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Are cost effective interventions enough to achieve the Millennium Development Goals? Money, infrastructure, and information are also vital [editorial]
BMJ. British Medical Journal. 2005 Nov 12; 331(7525):1093-1094.At a high level forum in Paris this month policy makers are meeting to discuss the financial sustainability and coordination of activities essential for achieving the millennium development goals. Building on other targets set in the 1990s, such as those at the 1990 UN children’s summit, these ambitious goals agreed by 189 countries aim to markedly reduce poverty and hunger and improve education and health throughout the world by 2015. But many less developed countries, especially in sub-Saharan Africa and south Asia, are falling short of the target to reduce child mortality by 4.4% a year, the rate required to cut deaths among children less than 5 years old by two thirds (from the 1990 level) by 2015. (excerpt)
Drug Safety. 2005; 28(4):277-286.Artemisinin combination therapies (ACTs) have been recommended for the treatment of malaria in countries where there is widespread resistance to commonly used antimalarial drugs. Several sub-Saharan African countries are, therefore, in the process of introducing ACTs in their malaria drug policies. However, there is limited information about the safety of ACTs outside South East Asia, where their use has been well documented. As with all other new medicinal compounds, the monitoring of a drug's safety or ’pharmacovigilance’ is important, especially in areas where co-morbid conditions, such as HIV/AIDS, malnutrition and tuberculosis, are common. Because in most malaria endemic countries, particularly Africa, there are no pharmacovigilance programmes in place, it has been suggested that the introduction of ACTs offers an opportunity for these countries to put drug safety monitoring systems in place. Backed by the WHO Roll Back Malaria department and other international cooperating partners, five African countries, which are in the process of introducing ACTs (Burundi, Democratic Republic of the Congo, Mozambique, Zambia and Zanzibar), have drawn up action plans to introduce pharmacovigilance in their health sector. It is planned that once the safety monitoring of antimalarials has been established, these activities can then be extended to cover medicinal compounds used in other public health programmes, such as HIV/ALDS, tuberculosis and the immunisation programmes. This article looks at the rationale for pharmacovigilance, the process of setting up monitoring centres and the challenges of implementing the project in the region. (author's)
Habitat Debate. 2005 Sep; 11(3):8.At the Millennium Summit world leaders pledged to improve the lives of at least 100 million slum dwellers by 2020, as proposed in Nelson Mandela’s Cities Without Slums initiative. Since its inception 30 years ago, the human settlements programme has taken significant steps on the conceptualization of slums and security of tenure. Yet the goals of security of tenure and adequate shelter have always remained on the periphery of the international development agenda, despite the Istanbul Summit of 1996. As the first major global instrument of the international human settlements community, the Habitat Agenda is primarily a declaration of good principles. But the broad range of themes it articulates in politically correct language allows any stakeholder to defend any argument. Indeed the Habitat Agenda falls short of providing a focused, results-oriented road map. (excerpt)
Habitat Debate. 2005 Sep; 11(3):13.Finding the right indicators and the best approach to monitoring the myriad problems of urban poverty around the world can be complex or simple. In this debate, David Satterthwaite, Senior Fellow at the London-based International Institute for Environment and Development, and Eduardo López Moreno, Chief of UN-HABITAT’s Global Urban Observatory, discuss some the alternatives. (excerpt)
Habitat Debate. 2005 Sep; 11(3):6.To answer the simple but central question of the title, the Millennium Development Strategy (MDS) prepared by the UN Millennium Project, recommended that, “during 2003- 2004, each country prepares its own Millennium Development Strategy Paper that builds explicitly on the targets of the Millennium Development Goals (MDGs)”. The strategy suggests that this could be a revised version of the Poverty Reduction Strategy Papers (PRSP)) which explicitly and suitably incorporate the MDGs. “Countries need to construct their own coherent strategy for achieving the MDGs, building on the various dimensions of policy,” it says. While many countries have undertaken such analyses in recent years, it would be interesting to find out, five years after the adoption of the Millennium Declaration, whether this work is systematically done. For UNHABITAT the question is: Are countries prepared to meet the target of improving significantly the lives of slum dwellers? To find out, a quick survey was conducted recently through the regional offices and UN-HABITAT Programme Managers (HPMs). (excerpt)
Habitat Debate. 2005 Sep; 11(3):12.Not enough is being done to gather street and house-hold-level statistics in slums and other urban pockets of poverty to implement the slum target of the Millennium Declaration. This is because country reports average out the figures they gather from all urban households, both rich and poor, to provide single estimates on poverty, education, health, employment, and the state of human settlements. Thus the plight of the urban poor is underestimated. It is further masked by the practice of simply providing averages between urban and rural areas. For instance, Demographic and Health Surveys (DHS) conducted in 20 African countries between 2000-2003 showed that children living in poor urban areas are as exposed to high morbidity and malnutrition as those in rural areas. The Nigeria data showed that malnutrition was higher in slums than in rural areas (38% versus 32%). (excerpt)
Habitat Debate. 2005 Sep; 11(3):10.The Millennium Declaration to which world leaders pledged themselves in 2000 has become the ‘organizing framework’ for many UN and bilateral programmes. This is because it contains a broad range of internationally agreed development goals ranging from poverty reduction, health, and gender equality to education and environmental sustainability. While the challenges and opportunities for achieving the Millennium Development Goals (MDGs) are varied, what is unique about them is the time-bound element and the outcome orientation embodied in the targets. It must be understood that the MDG targets are global targets based on aggregate trends of all countries. Therefore, even if the global targets are achieved, the inequalities between countries and among people may still persist. At the national and local levels, achieving these global targets requires political commitment and ownership, which can be mobilised only if these targets are set in local context. It must therefore be recognised that while the MDGs are global, they can most effectively be achieved through action at local level. Poverty is not only a global issue, but is deeply rooted in local processes that matter most to the poor. For poverty reduction programmes to become effective, it is necessary to achieve the MDGs at local level, set within the context of local reality, aspirations and priorities. (excerpt)
Habitat Debate. 2005 Sep; 11(3):11.Millennium Development Goal (MDG) Target 11 (By 2020, to have achieved a significant improvement in the lives of at least 100 million slums dwellers) provides an unprecedented opportunity to get the issue of urban poverty onto the international development agenda. Global reporting allows direct comparisons of progress to be made between countries and over time. But there has been criticism that these high level goals and targets lack national and local relevance. The slum estimates produced by UNHABITAT are a global public good. They allow the international community to monitor patterns and trends in the number and condition of slum dwellers. UNHABITAT’s projection that the slum population could double from 924 million in 2001 to 2 billion in 2030 shows how far we are from actually achieving cities without slums. (excerpt)
Interim WHO clinical staging of HIV / AIDS and HIV / AIDS case definitions for surveillance. African region.
Geneva, Switzerland, WHO, 2005.  p. (WHO/HIV/2005.02)With a view to facilitating the scale-up of access to antiretroviral therapy (ART) in the African Region the present document outlines recent revisions made by WHO to the clinical staging of HIV/AIDS and to case definitions for HIV/AIDS disease surveillance. These interim guidelines are based on an international drafting meeting held in Saas Fee in June 2004 and on recommendations made by experts from African countries at a meeting held in Nairobi in December of the same year. The revisions to the clinical staging target professionals ranging from senior consultants in teaching and referral hospitals to surveillance officers and first-level health care providers, all of whom have important roles in caring for people living with HIV and AIDS (PLWHA), including children. It is proposed that countries review, adapt and repackage the guidelines as appropriate for specific tasks at different levels of health service delivery. It is hoped that national HIV/ AIDS programmes in African countries will thus be assisted to develop, revise or strengthen their ART guidelines, patient monitoring and surveillance efforts. The interim clinical staging and revised definitions for surveillance are currently being reviewed in the other WHO regions and will be finalized at a global meeting to be held in September 2005. (excerpt)
WHO approach to track HIV drug resistance emergence and transmission in countries scaling up HIV treatment [letter]
AIDS. 2005; 19(12):1329-1330.Treatment access programmes are currently expanding in resource-limited settings. The potential barriers to long-term success (such as intermittent drug supply, drug stock-outs, poor patient monitoring, incorrect prescribing practices and low adherence) as well as the need to begin programmes quickly to treat millions of individuals, have raised fears that the aggressive plan to roll out antiretroviral therapy (ART), particularly in Africa, may generate an epidemic of drug-resistant strains of HIV. (excerpt)
Interim patient monitoring guidelines for HIV care and ART. Based on the WHO HIV Patient ART Monitoring Meeting, held at WHO / HQ, Geneva, Switzerland, from 29-31 March 2004. (March 2005 update of 6th August 2004 draft).
Geneva, Switzerland, WHO, 2005 Mar. 191 p.These guidelines have been provided by the World Health Organization (WHO) and other international partners in order to: 1. Facilitate national stakeholder consensus on a minimum, standardized set of data elements to be included in patient monitoring tools; 2. Aid in the development of an effective national HIV care/ART patient monitoring system; 3. Enable the rapid scale-up of effective chronic HIV care, ART and prevention; and 4. Contribute to effective programme monitoring and global reporting and planning through the measurement of district-, national- and international-level indicators. (excerpt)
Indian Journal of Tuberculosis. 2000; 47(1):27-33.Surveillance of drug resistance was carried out at State level to obtain data which are standardised and compaiable using guidelines prescribed by the WHO/IUATLD Working Group on Anti-tuberculosis Drug Resistance Surveillance. The objective was to determine the proportion of initial and acquired drug resistance in cases of pulmonary tuberculosis in Tamil Nadu, m order to use the level of drug resistance as a performance indicator of the National Tuberculosis Programme. Two specimens of sputum from each of a total of 713 patients attending 145 participating centres all over the state were tested by smear and culture examination and drug susceptibility tests of Isoniazid, Rifampicin, Ethambutol and Streptomycin. Out of 400 patients for whom drug susceptibility results were available, 384 (96%) had no history of previous anti-tuberculosis treatment. Of these, 312 (81%) were susceptible to all the drugs tested. Resistance to Isoniazid was seen in 15.4% of patients and to Rifampicin in 4.4%, including resistance to Isoniazid and Rifampicin in 3.4%. There has been a gradual increase in initial drug resistance over the years in this part of the country. (author's)
Impact of external assistance: review of the tuberculosis programme in Karnataka, India (1999-2001).
Health Administrator. 2003 Jan-Jul; 15(1-2):102-105.RNTCP in Karnataka is a centrally sponsored project financed by the World Bank at a total cost of about 18 crores. Inspite of the fact that Karnataka has been a pioneer in initiating Tuberculosis Programme, the state stands listed with Assam, Bihar, J&K, Madhya Pradesh, Meghalaya, Mizoram, Punjab and Uttar Pradesh as the most difficult areas for implementation. Questions are raised as to the impact of external assistance in the control and implementation of the Tuberculosis Programme. (excerpt)
Population 2005. 2003 Dec; 5(4):9.A survey conducted by the United Nations Population Fund (UNFPA), in collaboration with the International Center for Migration and Health, has tracked startling statistics regarding the health system in Iraq. According to UNFPA, the number of women who die from pregnancy and childbirth in Iraq has close to tripled since 1990. Among the causes of the reported 310 deaths per 100,000 live births in 2002 are bleeding, ectopic pregnancies and prolonged labor. In addition, stress and exposure to chemical contaminants are also partly to blame for the rise in miscarriages among Iraqi women. Access to medical facilities is becoming more difficult for women due to breakdowns in security and weakened communication and transport systems. This has caused nearly 65 per cent of Iraqi women to give birth at home, the majority without skilled help. (excerpt)
Summary and recommendations from the UNAIDS Resource Tracking and Priority Setting Meeting, Washington D.C., USA, 20-21 March 2003.
[Geneva, Switzerland], UNAIDS, 2003 Mar. 10 p.The key objectives of the meeting were: 1. To review current and future efforts on resource tracking by the practitioners; 2. To identify gaps; 3. To identify key (short/long term) priorities; 4. To develop a consensus on how to work together in the future with a discussion on the potential value of forming a Consortium. All of the presentations given during the course of the meeting are available on the UNAIDS website (www.unaids.org) and will not be discussed here. This report highlights the discussions on gaps, priorities, and recommends next steps. (excerpt)
IAEN: Current Issues in the Economics of HIV / AIDS. Prospects for support and development of monitoring and evaluation (M&E) of HIV / AIDS assistance programs, Thursday, April 24, 2003. Transcript.
[Palo Alto, California], Henry J. Kaiser Family Foundation, 2003. 50 p.Each of us who works in this field and who visits countries where HIV/AIDS is devastating society has their own tragic memories of people that we have met, of communities that we have visited, of parents, dying parents of children affected by HIV/AIDS, so I can't think of anything more important than this discussion on effective strategies for resource mobilization and resource allocation. This is and area that we are giving much greater attention at USAIDS as we have access to greater resources. We are now doing a specific strategic plan for each country, and of course those plans very much involve our relationship with our primary partner, the host country government (Unintelligible) in UNAIDS and we are constantly asking ourselves, what impact, what choices because we all know there are more good choices in which to invest HIV/AIDS and your money and so you really have to focus on what is the impact on human beings. Will you prevent an infection? Will you provide desperately needed care or treatment or will you help a family who sold all of its lands to those whose last resources. I guess two memories that keep me up at night are sitting with women in Uganda, part of that wonderful Ugandan women's group working against AIDS, who are making scrapbooks for their children that say, this is who your parents, as they are dying, this is who your father was, this is who your mother is. (excerpt)
Manila, Philippines, WHO, Regional Office for the Western Pacific, .  p.Social mobilization can propel people to act, redirect or create human and material resources for the achievement of a social goal. Central to social mobilization is the concept of "social capital" defined as the interaction among people through systems that enhance and support that interaction. Social capital is created from a myriad of everyday interactions between people and is embodied in such structures as civic and religious groups, family membership, informal community networks, and in norms of v voluntarism, altruism and trust. Even in areas with limited economic capital, social capital has been shown to generate the energy and resources needed to effect changes in the community. Contextually, social mobilization is an integrative process where stakeholders are stimulated to become active participants in social change, using diverse strategies to meet shared goals. Simply put, social mobilization is about people taking action towards a common good. (excerpt)
Promoting condoms in clinics for sexually transmitted infections: a practical guide for programme planners and managers.
Manila, Philippines, WHO, Regional Office for the Western Pacific, STI, HIV and AIDS Focus, 2001.  p.The promotion of condom use among patients with sexually transmitted infections (STI) is important in the prevention and control of STI, including HIV. This guide aims to help STI programme planners and managers to improve condom promotion among STI patients. It reviews the major areas in condom promotion for STI services, including: creating a favourable environment; training service providers; counselling clients on condom use; managing condom supplies; and monitoring condom use. Some additional resources and sample exercises are also outlined. Further information and technical support in promoting condoms for STI prevention may be obtained from the World Health Organization, Regional Office for the Western Pacific. (excerpt)
Manila, Philippines, World Health Organization [WHO], Regional Office for the Western Pacific, 2002.  p.A 100% condom use programme (100% CUP), targeting female sex workers in entertainment establishments, is important in prevention and control of STIs, including HIV. Monitoring and evaluation to measure the progress of the programme is one of its essential components, and requires appropriate indicators. An indicator is a way in which to quantify or measure the magnitude of progress toward something one is trying to achieve in a programme, whether it is a process, an outcome or an impact. Indicators are just that - they simply give an indication of magnitude or direction of change over time. They cannot tell managers much about why the changes have or have not taken place. While a single indicator cannot measure everything, knowing the magnitude and direction of change in achieving a programme objective is critical information for a manager. A good indicator for monitoring and evaluation needs to be: relevant to the programme; feasible to collect and analyse; easy to interpret; and able to measure change over time. Identifying an indicator to be followed in a 100% CUP also demands attention to how that indicator will be defined, the source of the information needed for it, and the timeframe for its collection and analysis. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach. Executive summary.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002 Apr. 31 p.Currently, fewer than five per cent of those who require ARV treatment can access these medicines in resource limited settings. WHO believes that at least three million people needing care should be able to get medicines by 2005—a more than ten-fold increase. These guidelines are intended to support and facilitate the proper management and scale-up of ART in the years to come by proposing a public health approach to achieve these goals. The key tenets of this approach are: 1) Scaling up of antiretroviral treatment programmes to meet the needs of people living with HIV/AIDS in resource-limited settings; 2) Standardization and simplification of ARV regimens to support the efficient implementation of treatment programmes; 3) Ensuring that ARV treatment programmes are based on the best scientific evidence, in order to avoid the use of substandard treatment protocols which compromise the treatment outcome of individual clients and create the potential for emergence of drug resistant virus. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002. 163 p.These guidelines are part of the World Health Organization’s commitment to the global scale-up of antiretroviral therapy. Their development involved international consultative meetings throughout 2001, in which more than 200 clinicians, scientists, government representatives, representatives of civil society and people living with HIV/AIDS from more than 60 countries participated. The recommendations included in this document are largely based on a review of evidence and reflect the best current practices. Where the body of evidence was not conclusive, expert consensus was used as a basis for recommendations. We hope that this guidance will help Member countries as they work towards meeting the global target of having three million people on antiretroviral therapy by 2005. (excerpt)
Reducing HIV prevalence among young people: a review of the UNGASS prevalence goal and how it should be monitored.
London, England, London School of Hygiene and Tropical Medicine, 2002 Oct. iii, 67 p.The present review discusses the limitations of HIV prevalence estimates when used to track changes in the HIV epidemic in young people. In particular, it highlights important factors that need to be considered in interpreting prevalence data obtained from antenatal care (ANC) surveillance. The document suggests that, despite substantial efforts made in recent years to improve the quality and representativeness of sentinel surveillance systems and to develop adjustment methods that can be used to obtain more accurate estimates of HIV prevalence in the population, current estimates may not accurately reflect trends of infection in young people. Behavioural changes, such as delay in sexual debut and changes in patterns of contraceptive use, are shown to be important factors that need to be accounted for. In particular, increases in condom use among young people may affect observed trends of HIV infection from ANC surveillance in either direction, depending on the sector of the population that is more likely to use them (e.g. high or low risk groups). Furthermore, the combined effect of the discussed factors is difficult to predict and will be determined by the characteristics of the site and the stage of the HIV epidemic. (excerpt)
Geneva, Switzerland, WHO, 2003. 79 p.The purposes of the HDRST include: 1) to work with the National AIDS Committee to consider the specific public health uses of HIV drug resistance surveillance in the country, and to assess feasibility of surveillance; 2) to develop an appropriate time line for resistance surveillance activities, in coordination with other important implementation plans such as expanding HIV treatment; 3) to assess the country's capacity for HIV drug resistance surveillance, to decide on the populations and groups to be targeted, and to identify additional resources and activities needed; 4) to perform HIV drug resistance threshold surveys to assess when the frequency of resistance in persons newly diagnosed with HIV has reached the 5% threshold indicating a need for resistance surveillance; 5) to implement, when appropriate, HIV drug resistance surveillance; 6) to collaborate with the National AIDS Committee and the national treatment programme; to explore the feasibility of treatment programme monitoring by adding a resistance monitoring component to other year-end programme monitoring activities; 7) after routine surveillance is established, to consider implementing other special studies for in-depth evaluation of certain aspects of drug resistance within the country; 8) to insure implementation of all activities in accordance with international ethical standards designed to promote the well- being and health of individuals and communities; 9) to insure the dissemination of results in order to promote and support the public health of the country. (excerpt)
Geneva, Switzerland, World Health Organization [WHO], 2003. 13 p. (Perspectives and Practice in Antiretroviral Treatment)The primary objective of the MTCT-Plus Initiative is to provide lifelong care and treatment for HIV/AIDS to families in resource-limited settings. In addition to reducing mortality and morbidity, the Initiative hopes to further reduce the mother-to-child-transmission of HIV; to promote voluntary counselling and testing and other preventive strategies; to strengthen local health care capacity; to decrease stigma among, enhance support for and empower people living with HIV/AIDS; and to develop a model for HIV care in resource-limited settings that can be generalized. An international review committee selected the initial sites after a request for applications was widely distributed in early 2002. Of the 47 eligible applicants – all of whom had ongoing programmes to prevent the mother-to-child-transmission of HIV, HIV prevalence of at least 5% and the ability to enroll at least 250 people per year – the committee selected 12 demonstration sites. An additional 13 sites were given planning grants. (excerpt)
Geneva, Switzerland, WHO, 2003. 43 p.The right to the highest attainable standard of health was enshrined in WHO’s constitution over 50 years ago, and recognized as a human right in article 12.1 of the International Covenant on Economic, Social and Cultural Rights. This right extends to the underlying determinants of health; central among these are safe water and adequate sanitation. Yet we have entered the new millennium with one of the most fundamental conditions of human development unmet: universal access to water. Of the world’s 6 billion people, at least 1.1 billion lack access to safe drinking-water. The lives of these people who are among the poorest on our planet are often devastated by this deprivation, which impedes the enjoyment of health and other human rights such as the right to food and to adequate housing. Water is the essence of life and human dignity. Water is fundamental to poverty reduction, providing people with elements essential to their growth and development. Recently, the Committee on Economic, Social and Cultural Rights, which monitors the implementation of the Covenant, adopted General Comment No. 15 in which water is recognized, not only as a limited natural resource and a public good but also as a human right. The right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water, and it must be enjoyed without discrimination and equally by women and men. At the Millennium Summit, States agreed to halve, by 2015, the proportion of people without access to safe drinking-water. We are pleased to issue this publication as a contribution to the International Year of Freshwater, celebrated worldwide throughout 2003 as an immense opportunity to highlight and promote the right to water as a fundamental human right. (excerpt)