Flavia Bustreo

Global Surveillance for Antituberculosis-Drug Resistance, 1994–1997

BACKGROUND Drug-resistant tuberculosis threatens efforts to control the disease. This report describes the prevalence of resistance to four first-line drugs in 35 countries participating in the World Health Organization-International Union against Tuberculosis and Lung Disease Global Project on Anti-Tuberculosis Drug Resistance Surveillance between 1994 and 1997. METHODS The data are from cross-sectional surveys and surveillance reports. Participating countries followed guidelines to ensure the use of representative samples, accurate histories of treatment, standardized laboratory methods, and common definitions. A network of reference laboratories provided quality assurance. The median number of patients studied in each country or region was 555 (range, 59 to 14,344). RESULTS Among patients with no prior treatment, a median of 9.9 percent of Mycobacterium tuberculosis strains were resistant to at least one drug (range, 2 to 41 percent); resistance to isoniazid (7.3 percent) or streptomycin (6.5 percent) was more common than resistance to rifampin (1.8 percent) or ethambutol (1.0 percent). The prevalence of primary multidrug resistance was 1.4 percent (range, 0 to 14.4 percent). Among patients with histories of treatment for one month or more [corrected], the prevalence of resistance to any of the four drugs was 36.0 percent (range, 5.3 to 100 percent), and the prevalence of multidrug resistance was 13 percent (range, 0 to 54 percent). The overall prevalences were 12.6 percent for resistance to any of the four drugs [corrected] (range, 2.3 to 42.4 percent) and 2.2 percent for multidrug resistance (range, 0 to 22.1 percent). Particularly high prevalences of multidrug resistance were found in the former Soviet Union, Asia, the Dominican Republic, and Argentina. CONCLUSIONS Resistance to antituberculosis drugs was found in all 35 countries and regions surveyed, suggesting that it is a global problem.

Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival

The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage of priority interventions to achieve the Millennium Development Goals (MDGs) for child mortality and maternal health. We reviewed progress between 1990 and 2010 in coverage of 26 key interventions in 68 Countdown priority countries accounting for more than 90% of maternal and child deaths worldwide. 19 countries studied were on track to meet MDG 4, in 47 we noted acceleration in the yearly rate of reduction in mortality of children younger than 5 years, and in 12 countries progress had decelerated since 2000. Progress towards reduction of neonatal deaths has been slow, and maternal mortality remains high in most Countdown countries, with little evidence of progress. Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced longstanding inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems. Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007. We provide evidence from several countries showing that rapid progress is possible and that focused and targeted interventions can reduce inequities related to socioeconomic status and sex. However, much more can and should be done to address maternal and newborn health and improve coverage of interventions related to family planning, care around childbirth, and case management of childhood illnesses.

Global health 2035: a world converging within a generation

Prompted by the 20th anniversary of the 1993 World Development Report a Lancet Commission revisited the case for investment in health and developed a new investment frame work to achieve dramatic health gains by 2035. The report has four key messages each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. Conclusion 1: there is a very large payoff from investing in health. Conclusion 2: a grand convergence is achievable within our lifetime. Conclusion 3: scale-up of low-cost packages of interventions can enable major progress in NCDs and injuries within a generation. Conclusion 4: progressive universalism is an effi cient way to achieve health and fi nancial protection.

Improvement of child survival in Mexico: the diagonal approach

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Quality of care for pregnant women and newborns—the WHO vision

In 2015, as we review progress towards Millennium Development Goals (MDGs), despite significant progress in reduction of mortality, we still have unacceptably high numbers of maternal and newborn deaths globally. Efforts over the past decade to reduce adverse outcomes for pregnant women and newborns have been directed at increasing skilled birth attendance.1, 2 This has resulted in higher rates of births in health facilities in all regions.3 The proportion of deliveries reportedly attended by skilled health personnel in developing countries rose from 56% in 1990 to 68% in 2012.4 With increasing utilisation of health services, a higher proportion of avoidable maternal and perinatal mortality and morbidity have moved to health facilities. In this context, poor quality of care (QoC) in many facilities becomes a paramount roadblock in our quest to end preventable mortality and morbidity.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework

A new Global Investment Framework for Womens and Childrens Health demonstrates how investment in womens and childrens health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just

Recent Trends in Maternal, Newborn, and Child Health in Brazil: Progress Toward Millennium Development Goals 4 and 5

5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of

Success factors for reducing maternal and child mortality

30 billion per year, equivalent to a 2% increase above current spending.

Towards a new global strategy for women's, children's and adolescents' health

We analyzed Brazils efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazils successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries.

Tackling health inequities in Chile: maternal newborn infant and child mortality between 1990 and 2004.

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Womens and Childrens Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in womens and childrens health towards 2015 and beyond.