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From Bangkok to Mexico: towards a framework for turning knowledge into action to improve health systems [editorial]
Bulletin of the World Health Organization. 2004 Oct; 82(10):720-721.As a follow-up to the International Conference on Health Research for Development that took place in Bangkok, Thailand, in 2000, WHO convened a Ministerial Summit on Health Research to be held in Mexico City in November 2004, to review progress to date and reflect on emerging opportunities in the global field of health research. In 1990, the Commission on Health Research for Development recommended that all countries should undertake essential national health research; it stipulated that international partnerships are the foundations for progress and that financing for these efforts should be mobilized from both international and national sources. In 1996, WHO'S Ad Hoc Committee on Health Research Relating to Future Intervention Options outlined a five-step priority-setting approach to decide how health research funds should be allocated. It identified "best buys" for the development of products and procedures in several key areas, including childhood infections, malnutrition, microbial threats, noncommunicable diseases and health systems. Overall, progress has been slow and there is much more to be done to deal with major health challenges. (excerpt)
East African Medical Journal. 2003 Jun; 80(6 Suppl):S1-S20.Health sector reform is 'a sustained process of fundamental changes in national health policy, institutional arrangements, etc. guided by government and designed to improve the functioning and performance of the health sector and, ultimately, the health status of the population'. All the forty six countries in the African Region of the World Health Organisation have embarked on one form of health sector reform or the other. The contexts and contents of their health reform programmes have varied from one country to another. Health reforms in the region have been influenced largely by the poor performance of the health systems, particularly with regard to the quality of health services. Most countries have taken due congnizance of the deficiencies on their health systems in the design of their health reform programmes and they have made some progress in the implementation of such programmes. Indeed, some countries have adopted sector-wide approaches (SWAps) in developing and implementing their health reform programmes. Since countries are at various stages of implementing their health reform programmes, there is a lot of potential for countries to learn from one another. This paper is a synthesis of the experiences of the countries of the Region in the development and implementation of their health sector reform programmes, it also highlights the future perspectives in this important area. (author's)
HEALTH FOR THE MILLIONS. 1995 Jan-Feb; 21(1):29-33.In India, the standard regimen (SR) for treating tuberculosis consisted of a 2-month intensive treatment by 2-3 inexpensive drugs followed by a 10-month course using 2 drugs. In the 1980s, this course was shortened to 6 months owing to the powerful drugs rifampicin and pyrazinamide. Thiacetazone was also replaced by the more expensive but less toxic ethambutol. The result was a short-course chemotherapy (SCC) employing 4 drugs for 2 months, followed by 2-3 drugs for 4 months of follow-up. The SCC is being pilot-tested as the Revised National Tuberculosis Program (RNTP); this RNTP strategy is being implemented in Delhi, Bombay, and Mehsana with the assistance of the Swedish international agency. The World Bank also endorsed RNTP, as SCC regimens under it were cost-effective. The SR and SCC regimens were also compared for Malawi, Mozambique, and Tanzania, and relatively minor differences were found in lives saved for expenditures. The claim that the rates of default under SR and SCC remain unchanged over time and the cure rates of the regimens must be challenged. The estimated cure rates of 60% for SR and 85% for SCC do not correspond to the reality in India, where 41% of patients completed treatment under SR versus 47% under SCC. The cost of treatment under SR does not have to be a 5-drug regimen; re-treatment can be a 3-drug regimen, whereby the cost would be lower than assumed. The Ministry of Health and Family Welfare (MHF) was probing 253 district SCCs even in 1992-93 and accepted SCC because the World Health Organization recommended a vastly improved administration for implementation and there was a felt need from patients for speedy cure. If the SCC is administered properly, it may increase the cure rate, even if cost-ineffective; if poorly managed, increased drug resistance of TB bacteria could result, which may be the present situation.
Lancet. 1993 Aug 14; 342(8868):441.The World Bank's prescription, unexceptionable and laudable where it can be afforded, fails to acknowledge the plight of those living in countries where an absolute lack of resources precludes any hope of an economic or social environment in which the prescription can be filled. This is a new situation, and one which has been created largely by the increasing pressure of debt, by the inefficient use of resources by both governments and international donors, by corruption, in some cases by conflict, by the resurgence of diseases such as malaria and tuberculosis, and by the growing impact of HIV infection. The result has been, in some cases, an almost complete collapse of government revenues for welfare services. For example, government expenditure on health in Uganda is Us$1.4 per capita yearly, a decline in real terms of 95% since 1972. In these circumstances, precisely where the need is greatest, the Bank's prescription for reform of the health sector cannot apply. Nobody can reallocate, or better manage, funds that do not exist. Although true equity in health remains a dream, the aspiration towards it is enshrined in all UN documents. By failing to acknowledge the plight of those living in parts of the world where there is an absolute lack of resources, this report may inadvertently encourage belief in the principle of "Health for All (those who can afford it) by the year 2000". (full text)
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1994; 72(4):639-51.The examination of the external assistance to the health sector quantified the sources and recipients of such assistance in 1990 by analyzing time trends for external assistance to the health sector over the preceding two decades, and, by describing the allocation of resources to specific activities in the health sector. The health sector external assistance data were collected through a questionnaire and follow-up visits to all major bilaterals, multilaterals, and large nongovernmental (NGO) agencies. The three major databases on development assistance were also used: the Organization for Economic Cooperation and Development (OECD) Development Assistance Committee (DAC) annual tables, the Creditor Reporting System (CRS) from OECD, and the Register of Development Activities of the United Nations system. From 1972 to 1980, there was a sustained increase in external assistance by 14% per year. Beginning in 1986, the pace of increase was lower than in the 1970s but had averaged 7% per year in both bilateral and multilateral agencies. In 1990 in developing countries, health external assistance totaled $4800 million, or only 2.9% of total health expenditures in developing countries. 82% of this sum originated from public coffers in developed countries and 18% from private households. Resources to the health sectors of developing countries included: 40% through bilateral development agencies, 33% through United Nations agencies, and 8% through the World Bank and banks such as the Asian Development Bank. Nongovernmental Organizations (NGOs) accounted for 17%, and 1.5% came from foundations. The USA accounted for 27.5% of all assistance, France for 12.9%, and Japan for 11.5%. One quarter of all health sector assistance was paid for by Sweden, Italy, Germany, and the United Kingdom. The study confirms prior findings that health status variables per se are not related to the amount of aid received. Comparing investments to the burden of disease shows tremendous differences in the funding for different health problems. A number of conditions are comparatively underfinanced, particularly noncommunicable diseases and injuries.
SOUTHERN AFRICA POLITICAL AND ECONOMIC MONTHLY. 1994 Mar; 7(6):14-5.Since the International Monetary Fund/World Bank Economic Structural Adjustment Program (ESAP) in Zimbabwe was adopted in 1990, health care and education costs have escalated, and many people fail to get these services owing to poverty. The post-independence era in Zimbabwe witnessed a tremendous growth in education and health with many schools, colleges, hospitals and clinics built, professional staff employed, and a general expansion in demand. Nevertheless, the question of drug shortages and ever-increasing health care costs were not addressed. A deficient transport network, the increases in drug prices, the exodus of professional staff, the devaluation of the Zimbabwe dollar, and the cost recovery measures endangered the right to acceptable health care. The social service cutbacks adopted by the government in education will deepen poverty. After independence, the Zimbabwean education system had a free tuition policy at primary school levels. Now that the government reintroduced school fees, a generation of illiterate and semi-illiterate school dropouts will grow up. The social implications of this include increases in crime, prostitution, the number of street kids, the spread of diseases, and social discontent, which are the symptoms of a shrinking economy. As a result of the cost recovery measures, school enrollment in rural areas has gone up. Some urban parents have been forced to transfer their children to rural schools. Higher education also suffers, as government subsidies to colleges and universities have been drastically curtailed. The budgetary cuts have grave repercussions for teaching and research, as poor working conditions and low morals of lecturers and students become prevalent. Most wage-earning Zimbabweans' living standards have deteriorated as the cost of living continues to escalate, coupled with the cost recovery measures in the name of ESAP.
PEOPLE AND THE PLANET. 1993; 2(4):10-3.Nepal faces the choice between sustainable development in a fragile mountain environment in balance with a growing population or the continuation of stagnation and inertia. The political change of April 1990 created new optimism for the country's 18.5 million people, 70% of who live in abject poverty despite international aid making up 60% of the development budget. The maternal mortality rate stands at an exorbitant 850 deaths/100,000. The life expectancy of women is lower than that of men, and there is only 1 doctor for every 30,000 people, while 90% of births are not attended by a trained practitioner. The annual population growth rate amounts to 2.1%, which could double population in 30 years. This rate had outstripped crop production on a limited supply of land, resulting in the addition of another 250,000 poor people every year to the total. Government policies are skewed; a major hydroelectric project is planned to be constructed in 1994 despite talk about poverty alleviation. The National Conservation Plan of 1988 is in its 3rd phase of implementation, with plans in forestry, irrigation, livestock, and horticulture also being implemented at the request of the World Bank. Family planning lapsed as the vertical delivery system was replaced by a horizontal one encouraging villages to build sub-health posts providing family planning and primary health care. 700 such village health posts exist among 4000 villages, and another 600 are scheduled to open in 1994. Positive signs of meaningful development efforts include the budgetary shift to education, health care, and clean drinking water provision. Decentralization laws passed in 1992 and subsequent local elections aimed at handing over to local people the responsibility for their development assisted by government funds and technical support. The poor and often illiterate people have the manpower to dig irrigation canals and stabilize hillside terraces; therefore, the ruling party's central policy is to mobilize there human resources for development
BMJ. British Medical Journal. 1993 Sep 18; 307(6906):729-30.The former Minister of Health responds to an earlier, inaccurate article about the dispute between some emergency ward physicians and the public sector in Chile. Even though the economy appears to be healthy, 38% of the population are poor. Chile has had a longterm social policy addressing socioeconomic problems in health and in education, resulting in impressive health indicators (e.g., in 1990, 97% immunization rate for children under 5 years of age. The Pinochet regime whittled away at the strong national health service, however, including a large reduction in staff in the mid-1970s and a 40% reduction in expenditures (and a response to the economy adjustment crisis). These actions became time bombs which exploded in May 1990, 2 months after the inauguration of the 1st democratically chosen president in years. The health unions and, later, physicians asked for higher wages. In late 1992, the government increased salaries by 35% in real terms and 100% in nominal terms. Between 1990 and 1993, 6000 people, which included 1200 physicians for rural areas, were added to the public sector staff. The government increased investment in equipment (around 10,000 pieces of equipment, including 10 CAT scans) and in infrastructure by 240%. 190 public hospitals are undergoing repair and renovation. 2 small hospitals have opened. 4 large regional hospitals are scheduled for completion in 1993 and 1994. During the 3 years of democracy, the public sector budget increased 50% in real terms. The World Bank has provided assistance for a health sector reform project to meet the challenges that accompany the demographic and epidemiologic transition, transitions from a planned to a market economy and from dictatorship to democracy, a cultural transition, and behavioral changes. Politicians and physicians do not necessarily support reforms, however, sometimes resulting in changes in ministers, such as the author of this article.
Arlington, Virginia, John Snow, Inc. [JSI], Resources for Child Health Project [REACH], 1987.  p. (USAID Contract No. DPE-5927-C-00-5068-00)In 1987, consultants went to Niger to prepare the plan of operations for the national Expanded Programme on Immunization (EPI). US$ 6 million from the World Bank Health Project and around US$ 5 million from the UNICEF EPI Project were available for EPI activities. Low vaccination coverage prevailed outside Niamey. Outbreaks of diseases that EPI can prevent continued to kill children. The cold chain was not maintained, especially at the periphery. Mobile teams continued to use inadequate strategies. Record keeping did not exist. The central level did not supervise the periphery. EPI staff at departmental and division levels did not have current written guidelines. Not only did poor working communications exist between the central level and the periphery, but also between the EPI Director and the other Minister of Health divisions, between WHO and UNICEF, and between both UN agencies and EPI. The EPI Director did have a good relationship with the USAID office, however. No one took inventory of EPI resources or monitored temperatures at any point in the cold chain. Even though the World Bank Health Project intended to five EPI 50 ped-o-jets, 46% of the existing 88 ped-o-jets were in disrepair and no one knew how to repair and maintain them. Thus EPI should not routinely use ped-o-jets. The consultants recommended that USAID stay involved with EPI in Niger since the EPI Director considered it an acceptable partner. EPI staff at each level should take a detailed inventory of all material resources. Effective and regular supervision should occur at the central, regional, and peripheral levels. A health worker needs to record the temperature of the refrigerator twice a day. Technical grounds should determine the standardization and selection of all equipment. Someone should maintain an adequate supply of spare parts and technicians should undergo training in maintenance.
Arlington, Virginia, John Snow, Inc. [JSI], Resources for Child Health Project [REACH], 1986 Jun. , 31,  p. (USAID Contract No. DPE-5927-C-00-5068-00)In the mid 1980s, the Government of The Gambia (GOTG) sought funds from the World Bank and other donors to restructure and strengthen its health system. Since the World Bank thought that recurrent cost obligations that the GOTG would find unacceptable should accompany the implementation of the National Health Project (NHP), this study was undertaken. The Italian Government agreed to fund US $9.8 million to NHP, most of the funds going to renovating and refurbishing the pediatric ward and central laboratory at Royal Victoria Hospital in Banjul. Trends in health sector expenditures showed that the devaluation of the dalasi continued to bring about shortfalls in nonsalary costs, especially in drugs and dressings. Therefore the GOTG must address the shortfalls before even considering expansion of the already inefficient health delivery system. It also needs to develop a cost recovery system for drugs which maintains a reliable source and adequate supplies of drugs in the proper amounts, effectively distributes the drugs, and manages the finances effectively. The GOTG should also develop the Ministry of Health's ability to coordinate donor support and to develop a process of budgeting, spending, and planning. The study team also recommended consolidating staff rather than expand staff in light of financial constraints. A flotation policy and exchange rates less favorable to the dalasi may grant the GOTG more access to exchange within the banking system.
FRONT LINES. 1991 Nov; 16.Indonesia's success in reaching World Health Organization (WHO) universal immunization coverage standards is described as the result of a strong national program with timely, targeted donor support. USAID/Indonesia's Expanded Program for Immunization (EPI) and other USAID bilateral cooperation helped the government of Indonesia in its goal to immunize children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by age 1. The initial project was to identify target areas and deliver vaccines against the diseases, strengthen the national immunization organization and infrastructure, and develop the Ministry of Health's capacity to conduct studies and development activities. This EPI project spanned the period 1979-90, and set the stage for continued expansion of Indonesia's immunization program to comply with the full international schedule and range of immunizations of 3 DPT, 3 polio, 1 BCG, and 1 measles inoculation. The number of immunization sites has increased from 55 to include over 5,000 health centers in all provinces, with additional services provided by visiting vaccinators and nurses in most of the 215,000 community-supported integrated health posts. While other contributory factors were at play, program success is at least partially responsible for the 1990 infant mortality rate of 58/1,000 live births compared to 72/1,000 in 1985. Strong national leadership, dedicated health workers and volunteers, and cooperation and funding from UNICEF, the World Bank, Rotary International, and WHO also played crucially positive roles in improving immunization practice in Indonesia.
AMERICAN JOURNAL OF PUBLIC HEALTH. 1990 Oct; 80(10):1188-92.Health trends since 1950 in both developed and developing countries are classified and discussed in terms of causative factors: socioeconomic development, cross-national influences and growth of national health systems. Despite the vast differences in scale of health statistics between developed and developing countries, economic hardships and high military expenditures, all nations have demonstrated significant declines in life expectancy and infant mortality rates. Social and economic factors that influenced changes included independence from colonial rule in Africa and Asia and emergence from feudalism in China, industrialization, rising gross domestic product per capita and urbanization. An example of economic development is doubling to tripling of commercial energy consumption per capita. Social advancement is evidenced by higher literacy rates, school enrollments and education of women. Cross-national influences that improved overall health include international trade, spread of technology, and the universal acceptance of the idea that health is a human right. National health systems in developing countries are receiving increasing shares of the GNP. Total health expenditure by government is highly correlated with life expectancy. The view of the World Bank and the International Monetary Fund that health care should be privatized is a step backward with anti-egalitarian consequences. The UN Economic Commission for Africa attacked the IMF and the World Bank for promoting private sector funding of health care stating that this leads to lower standards of living and poorer health among the disadvantaged. Suggested health strategies for the future should involve effective action in the public sector: adequate financial support of national health systems; political commitment to health as the basis of national security; citizen involvement in policy and planning; curtailing of smoking, alcohol, drugs and violence; elimination of environmental and toxic hazards; and maximum international collaboration.
In: Management information systems and microcomputers in primary health care, edited by Ronald G. Wilson, Barbara E. Echols, John H. Bryant, and Alexandre Abrantes. Geneva, Switzerland, Aga Khan Foundation, 1988. 17-20.A wide array of issues must be addressed if the development and use of management information system (MIS) and microcomputers are to improve management of primary health care (PHC) programs and increase the equity and cost-effectiveness of PHC. These issues include: specification of the purpose and objectives of MIS at community and district levels; distinquishing types of information required; the understanding of organizational issues that must be resolved as a result of introducing MIS; the practical definition of the most useful indicators of program effectiveness and efficiency; the specification and monitoring of data collection, compilation, and analysis requirements and procedures; procedures for generating and using processed MIS data and management information; the PHC program's capacity to absorb technological innovations; and personnel requirements. The need for improved data systems must be recognized. Data quality and systematic flow of information must be ensured from the field level upwards, and minimum information requirements need to be defined. The success of any MIS is heavily dependent on feedback of the data collected. Unless staff at all levels of a PHC program understand the importance of the data they are collecting, the value and use of the information system will be negligible. Examples of the Egyptian government's National Health Information System and the role of the World Bank are used to show how MIS and microcomputer can be introduced and used in PHC.