Brazil is in the news these days, and it’s not because of the Confederations cup. If even football is not safe anymore in a country like Brazil where football is for most people a religion, then the world is truly changing. See also Lionel Messi’s tax issues in Spain. Our world is changing for the better, due to a mix of rising expectations, social media, and many other (context-specific) causes. Having said that, football of course of course remains the most important issue on earth, with global health as a close second. If you follow this newsletter, you probably know I’m both a football and a “Leo” fan. In 1994, I even reckoned that a gifted guy like Maradona should have been allowed to take performance enhancing drugs. Not a big fan of Sepp Blatter though. But yes, I think Simon Jenkins’ op-ed in the Guardian on the organization of extravaganzas like the World Cup and the Olympics contains more than a grain of truth. And football stars need to be properly taxed, just like anybody else.
In this week’s newsletter, we’ll pay some attention to the G8 summit (where the Syrian horror and the Trade agreement negotiations between the US and the EU got most of the attention of the world leaders, obviously, but at least a start was also made with Tax & Transparency issues, the other two ‘T’s Cameron wanted to focus on). We also zoom in on the health metrics conference in Seattle. In an opening speech, Richard Horton, increasingly the global health community’s conscience, said he wants the gap between the human rights community and the health metrics community to be bridged, in this new era of ‘Big Data’. Then there was the WHO report on violence against women (both by partners and non-partners), a global health problem of epidemic proportions. In the US, John Kerry and many others celebrated 10 years PEPFAR, and the Global Fund Observer guys were also fairly busy this week.
Kerry’s boss, Obama, was in Berlin this week – the magic is no longer there, we felt. Anyway, on the plane back home, the US president should take the time to read some Lancet stuff ( a World report and a Letter ) related to Guantanamo, one of the many nails in his political coffin.
In this week’s newsletter’s guest editorial, Khim Vathanak, a 2010 Emerging Voice and Phd-student in Australia, gives some of his impressions on the recent PBF workshop in Bergen. The dialogue between researchers and practitioners was very enriching in Norway, and the PBF ‘black box’ was – to some extent – opened.
Enjoy your reading.
Kristof Decoster, Ildikó Bokros, Peter Delobelle, Basile Keugoung & Wim Van Damme
The PBF workshop in Bergen: impressions and observations from a junior researcher
By Keovathanak Khim, 2010 Emerging Voice and PhD candidate at the University of Melbourne, Australia
Communication and exchange of ideas that work are as important as applying these ideas in the field to address today’s increasingly complex and diverse health problems. The Performance-based financing (PBF) community embraces this philosophy, so it recently organized another two-day workshop, “Performance-based financing of health care provision in low-income countries: Going beyond impact evaluation” (June 13-14), in Bergen, Norway. The workshop was supported by the Christian Michelsen Institute, with participation of approximately 35 researchers from academia, PBF experts, practitioners, and policy makers from government and aid agencies. The aim of the workshop was to present research delving into the question “what exactly happens to health care services when PBF is introduced” and contribute to the clarification of the overall research programme on PBF. In this piece I will share my impressions of the workshop and give a number of observations pertaining to PBF.
The workshop was a combination of presentations, questions and answers, open plenary and small group discussions. The first day started with presentations of theoretical explanations and experimental research related to providers’ behavior under different regimes of incentives, and research on PBF schemes in Cambodia, Tanzania and Burundi. The second day focused on research designs, feasibility of different designs, efficiency of a PBF scheme relative to alternative schemes and transaction cost issues. Further in-depth discussions took place in small groups which explored professionalism boosting programmes, key dimensions of the PBF “black box”, the interaction between PBF and health system functions and different designs of impact evaluation. Many of the topics were related to previous publications and ongoing debates about PBF. Discussions were well moderated allowing a variety of voices and insights from the field and government officials to be heard. Consequently, sessions were well attended and discussions were lively and engaging. They reflected a sincere interest to share, learn and foster a better understanding.
As expected, PBF definitions differed widely, influenced as they were by different experiences, settings and understandings. Everybody however seemed to agree on the basics of Performance-Based Financing: PBF is a form of supply-side interventions based on a contractual arrangement that creates an enabling environment for staff and facilities to improve their performance. PBF is a sub-set of Results-Based Financing (RBF), which was recently mentioned by Jim Kim as a key mechanism for the World Bank’s global health activities. Whereas all PBF schemes employ some form of payment to incentivize facilities (which may then decide themselves to reward their staff for the extra effort), not all schemes that use financial incentives can be labeled as PBF schemes. PBF contains several other elements which, for instance, clearly delineate the mission of each health system component, improve the efficacy of monitoring and verification of results, or promote community participation. These elements are flexible and can be adapted for use in different contexts, and add to the strengths of PBF.
Two trends were apparent in Bergen.
The first one was related to the need to better understand how different elements of PBF interact with and improve staff performance and health system functions and vice versa. For example, to what extent and in what context do financial incentives improve staff motivation or undermine intrinsic motivation; when and in what context do other mechanisms, e.g. encouragement and supervision, impact staff performance; when and how does empowerment of staff and managers impact interactions and communication within a system, and improve results? Participants agreed that qualitative approaches can address some of the current evidence gaps in PBF by explaining processes of PBF and the impact of the approach.
Second, many participants also emphasized the need for impact evaluation designs which are both methodologically robust and feasible in the field. Impact measures should be related to higher order- outcomes, such as changes in equity and efficiency in a health system, morbidity and mortality in a population, and issues such as catastrophic health care expenditure.
Global health problems tend to be complex and context-specific; they thus need an approach that is versatile and adaptable, such as PBF. PBF approaches promise to tackle and overcome health system constraints. These promises can be met with adequate research and documentation. This workshop represented another step forward in this direction by engaging researchers and practitioners in an open and fruitful dialogue and fostering a better understanding of PBF approaches. One can only hope that this workshop will be followed by other workshops of a similar nature. It is fair to say that workshops like this one are increasingly becoming the hallmark of the PBF community.
Excellent overall analyses of the G8 summit were produced by Andrew Norton (ODI’s director of research) and Alex Cobham & Owen Barder (CGD). Most analysts agree a start has been made with respect to tax & transparency, but that the road is still long, and sustained public pressure will be necessary. Some of the pundits reckon the chillaxing British prime minister didn’t put in enough effort to hammer out the details ahead of the summit. But let’s give the guy credit for at least talking the talk. Now it will be up to all of us to keep up the pressure. Anyhow it’s clear tax has become a major development issue, as many people are beginning to see the links between tax dodging and global poverty, including the vast health inequities.
You find the final G8 declaration & communiqué here. “The Lough Erne Declaration from the G8 Summit 2013 sets out agreed principles for the future. It focuses on private enterprise, which drives growth, reduces poverty, and creates jobs and prosperity for people around the world. It also sets out that governments have a special responsibility to make proper rules and promote good governance. In addition, fair taxes, increased transparency and open trade are vital drivers of this. The G8 leaders will make a real difference by acting on the principles in the declaration.”
1. BMJ (news) – Science ministers discuss the growing threat of antimicrobial resistance
G8 science ministers met to discuss the threat of antimicrobial resistance and they were apparently shocked at the scale of the problem. In the final outcome document, they pledged to work with international agencies such as WHO to support international cooperation and share surveillance data.
Seattle GHME conference
2. Lancet special issue on GHME conference – with all the abstracts
“How do we achieve democracy of knowledge and delivery of justice—two values that not only characterise global health but also make it one of the most important social movements of the 21st century?” (sounds like Richard)
This week, The Lancet published online 149 conference abstracts from almost 50 countries. The research presented at the third Global Health Metrics and Evaluation Conference in Seattle is a powerful example of the global conversation about health that a rapidly expanding international metrics community has helped to sustain and strengthen.
3. Richard Horton – Metrics for what?
In this editorial, Horton reflects on the future for global health metrics, but also regrets the loss of the Child Health Epidemiology Reference Group (CHERG). He has been tweeting throughout the GHME conference, and it’s worth to check out some of the pictures (on presentations and important graphs) he shared with the Twitter community.
4. Humanosphere – Call for global health geeks to join forces with human rights activists
Human rights and global health metrics experts should join together to ensure marginalized populations aren’t left out in the push for broad health gains, Richard Horton urged at the conference in Seattle. This blog includes a video (of about 6 minutes) with Horton eloquently making his case, including typical body language.
“Human rights and health metrics is not the most obvious marriage. In fact, the human rights community often tends to look upon the health data community with suspicion, and vice versa. But numbers are not facts, and disease charts do not naturally translate into policy decisions. The next step for making the best use of this powerful new tool, is to focus on translating the data into meaningful policy decisions and political action. We can use these new data, with the combined forces of the human rights and global health community, to make the uncounted count, to make the invisible more visible and to bring more attention to those now marginalized.”
See also a blog post on Smart Global Health (by Nellie Bristol) on Horton’s passionate plea.
Violence against women as a global health issue
5. Lancet (Editorial) – Violence against women: ending the global scourge
New data published in a Lancet Article and included in a new WHO report (see below) highlight how at least one in seven homicides worldwide are committed by an intimate partner. The findings and their implications for public health are discussed in a Lancet Comment and this Editorial.
6. WHO – WHO report highlights violence against women as a ‘global health problem of epidemic proportions’
Physical or sexual violence is a public health problem that affects more than one third of all women globally, according to a new report released by WHO in partnership with the London School of Hygiene & Tropical Medicine and the South African Medical Research Council. (Shocking statistics, sadly.)
7. BMJ (Editorial) – Responding to intimate partner and sexual violence against women
Alex Hardip Sohal et al.;
The new WHO guidelines outline what to do.
If you happen to be a man, ‘the villain of the world’, and have to face your wife this weekend, you might want to read this article in the Atlantic, in which Olga Khazan argues that sometimes men can also be a force for the good. Some traditional male chiefs are increasingly agents of progress in female health in Africa, it turns out.
Sustainable Development Solutions network report
8. report SDSN network – An Action Agenda for Sustainable Development
Sustainable Development Solutions network;
Last week, we probably didn’t pay enough attention to this report on SDGs by the Sustainable Development Solutions network, the network in which Jeffrey Sachs plays a vital role. So we’ll make up for it this week. The report was submitted to Ban Ki Moon early June. It includes a health section – goal 5 is labeled ‘achieve health and wellbeing at all ages’, which looks somewhat different from the HLP report health section. In this era of sustainable development, it’s obviously worth reading the whole report.
Global Fund update
9. Global Fund Observer – 2 new issues
Plenty of news about the Global Fund this week, so it’s worth checking out the two recent GFO issues. See here (17 June) and here (20 June). With news on the approval of the first concept notes by the GF, an analysis of the NFM allocation methodology, the appointment of a new Inspector-General (Martin O’Malley), a summary of the main decisions made by the Board at a recent meeting in Sri Lanka, the first formal report delivered by Mark Dybul to the Board, rather harsh criticism by Jaramillo of the GF’s governance structures, … And last but not least, the new board chair and vice chair also started their work.
10. PHM report on 133rd Executive Board meeting
The People’s Health Movement produced a summary (as well as more detailed notes) of the 133rd Executive Board meeting of the WHO.
A contentious issue was related to the LGBT population, with apparently an item deleted from the agenda due to pressure from some African and Middle Eastern countries – see Nils Daulaire’s blog post in the Huffington Post.
11. WHO – Investing in the World’s Health organization – Taking steps towards a fully-funded Programme Budget 2014-2015
‘Investing in the World’s health organization’ provides WHO’s member states and other partners with an easy-to-read overview of the Programme budget. Its aim is to foster a dialogue with our funders, in order to improve the transparency, alignment and predictability of WHO’s financing. Its ultimate goal is to ensure the 2014-15 Programme Budget is fully funded. (A first step in the run-up to the financing dialogue)
Health Policy & financing
12. Health & Human rights – June issue – Realizing the Right to Health Through a Framework Convention on Global Health?
“Just as the world is focused on the post-2015 sustainable development agenda, and concerns have been raised over global governance for health and other aspects of development, this special issue of Health and Human Rights focuses on one potentially important contribution—a global treaty grounded in the right to health. The Framework Convention on Global Health (FCGH), first proposed in 2008, has seen growing momentum, perhaps most prominently from the United Nations Secretary-General and the Director of UNAIDS, and has the overarching aim of dramatically reducing health inequities within and among countries,” argue Eric Friedman and co-authors in the Introduction to this special issue.
You might want to read the whole issue, but most people will start by reading the Introduction and the Editorial (by Tim Evans). Then they’ll probably head straight for the issue’s “Star Wars” paper – “Dark sides of the proposed Framework Convention on Global Health’s many virtues: A systematic review and critical analysis” (by Steven J. Hoffman and John-Arne Røttingen). At least, that’s the impression we get on Twitter. But there’s a lot more, including papers on global health funding & governance. (Anyhow, it appears FCGH is the talk of the town, these days. Which is great.)
13. Lancet (Comment) – AIDS governance: best practices for a post-2015 world
Michel Sidibé & Kent Buse;
Another piece with a view on post-2015 global health discussions. Sidibé & Buse introduce the ‘UNAIDS and Lancet Commission: From AIDS to Sustainable Health’, co-chaired by Joyce Banda, Nkosazana Dlamini Zuma, and Peter Piot.
For the latest on this Commission, see this UNAIDS feature article. It gives a brief update ahead of the meeting in Lilongwe (28-29 June). You find the full list of Commissioners here. (I felt shock and awe, when going through the list)
14. Helsinki conference statement
The Health Promotion conference in Helsinki was concluded with this conference statement. Check out also Fran Baum’s last blog post for BMJ, in which she reports on the last day of the Helsinki meeting (and the alternative declaration, by the People’s Health Movement).
You find a nice op-ed on the various theories explaining health inequalities on Project Syndicate ( by Claire Bambra).
15. Lancet (Perspective) – Health activism in a globalising era: lessons past for efforts future
Speaking of the People’s Health Movement, Ronald Labonté is of course one of the key people in the movement. No doubt he’ll be watching events in Turkey and Brazil, and perhaps he’ll even see some traces in them of the ideas on health activism he puts forward in this Lancet Perspective: health activism in a globalising era.
16. Science Speaks – Supreme Court strikes down anti-prostitution AIDS funding requirement: “It violates the First Amendment and cannot be sustained”
The Supreme Court decided in a way that will no doubt be a big relief for the global health community; there were some dissenting voices though, among the judges. AmFar already called the decision “a victory for human rights and global health.”
17. CGD – Is the Price Right? Evaluating Advanced Market Commitments for Vaccines
Amanda Glassman & Kate McQueston;
Glassman et al. comment on a 2012 report by Dalberg Global Development Advisors on a Pilot AMC for Pneumococcal Vaccines.
In other global vaccination news, a short ‘Next Billion’ blog post focuses on the situation in middle- income countries or countries which will soon graduate from GAVI support (like Honduras, Bolivia, Angola, …). “With a majority of the world’s poor living in middle income countries, does removing support from countries that make marginal economic advances really help those in greatest need?” The problem with GAVI’s approach is that it ignores distribution of income, the author argues.
18. Meeting Report – Advancing Country Ownership: Civil Society’s Role in Sustaining Public Health
AmfAR, The Foundation for AIDS Research; the Health Policy Project, a USAID-funded project of Futures Group; the International Planned Parenthood Federation Africa Region; and the Planned Parenthood Federation of America; (yes, that’s a mouthfulJ)
This week, a number of American organisations released a report based on a consultation held in late 2012 and that included civil society leaders from 20 countries. The consultation, “Advancing Country Ownership: Civil Society’s Role in Sustaining Public Health,” sought to identify priorities and models for ensuring civil society engagement in health decision-making — and to identify some key principles around country ownership of health programming and policymaking.
Check out also this Science Speaks blog post on the same report – the blog emphasizes the distinction between country ownership and government ownership.
In other civil society news, a Smart Global Health blog post (by David J. Olson) points out that many NGOs, which have focused historically on delivering health, increasingly take up an advocacy role. Olson gives some examples in a number of countries.
19. Lancet (Editorial) – Dengue—an infectious disease of staggering proportions
About 50—100 million dengue infections occur every year, and the burden of disease falls heavily on southeast Asia, but also throughout Latin America. Today, about two-fifths of the world’s population live in dengue-endemic countries, this Lancet Editorial states. There’s still a lot of work that needs to be done to transform dengue into a preventable and treatable disease…
20. Lancet (Comment) – Socioeconomic development to fight malaria, and beyond
Jürg Utzinger et al.;
The poorest children in the world’s most impoverished communities are twice as likely to contract malaria as the least poor, according to a new study published in the Lancet. “That malaria control remains largely the preoccupation of the health sector alone is a failing of both those who work in health and those who work in international development.” Utzinger et al. agree with the authors of the Lancet study that investments that support socioeconomic development in malaria settings will prove an effective and sustainable intervention against malaria, but they say the same is true for many other poverty-related diseases, including the neglected tropical diseases.
21. Plos – Targeting Asymptomatic Malaria Infections: Active Surveillance in Control and Elimination
Hugh Sturrock et al.;
Hugh Sturrock and colleagues discuss the role of active case detection in low malaria transmission settings. They argue that the evidence for its effectiveness is sparse and that targeted mass drug administration should be evaluated as an alternative or addition to active case detection.
22. BMJ (Analysis) – How evidence based are public health policies for prevention of mother to child transmission of HIV?
Philippe Van de Perre et al.;
WHO is due to issue new guidelines on preventing transmission of HIV from mother to child at the end of June. Philippe Van de Perre and colleagues argue that recommendations have gone ahead of the evidence and call for a more cautious approach.
23. NEJM – How Point-of-Care Testing Could Drive Innovation in Global Health
Ilseh V. Jani et al.;
In areas of limited resources, point-of-care diagnostic testing is being increasingly used to identify disease, determine prognosis, and monitor treatment. Investments in new diagnostics are starting to improve care. Health systems need to evolve to reap benefits for global health.
24. WHO – Lax marketing regulations contribute to obesity crisis in children
WHO calls for tighter controls on the marketing to children of foods high in saturated and trans fats, free sugars and salt, in order to fight childhood obesity. Tightening restrictions on marketing is central to this fight, according to a new report from WHO/Europe: “Marketing of foods high in fat, salt and sugar to children”. (Not just relevant for Europe, obviously; along the same lines, we hope WHO will one day also call for tighter controls on marketing of deceptive political messages to vulnerable adults).
25. Speaking of Medicine – Restoring Invisible and Abandoned Trials: A Creative Approach to a Public Good; Now a Creative Approach to Implementation is Needed
Margaret A. Winker & Virginia Barbour (on behalf of the Plos editors);
A proposal for Restoring Invisible and Abandoned Trials (RIAT), a step toward the AllTrials initiative to publish all randomized trials, was published in the BMJ last week with an accompanying editorial signed by PLOS Medicine Chief Editor, Ginny Barbour, and Senior Research Editor, Margaret Winker, on behalf of the PLOS Medicine editors. Read more about this proposal in this Speaking of Medicine blog post.
You find the BMJ analysis here.
26. Plos – Bigotry and Oppressive Laws in Africa Drive HIV in Men Who Have Sex with Men
Jerome Singh et al.;
Jerome Singh discusses the findings of a new study by Rachel Jewkes and colleagues in the context of cultural and legal barriers hindering access for African men who have sex with men to HIV-related health services.
27. Smart Global Health – The Obamas’ Africa Opportunity
Some reflection ahead of the Obama visit to Africa. “The Obamas have an opportunity to make this trip historic by explicitly committing the United States to focus on women and girls as a key pathway to progress for Africa. But will they seize it?”
Global health bits & pieces
- 10 years PEPFAR. Ten years ago, President George W. Bush announced the creation of PEPFAR in his State of the Union Address. Its aim was to provide antiretroviral treatment to 2 million people, prevent 7 million new HIV infections and provide care and support to 10 million people by 2010. If Bush has a ‘legacy’, this is probably it. At a ceremony lauding the 10th anniversary of PEPFAR, this week, Secretary of State John Kerry was the key speaker. (Funny it was the former opponent of Bush who had to speak – not sure he showed off his best French accent.) Among other things, Kerry said that, according to an updated analysis by PEPFAR, 13 countries are at the programmatic tipping point in their AIDS epidemic — the point where the annual increase in adults on treatment is greater than the number of annual new adult HIV infections.
- The recent Rotterdam ‘global health innovators’ conference produced a very nice Youtube video – with some key messages. Check it out!
- MERS: I watched Pandemic (2007) yesterday, together with my 13-year old son – the boy considered it a ‘horror movie’. So it’s only fair this newsletter gives a short update on MERS. The new coronavirus is a serious risk in hospitals because it is easily transmitted in health care environments, infectious disease experts said on Wednesday. In a study published in the New England Journal of Medicine, the researchers said MERS was not only easily transmitted from patient to patient, but also from the transfer of sick patients to other hospitals.
- Upcoming Dialogue Forum on UHC in Zambia: The government of Zambia is hosting a dialogue forum between African and Asian countries on achieving UHC on June 25-28, 2013 in Lusaka, Zambia. The forum is organized by the African Development Bank, GIZ, ILO, WHO & the WB.
28. WHO Bulletin (early online) – Health financing for universal coverage and health system performance: concepts and implications for policy
Joe Kutzin, UHC, … do I need to say more? A must-read.
29. HHR – The ghosts of user fees past: Exploring accountability for victims of a 30-year economic policy mistake
Interesting article. If your name is David De Ferranti, you will probably want to read this piece.
30. HP&P – Access to subsidized ACT and malaria treatment—evidence from the first year of the AMFm program in six districts in Uganda
Günther Fink et al.;
The results of this study suggest that, during its first year of implementation in Uganda, the AMFm achieved its main objective of increasing the availability and use of ACTs. Estimates of the impact of the AMFm on ACT use for children under 5 imply that the program should be considered highly cost-effective under current WHO guidelines. The overall results look promising, but larger and longer term studies will be needed to assess the health impact and cost-effectiveness of the program, the authors argue.
31. Thematic series: Promoting Universal Financial protection
The Alliance for Health Policy and Systems Research and the WHO Health Systems Financing Department provided financial support to the Thematic Series: “Promoting Universal Financial Protection“, the first two papers of which were recently published. This Thematic Series presents the findings of seven country case-studies that explore factors that have facilitated or hindered expansion of financial risk protection. The two papers that were recently published are:
- Borghi J et al. (2013). Promoting universal financial protection: a case study of new management of community health insurance in Tanzania (in Health Research policy & systems – http://www.health-policy-systems.com/content/11/1/21
- Onaka C et al. (2013). Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria – http://www.health-policy-systems.com/content/11/1/20/.
32. African Development Bank (Brief) – Health in Africa over the next 50 years
The health landscape has transformed dramatically since the independence of African countries about 50 years ago, and this is expected to continue as the continent progresses over the next half-century. The African Development Bank has published a brief that looks at progress made and lays out the prospects of health in Africa over the next fifty years. This brief was already published in March.
33. Journal of Health Diplomacy (online) – first issue
Check out some of the online articles, for example on harnessing global health diplomacy to curb corruption in health, the Trans Pacific Partnership Agreement, the governance of counterfeit medicines, …
34. TMIH – Profile of suicide in rural Cameroon: are health systems doing enough?
Basile Keugong et al.;
Suicides are not a rare event in rural settings in Cameroon. The health district capacity to provide quality mental care is almost insignificant. The integration of minimal mental health care services at the community and primary health care levels should be considered a priority in sub-Saharan Africa, our colleague Basile argues.
- Climate Change: The WB produced another worrying report on climate change, in case it’s still needed. “In fewer than 20 years, climate change impacts — from flooded major cities to crashing food production — threaten to fundamentally reshape the world economy and dramatically worsen human lives. It is time to stop arguing about whether (climate change) is real or not,” World Bank President Jim Yong Kim said. Kim refuses to give up, obviously, and for good reason. (see Reuters) ( my guess is, though, that Obama & other Cameron’s have given up on the aim of an increase of maximum 2 degrees, although they will never say so in public. With another shocking IPCC report coming up, they’d be dead meat, politically speaking).
- The Broker online has two blog posts related to the launch of the 2013 European Report on Development (ERD), Post-2015: Global Action for an Inclusive and Sustainable Future. Read them here and here. For the full report, see here.
- There’s a new ODI publication on the history of the humanitarian system, and especially its Western origins and foundations.
- Jonathan Glennie reports on forthcoming evidence on the importance of localised aid (in the Guardian).