Dear Colleagues,


Today MSF’s scientific day is being streamed online – but unfortunately, as we’re running late, the event might be over before you actually receive this newsletter. This week (May 5), we celebrated the International Day of the Midwife, and on Sunday, Mothers will get flowers and kisses all over the world; this week’s newsletter pays quite some attention to maternal (and child) health. We also selected some material on the upcoming World Health Assembly (agenda), and Botswana hosted yet another high-level health event, the 4th International Roundtable on China-Africa Health Cooperation. In Cape Town, a World Economic Forum on Africa meeting is taking place (with also some global health announcements – see #WEF).


Last week, our colleague Bruno Meessen, a health economist, held a lecture to celebrate the occasion of his appointment as professor at our institute. He gave a presentation on PBF – no surprises thereJ; Jean-Pierre Unger was the discussant. As you can imagine, the debate was lively, so we invited both gentlemen to summarize some of their points in a blog post. Jean-Pierre wrote this week’s guest editorial; no doubt Bruno will soon give his view too. Stay tuned.



Enjoy your reading.


Kristof Decoster, Ildikó Bokros, Peter Delobelle, Basile Keugoung & Wim Van Damme






PBF, a new episode in the war led by managed care on professionalism?


Jean-Pierre Unger (ITM)


PBF, ostensibly a motivating technique, consists of payment per service, in theory with a productivity goal. It is also said to be a technique to reform / restructure health care systems.


From a descriptive, political economy angle, PBF can be viewed as a simplified version of econometric methods applied to cost health care activities, which is needed to contract health care activities in the context of policies based on a purchaser-provider split. As such, it paves the way for the introduction of elaborated managed care techniques within public health services and care commoditization.


Importantly, Musgrove defined PBF as encompassing control of paid production. PBF sustainability is, however, everywhere an issue as middle- and even high-income countries are not capable of controlling the quantity of services provided and even less their quality. Here are some examples:


  • The HESVIC project (2009-2012) studied governance, regulation and control of maternal health activities in Vietnam, India and China. It concluded that of 9 such case studies, 8 revealed large-scale regulatory failure and only one showed relative success. But this last achievement was due to public control intertwined with central planning techniques;
  • Latin American countries with lengthy experience in health care commoditization ( e.g. Chile; Costa Rica ) failed to make their systems efficient i.e. because of weak regulation;
  • Costa Rica used a mild form of PBF: upon productivity assessment, its public health facilities received additional resources to improve care. Although relatively mild, these ‘management contracts’ seriously hampered access to and quality of acute care (W.Soors, P.De Paepe, JP Unger. Management Commitments and Primary Care: another Lesson from Costa Rica for the World? Int J Health Services, 2011, in press).
  • The mechanisms linking regulation failures and LMIC characteristics have been discussed at length elsewhere. In spite of possible positive projects in LIC and failed states, there are reasons to believe that PBF won’t be sustainable unless the international agenda is to make LIC health systems rely in the long-term on international aid: reproducibility of pilot projects in situations where development aid is not the dominant source of health system financing remains dubious.


Even in LIC, PBF may lack valid evidence. Apparent successes in Rwanda, for instance, can be explained by characteristics of the health system itself, e.g. a decently financed public system. The initial low income level of health workers probably also explains to some degree PBF effectiveness, as PBF helps to increase the revenue of care providers.


The key problem with PBF, however, concerns effectiveness and ethics. Indeed, PBF may work against care quality while distorting the professional identity of health workers and professionals (nurses, clinical officers, medical assistants and doctors) because it relies on the assumption that they are merely economic actors and contributes in fact to making them so in some kind of a self-fulfilling prophecy.


Instead of comparing PBF intervention groups with a control group, it would have made more sense to compare PBF groups with other ones that are subject to strategies designed to reinforce professionalism in health systems. Indeed, although professional skills and identity cannot be measured and as such are not easily taken into account by the economic and epidemiologic sciences, they are key conditions of care quality since good consultations entail


  • Complex decision making as in bio-psychosocial care, which is an issue of family medicine;
  • Ethos, with a praxis referring to a complex ethical system, which is a philosophical issue;
  • Acquiring manual and behavioral skills, a psycho-pedagogical issue;
  • Reflective methods in care delivery (such as audit, supervision, intervision, action research, etc), which involves medical knowledge.


Economists tend to gather all these care components under one (supposedly measurable) umbrella concept – responsiveness, see the WHO 2000 classification of countries’ performance – which reveals the knowledge limits of this science when it comes to care quality.


Besides a sociopolitical concern for equity, ethics, communication, skills, reflectivity and symbolic motivation of health professionals (a component of their intrinsic motivation) are all dimensions that should help structure health systems aiming to deliver individual health care.


Because experience with managed care techniques and disease control programs shows that they harm professional identity and the delivery of bio-psychosocial care, economic techniques such as capitation and PBF taken in isolation should not be permitted to structure health care systems. Rather, patients’ care trajectories, co-management and ethically inspired professionalism should.



World Health Assembly


1.     Health Diplomacy Monitor – Volume 4 Issue 3

This issue is a must-read, and not just because our colleague Gorik Ooms wrote a nice editorial together with Jon Lidén, “To Beat Climate Change Together, We Also Need to Improve Global Health Together “.


The articles in this issue consider the upcoming World Health Assembly, placing it in the context of change where issues such as climate change, the rise of noncommunicable diseases and an ever more complex and interconnected health governance landscape dominate. Delegates will tackle issues such as the rising burden of NCDs, reform of the World Health Organization, as well as a

discussion of the place of health in the post-2015 development agenda.”


Check out also GHD-NET org’s companion guide to the upcoming 66th World Health Assembly. Based on the Assembly’s provisional agenda, the WHA Companion highlights resources available on the GHD-NET website for use in preparation for the upcoming meeting scheduled May 20-28 in Geneva.



  • For the WHO’s WHA Media centre, see here.



  • MMI also has a wealth of resources (and updates) related to WHO reform and global health governance.


Check out for example the inputs from a ‘Democratising Global Health Coalition on the WHO reform’ (DGH) briefing, which took place on May 7  (with contributions from Nicoletta Dentico, Thomas Schwarz and Patti Rundall). DGH gathers a group of public interest NGOs and individuals committed to the realization of the right to health based on equity and universality, who highly value the constitutional mandate of the WHO for the realization of this right worldwide.


Thomas Schwarz also wrote the editorial in MMI’s May newsletter, ‘Global Health Democracy (starts at home)’, with a view on the upcoming WHA.


Maternal and child health


2.     Save the Children (report) – State of the World’s Mothers -2013

This report was all over the press. Sarah Boseley summarizes key messages in the Guardian.


3.     International Day of the Midwife – Statement for the International Day of the Midwife 2013

UNFPA & International confederation of Midwives;

A joint statement by the U.N. Population Fund (UNFPA) and the International Confederation of Midwives marked the International Day of the Midwife, observed on May 5.  “On this International Day of the Midwife, UNFPA, the United Nations Population Fund, and the International Confederation of Midwives (ICM), celebrate the work of midwives in contributing to the miracle of birth—and for the myriad other things they do every day to contribute to the wellbeing of mothers and children around the world. The tireless work of midwives is also a crucial step towards achieving the Millennium Development Goals (MDGs) 4 and 5, targets A and B, by 2015 and beyond.” The statement mentions a shortage of 350000 midwives.


4.     Plos – Measuring Coverage in MNCH: New Findings, New Strategies, and Recommendations for Action

Jennifer Bryce et al.;

PLOS published a new collection earlier this week, titled, “Measuring Coverage in Maternal, Newborn, and Child Health.” In a post (on the blog ‘Speaking of Medicine’), Jennifer Bryce, who assisted in preparing the collection, “explains why measuring coverage of maternal, newborn, and child health interventions matters and what we can learn from the new PLOS collection”.


You find the Plos collection here.


5.     Plos – Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes

Atif Rahman et al.;;jsessionid=373C9335F374038450BBAB5D21F7B1F9

In the second article of a five-part series providing a global perspective on integrating mental health, Atif Rahman and colleagues argue that integrating maternal mental health care will help advance maternal and child health.


6.     Humanosphere – Gates-backed vaccine alliance targets cervical cancer in poor countries – for a price |

Tom Paulson;

At this week’s World Economic Forum on Africa meeting in Cape Town, GAVI announced that two drug companies, Merck and GlaxoSmithKline, have agreed to provide their HPV vaccines to poor countries for $4.50 and $4.60, respectively, per dose. Paulson gives some background (including MSF criticism); Sarah Boseley does the same in the Guardian.


7.     Humanosphere – Bill Gates’ humanitarian plan for world (vaccination) domination

Tom Paulson;

Now that we’re in the middle of the ‘Decade of Vaccines’, this article gives a bit of the historical background. The Gates foundation has been a game changer in the global vaccination drive. As in the previous article on HPV vaccines, MSF criticism of GAVI is also discussed.


8.     Politico – Bill Gates, time traveler

Bill Gates went to Washington this week to promote his GPEI plan.  Gates appeared with former President Bill Clinton at a public forum and met with a number of Congressmen. Gates is “asking Washington to increase its annual commitment to an international polio fund from $100 million to $150 million. That’s a 50 percent increase — post the March sequester.”


9.     Guardian – Save the Children teams up with GlaxoSmithKline

Sarah Boseley;

The international charity Save the Children is embarking on a partnership with GSK in a controversial move which the two organisations say is designed to save a million children’s lives. “The initiative launched by the two organisations on Thursday in Kenya will see Save the Children with a seat on the R&D board, advising on new products for the poorest countries, while GSK also pays for the training of more healthcare workers who will dispense medicines and give vaccines.”


Roundtable on Africa-China health cooperation in Botswana


10. UNAIDS feature story – Leaders from China and Africa come together to strengthen partnership, cooperation and innovation

Leaders from China and Africa met in Gabarone, Botswana this week for the 4th International Roundtable on China-Africa Health Cooperation in order to strengthen collaboration in health development and share knowledge and technology. The two-day roundtable from 6-7 May was the first to be held in Africa.


Check out also coverage in Xinhua and on the CNN website;  in an opinion piece, Lucy Chen, executive deputy director of the Institute for Global Health at Peking University, examines the underlying reasons for China and Africa collaboration on health. It’s a win-win relationship, she argues, and for this reason she foresees even more collaboration in the future.



Global Fund update


A new GFO issue was published this week.


Among others, there’s an article on Pakistan which has become the first country to be awarded money under the new funding model; and Switzerland announced a large increase in its 2013 pledge to the GF: an increase of 43 %; now the figure is 10.6 million dollar. (still peanuts for hedge fund managers and tax havens … )


Health Policy & Financing


11. Lancet – The Rockefeller Foundation and the international health agenda

Anne-Emanuelle Birn et al.;

The Rockefeller Foundation exists a century. Birn gives an overview of its achievements and priorities in all these years.


12. CFR Global Governance report card – Global Public health

This report card grades the battle against NCDs, the fight against HIV/AIDS, developing health systems in poor countries, and much more.


It’s based on a CFR backgrounder (recommended reading by the way!).



13. CSIS – The Changing Landscape of Global Health Diplomacy

Katherine E. Bliss (editor);

A nice collection of analyses on the changing landscape of global health diplomacy (with chapters on China, EU, South-Korea, Japan, Russia, …) and opportunities for American diplomats and the Obama administration to cooperate and set up alliances.


14. CSIS – Japan’s global health diplomacy: developing a comprehensive approach in a period of economic stress

Katherine E. Bliss (editor)

The latest on the land of the rising sun, which, according to the authors of this note, needs to develop a comprehensive approach that acknowledges the new global health reality, and this in challenging economic times.

15. The Journal of Law, Medicine & Ethics – Special issue: Symposium: Global Health and the law

In the introductory article to this special issue, Colleen Flood & Trudo Lemmens give an overview of the papers resulting from a recent conference on Global Health Challenges and the Role of Law (in Toronto on May 4-5, 2012).  Participants were asked to explore the various ways in which law functions (or malfunctions) as a tool for reform in global health, and more broadly, the interactions between law and other mechanisms of global health governance. Check out for example the article by Bryan Thomas & Lawrence Gostin on tackling the NCD crisis.


16. BMJ (Editorial) – Revising the declaration of Helsinki;

Vivienne Nathanson;

You can still contribute to the final version of the new revision of the Helsinki Declaration  (see also last week’s IHP newsletter) –  The Declaration of Helsinki was published in 1964, and set out rules and limits for human experimentation based on the findings of the Nuremberg trials and an unshakeable conviction that human experimental subjects have fundamental rights that drive a series of duties for the experimenter.


The World Medical Association (WMA) will take into account all comments submitted by all interested parties—be they researchers, research subjects, lay groups, or healthcare practitioners. Comments should be submitted by 15 June 2013. This is your chance to influence research governance.


17. Guardian – Source code: PharmaSecure goes mobile in battle against fake drugs

Pharmaceutical Security Institute is a not-for-profit network of the security divisions of 25 big pharma companies. It prints unique codes on medicines to enable consumers to verify their validity and potency using their phones. The network’s activities are expanding.


18. Lancet (Editorial) – Assessing the end of the UK’s aid to South Africa

In this editorial, the Lancet examines (and laments) the health implications of the end of bilateral UK aid to South-Africa.


19. Lancet (World Report) – Mitigating disasters—a promising start

John Maurice;

A 10-year UN plan to make the world safer from natural disasters went into effect in 2005 (i.e. the Hyogo Framework for Action). With 2015 nearing, countries are now assessing how well it has worked. John Maurice reports.


20. BMJ (news)  – India remains on US trade “priority watch list” for failing to uphold international drug company patents

Sophie Arie;

The US government has said that it is seriously concerned about recent rulings in India on drug patenting that have favoured the country’s generics industry over international drug companies. In its annual report on intellectual property protection by trading partners, the Office of the US Trade Representative has kept India on its “priority watch list,” citing recent decisions by Indian courts to deny international companies exclusive rights over anticancer drugs that they had developed. The report also said that India had made limited progress in 2012 in improving its weak legal framework on intellectual property rights and the enforcement system.


21. World Bank – Cost-effectiveness vs. universal health coverage. Is the future random?

Adam Wagstaff

Yet another blog post from Wagstaff, less funny than usual, perhaps, but equally interesting.



22. WHO – More than 270 000 pedestrians killed on roads each year

More than 270 000 pedestrians lose their lives on the world’s roads each year accounting for 22% of the total 1.24 million road traffic deaths. WHO is calling on governments to take concrete actions to improve the safety of pedestrians. Under the banner “Make Walking Safe”, the Second United Nations Global Road Safety Week (6-12 May) kicked off earlier this week. With events registered in nearly 70 countries, the Week seeks to draw attention to the needs of pedestrians; generate action on measures to protect them; and contribute to achieving the goal of the Decade of Action for Road Safety 2011-2020 to save 5 million lives.


23. Chatham House (Comment) – Why Don’t Health Crises Result in Mass Migration?

Khalid Koser;

In recent years migration has regularly been triggered by humanitarian crises. This can arise from natural disasters such as cyclones, tsunamis, and earthquakes; human-made disasters like nuclear and industrial accidents; environmental degradation which is likely to be exacerbated by climate change; as well as situations of general violence and political instability. In contrast health crises – such as SARS or H1N1 – very rarely result in mass migration. Koser explores why this is the case.





HP&P: The effectiveness and cost implications of task-shifting in ART delivery

(Noreen D. Mdege et al.)

The new issue of HPP includes a systematic review on task-shifting in the rollout of ART to HIV-infected patients, based on a non-pooled analysis of six effectiveness studies including nearly 20 000 patients. Although most of the studies were underpowered to detect any difference, results suggests that task-shifting from doctors to nurses, or from health care professionals to lay health workers can potentially reduce the cost of ART provision without compromising health outcomes.


HP&P: Perceptions of per diems in the health sector: evidence and implications

(Taryn Vian et al.)

This qualitative study conducted among governmental and non-governmental officials in Malawi and Uganda indicated that, despite the advantage of using per diems to motivate staff in the health sector, a lot of discontent exists about the practice, stating that they create conflict, contribute to a negative organizational culture and lead to negative changes in work time allocation. The authors conclude that the pressure and incentives to abuse per diems should be curbed and transparency in policy implementation increased, in which donors could play an active role.



HP&P (advance access): Task shifting and sharing in maternal and reproductive health in LIC

(Angela J. Dawson et al.)

In this narrative synthesis of the currently available evidence around task shifting to reduce maternal mortality and provide universal access to reproductive health, the authors found that task shifting and sharing may increase access to and availability of maternal and reproductive health services without compromising performance or patient outcomes, whilst potentially being cost-effective. Collaborative approaches involving community members and health workers to deliver these interventions effectively should, however, be accompanied by ongoing investment in the health care system.


Int J Health Serv: African Development Bank, Structural Adjustment, and Child Mortality in sub-Saharan Africa

(Lauren E. Pandolfelli and John M. Shandra)

In this cross-national analysis of data from 35 African nations, the hypothesis that African Development Bank structural adjustment adversely impacts child mortality is supported and remains stable even when controlling for the selection bias of whether or not the nation received a structural adjustment loan. The authors conclude by discussing several methodological implications, policy suggestions, and directions for future research in this field.


Global Public Health: Rethinking health research capacity strengthening

(Emily E. Vazquez et al.)

Drawing on a desktop review around health research capacity strengthening (HRCS) and their field experience, the authors of this article highlight some of the considerations that remain underarticulated and examine the impact of US public health funding on the ecology of knowledge production in LMICs, the barriers US researchers face to effectively collaborate in capacity strengthening for research-to-policy translation, and the potential for unintentional negative consequences if HRCS efforts are not sufficiently reflexive about the dominant paradigms in public health research and intervention.


Gaceta Sanitaria: Inequidades en salud entre países de Latinoamérica y el Caribe

(Doris Cardona et al.)

In this ecological study the authors assess recent (2005-2010) health inequalities among twenty Latin American and Caribbean countries using an index of socio-economic and health indicators considered as proximal and contextual health determinants. Results indicate the existence of wide health inequalities in the region with Cuba showing the most favorable health indicators and Haiti the least favorable, leading the authors to recommend a systematic evaluation of health inequalities in order to inform actions, policies and programs aimed at reducing inequities in the region. You find an English summary on

Emerging Voices


24. Health Policy & Planning – Universal financial protection through National Health Insurance: a stakeholder analysis of the proposed one-time premium payment policy in Ghana

Gilbert Abotisem Abiiro & DiMcIntyre;

Ghana introduced a mandatory National Health Insurance system in 2004 to provide financial protection for both the formal and informal sectors through a combination of taxes and annual premium payments. As part of its election promise in 2008, the current government (then in opposition) promised to make the payment of premiums ‘one-time’. This has been a very controversial policy issue in Ghana. This study sought to contribute to assessing the feasibility of the proposed policy by exploring the understandings of various stakeholders on the policy, their interests or concerns, potential positions, power and influences on it, as well as the general prospects and challenges for its implementation. The study revealed a lot of confusion and uncertainty surrounding the issue among stakeholders, pointing to the need to use terminology that clearly reflects the policy objectives related to health reform






* ODI working paper, The future of EU aid in middle-income countries: the case of South-Africa.    This ODI Working Paper focuses the debate on the European Union’s  new proposed policy approach to middle-income countries (MICs) – ‘differentiation’ – at the case study level, through an analysis of South Africa.


* The Broker has put together and online dossier on the post-2015 agenda, looking at the progress made so far, the different angles taken by different actors, and an overview of the resources available: Navigating the post-2015 debate.


* The WTO has a new boss – a Brazilian (see the Guardian ).


* Bill Gates wrote an interesting op-ed on the need for more accurate GDP data for poor countries (on  Project Syndicate ).


* J Sachs (and pretty much everybody else with comparatively little money in their pockets) thinks it’s time to end tax havens (see  the Huffington Post ). For more on Britain’s dirty secret (island havens) and the link with the upcoming G8 summit, you can also read this blog post on Global Dashboard (by Ben Phillips).


* Duncan Green wrote two blogs on ‘blogging in international bureaucracies’ (WB, UN) (see here and here )



* Through the weekly ‘CGD in Europe’ digest, we learnt about:


–   a new draft working paper in which Itai Grinberg explains why current trends in addressing offshore accounts may result in a fragmented automatic information exchange system that serves only the interests of the stronger states (read: the North) with only limited improvements for developing countries.

– Harvard researchers have developed “Aid Explorer ,” a network-based tool for analysing the global aid system, aimed at facilitating aid coordination. A detailed description of the approach can be found in the accompanying paper, ” The Structure and Dynamics of International Development Assistance,” published in February 2013 in the Journal of Globalization and Development. (See also this  blog post  from Ben Ramalingam).



* The Draft UNSDSN (UN Sustainable Development Solutions Network) report on post-2015 SDGs is open for comments and feedback. The draft report puts forward 10 proposals for SDGs. One of them being: achieve health and wellbeing at all ages.



* The Guardian’s Global Development professionals network has an article exploring whether the BRICS development bank will deliver a more just world order.

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