The latest snapshot on global health financing is in. Dr. Chris Murray and colleagues from The Institute for Health Metrics and Evaluation presented today the findings from IHME’s third annual report on global health financing, titled Financing Global Health 2011: Continued growth as MDG deadline approaches. Yes, the report states the well-known trend that global health financing has transitioned out of the “massive scale-up phase” (many arguing with huge consequences) and into a period of slower growth, similar to that seen during the 1990’s. But some of the latest tracking data shed light on some interesting trends, prompting many key questions.

• What’s the appropriate balance between government and non-governmental? – The 2011 IHME report just begins to scratch the surface of a critical choice having to be made by financers of global health – ‘should this sum of money be channeled through a national government or some non-governmental organization?’ With difficult trade-offs having to be made at the donor level, which route is going to provide the biggest return on investment, particularly with more calls to demonstrate the results generated from dollars spent? This question gains even more complexity when thinking about what gets funded, as Cristian Baeza, Director of the World Bank’s Health, Nutrition, and Population program, described at today’s event. With greater fiduciary oversight and a movement to link resources with results, Dr. Baeza expressed real concern about returning to practices of a decade ago, when donors “focused on commodities in the value chain, rather than systems.”

• Are developing countries stepping up? – Yes, the rate of growth for bilateral health funding is decreasing. Some are voluntarily backing away from previous commitments to the Global Fund. Others, like the US, are in a position where government spending cuts both scores political points in an election year, but are also a stark reality under the Budget Control Act of 2011. But, despite all of this, public investment in health continues to grow in many of the poorest regions around the world, namely East, Central, and West sub-Saharan Africa. In fact, government health expenditures as a source of financing nearly doubled in East sub-Saharan Africa between 2000 and 2009 ($1.69 billion to $3.26 billion). With continued calls for more country ownership, isn’t this the trend we should be most focused on improving? At the same time, however, “subadditionality” strongly persists, which shows funding intended for a Ministry of Health isn’t totally additional. Instead, the finance minster redirects intended MoH funding to another sector because of the incoming donor support for health. This naturally leads to another question of weighing health spending vs. non-health sector spending.

• Is health sector spending the more efficient and effective way to produce health? – UN member states gathered in Brazil late last year and declared their commitment to “take action on the social determinants of health.” Just a month earlier member states were in New York to agree on collective action to address the growing burden from non-communicable diseases, including through a “health in all policies” approach. So to achieve both aims, do we need to spend in health to produce health? As the question was rhetorically posed at today’s event, “If greater reductions for child mortality come from girls education, should we focus our increasingly constrained spending here?” Should we not prioritize funding for the things that produce the greatest health outcomes? Maybe, but in an era of “demonstrating results” and “returns on investment,” this becomes more complex trying to trace dollars and causality from one sector to another.

• What to do about shifts in the “bottom billion”? – Unfortunately, I didn’t hear anything on the issue today, but as Amanda Glassman and colleagues argued in a recent Center for Global Development working paper, our conceptualization of financing programs targeting the poorest and most vulnerable populations may require some re-conceptualizing. With donors often under stipulations regarding the types of countries they are able to give money to (this means middle-income countries, though they are now home to the largest population of poor people), will this at all influence preferred channels of assistance?

Dr. Murray and his colleagues continue to do great work providing a depiction of the increasingly complex network of actors and how global health dollars pass between them. Post your comments and let me know your thoughts on the emerging challenges in global health resource tracking.

This is a guest blog by Greg Paton, Policy Manager, NCD Alliance

This past December representatives from various UN agencies met in New York to discuss UN wide collaboration on Non-communicable Diseases (NCDs). The release of the meeting’s report last week drew little attention from the global health world. This is understandable given the gauntlet of NCD themed ministerial meetings, stakeholder dialogues and civil society hearings in 2011 which culminated with the High-Level Meeting (HLM) on NCDs and nearly 50 side events in New York last September.

The World Health Organization (WHO), tasked by member states to coordinate the UN wide response to NCDs, has large expectations to live up to. The responsibility of implementing the long list of actions set out in the HLM Political Declaration is made no easier by the fact that barely a handful of member states have pledged additional resources to strengthen WHOs NCD work. The organizations well publicized budget woes have forced the NCD Department to make difficult decisions amongst a backdrop of shrinking resources and the loss of key staff positions. Richard Horton, Editor of the Lancet, recently gave voice to the concerns whispered by many: ‘It will consult member states. Discussion papers will be written. Options Documents will be drafted…Unless the [WHO] Director-General makes NCDs a signature initiative; there is little likelihood that gains made at the UNGA will be sustained, let alone advanced”.

Declining budgets are not the only reason for concern. One of the biggest shortcomings in many countries response to NCDs has been the difficulty in getting non-health ministries to step up their efforts (and resources) for NCDs. The early days of the HIV/AIDS epidemic faced similar challenges – according to a UNAIDS publication detailing the history of the AIDS epidemic, UN staff in the early 1990s “tried hard to take a multisectoral stance but, as part of WHO, they inevitably had to work with ministries of health that were wary that multisectoralism would take power and money away from them. The concept of multisectoralism was accepted by countries but rarely put into operation.” The HIV/AIDS community has made great strides since then, driven by the establishment of UNAIDS to lead the international response and the Three Ones Principle (one HIV/AIDS plan, one coordinating board and one M&E system) to lead the national response. Major progress in the fight against NCDs will require replicating the success of the AIDS community in bringing a diverse group of partners to the table, including UN agencies, government ministries, civil society, people living with NCDs and the private sector.

This is why December’s meeting of UN agencies, if properly followed up, will come to be regarded as a key turning point in the global fight against NCDs. It could set off a chain of actions second in importance only to the HLM itself. It was a similar process initiated by UN agencies in 1989 that paved the way for an effective UN wide response to the HIV/AIDS epidemic. According to the UNAIDS publication, this process was a key factor in greater cooperation and multisectoralism on HIV/AIDS at national level.

It is therefore critical that both member states and civil society have a strong stake in the follow-up to this meeting and that UN agencies show leadership in turning the promises made on paper into action. The agencies that did not attend should be reminded of their commitment to act, as set out in the HLM Political Declaration. Many of the meetings outputs could be of major significance to the global NCD response. Highlights include:

1. Integration of NCDs into National UN Frameworks:  UN agencies committed to a joint initiative headed by the UNDP and WHO to formalize integration of NCDs into UN Development Assistance Frameworks (UNDAF). This would start with the 20+ countries scheduled to launch new frameworks in 2012-2013. These frameworks serve as national roadmaps for the work of UN country offices and are developed by recipient governments based on national priorities. They are often backed by major resources – in November the UN announced funding of $375.7 million for the Philippines UNDAF.  This would be supported by training and additional technical assistance for UN country teams to strengthen their capacity to implement NCD programmes.

2. Acknowledgement of the need for a UN wide roadmap for NCDs: Many organizations, including the NCD Alliance, agree that a new UN agency on NCDs would create further disease silos and is not the answer to addressing the NCD crises.  If done correctly, developed in consultation with key stakeholders, and backed with adequate resources, such a roadmap could have a major impact and provide a framework for scaled up responses at country level. It could also ensure that NCDs are included in the post 2015 MDG framework.

3. Increased integration of NCDs into UN agency programmes: All of the agencies in attendance committed to exploring the development of joint NCD projects and each agency shared a list of possible project areas. This has major resource implications if UN agencies integrate NCDs into their planning processes and programs. The UNDP alone has an annual budget of over $6 billion dollars, as does the World Food Programme. The core UN budget, which doesn’t factor in most of the agencies who attended the meeting, is over $13 billion dollars annually. Even if no new money is pledged, mainstreaming NCD interventions into the projects those funds currently support could have a major impact.

4. A network to coordinate the UN response to NCDs:  Participants agreed to establish an informal network to coordinate NCD activities among UN agencies. Several years ago, NCDs were rarely recognized as a development issue in mainstream global health circles. Many donor organizations still mistakenly believe that the causes and impact of NCDs have little bearing on poverty. This informal network is therefore an important first step in changing this. The WHO was requested to send a letter to all UN agencies at the meeting outlining details for this collaborative arrangement. Participants also agreed that following an initial period, ‘it may be opportune to formalize arrangements in the establishment of an UN Ad‐Hoc Coordination Mechanism on NCDs’. This is the first time UN agencies have suggested the possibility of a formal cooperation mechanism on NCDs. Civil society and NCD advocates should monitor this closely and ensure that such a mechanism would have inclusive representation.

By bringing together UN agencies to help define the post HLM landscape, WHO has shown strategic leadership and initiated an important first step in what has the potential to be a game changer in the future fight against NCDs. Whether the potential will be reached is a question of debate, but if the AIDS experience is anything to go by, a UN wide plan of action with buy-in and ownership from key UN agencies will be an essential factor.

Tuesday, Jan 10, 12:30-2:00pm

Quality TB Care: Using Smartphone Technology for Data-driven Improvements in Nigeria

Using Smartphones to collect TB data has eliminated use of printed forms, minimized human error in data entry, reduced the lag time of availability of data for policymakers and managers,and helped pinpoint ways to improve delivery of care.

Presenter: Leah Ekbladh

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“What’s happening to Development Assistance for Health as the MDG deadline approaches?”

Thursday, January 19, 2012 from 10:30 to noon

Global Health Council

1111 19^th St. NW Washington, DC 20036

Featuring Dr. Christopher Murray of the Institute for Health Metrics and Evaluation

The speakers will analyze current trends in public and private financing of health programs worldwide and discuss findings from IHME’s just published policy report “Financing Global Health 2011: Continued Growth as MDG Deadline Approaches.” This rare gathering of accomplished health financing experts will explore:

• How the economic slowdown is influencing the rate of growth in DAH
• Which channels of assistance are increasing health spending and which are cutting back
• Whether funding for specific health focus areas — such as HIV/AIDS, non-communicable diseases, and maternal, newborn, and child health – are thriving or faltering
• How the distribution of DAH across countries corresponds with disease burden
• How developing country governments respond with their own health funding to increases and decreases in DAH

Speakers:

• Dr. Christopher J.L. Murray, Director, Institute for Health Metrics and Evaluation, University of Washington
• Dr. Michael Hanlon, Senior Lecturer, Institute for Health Metrics and Evaluation, University of Washington
• Dr. Cristian Baeza, Director of Health, Nutrition, and Population, World Bank

Please join us for this timely and important discussion about the shifts in development assistance for health and how this may affect progress to reach the MDG targets as the 2015 deadline draws near.

Due to an overwhelming response for this event, RSVPs are now closed. Please consider participating in this event via webinar at  https://www3.gotomeeting.com/register/993008086

“What are the two things that you will find in the most remote areas of the world?” Pernessa C. Seele, Founder and CEO of The Balm in Gilead, asked the audience of the event, Women, HIV and the Faith Community: Bringing the Voices of African Women to Washington, DC. The audience was quizzically silent for a moment before Seele responded, “A bottle of Coca-Cola and a Church.”

Sponsored by the Center for Health and Gender Equity (CHANGE), UNAIDS, International Community of Women Living with HIV/AIDS (ICW Global), and The Balm in Gilead, the event featured women religious leaders from Kenya, Tanzania and Zimbabwe who are leading HIV programs in faith-based communities across Africa. Faith-based organizations (FBO) and local religious communities play a critical role in the fight against HIV/AIDS; in fact, the World Health Organization estimates that faith-based groups provide between 30 percent and 70 percent of all health care in Africa. FBOs build and run hospitals and clinics, train and employ health care workers, provide care and support for orphans and vulnerable children, and educate their congregations and communities. They are also major funders of global health, tapping into faith-based networks across the world for donations.

Despite this, many international health groups are reluctant to work with FBOs. Due to religious beliefs, FBOs may not support some interventions endorsed by the broader public health community. Public positions and statements from prominent members of the faith community can, in some cases, increase stigma or discrimination. Public debates within the faith-based community on condoms and family planning have highlighted these tensions. Such issues can create mistrust between FBOs and other groups, leading to unwillingness to work with FBOs despite their valuable contributions to health.

However, by refusing to work with FBOs, the panel argued, the global health community is ignoring an important ally in the fight against HIV/AIDS. FBOs are not monolithic in nature, and panelists urged global health practitioners not to be so quick to make assumptions about FBOs and religious communities. Even if specific FBOs or religious communities are unwilling to endorse certain health interventions, they can provide other useful services that should not be ignored. Partnerships within and outside of the faith-based community are key to providing the full range of services all individuals need to stay healthy.

Panelists at the event described their experiences working with FBOs. Some of their experiences were positive, others negative, but all the panelists agreed that FBOs have a significant and important role to play in ending the HIV/AIDS epidemic. FBOs represent one of the most sustainable ways to provide HIV services; they have existed in communities long before the epidemic started, and will continue to exist long after it has ended. In order to fully capitalize on the services FBOs provide, it is important to build strong, thoughtful, communicative, mutually respectful partnerships to provide all individuals with a full range of services for a healthy life.

In 2012, Globalization and Health will publish a new special issue “Climate Change and Global Health: Implications for Human Health and Health Systems.” This new issue will explore the ability of health systems to respond to potential disasters linked to climate change.

Climate change contributes to extreme weather conditions and significant changes in precipitation, which in turn affect air and water quality, agriculture and food production, housing security, and disease vectors. Since the 1970s, global warming will have caused an additional 140,000 deaths per year by 2004.

• Extreme heat contributes to cardiovascular and respiratory disease, and increased ground level carbon concentrations may exacerbate allergies.
• Increased precipitation can cause major flooding and drowning deaths, and may also affect the water supply and result in the spread of water-borne diseases.
• Increased water scarcity, especially in regions with already diminished water supplies, may result in droughts, increased civil conflict, and greater migration.
• The length of diseases transmission seasons and geographic range of disease vectors will likely change in response to changing temperatures, particularly affecting water-borne diseases.

In response to the growing challenges climate change will pose to health, “Climate Change and Global Health Implications for Human Health and Health Systems” will address the following issues:

• Health policy and financing mechanisms that will encourage public action and adaption strategies for health systems;
• Assessments of the ability of public policy and institutions to respond to climate change and human health;
• Merging the economics of climate adaptation and traditional health economics;
• How to mitigate asymmetrical effects of climate change on the global population;
• Interdisciplinary education and research.

 Globalization and Health will be accepting submissions for the special issue until January 13^th, 2012. Manuscripts may include research papers, reviews, policy analyses, short reports, commentaries, or debates. For any more questions, please contact the journal’s editorial team at  globalizationandhealth@lse.ac.uk.

This is a guest blog by Erin Fry, Government Affairs Officer of PATH.

The United Nations Environment Programme (UNEP) is supporting the development of a treaty on mercury which may include language that impacts access to vaccines in poor countries.

Thiomersal (which also goes by the name thimerosal) is a key preservative that contains small amounts of ethylmercury and is used in most multi-dose vaccines to prevent bacterial and fungal growth in vaccine vials. It can be found in vaccines for major killers of infants and children like tetanus and pertussis, as well as hepatitis B, rabies, influenza, and meningococcal diseases.

Although data from many studies show no convincing evidence of harm caused by the low doses of thiomersal in vaccines, the UNEP International Negotiating Committee (INC) has added pharmaceutical products, including vaccines, to a draft list of mercury-added products to be banned in its most recent draft.

Over the past ten years, reputable scientific bodies have evaluated the safety of thiomersal. The World Health Organization’s (WHO) Global Advisory Committee on Vaccine Safety concludes that existing thiomersal-containing vaccines are safe and that any risks are unproven. Similar conclusions have been drawn by the US Institute of Medicine, the American Academy of Pediatrics, the UK Committee on Safety of Medicines, and the European Medicines Agency.

The implications of restricting the manufacture, distribution, or use of thiomersal could significantly limit access to several lifesaving vaccines in poor countries. According to WHO, making vaccines thiomersal-free would require using either:

• an alternative preservative (which would require costly and time-consuming clinical studies, thereby driving up the cost of the vaccines); or
• preservative-free single-dose vaccines exclusively (which would considerably increase costs and require twice the storage and transport capacity, an impossibility for most countries).

Neither of these scenarios is desirable, particularly given that there is no evidence to suggest that removing thiomersal from vaccines would result in a positive health impact.

The treaty is under the auspices of environmental entities, and the global health community is just beginning to engage. Civil society organizations are invited to formally submit comments to the UNEP; however, the majority of health-related comments submitted to date reflect inaccurate scientific information and suggest that thiomersal should not be used in vaccines.

It is critical that the global health community’s voice be heard in the upcoming negotiations and that access to life-saving vaccines not be limited by misinformation about thiomersal. Please contact Erin Fry at efry@path.org if you would like to get involved.

This is a guest blog by Leonard Rubenstein, senior scholar at  the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health

The international media attention to repression in response “Arab Spring,” included reports of  and expressions of outrage about attacks by Bahrain’s security forces on health workers, obstruction of hospital access and arrest and prosecution of doctors and nurses.   The attention was atypical, as assaults on hospitals, medical personnel, ambulances and patients during armed and civil conflict usually pass without notice or protest.

An analysis by the International Committee of the Red Cross in 16 countries released on August 10 in conjunction with its new campaign, Health Care in Danger, revealed 655 violent events against health care, including kidnapping, killing, and wounding health care workers, over just two a half years.   Few of these attacks elicited a response from the medical, human rights, or the global health community.  Indeed, systematic reporting of incidents, sustained inquiry into the medium and long-term impacts of attacks on health care on health infrastructure and health worker migration, prevention and accountability strategies, are also absent.  To be sure, assaults on humanitarian workers have stimulated attention to their vulnerability and the need for better security, but local health providers, emergency personnel and facilities, which are most frequently targeted, are all but ignored.

Yet the lassitude may be ending, with new initiatives by the International Committee of the Red Cross, the US State Department, the World Health Organization and the UN Security Council to advance documentation and reporting of violations, development of prevention strategies, accountability, and mobilization of political will.

The first child in Sudan to be vaccinated against rotavirus drew a big crowd at Samir Health Center.

This is a guest blog by Dr. Amani Abdelmoniem Mustafa, manager of the Expanded Programme on Immunization for Sudan.

KHARTOUM, Sudan — The day that we were waiting for arrived. The children of Sudan have long suffered terrible, sometimes deadly, diarrhea caused by rotavirus. Fortunately, there is a vaccine that can save our children from so much suffering. After years of waiting, it was finally delivered to Sudan.

The first stop was the Khartoum International Airport. It was a great event.

The Martinair flight landed at 7:45 at night. The media with their cameras huddled in the non-permitted area where the flights land. They were accompanied by cars with generators to light up the runway. Those of us on Sudan’s Expanded Programme on Immunization (EPI) team crowded into the packed VIP hall. We had the challenging and exciting job of making sure this new vaccine travels the length and breadth of the country to reach all the children. At that moment, we wanted to be as close as possible to watch the vaccine coming to Sudan.

“It’s about addressing the professional isolation of rural practice and greasing the wheels of the machine so that ultimately rural doctors are happier and can get on with what they’re trained to do in an environment that works for them.” – Dr. Tim Wilson 

This is a guest blog by Lindsay Harris, Jeanette Strydom and Kate Thiers of Africa Health Placements, a member organization of the Global Health Council based in South Africa.

JOHANNESBURG, South Africa — In Europe, rural health workers enjoy a high status in their own communities but a low one among their peers, according to the European Charter for Rural Practice. This is related to isolation, limited resources and a high workload.

In Australia, “recruitment and retention in rural areas may be improved in the future through strategies to reduce perceived professional isolation, improve management support, access to continuing education and the development of career pathways,” according to the Department of Rural Health at the Australian University of North South Wales.

This trend is also evident in the rural public health sector in South Africa, which is facing huge challenges in the recruitment and retention of medical officers. The South African Department of Health (1998) has noted the difficulties in attracting and retaining doctors in rural communities because of professional isolation from their peers, lack of continued medical opportunities, low patient volume and loss of continuity when patients are referred to hospitals in larger urban centers.