Jim Yong Kim

Programmes and principles in treatment of multidrug-resistant tuberculosis

Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB treatment, which consists entirely of retrospective cohort studies. Although direct comparisons of these studies are impossible, some insights can be gained: MDR-TB can and should be addressed therapeutically in resource-poor settings; starting of treatment early is crucial; aggressive treatment regimens and high-end dosing are recommended given the lower potency of second-line antituberculosis drugs; and strategies to improve treatment adherence, such as directly observed therapy, should be used. Opportunities to treat MDR-TB in developing countries are now possible through the Global Fund to Fight AIDS, TB, and Malaria, and the Green Light Committee for Access to Second-line Anti-tuberculosis Drugs. As treatment of MDR-TB becomes increasingly available in resource-poor areas, where it is needed most, further clinical and operational research is urgently needed to guide clinicians in the management of this disease.

Redefining global health-care delivery

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Children affected by HIV/AIDS: SAFE, a model for promoting their security, health, and development

A human security framework posits that individuals are the focus of strategies that protect the safety and integrity of people by proactively promoting childrens well being, placing particular emphasis on prevention efforts and health promotion. This article applies this framework to a rights-based approach in order to examine the health and human rights of children affected by HIV/AIDS. The SAFE model describes sources of insecurity faced by children across four fundamental dimensions of child well-being and the survival strategies that children and families may employ in response. The SAFE model includes: Safety/protection; Access to health care and basic physiological needs; Family/connection to others; and Education/livelihoods. We argue that it is critical to examine the situation of children through an integrated lens that effectively looks at human security and childrens rights through a holistic approach to treatment and care rather than artificially limiting our scope of work to survival-oriented interventions for children affected by HIV/AIDS. Interventions targeted narrowly at children, in isolation of their social and communal environment as outlined in the SAFE model, may in fact undermine protective resources in operation in families and communities and present additional threats to childrens basic security. An integrated approach to the basic security and care of children has implications for the prospects of millions of children directly infected or indirectly affected by HIV/AIDS around the world. The survival strategies that young people and their families engage in must be recognized as a roadmap for improving their protection and promoting healthy development. Although applied to children affected by HIV/AIDS in the present analysis, the SAFE model has implications for guiding the care and protection of children and families facing adversity due to an array of circumstances from armed conflict and displacement to situations of extreme poverty.

The Global Financing Facility: country investments for every woman, adolescent, and child.

On July 13–16, 2015, leaders from around the globe will meet in Addis Ababa, Ethiopia, for the Third International Financing for Development Conference. The promise of this conference is in both fi nding new resources for development and doing development diff erently. We are setting a course of bold action for sustainable results to achieve a world in which every woman, child, and adolescent thrives and realises her full potential. The launch of the Global Financing Facility (GFF) at the conference in Addis Ababa will be an essential pillar to support this goal. Healthy women, children, and adolescents are the foundations of robust economies and resilient societies. They are our smartest investment. This is why the soon-to-be-completed UN Secretary General’s new Global Strategy for Every Woman Every Child will be an important part of the Sustainable Development Goals (SDGs) for 2030. The new Global Strategy for Every Woman Every Child builds on the momentum established by the Millennium Development Goals. More than 100 million children’s lives have been saved since 1990, and the risk of dying in pregnancy for mothers has almost been halved. Low-income countries such as Ethiopia have seen remarkable progress in reducing maternal and child mortality as a result of steadfast commitment of governments, an unprecedented level of global development assistance, and increased community empowerment. Despite this progress, there is no room for complacency. Today the under-5 child mortality rate in low-income countries is still more than 15 times higher than in high-income countries, and the maternal mortality rate is nearly 30 times higher. Eliminating these inequities requires universal access to quality essential health services for every woman, child, and adolescent. The good news is that the world has the knowledge, the means, and innovative capability to close this gap. For example, Ethiopia’s national deployment of community health workers has been a key driver of improved health outcomes in rural communities. At least three dozen countries, from Afghanistan to Zambia, are achieving improved health outcomes in child and maternal health with existing funds through the use of results-based fi nancing to expand delivery of essential interventions, such as family planning, antenatal care, skilled birth attendants, and childhood vaccinations. There is also evidence that investing in the health and education of women is vital to the survival and prosperity of their children. Building on this experience, the report of the Lancet Commission on Investing in Health forecast that a convergence in mortality of mothers and children between highincome and low-income countries is possible within a generation, with a potential economic return of between US

Is the “3 by 5” Initiative the Best Approach to Tackling the HIV Pandemic?

9 and

Improving Prevention of Mother-to-Child Transmission of HIV Care and Related Services in Eastern Rwanda

20 on every

Poverty, Health, and Societies of the Future

1 invested. The annual fi nancing shortfall of the 63 countries with the highest burdens of maternal and child mortality for these vital interventions currently stands at

Time for even greater ambition in global health

33 billion, or almost

Building Capacity for Multidrug-Resistant Tuberculosis Treatment: Health Systems Strengthening in Lesotho

10 per person. The GFF can help reduce this shortfall. A key fi nancing platform for the Global Strategy for Every Woman Every Child, the GFF is a country-led fi nancing partnership that aligns and unites resources from low-income countries, international donors, and the private sector to accelerate investments in the health of women and children. The GFF will provide fi nancing that incentivises stronger performance and demand, while also increasing effi ciency and improving measurement and accountability for results, for example with impact evaluations. For the Third International Financing for Development Conference see http://www.un. org/esa/ff d/ff d3/conference.html

The treatment of tuberculosis in South Korea.

Background to the debate: The World Health Organization (WHO) and its partners aim to treat 3 million people infected with HIV in poor and middle income countries with antiretroviral treatment by the end of 2005. The ambitious “3 by 5” initiative has had its supporters and its critics since its announcement in 2002.