Karen A Grépin

HIV Donor Funding Has Both Boosted And Curbed The Delivery Of Different Non-HIV Health Services In Sub-Saharan Africa

Donor funding for HIV programs has increased rapidly over the past decade, raising questions about whether other health services in recipient-country health systems are being crowded out or strengthened. This article--an investigation of the impacts of increased HIV donor funding on non-HIV health services in sub-Saharan Africa during 2003-10--provides evidence of both effects. HIV aid in some countries has crowded out the delivery of childhood immunizations, especially in countries with the lowest density of health care providers. At the same time, HIV aid may have positively affected some maternal health services, such as prenatal blood testing. These mixed results suggest that donors should be more attentive to domestic resource constraints, such as limited numbers of health workers; should integrate more fully with existing health systems; and should address these constraints up front to limit possible negative effects on the delivery of other health services.

Maternal education and child mortality in Zimbabwe

In 1980, Zimbabwe rapidly expanded access to secondary schools, providing a natural experiment to estimate the impact of increased maternal secondary education on child mortality. Exploiting age specific exposure to these reforms, we find that children born to mothers most likely to have benefited from the policies were about 21% less likely to die than children born to slightly older mothers. We also find that increased education leads to delayed age at marriage, sexual debut, and first birth and that increased education leads to better economic opportunities for women. We find little evidence supporting other channels through which increased education might affect child mortality. Expanding access to secondary schools may greatly accelerate declines in child mortality in the developing world today.

How to do (or not to do) ... Tracking data on development assistance for health

Development assistance for health (DAH) has increased substantially in recent years and is seen as important to the improvement of health and health systems in developing countries. As a result, there has been increasing interest in tracking and understanding these resource flows from the global health community. A number of datasets, each with its own strengths and weaknesses, are available to track DAH. In this article we review the available datasets on DAH and summarize the strengths and weaknesses of each of these datasets to help researchers make the best choice of which to use to inform their analysis. Finally, we also provide recommendations about how each of these datasets could be improved.

International donations to the Ebola virus outbreak: too little, too late?

Karen Grépin examines the pledges made to the Ebola crisis, how much has actually reached affected countries, and the lessons to be learnt

Efficiency considerations of donor fatigue, universal access to ARTs and health systems

Objectives To investigate trends in official development assistance for health, HIV and non-HIV activities over time and to discuss the efficiency implications of these trends in the context of achieving universal access to treatment and health systems. Methods Official development assistance for health, HIV programmes and non-HIV programmes were tracked using data from 2000 to 2009. A review of the literature on efficiency, treatment and health systems was conducted. Findings The rate of growth of donor funding to HIV programmes has slowed in recent years at levels below those required to sustain programmes and to move towards universal access to treatment. These trends are likely due to increased pressure on foreign aid budgets and donor fatigue for HIV programmes. Conclusions There is great need to consider how the limited resources available can be used most efficiently to increase the number of lives saved and to ensure that these resources also benefit health systems. Improving efficiency is much more than just improving the productive efficiency and also about ensuring that resources are going to where they will be the most beneficial and making investments that are the most efficient over time. These choices may be essential to achieving the goal of universal access to treatment as well as the sustainability of these programmes.

Ebola virus disease in West Africa - The first 9 months: To the editor [2]

The n e w e ng l a n d j o u r na l of m e dic i n e c or r e sp ondence Ebola Virus Disease in West Africa — The First 9 Months To the Editor: The World Health Organization (WHO) Ebola Response Team (Oct. 16 issue) 1 predicted that the current Ebola epidemic would claim a dreadful 20,000 combined cases by early November 2014, assuming no change in the con- trol measures applied in West Africa. The threat that Ebola poses to national public health and social, economic, and security foundations may worsen if a secondary epidemic eventually ex- plodes in the region. Since June 2014, nearby Ghana has been affected by a serious cholera epidemic that was responsible for 12,622 cases as of September 6. 2 Current cholera and Ebola zones are separated by Ivory Coast, a frequent crossing point for commuters traversing West Africa. To effectively control cholera epidemics, specialized treatment centers, access to potable water, sani- tation, and community hygiene awareness are critical. However, in Ebola-affected areas, quaran- tine units are overwhelmed, many health facili- ties are dysfunctional after the desertion by staff members who fear viral contamination, and it has become increasingly dangerous to conduct awareness campaigns owing to violence against health and humanitarian workers accused of this week’s letters 188 Ebola Virus Disease in West Africa — The First 9 Months 189 Goal-Directed Resuscitation in Septic Shock 191 Malpractice Reform and Emergency Department Care 193 Physiological Approach to Acid–Base Disturbances 196 Inefficacy of Platelet Transfusion to Reverse Ticagrelor spreading Ebola. Likewise, neglecting to rapidly control this cholera epidemic in Ghana could have unpredictable yet potentially devastating consequences. Stanislas Rebaudet, M.D., Ph.D. Assistance Publique–Hopitaux de Marseille Marseille, France Sandra Moore, M.S., M.P.H. Renaud Piarroux, M.D., Ph.D. Aix–Marseille University Marseille, France renaud.piarroux@ap-hm.fr No potential conflict of interest relevant to this letter was re- ported. 1. WHO Ebola Response Team. Ebola virus disease in West Africa — the first 9 months of the epidemic and forward projec- tions. N Engl J Med 2014;371:1481-95. 2. Cholera outbreak in the West and Central Africa: regional update, 2014 (week 35). New York: UNICEF (http://www.unicef .org/cholera/files/Cholera_regional_update_W35_2014_West_ and_Central_Africa.pdf). DOI: 10.1056/NEJMc1413884 To the Editor: The WHO Ebola Response Team describes the epidemiology of Ebola virus dis- ease (EVD) in West Africa using anonymized pa- tient-level data generated from EVD surveillance in multiple countries. These data document the demographic profile of patients with EVD, their risk factors, and the course of their illness. We regret that the WHO neither makes this data set publicly available nor provides an interface to ex- tract customized tabulations. Such data sharing could accelerate the discovery of key factors in the epidemic and could yield insight into the eco- nomic and demographic drivers of the outbreak. It would also permit a better assessment of pos- sible control scenarios. Current models of EVD transmission 1,2 are parameterized with the use of outdated data from much smaller Central Afri- can outbreaks, which limits their applicability to West Africa. Some patient-level data sets collect- n engl j med 372;2 nejm.org january 8, 2015 The New England Journal of Medicine Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on January 11, 2015. For personal use only. No other uses without permission. Copyright

Tracking the flow of health aid from BRICS countries

At the same time, emerging economies such as Brazil, the Russian Federation, India, China and South Africa – the so-called BRICS – are playing increasingly important roles in global health, including being donors of international health aid. In 2010, these five countries had estimated foreign as -sistance budgets of 400–1200, 427, 680, 3900 and 143 million United States dol -lars, respectively.

Patterns of demand for non-Ebola health services during and after the Ebola outbreak: panel survey evidence from Monrovia, Liberia

Introduction The recent Ebola virus disease (EVD) outbreak was unprecedented in magnitude, duration and geographic scope. Hitherto there have been no population-based estimates of its impact on non-EVD health outcomes and health-seeking behaviour. Methods We use data from a population-based panel survey conducted in the late-crisis period and two postcrisis periods to track trends in (1) the prevalence of adult and child illness, (2) subsequent usage of health services and (3) the determinants thereof. Results The prevalence of child and adult illness remained relatively steady across all periods. Usage of health services for children and adults increased by 77% and 104%, respectively, between the late-crisis period and the postcrisis periods. In the late-crisis period, (1) socioeconomic factors weakly predict usage, (2) distrust in government strongly predicts usage, (3) direct exposure to the EVD outbreak, as measured by witnessing dead bodies or knowing Ebola victims, negatively predicts trust and usage and (4) exposure to government-organised community outreach predicts higher trust and usage. These patterns do not obtain in the post-crisis period. Interpretation Supply-side and socioeconomic factors are insufficient to account for lower health-seeking behaviour during the crisis. Rather, it appears that distrust and negative EVD-related experiences reduced demand during the outbreak. The absence of these patterns outside the crisis period suggests that the rebound after the crisis reflects recovery of demand. Policymakers should anticipate the importance of demand-side factors, including fear and trust, on usage of health services during health crises.

China’s role as a global health donor in Africa: what can we learn from studying under reported resource flows?

BackgroundThere is a growing recognition of China’s role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China’s engagement as a donor with that of more traditional global health donors.MethodsUsing newly released data from AidData on China’s development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000–2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China’s activities to projects from traditional donors using data from the OECD’s Development Assistance Committee (DAC) Creditor Reporting System.ResultsSince 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China’s contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries.ConclusionsChina is an important global health donor to Africa but contrasts with traditional DAC donors through China’s focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China’s approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Maternal health: a missed opportunity for development

www.thelancet.com Vol 381 May 18, 2013 1691 Millennium Development Goal 5 sets the ambitious goal of a 75% reduction in maternal mortality worldwide by 2015. Although some progress has been made, the risks from childbearing remain unacceptably high: an estimated 287 000 maternal deaths occurred in 2010, almost all of which were in developing countries. Moreover, maternal deaths are just the tip of the iceberg—millions more women suff er adverse health consequences from childbirth. Although medical solutions do exist, increased government attention is needed to implement policies and programmes to improve the supply of, and demand for, services. Although part of the challenge has been the scarcity of resources—countries with the highest rates of maternal Maternal health: a missed opportunity for development fees for poor patients, and a colour-coding system was designed to streamline referrals. A woman given a red card, for example, could be referred to hospitals directly without going through the regular bureaucracy. Thanks to these eff orts, maternal mortality rates fell by a further 33% from 1960, and 75% of women were delivering in hospitals. Furthermore, most home deliveries were attended by skilled health workers. The world began to take note of Malaysia’s success. Offi cials were invited to share experiences with Safe Motherhood programmes at international meetings, and the country was fl agged as an example for others to follow. Malaysia was able to change its national state of maternal health by expanding access to deliveries attended by trained skilled personnel; providing mothers with necessary medicines, equipment, and support; and ensuring the availability of emergency obstetric care at district hospitals. Attention has recently focused on several challenges that remain—namely, barriers to contraception access. In 2003, the Ministry of Women, Family and Community Development developed Nur Well-Being clinics across the country to expand access to family planning. More than 4000 family planning facilities now operate throughout Malaysia. Malaysia has recently made eff orts to reduce maternal deaths by allowing abortion if delivery would endanger the woman’s physical or mental health. In September, 2012, a termination of pregnancy guideline document was developed by the Ministry of Health and distributed to affi liated hospitals. The government has expanded training for healthcare providers to ensure skilled care for all patients. For the past 2 years, the Ministry of Health has operated a government-funded obstetric life-saving skills course and an advanced diploma in midwifery programme. The Ministry of Health has also increased the training of subspecialists in maternal, newborn, and reproductive health. One remaining obstacle for the Ministry of Health has been to serve diffi cult-to-reach populations. In 2001, the Malaysian Government implemented the National Adolescent Health Policy, which aims to promote adolescent health by providing the knowledge and skills needed to practise healthy behaviours. Through the Ministry of Women Family and Community Development, the Kafé@TEEN centre in Kuala Lumpur was opened to provide reproductive health information and services in a youth-friendly manner. Investment in young people is an investment in the future of Malaysia. Looking forward, there is much to learn from our rich history in maternal and reproductive health. However, our work is far from over. Now is the time to share new ideas, innovations, and technologies so that we can close every gap between the needs of mothers and the care they deserve. Malaysia is proof of the benefi ts that accrue when we prioritise the health of girls and women.