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BMJ. British Medical Journal. 2000 Mar 25; 320(7238):825.1 billion children will be permanently handicapped by malnutrition between now and 2020 unless the UN, donors, and national governments start to act. This warning from a report that was commissioned by the UN strongly criticizes international agencies and others for failing to curb a major avoidable problem. Worldwide more than 150 million children of preschool age are underweight and 200 million children are stunted. 1 in 4 babies born in developing countries have intrauterine growth retardation and are at risk of mental impairment, the report says. The current approach for coping with the world malnutrition problem completely misses the point with the assumption that poverty reduction is the way to go, said Professor Philip James, chairman of the Commission on Nutrition Challenges of the 21st Century, which produced the report. Instead, said Professor James, more sharply focused and coordinated action by governments and international agencies could, with modest investment, end malnutrition in preschool children by 2020. The Commission's sharpest criticism is reserved for the UN s own agencies, such as the Food and Agriculture Organization and the WHO. The Commission is aware of a number of uncoordinated approaches by different agencies. These often seem to be based on institutional rivalry and different disciplinary and sectoral approaches rather than on collaboration and the development of a cohesive effort, says the report. (full text)
Connections. 2006 Jan;  p.In September 2005, the World Health Organization (WHO) awarded Ukraine a 2.5 million dollar grant to combat the country's growing tuberculosis epidemic, according to Mykola Polischuk, who was Minister of Health at the time the grant was awarded. This funding will provide for the purchase of high-quality medications and allow for the cost-effective treatment of 75,000 patients over three years beginning in January 2006. The new treatment program will employ the DOTS (Directly Observed Therapy-Short Course) strategy, which has been recognized as the world's best strategy for fighting TB largely due to its reliance on cheaper microbiological methods of diagnosis rather than X-rays. Patients are first identified using microscopy services then prescribed the correct dosage of anti-TB medicines for a period of six to eight months. If administered accurately, DOTS can successfully treat TB in 99 percent of cases. Ukrainian President Viktor Yushchenko echoed WHO's decision to increase TB funding in October when he pledged to increase health funding, restore the country's failing health system, and fight the spread of HIV and tuberculosis, according to the Associated Press. (excerpt)
INTERNATIONAL JOURNAL OF GYNECOLOGY AND OBSTETRICS. 2000 Jul; 70(1):175-82.This paper reviews the role and activities of the International Federation of Gynecology and Obstetrics (FIGO) as a global federation with a mission to promote the health and well-being of women and to improve the practice of gynecology and obstetrics. To accomplish its mission, the General Assembly was formed to ratify recommendations on the governance of the organizations made by the Executive Board and the Officers. Among the structured activities of FIGO are included the Save the Mothers Fund Project Study Group on Women's, Sexual and Reproductive Rights, the Working Group on FIGO Classification of Female Urinary Incontinence, 21 Advisory Panels, FIGO Publications, FIGO Congress Bureau, the FIGO 2000 Congress Organizing Committee, the Scientific Committee, and the FIGO Secretariat based in London. Detailed discussion of the structured activities and their role in the advancement of women's health in the year 2000 are highlighted in this paper.
Lancet. 2000 Jul 22; 356(9226):321.On July 12, the Taliban government revoked its controversial edict that barred Afghan women from working for international relief agencies in war-ravaged Afghanistan. "Quietly things will return to normal. Afghan women can return to work", commented UN coordinator for Afghanistan, Erick de Mul after talks with Taliban officials in Qandahar. The announcement, which indicates a sharp shift in the Taliban's policy, is considered a great step forward to improving women's rights in the country. The Taliban also freed Mary MacMakin, a US relief worker who, along with seven female employees, was arrested on July 9 on charges of spying and attempting to convert Muslims to Christianity. MacMakin was arrested after the Taliban's Minister for Vice and Virtue, Mullah Mohammed Turabi, warned international aid groups, including the UN, against employing Afghan women. As a result, hundreds of women who worked for aid agencies, including health workers, stayed at home for fear of being publicly beaten. Health experts believe that getting the edict rescinded has saved dozens of health and nutrition projects. But although some concessions have been made by the Taliban in the areas of health and emergency social services, women are still forbidden to work. Hundreds of women health workers effectively remain prisoners in their homes. (full text)
Lancet. 2006 Apr 8; 367(9517):1137.Francisco Songane, a former Mozambican health minister who took over as Director of the new Partnership for Maternal, Newborn and Child Health on Feb 1, 2006, is a man with a mission. His goal is to capitalise on emerging political will--after years of neglect by the international community-- to reduce the unacceptably high toll of 11 million women, infants, and children under the age of 5 years who die every year from largely preventable diseases. "Children are dying and mothers are dying", he told The Lancet. "It is not normal to die in childbirth. It is not normal to die as a newborn", he says, commenting that in some countries, such as Mozambique, many women do not name their children for the first month because so many babies die. "We have to change that kind of fatalism. We cannot accept that people who make up two thirds of the world's population are dying silently without anyone helping", Songane asserts. (excerpt)
WIPHN NEWS. 2000 Summer; 25:4.In Swaziland, men have complained that a consignment of condoms from Asia had a bad odor, looked ugly and “killed any romance” between couples. They said the condoms also could not withstand pressure. Anti-AIDS activist Delsile Bhembe reported that over 20 youths protested at the national library in Mbabane, where health officials provide condoms free of charge. She agreed the Asian condoms were defective, saying they were made 2 years ago, but did not have expiration dates on them. She added that all 43,200 condoms would be returned to the government storeroom and accused the government of not being committed to AIDS awareness if it accepted reject condoms. In defense, Swaziland National AIDS Program Project Manager Beatrice Dlamini said that such actions are discriminatory, stating that the Swazis under-rate the condoms because they come from Asia. Dlamini reported that the condoms were part of a donation from UN agencies, making it hard for her office to turn them down. However, Bhembe was concerned the Asian condoms would undermine the anti-AIDS campaign, appealing to the country's only cellular network provider to provide better condoms as part of the company's social development program.
Science. 2000 Jun 23; 288(5474):2176-8.The HIV/AIDS epidemic is catastrophic both from a public health perspective, and its impact on economic and social stability of the most severely affected nations, including virtually all of southern Africa. A public health response alone is inadequate to address its devastating impact. Political leadership at the highest levels is required to mobilize a multisectoral response to the effect of HIV/AIDS on educational systems, industry, agriculture, and the military and other sectors. With a few notable exceptions, political response was slow to mobilize in the early years of the epidemic, but response has significantly improved in the past 18 months. The Joint UN Programme on HIV/AIDS (UNAIDS) is involved in ongoing efforts to encourage political leaders to make a multisectoral response to the epidemic a major focus of their national plans. UN Theme Groups on HIV/AIDS have been successful in mobilizing political commitment in over 100 affected countries. Moreover, UNAIDS is also the Secretariat for the International Partnership Against AIDS in Africa, a coalition which aims to accomplish existing goals such as ensuring that HIV incidence, in the most affected countries, is reduced by 25% in youth aged 15-24 years, by 2005. Currently, the challenge is to be highly strategic, highly skillful, highly coordinated, and highly disciplined in applying what have been learned and to hasten a social movement against AIDS, fully involving those living with HIV.
Development. 2000 Mar; 43(1):46-52.This article is on the considerable efforts by the international community to protect children in times of war. According to the author, there continues to be a gap in child protection and service provision due to current emergency and development programming and funding methods. Because of this gap, the author advocates a new approach to programming, budgeting, and evaluation of child protection programs. Furthermore, the author stressed the urgency to revised thinking about programming, funding, and evaluation of the demobilization and reintegration programs and all interventions for children in war and chronic emergencies. This urgency is in response to the need to develop ‘lesson learned’ and useful models of ‘best practice’ as well as the technical expertise or methodologies necessary to implement services for the protection of children.
BMJ. British Medical Journal. 2000 Jul 15; 321(7254):132.UN International Children's Emergency Fund (UNICEF) is about to form partnerships with companies that produce infant formula and that do not comply with the international code of marketing of breast milk substitutes, it was claimed this week. Two UNICEF employees have resigned in protest, and others are expected to tender their resignations. A document written by a UNICEF employee, who does not wish to be named, states that “decisions have been taken at UNICEF's top level to make alliances with pharmaceutical companies... which market their breast milk substitutes in disregard [of the code]”. UNICEF has previously refused to accept funding from the baby food industry, and it has supported breast-feeding advocacy groups in the developing world. A new partnership with industry would add to the growing concern among infant feeding specialists that international health agencies, including the WHO, are going too far in their dealings with the private sector. The International Baby Food Network commented: “There is a need for UNICEF to protect its status as a truly independent advocate for human rights and health for all, and to ensure that its policies, research priorities, and direction are not unduly influenced.” On 4 July, Carol Bellamy, executive director of UNICEF sent a memorandum to all UNICEF representatives, managers, and directors, which stated that UNICEF will “engage in dialogue with the private sector when it is clear that such an endeavor can contribute to the best interests of the child.” Michael Latham, professor of international nutrition at Cornell University in New York, said: “Carol Bellamy does not seem willing to state that UNICEF will not form partnerships with, nor accept funds from, corporations that violate the code.” (full text)
Lancet. 2000 Aug 26; 356(9231):748.Following the closure of UN-supported widows' bakeries in Kabul, Afghanistan, Taliban authorities announced that they would allow 360 female employees to return to work. This invalidation is in line with the decree that bans women from working for UN agencies and international nongovernmental organizations except in the health sector. Although no explanation for the sudden policy change has been given, Taliban's Foreign Minister stated that the government has no objection to these women working at the bakeries because they are not regular employees of the UN. According to Stephanie Bunker, spokesperson for the Office of the UN coordinator for Afghanistan, the policy change is a positive step in the right direction on the part of the local authorities in Kabul. However, the UN continues to be concerned about the impact of the decree on Afghan women overall.
Journal of Tropical Pediatrics. 2000 Aug; 46(4):192-3.During the meeting of international experts on Child Health and Poverty, it was noted that the highly unequal distribution of the wealth of the world was widening. In addition, one in five of the world's population is still living in abject poverty and in Africa this figure was actually increasing. To this effect, delegates saw the alleviation of world poverty as crucial for the future of the children who are affected with poverty, especially as much international financial aid for health was considered to be inadequate, insensitive, inappropriate, inefficient, and ultimately ineffective. It is noted that while donor interventions and international debts can help alleviate poverty and improve child health in poor countries, its consequences may actually worsen the situation. In view of this, the delegates recommended that international debts be cancelled and financial support for integrated technical strategies be massively expanded.
Lancet. 2000 Aug 19; 356(9230):680.This article comments on the editorial report of the Lancet on global health policy insinuating that the World Trade Organization (WTO) equates with a total absence of government intervention. The author defended this saying that no country would accept international trade rules which restrict its ability to regulate the marketing and importation of the products. WTO rules make it extremely clear that member countries have an absolute right to ban or restrict the sale and importation of goods when doing so is necessary to protect public health at the level that they choose. Another allegation made is that the WTO is opposing the health agenda set out by the WHO. The author defended this by contending that to the extent of trade and health, the WTO work closely with WHO carrying out the mandate that its member government have given.
Measuring progress towards the MDG for maternal health: Including a measure of the health system's capacity to treat obstetric complications.
International Journal of Gynecology and Obstetrics. 2006 Jun; 93(3):292-299.This paper argues for an additional indicator for measuring progress of the Millennium Development Goal for maternal health—the availability of emergency obstetric care. MDG monitoring will be based on two indicators: the maternal mortality ratio and the proportion of births attended by skilled personnel. Strengths and weaknesses of a third indicator are discussed. The availability of EmOC measures the capacity of the health system to respond to direct obstetric complications. Benefits to using this additional indicator are its usefulness in determining an adequate distribution of services and showing management at all levels what life-saving interventions are not being provided, and stimulate thought as to why. It can reflect programmatic changes over a relatively short period of time and data requirements are not onerous. A measure of strength of the health system is important since many interventions depend on the health system for their implementation. (author's)
Building effective public-private partnerships: experiences and lessons from the African Comprehensive HIV / AIDS Partnerships (ACHAP).
Social Science and Medicine. 2006 Jul; 63(2):397-408.This paper examines the processes for building highly collaborative public--private partnerships for public health, with a focus on the efforts to manage the complex relationships that underlie these partnerships. These processes are analyzed for the African Comprehensive HIV/AIDS Partnerships (ACHAP), a 5-year partnership (2001--2005) between the government of Botswana, Merck & Co., Inc. (and its company foundation), and the Bill & Melinda Gates Foundation. ACHAP is a highly collaborative initiative. The ACHAP office in Botswana engages intensively (on a daily basis) with the government of Botswana (an ACHAP partner and ACHAP's main grantee) to support HIV/AIDS control in that country, which had an adult prevalence of 38.5% HIV infection in 2000 when ACHAP was being established. The paper discusses the development of ACHAP in four stages: the creation of ACHAP, the first year, the second and third years, and the fourth year. Based on ACHAP's experiences over these four years, the paper identifies five lessons for managing relationships in highly collaborative public--private partnerships for public health. (author's)
Lancet. 2000 Oct 28; 356(9240):1525-6.Although the paper by Martha Ainsworth and Warantya Teokul provides superficially attractive suggestions for reducing the impact of the HIV/AIDS pandemic, the analysis is dangerous and dishonest since it omits any assessment of the World Bank's own role in driving the AIDS epidemic. It is noted that for over the past 20 years the World Bank has weakened governments of resource-poor countries and eroded public health policy, along with the International Monetary Fund (IMF). The liberalization of economies and its ensuing changes have all led to the severe deterioration in health care delivery systems, especially in Africa. Despite the situation, the Bank has continuously promoted cost recovery for health care. As a result, HIV-1 testing, condoms, treatment for sexually transmitted diseases and co-infections of the virus became subject to user charges and, therefore, became unaffordable to many. Although it is true that the relation between AIDS and poverty is complex, plagues seldom arise in wealthy populations. In this view, it is suggested that there is a need for changing the constitutional rules and other features of the IMF and World Bank to promote good governance and accountability within these institutions themselves.
Effect of an armed conflict on human resources and health systems in Cote d'Ivoire: Prevention of and care for people with HIV/AIDS.
AIDS Care. 2006 May; 18(4):356-365.In September 2002, an armed conflict erupted in Cote d'Ivoire which has since divided the country in the government-held south and the remaining territory controlled by the 'Forces Armees des Forces Nouvelles' (FAFN). There is concern that conflict-related population movements, breakdown of health systems and food insecurity could significantly increase the incidence of HIV infections and other sexually-transmitted infections, and hence jeopardize the country's ability to cope with the HIV/AIDS epidemic. Our objective was to assess and quantify the effect this conflict had on human resources and health systems that provide the backbone for prevention, treatment and care associated with HIV/AIDS. We obtained data through a questionnaire survey targeted at key informants in 24 urban settings in central, north and west Cote d'Ivoire and reviewed relevant Ministry of Health (MoH) records. We found significant reductions of health staff in the public and private sector along with a collapse of the health system and other public infrastructures, interruption of condom distribution and lack of antiretrovirals. On the other hand, there was a significant increase of non-governmental organizations (NGOs), some of which claim a partial involvement in the combat with HIV/AIDS. The analysis shows the need that these NGOs, in concert with regional and international organizations and United Nations agencies, carry forward HIV/AIDS prevention and care efforts, which ought to be continued through the post-conflict stage and then expanded to comprehensive preventive care, particularly antiretroviral treatment. (author's)
AIDS WEEKLY. 2000 Nov 13; 11.UN Partnerships between developing countries--or what is known as South-South cooperation--is essential in limiting the spread of HIV/AIDS, according to the head of the lead UN agency in the fight against the disease. Calling South-South cooperation “a priceless commodity” in the struggle against the HIV virus, Dr. Peter Piot, executive director of the Joint UN Program on HIV/AIDS (UNAIDS), told an international health conference in Tokyo, Japan, on November 2, 2000, that such partnerships could be used to good effect in planning, mobilization, and capacity strengthening. The 2-day African Seminar on Health Development, which was sponsored by the Government of Japan, is expected to promote South-South cooperation on HIV/AIDS by providing a forum for Asian, Latin American, and African countries to share their experiences on effective responses to the virus. The meeting is also expected to produce cooperative networks that help in the administration of HIV/AIDS programs and strengthen the International Partnership Against AIDS in Africa, a collaborative network established in September 1999 between UN agencies, the World Bank, and African governments, donor countries, and pan-African and other international organizations. “The International Partnership is the largest example of intensified South-South cooperation in the response to the AIDS epidemic,” Piot said. “It is a knowledge strategy, which recognizes that partners sharing knowledge become more powerful and effective. Nowhere is this demonstrated more clearly than the emerging influence of South to South contact as a strategy to drive down price of AIDS drugs”. To date, AIDS has killed 18.8 million people around the world, including 3.8 million children, according to UNAIDS. Sub-Saharan Africa has been the hardest hit, with more than one-tenth of the adult population aged 15-49 in 16 countries infected with the virus. (full text)
ENTRE NOUS. 2000 Autumn; (47-48):9.In early 1997, an initiative was started in response to the challenge of coordinating and planning international adolescent health work. The first task adopted by the Interagency Group on Adolescent Health and Development was to clarify the respective roles of each of the organizations to advocate adolescent health and address the risk conditions that affect the health of young people. It is clear that comprehensible and sustainable social and economic conditions are decisive for the healthy development of children. In addition, since adolescent health has much to do with the overall contexts in which health can be produced, economic adjustments, which have caused social adjustments, have taken their toll on children and adolescents. A strategic and well-coordinated World Bank/UN International Children's Emergency Fund, UN Population Fund, and the WHO program, designed to increase social cohesion, economic security, and social safety, would have effects on the health of young people and on positive economic and social development as a whole. Thus, individual players of the international health, economic and social development community should broaden their outlook and increasingly coordinate their activities.
Ensuring the reproductive rights of refugees and internally displaced persons: legal and policy issues.
International Family Planning Perspectives. 2000 Dec; 26(4):167-73.More than 26 million refugees, asylum-seekers and internally displaced persons (IDPs) are registered worldwide with the UN agencies, while millions still remain uncounted. In addition, girls and women make up about 50% of refugee and internally displaced populations, although the gender composition of refugee groups varies between regions and countries. These women and girls were at high risk of rape, unwanted pregnancies, unsafe delivery, and sexually transmitted diseases. This article examines the international legal framework for the reproductive rights of refugees and IDPs, as well as some aspects of UN and nongovernmental organization policies relevant to refugees' reproductive health. Three interrelated fields of international law come to bear on a discussion of the reproductive rights of refugees and IDPs: general international human rights law; refugee and humanitarian laws. These laws protect the rights of women against violence and all forms of discrimination. While international law requires countries that have ratified the relevant treaties to provide refugees and IDPs with sexual and reproductive health services, in practice UN agencies and nongovernmental organizations usually have to help provide these services.
Lancet. 2006 Jul 15; 368(9531):187-188.With global health likely to be high on the agenda of this year's G8 Summit, starting today in St Petersburg, Russia, it is worth taking stock of international assistance funding trends and prospects. High-level attention to global health has risen markedly over the past two decades, particularly since 2000. One concrete measure of the priority placed on health by donors is the level of funding provided for the developing world. Previous analyses have shown that funding has been on the rise. Our analysis of data from 2000 to 2004 found a continuation of this trend, with donor funding for global health approaching US$14 billion in 2004--in part good news, as donors seem to have heeded the global health call. Still, funding for health falls far short of global need, as estimated, in part, by the WHO Commission on Macroeconomics and Health, which found that donors would need to provide an additional $22 billion a year by 2007 and $31 billion a year by 2015 to help finance the scaling-up of essential interventions, health-system development, and research and development devoted to the diseases of the poor. In addition, investments in health seem to be uneven, raising cautionary notes about the global community's ability to meet, let alone sustain, financing needs over time. (excerpt)
Lancet. 2006 Jul 22; 368(9532):323-332.Rotavirus is the most common cause of severe diarrhoea in children worldwide and diarrhoeal deaths in children in developing countries. Accelerated development and introduction of rotavirus vaccines into global immunisation programmes has been a high priority for many international agencies, including WHO and the Global Alliance for Vaccines and Immunizations. Vaccines have been developed that could prevent the enormous morbidity and mortality from rotavirus and their effect should be measurable within 2--3 years. Two live oral rotavirus vaccines have been licensed in many countries; one is derived from an attenuated human strain of rotavirus and the other combines five bovine-human reassortant strains. Each vaccine has proven highly effective in preventing severe rotavirus diarrhoea in children and safe from the possible complication of intussusception. In developed countries, these vaccines could substantially reduce the number and associated costs of child hospitalisations and clinical visits for acute diarrhoea. In developing countries, they could reduce deaths from diarrhoea and improve child survival through programmes for childhood immunisations and diarrhoeal disease control. Although many scientific, programmatic, and financial challenges face the global use of rotavirus vaccines, these vaccines--and new candidates in the pipeline--hold promise to make an immediate and measurable effect to improve child health and survival from this common burden affecting all children. (author's)
[Unpublished] 2000. 15 p.International conferences on various topics are considered to be a good means of sharing information and allowing delegates to exchange experiences. For this reason, global and regional conferences on HIV/AIDS have been organized since early on in the epidemic. This paper examines the role of the international AIDS conferences on extending information exchange beyond the session halls. An overall conclusion of the impact of the work is that the conference preparatory discussion and session coverage conferences adds value to face-to-face meetings by making them accessible to people unable to attend in person, and by generating a collective memory of discussions, declarations and conclusions. It is noted that when considering International AIDS Conferences specifically, coordinating concurrent virtual conferences is not only important but also necessary to creating truly global discussions. Hence, such conferences should extend the dialogue, make an impact on national agendas and ensure that weeklong meetings develop into more specific collections. Several general lessons drawn from the experience of working with global and regional conferences that should also be seen as recommendations to future conferences are cited.
FPAN NEWSLETTER. 2000 May-Aug; 20(3-4):7-8.On World Population Day, the Ministry of Population and Environment awarded a cash prize of Rupees 50,000 and a certificate to the Family Planning Association of Nepal (FPAN) for its outstanding work and contribution in the field of population and reproductive health. On the same event, FPAN also inaugurated a photo exhibit on “Reproductive Health and Sex Education”. A variety of photographs were collected from prominent photographers and contestants and were displayed for 3 days for public viewing. The function was attended by representatives from various international nongovernmental organizations/governmental organizations and government officials. Moreover, Mr. Sunil Kumar Bhandari, past president of FPAN also received a certificate of appreciation for his dedicated work and contribution to the population program. It is emphasized that receiving two awards on the occasion of the World Population Day has been a great honor and recognition of FPANs work by the Government.
The United Kingdom. Policies, programs, and financing since the International Conference on Population and Development.
In: Promoting reproductive health: investing in health for development, edited by Shepard Forman and Romita Ghosh. Boulder, Colorado, Lynne Rienner Publishers, 2000. 221-49. (Center on International Cooperation Studies in Multilateralism)This paper describes the actions taken by the UK government in response to the important sphere of international development. Organized into four main sections, this paper begins by outlining the approach and analytic framework employed in undertaking the study. Subsequent sections discuss: 1) the official policies and strategies in the field of reproductive health; 2) the performance of the government in the implementation of reproductive health policies aimed at meeting the International Conference on Population and Development targets; and 3) the trends in reproductive expenditures and resources. There is no universally recognized or widely used evaluation framework for assessing international policy evolution, program performance, and trends in resource allocation that directly meets the needs of this study. Accordingly, the approach adopted in this paper has been drawn to and adapted a policy analysis technique developed for use on health-sector reform in developing countries. Outcome of this analysis suggests that the Department for International Development should consolidate its work on partnership building in the health sector through the clearer articulation of its current perspective on the roles and responsibilities, including obligations, and limits to power, of governments, civil society organizations, and the private sector.
In: Promoting reproductive health: investing in health for development, edited by Shepard Forman and Romita Ghosh. Boulder, Colorado, Lynne Rienner Publishers, 2000. 281-97. (Center on International Cooperation Studies in Multilateralism)Reproductive health and reproductive rights were the centerpiece of the historical agreement reached at the International Conference on Population and Development held in Cairo, Egypt in 1994. This agreement represent a dramatic policy shift away from target-oriented policies on population put into effect in many developing countries following the 1994 Bucharest conference on population. It further requires countries to reorient their policy objectives, redesign existing family planning program strategies, and find new, cost-effective approaches to service that include a strong health component. Many countries have used the ICPD Programme of Action as a guide in the development of reproductive health agenda and analysis of the outcome has provided several lessons. The major lesson was the need for additional funds for developing new service options and test delivery models and cost-sharing schemes that will facilitate the Cairo agenda. Also, donor support is critical for the development of reproductive health programs and for encouraging family planning organizations to incorporate new areas of care formerly excluded in their services, such as treating and preventing reproductive tract infections and sexually transmitted diseases. Moreover, results of case studies of developing countries suggest that a massive influx of external aid money, donor-driven agenda, and externally planned program strategies tend to overpower local policy decision making. Therefore, this concern poses an enormous challenge for economists, sociologists, health researchers, and operational researchers.