase in resources is coupled with an increasing number of actors becoming involved in the AIDS response, often leading to unclear roles and leadership and dispersed authority that may undermine national plans and priorities. Furthermore, resources are often dissipated and scattered, transaction costs have increased, capacities are distracted and weakened while monitoring and evaluation remains fragmented. The result has been that a substantial amount of available resources are not being used effectively and not getting to the people that need them most. (excerpt)