Dear Colleagues,


This week our colleague An Appelmans wrote the introduction to this newsletter. She will soon leave ITM, on Friday 13th apparently. After a rather drastic ‘Facebook status’ update last year, when she played the lead role in ‘One Wedding and Four Kids’, An is now looking for greener pastures. She will be missed in Antwerp, as a friend and as a very committed colleague. Below you find her ‘farewell message to global health’.


Health markets: a messy reality but a moral duty for all of us! 

Having worked previously in the private health insurance sector, I was a bit overwhelmed and disappointed when I put my first steps into the academic world of health policy research some years ago: for some reason, talking about the private sector seemed to cause furrowed brows.

I’m glad to report that that was only my first impression and that a more nuanced view is becoming more common. With WHO and the UN urging countries to work towards UHC, the dichotomy public versus private that often opposes the sectors against one another seems to shift and becomes less clear-cut. This week’s Bangladesh series in the Lancet underwrites this shift. Instead of getting stuck in an idealized conceptual world view, it takes into account what is actually happening out there in the real world. There is a growing body of evidence that people, especially in poor countries in Asia and Africa, often use the private health sector (non-profit and for-profit). Non-state actors (the holistic name I prefer as there is no real consensus about what the private sector covers) play a significant role in delivering healthcare  to people in developing countries, although I acknowledge that this poses some challenges. But there are also opportunities in terms of regulation, quality, accessibility, effectiveness and cost of health services.

The question is what to do about this reality. It is not an easy one to answer but we  need to start by taking an inclusive view. So I was happy to learn that Health Systems Global flagged ‘The private sector in Health’ as one of its approved thematic working groups. This assures that efforts towards affordable, equitable, high-quality health care from a pluralistic health system will be brought together under a challenging research agenda.

And whether you work in the public or in the private sector (to refer a last time to the classical but outdated boundaries), you need to engage in the health markets on the path towards UHC. It is our ‘moral duty’, so to speak, and we cannot walk out of the talks (though isn’t that what just happened at the climate summit in Warsaw?).


An Appelmans




In this week’s guest editorial, some MPH students reflect on the role of the GP in the Belgian health systems, sharing lessons from LMICs in the process.


Enjoy your reading.

Kristof Decoster, An Appelmans, Peter Delobelle, Basile Keugoung & Wim Van Damme




Mind the GP!

The role of the general practioner in the Belgian system: sharing lessons from low-and-middle-income countries and vice versa


Radhika Arora (India), Felipe Rojas Lopez (Chile), Leen Jille (The Netherlands) & Sushma Krishna (India): Students MPH 2013-14, Institute of Tropical Medicine Antwerp



“The general practitioner is a licensed medical graduate who gives personal, primary and continuing care to individuals, families, and a practice population, irrespective of age, sex and illness. It is the synthesis of these functions which is unique. He will attend his patients in his consulting room and in their homes and sometimes in a clinic or hospital… He will include and integrate physical, psychological and social factors in his consideration about health and illness.” Leeuwenhorst definition, 1974


Recently, a group of international public health students at the Institute of Tropical Medicine in Antwerp had the opportunity to observe the provision of primary health services in Belgium. As part of this group, we the authors of this post were impressed by the role that the general practitioner (GP) held within the local health system here. We noticed GPs had time to spend with their patients; often, they knew about the social background of their long-standing patients. GPs provided home-visits to the elderly and others without the capacity to travel to a health centre, impressed by the patient centeredness of care that this system of primary health care encouraged. However, it also pushed us to reflect upon the significance of GPs as providers of primary care in our home countries and in the health systems in countries such as India, Chile and Mozambique, where we had worked.

The definition of a GP varies in different settings, but the essence of the role of this healthcare provider remains largely the same everywhere – as one who provides holistic, primary healthcare services to a community. In many of our contexts the presence of the GP is gradually fading. There was a collective expression of nostalgia of a time when the GP or the family doctor  – we use the terms general practioner, family doctors, family physicians interchangeably – made house calls when a member was unwell; a doctor who knew the medical history and family of his patients intimately and often had social ties within the community he served in. This daily town tour done by the GP in the past is currently nothing but a memory of the days gone by; the visits are now more and more restricted to those unable to visit a health centre. The decline in the change in home visits could also perhaps be attributed to the fact that fewer medical graduates chose to work as general practitioners. Even in Belgium, we are told, general practice as a career choice in medicine is being traded in for practice in specialised medical fields. And so, at a time when effective management of health workforce towards providing primary health services, both in the global South and North, is one of the key challenges facing the health system, we asked ourselves, what happened to the general practioner? We juxtaposed this with settings in Mozambique and India, which have a shortage of qualified physicians so acute that being visited by a Community Health Worker (CHW), trained in the absolute basic of health care services is considered a luxury. As essential primary health providers, the GP’s role is crucial in providing preventive, curative, palliative and informal care. For both low-middle- and-high income countries this can mean reducing the burden on specialists. GPs provide crucial preventive and curative services for ailments that require less specialised care. Often GPs can practice with fewer years of medical education than it requires to practice as a specialist, thereby giving the opportunity to produce more trained physicians within a relatively shorter time. With the demographic transition and the burden of chronic diseases in the North and also increasing in the South, the GP’s multifaceted role becomes even more relevant and indispensable.

We realised that there are lessons to be shared between the global North and South. For example, many countries in low-resource settings employ task-shifting to make more efficient use of available resources – a lesson which could be relevant to the North. The role of nurses and midwives could be expanded from that of ‘support’ staff, to expanding the type of services they can provide. Lessons in task-shifting from the South where nurses take over certain routine procedures for chronic patients, where midwives at first level can deal with antenatal care, family planning, counselling, etc. is an option open to both high and low-income countries. For example, at a not-for-profit health centre in Antwerp, we noticed nurses being trained to provide routine care and counselling services to diabetic patients, thus freeing up the GP’s from that service. This, of course requires the support of both, the state and health providers, as well as investment in developing appropriate medical education strategies for the future. This is also relevant in areas with an inequitable distribution of workforce. For example, in Mozambique which already has a low health worker-population ratio, physicians are often located at distances inaccessible for most people. Here nurses and nurse-practitioners often run the first line health care services and provide essential health care services to the community.

Providing adequate and quality primary health services is, from a human rights perspective, a permanent matter of concern. Under this frame, human resources play a paramount role. Even as Belgium has 3.8 doctors per 1,000 people, Chile has 1, there are 0.6 in India and only 0.03 in Mozambique, there are shortages of general physicians in Belgium, especially in underserved areas. Currently in countries with adequate health care professionals, those choosing a career as primary health care providers (such as GPs and family doctors) are reducing. A common complaint, noticed during our visits was “we don’t have enough staff”, particularly GPs. And so, while impressed by the amount of time doctors and nurses had with their patients in Belgium, as compared to settings with chronic health worker shortages, we noticed that in both settings the doctors at the primary or community level were outnumbered and outgunned.

But why, one might ask, is there such a shortage of medical professionals interested in primary health care? Could it be financial remuneration and associated prestige (in comparison with their peer doctors)? In the North, for example, in the OECD countries, particularly Belgium, the Netherlands and Austria, GPs earn less than half that of specialists. In the United States, they are the lowest earning medical doctors. Even in the South, where the qualified medical practitioners are woefully short of WHO’s recommended figure of 23 health workers per 10,000 people , and inequitably distributed between urban and rural areas, specialisation is preferred over the provision of primary health services among the medical fraternity. A nationwide campaign demanding more seats in medical colleges for specializations took off in mid-2013 in India. The country produces 46,000 medical doctors and 22,000 specialists every year,  as almost 99% of undergraduate students indicated an interest in pursuing a specialization after their basic medical training, indicative of a reluctance to work as primary health care providers, certainly in rural areas with less attractive living conditions?. Conversely, the Netherlands and Chile have witnessed the production of more specialists than the health system can absorb, but clearly, in most settings there is a strong preference towards working as a specialist rather than as a general, primary health care specialist.

Although there is a difference in the magnitude of the human resources constraints facing countries in the North and South, each presents its challenges in their individual contexts. There is a need to share experiences towards encouraging qualified professionals (and finding ways to produce more qualified health professionals) who are motivated to provide primary health care services to the community. Strategies such as task-shifting are quite popular in low-resource settings. Affordable health technologies are gaining ground as they provide a more efficient use of resources in diverse settings in providing primary health care. For example, mHealth initiatives are being used for drug adherence for antiretroviral therapy and also to improve the coordination and productivity of CHWs in low-resource settings.  In India, trials are underway for a new kind of baby incubator which requires little or no electricity – essential in countries with limited resources and weak health systems.  Belgium’s Impulseo I which offers financial incentive to physicians who chose to work in areas with a low doctor-patient ratio is  just as pertinent to the needs of the country, as India’s own initiatives to incentivise physicians to provide primary health care in rural areas.

It is time to once again look at ways to resurrect the family physician’s role in the provision of primary health care services whether in India, Belgium or Chile to find ways to ensure that the role of GP’s as primary providers is insured by mechanisms to develop structured referral systems, encourage people to see the benefits of developing links with their family doctors, as well as, ensure a more equitable status. Whether it’s in countries like Mozambique with an overall shortage of health workers or in Belgium with its inequitable distribution of health workforce, the use of the skills of trained nurses, midwives and other allied health care professionals, has the potential to bridge the gap, and provide quality public and primary health services to people.

Author information

Leen Jille: Originally from The Netherlands, Leen has worked in the area of Procurement and Supply Chain Management for medicines and medical supplies in several LMIC since 2003, most recently in Mozambique.

Felipe Rojas Lopez: A midwife from the University of Valparaiso, Chile with a diploma in Family Health, University of Chile, Felipe has four years of experience in primary health services in Chile. And four years of humanitarian experience with MSF and IRC.

Radhika Arora: Has lived and worked in India for most of her life. Her initial training and work was as a features journalist. She worked with the Public Health Foundation of India, before joining ITM as a student of public health.

Sushma Krishna: worked as a Medical Doctor, Lab Microbiologist and was faculty at University Teaching hospital in India before starting MPH at ITM, Belgium.



Lancet  series on Bangladesh


A new six-part Lancet Series takes a comprehensive look at one of the “great mysteries of global health”, investigating a story not only of “unusual success” but also the challenges that lie ahead as Bangladesh moves towards UHC. This Series reports on the exceptional improvements in the survival of infants and children under 5 years of age, life expectancy, immunisation coverage, and tuberculosis control in Bangladesh, despite low spending on health care, a weak health system, and widespread poverty. But the nation still faces considerable problems, including deep poverty and malnutrition, and this is being exacerbated by an evolving set of 21st-century challenges.

With contributions (Comments) from  Das & Horton, Amartya Sen, a first series paper  summarizing the series, a last series paper on innovations necessary for more progress towards UHC, and much more. The Series is also discussed in a podcast.


Mark Tran also wrote a nice summary in  The Guardian.


COP 19 in Warsaw


It’s been a turbulent two weeks so far in Warsaw, no need to go into detail here as I assume you’ve been following the annual “COP circus” to some extent, even if from a distance. This multilateral process is still extremely important for global health, but not very encouraging. In two years, in Paris, it will be ‘money time’; many people think we can’t even wait till then and anyhow, the picture for the road to Paris looks bleak too. You can read it all in the Guardian’s coverage of this COP event.


Kevin Watkins’ (ODI) analysis from earlier this week is a nice read. It’s obvious the Polish organizers and the Australians, Japanese and Canadians aren’t playing the most constructive role there. Watkins: “At the heart of the gloom in Warsaw is a trust deficit between developed and developing countries. That deficit has widened with the decision by Australia, Canada and Japan to reduce their emission reduction targets.”  But issues like historic responsibility for climate change & compensation are extremely hard to solve, especially now that the distinction between developed and developing countries becomes more and more blurred, as the globalized elite is interconnected and a bit everywhere nowadays.  See for example the new research on the 90 companies responsible for two thirds of man-made climate change.


I applaud the fact that a number of green & development groups and trade unions and social movements walked out of the UN climate talks, as at some point one should refrain from giving legitimacy to decision makers’ so called “negotiating”, if the political will is not there to do something substantial. But it’s a tricky thing, as you can only do this once.  The trade-off between ‘purity’ and ‘trying to influence the process as a responsible stakeholder’ is difficult, see also the ‘divesting from fossil fuel companies’ issue (see the Guardian’s head to head debate), which is less clear-cut than you and me think. In Geneva (WHO), they probably also know a thing or two about this sort of trade-off, for example with respect to NCD policies.


To end this short reflection on climate change negotiations, do read Kevin Anderson’s radical suggestion for transformative change. Nations should give up their growth obsession and the world should focus on making the few who emit the most change their consumption patterns, he says.  “50% of emissions come from 1% per cent of the population. This 1% includes climate scientists and nearly everyone at the UN talks and just about all the rich.” I would add – it probably also includes a big chunk of the ‘happy flier’ global health community…


It’s clear that the mega-typhoon in the Philippines, unfortunately, hasn’t had the catalytic impact needed on the ‘people who matter in this world’. An ‘Al Qaeda-style’ ecological disaster, hitting US shores, European capitals, Tokyo & Sydney all at the same time, might be needed before there’s enough “bottom-up pressure” on global leaders to change their ways. Whether that’s an enticing prospect is something else. Moreover, it’s not very likely in the near future, as countries in the South are more in danger for the moment. But in the absence of it, I don’t think Paris will produce the magical breakthrough.


On the sidelines of the UN climate negotiations, a climate & health summit also took place. “Attacking health and climate change problems together makes sense, experts said, but changing behavior that causes global warming can be just as difficult as changing behavior that leads to health problems, doctors at the summit admitted.”


Finally, on a more hopeful note, this article from an activist, inspired by Naomi Klein, is a necessary read. “The fight for the climate isn’t a separate movement, it’s both a challenge and an opportunity for all of our (i.e. social) movements. We don’t need to become climate activists, we are climate activists. We don’t need a separate climate movement; we need to seize the climate moment.”


Post-2015 & UHC


1.    Lancet – Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework

Karin Stenberg et al.;

A new Global Investment Framework for Women’s and Children’s Health demonstrates how investment in women’s and children’s health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments.”  This new global investment framework could serve as a guide to countries to optimise investments in women’s and children’s health within national health and development plans over the next two decades.

2.    WHO – Universal Health Coverage: Supporting Country Needs

UHC is the talk of the global health town, but a lot of countries are still struggling with the implementation. WHO has therefore published a document that clarifies what UHC is and is not, and how countries can take steps to move closer and monitor their own progress. This short document covers the main elements of UHC.

3.    Humanosphere – Is the new ‘golden age of philanthropy’ a sign of good times or bad? |

Tom Paulson;

Important question…


Next week, the European Development Days (26-27 November) will be held in Brussels. One of the speakers there, Tim Crocker-Buque, wrote this viewpoint on integrating health into the post-2015 agenda (on Devex ). He argues for a more comprehensive and integrated approach to tackle the synergistic relationship between poverty and ill health.



Lancet Infectious Diseases on antibiotic resistance


The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. A new   Commission published in The Lancet Infectious Diseases describes the global situation of antibiotic resistance, its major causes and consequences, and identifies key areas in which action is urgently needed. The report, written by a group of 26 leading experts, suggests that the global health-care delivery system must be re-engineered to counter the threat of antibiotic resistance.


Against this bleak backdrop, the global activities of Antibiotic Awareness Week, starting November 18, seek to draw attention to a dire situation that threatens to take us back to a preantibiotic era.”


To maintain and build on current interest, antibiotic resistance should feature prominently in discussions of post-2015 development goals. We hope that the Commission will provide encouragement that, although the picture is bleak, there is hope“.


4.    Lancet Global Health – What do we need to do to tackle antimicrobial resistance?

Robin Fears;

On the same issue, check out also this Lancet Global Health Viewpoint. Notwithstanding earlier assumptions, the threat of antimicrobial resistance is global.

Recently, academies have started to work together to deliver stronger messages to policy makers. This Comment is published to coincide with the launch of a statement by the global network of science academies represented by the InterAcademy Panel (IAP, representing academies of science) and the InterAcademy Medical Panel (IAMP, representing academies of medicine). The IAP-IAMP statement is a call for action, capitalising on previous work by member academies and others. In addressing recommendations to international and national policy makers, IAP and IAMP emphasise that antimicrobial resistance must receive much greater prominence in global strategic discussions. For example, although growing recognition of this threat to global health was apparent at the 66th World Health Assembly in May, 2013, the recent report by the UN high-level panel on the post-2015 development agenda omitted mention of antimicrobial resistance in the illustrative goals for health.”


In related news, check out a new Plos article on a recent Chinese government strategy to promote rational use of antimicrobials in health care.


World Toilet day (19 November)


5.    Humanosphere – For World Toilet Day Gates Foundation motto: Every shit has value

Tom Paulson;

How to turn shit into a commodity, that’s the question.


Meanwhile, the NYT published a rather critical viewpoint (by Jason Kass, founder of Toilets for People) on the Gates foundation’s approach. Kass advocates low-tech ecological toilets.

6.    CGD – How a toilet makes everybody taller

Victoria Fan;

Victoria Fan et al. wrote this nice blog post on a somewhat overlooked advantage of toilets. “On World Toilet Day, we’d like to take a moment to celebrate the toilet for not only saving lives – by reducing the risk of deadly diarrhea – but also for helping people to grow taller, a key measure of childhood malnutrition.”


As usual, many other World Days were celebrated this week, including

Universal Children’s Day, The World Day of Remembrance for Road Traffic Victims (see Ban Ki Moon on this; he called for urgent action to make roads safer for all those who use them in an effort to save millions of lives worldwide. He also applauded the fact that governments have agreed to a ‘Decade of Action for Road Safety’, 2011-2020, with the target of saving five million lives.)


And of course, we also celebrated ‘International Men’s day’ this week J. (Hope all men among you engaged in ‘risky behavior’ (booze, … etc., see below) to celebrate the occasion; meanwhile, the Gates Foundation celebrated International Men’s day in its own way, with prizes for the “next-generation” condoms to boldly go where no man has dared to go before; who said again the Gates Foundation only cares about women?).


ITM/IPH colloquium on neglected diseases and HS in Bangalore


Bangalore’s Institute of Public Health (IPH) in collaboration with ITM Antwerp holds the Colloquium 2013 with the theme “Health systems and control of neglected diseases in Asia” from Nov 20 to Nov 23 in Bangalore. “Over 200 delegates from 30 countries – from Uganda to China and Belgium to India – representing governments, academic institutions and NGOs participate. The term ‘neglected diseases’ is a political one to highlight a wide array of diseases that are not given due attention and that in fact have become drivers of poverty. These include the so-called ‘big three’ (HIV, TB and malaria) but also 23 neglected tropical diseases that still impoverish and kill people but hardly get attention from health services and policymakers. As per the World Health Organization these “diseases are a proxy for poverty and disadvantage, affect populations with low visibility and little political voice, cause stigma and discrimination…are low on many research funders’ agenda…”


Check out the colloquium website for the latest on the event, including reporting from bloggers on various sessions.


More blogging on Recife Forum and other HRH news



Apparently many people are hellbent on getting the message out from Recife, as well as on framing the road ahead.


7.    Get involved in global health – A renewed agenda for HRH, with some grey areas

Giulia De Ponte et al.;

De Ponte left Recife with a few question marks in her head, related to the actual meaning of the consensus which emerged in Brazil, for example on the exact meaning of ‘political will’ etc. In this blog post, she addresses a number of other “grey areas” as well.


8.    Health poverty action – The Health Worker Crisis: Natalie Sharples blogs from the Third Global Forum on Human Resources for Health

Nathalie Sharples

Sharples had the feeling the Third Global Forum somewhat overlooked the brain drain issue. Although migration was mentioned a few times, her impression was that the issue of “compensation” as a response to the brain drain didn’t get anywhere near the attention it deserved. She assesses why this could be the case. She concludes: “It’s time to revive the debate about compensation.


Sharples also wrote a blog post for Action for Global Health, focusing on Remco van De Pas’ presentation, who emphasized progressive taxation and reminded the audience of the need to situate the HRH discussion within wider debates about trade negotiations, capital flight, the protection of labour rights and compensation.

Sharples also regretted the dismal performance of donor countries.


On the same issue (lackluster donor commitment), read also this very nice blog post by Frazer Goodwin (Save the Children), who is slightly more positive.


9.    Strengthening Health Workforce in Africa – A Priority for the AfDB

The global community needs to change its traditional approach to health workforce in a fundamental way. It is critical to adopt a comprehensive labour market approach to understand the market forces influencing both supply and demand of health workforce. This is particularly important to Africa with high disease burden and low density of health workforce,” said Agnes Soucat, AfDB’s Director for Human Development, in Recife. She also discusses this theme in her recent book ‘The Labor Market for Health Workers in Africa: A New Look at the Crisis’.


10. Intrahealth – HRH + Private Sector = A Happy Marriage?

Rebecca Kohler;

‘Partnership with the private sector’ was a strong theme at the Third Global Forum on HRH in Recife. But where were our private-sector partners, wonders Rebecca Kohler. “ Their limited presence made me wonder: Are we really welcoming what the private sector has to offer? Or are we just looking for funding?”


11. Intrahealth – Let’s talk tactics

Ok Pannenborg;

Yet another insightful assessment of the Recife meeting, with also an in-depth reflection on what needs to come next.

12. Global Health Workforce Alliance – Mid-level health workers for delivery of essential health services: A global systematic review and country experiences

Critical shortages, maldistribution, retention and performance gaps of human resources for health hinder the delivery of interventions required to attain the health MDGs and advance towards UHC. The objective of this analysis was to assess the effectiveness of care provided by mid-level health workers (MLHWs), a group of cadres who are trained for 2-5 years to acquire basic skills in diagnosing, managing common conditions, and preventing disease. “MLHWs can be part of the solution”.


13. NEJM Special Report  – The Human Resources for Health Program in Rwanda — A New Partnership

Agnes Binagwaho, Eric Goosby et al.;

This Special Report details Rwanda’s Human Resources for Health Program, “the largest-scale global health partnership ever initiated between American universities and a low-income country.” It’s a seven-year, $150 million collaboration between the U.S. and Rwandan government and 25 leading U.S. academic institutions. Eric Goosby and Agnes Binagwaho both serve as lead authors of the article.





14. Progress in Cardiovascular diseases – Urbanization and International Trade and Investment Policies as Determinants of Noncommunicable Diseases in Sub-Saharan Africa

Ashley Schram, R. Labonté & David Sanders;

There are three dominant globalization pathways affecting NCDs in Sub-Saharan Africa (SSA): urbanization, trade liberalization, and investment liberalization. This article explores globalization processes, the food environment, and dietary health outcomes in SSA through the use of trend analyses and structural equation modelling.


15. World Bank (Report) – Risking your Health: Causes, Consequences and Interventions to Prevent Risky Behaviors

A new World Bank report warns that risky behaviors – smoking, using illicit drugs, alcohol abuse, unhealthy diets, and unsafe sex— are increasing globally and pose a growing threat to the health of individuals, particularly in developing countries. The report looks at how individual choices that lead to these behaviors are formed and reviews the effectiveness of interventions such as legislation, taxation, behavioral change campaigns, and cash transfers to combat them.  (are we now arguing for a total war on ‘risky behaviour’? That’s a war even harder to win than the ‘War on Terror’ – I suggest, as a pilot, we start with the expat community)



Editor Damien De Walque gives some key messages in this  blog post. Check out also the Guardian’s coverage.


16. WHO – Global coordination mechanism for NCDs

Some documentation of the meeting of WHO Member States, 11-12 November 2013 on the global coordination mechanism for NCDs.


17. Lancet (Editorial) – The global dominance of diabetes

The Diabetes Atlas, published by the International Federation of Diabetes on Nov 14, World Diabetes Day, shows the seemingly relentless spread of diabetes that now affects an estimated 382 million people worldwide, a number likely to approach 600 million by 2035. 80% of those affected are in developing countries, and worryingly, the age of onset is falling.” … “Unchecked, diabetes threatens to overwhelm societies and health-care systems. Yet, the rise of diabetes is not inevitable. Societies and individuals have choices about lifestyle, food production, famine relief, urbanisation, and the built environment. Through their daily exposure to people with diabetes, its risk factors, and complications, health professionals are ideally placed to advocate for healthier choices that can reduce the prevalence and consequences of diabetes. How well they do this will be reflected in future editions of the Atlas.”



Infectious Diseases



18. UNAIDS – Ahead of World AIDS Day 2013 UNAIDS reports sustained progress in the AIDS response

Accelerated progress has been reported in most parts of the world. However, there are worrying signs that some regions and countries are not on track to meet global targets and commitments on HIV.” More attention is also needed for children and adults aged 50 and over. But record numbers of people living in low- and middle-income countries are now receiving antiretroviral treatment. Also on the bright side, despite a flattening in donor funding for HIV, which has remained around the same as 2008 levels, domestic spending on HIV has increased, accounting for 53% of global HIV resources in 2012. The total global resources available for HIV in 2012 was estimated at US$ 18.9 billion, US$ 3-5 billion short of the US$ 22-24 billion estimated to be needed annually by 2015.



The Guardian covered the two new UNAIDS reports (see  here ).


19. KFF – House Passes PEPFAR Stewardship And Oversight Act; President Expected To Sign Bill

Legislation that would extend PEPFAR for five years is proceeding smoothly, it’s almost on Obama’s desk. (the man will be relieved to hear at least something is going well in his second term).

In other HIV related news, as already mentioned above, the NYT examined some of the winners announced by the Gates Foundation “on a contest to create a condom that men would actually use”. The so called ‘Condom Conundrum’ is that only 5 percent of men worldwide use condoms despite massive public health campaigns.

20. CSIS blog – Fighting Drug-resistant Malaria with Bad Drugs

J. Christopher Daniel;

Drug resistant malaria was a major focus of attention last week at two conferences, at CSIS and the annual meeting of the American Society of Tropical Medicine and Hygiene respectively.


21. KFF – Researchers Report P. Vivax Malaria Evolving To Become More Infectious

Roughly 95 percent of people in sub-Saharan Africa  are thought to be resistant to Plasmodium vivax,  but two new genetic studies of P. vivax suggest that it may be evolving new ways to invade human blood cells. If vivax can establish itself in Africa, it can really undo a lot of the malaria progress made.


Check out also some Lancet letters in this week’s issue on the challenge of malaria elimination (see here and here ).


22. NEJM – No Country Is Safe without Global Eradication of Poliomyelitis

Trevor Mundel et al.;

This viewpoint refers to a recent (2011) 2011 poliomyelitis outbreak in China, but recent polio news has of course only confirmed further the author’s stance.



Global Fund


23. Science Speaks blog – Support antiretroviral treatment for 12 million with HIV by 2016, Republicans, Democrats urge Obama

Antigone Barton;

The heat is on for the GF replenishment. “In a powerful display of humanitarian bipartisanship, with World AIDS Day on the way, and the Fourth Replenishment for the Global Fund to Fight AIDS Tuberculosis and Malaria Conference set for the same week in Washington, DC, 40 United States lawmakers — Democrats, Republicans, Senators and Congressional Representatives — have united across party lines and legislative bodies, signing a letter urging President Obama to set this nation’s AIDS-fighting goals higher than ever, and ensure that 12 million people living with HIV are receiving treatment by 2016.”

South Korea already did its part, via innovative financing.

24. GF Board Document – New funding model: eligibility, counterpart financing and prioritization policy revision

This paper presents the proposed revisions to the current Eligibility, Counterpart Financing and Prioritization Policy in order to incorporate previous Board decisions, align with the new funding model and address issues raised at the 8th and 9th meetings of the Strategy, Investment and Impact Committee (SIIC).


Another document, ‘Strategy, investment, and impact committee decisions and recommendations to the board’ is a report that served to inform the Board about the decisions taken by the Strategy, Investment, and Impact Committee since the June 2013 Board Meeting in accordance with its Charter.

(remark: open the docs in Internet Explorer, not in Google Chrome)


In other GF related news, the latest GF News Flash discusses ‘Regional Applications in the New Funding Model’: “Diseases know no borders, so the effective response to HIV, TB and malaria sometimes requires a regional approach with cross-border interventions. Under the new funding model, the Global Fund will continue to support strategically-focused regional applications that achieve high impact, represent value for money and reach key affected populations. The new approach to funding aims to make the process of accessing funds more predictable, more responsive and more flexible. With this in mind, all regional applications will follow a two-step process under the new funding model. Applicants will first be asked to submit a short expression of interest that makes the case for their regional proposal, expected impact and funding needed. Eligible expressions of interest will then receive an invitation to submit a concept note, and applicants will also be given an indicative funding amount. During country dialogue and concept note development, the Global Fund will engage with the applicant to ensure active participation of key affected population networks and partners. In order to ensure that there is an equal opportunity to access funding set aside for regional applications, there will be two windows for applicants to express interest: one in April 2014 and the other in April 2015.”


25. Guardian – Global Fund halts contracts over bribes for mosquito bednets in Cambodia

You probably already know about this by now. Earlier this week, the New York Times also reported on the Global Fund’s suspension of contracts with two international suppliers of mosquito nets after discovering the companies had paid bribes to health officials in Cambodia.  “Although the suspensions raise the possibility that the world will not get the 200 million nets it needs in 2014, a spokesman for the Global Fund … said he was confident no shortage would develop.” Global Fund Director of Communications Seth Faison said the two companies are still fulfilling their current contracts and hopes to have seven suppliers soon.


Finally, Friends of the Global Fight, the US affiliate of the Global Fund, has released a new report titled ‘Steps Toward Sustainability’, describing progress made in fighting these diseases and establishing more sustainable communities. The report focuses on the Dominican Republic, Indonesia, Namibia, Nicaragua, Sri Lanka, and South America.

Health Policy & Financing


26. Lancet – Offline: Is global health neocolonialist?

Richard Horton;

There’s only one wa-a-a-y of life, and there’s only one Richard Horton too. Global health’s conscience explores another tricky, albeit not very new, global health question in his weekly Offline article. “Global health is a product of nations whose histories are characterised by the struggle for power, wealth, and influence. Is 21st-century global health just a polite way to decorate these repackaged colonial ambitions? This was the question posed at last week’s Global Health Lab, held at the London School of Hygiene and Tropical Medicine. ” Interesting reflection.


27. Lancet Correspondence – Germany and global health: an unfinished agenda?

Kayvan Bozorgmehr et al.;

This Letter is part of two Lancet Letters on the recently released concept note for Global Health by the German Government. See  here for the other Letter (by Olaf Müller et al.)   Meanwhile, in encouraging news from Germany itself, the minimum wage seems to be materializing, although apparently “it conflicts with Mrs Merkel’s sense of justice”.

28. Reuters – Merck brings maternity program from poor nations to U.S. as deaths rise

A sign o’ the times… Merck & Co expands its ‘Merck for Mothers’ program, which aims to reduce pregnancy-related deaths from impoverished countries such as Senegal and Zambia, to the United States.


29. Health Policy – Sexual and reproductive health of migrants: Does the EU care?

Ines Keygnaert, Gorik Ooms et al.;

The European Union refers to health as a human right in many internal and external communications, policies and agreements, defending its universality. In parallel, specific health needs of migrants originating from outside the EU have been acknowledged. Yet, their right to health and in particular sexual and reproductive health (SRH) is currently not ensured throughout the EU. This paper reflects on the results of a comprehensive literature review on migrants’ SRH in the EU applying the Critical Interpretive Synthesis review method. The authors highlight the discrepancy between a proclaimed rights-based approach to health and actual obstacles to migrants’ attainment of good SRH.

30. Lancet (Comment) – A University of the Hajj?

Abdullah S Aljoudi

Prince Khalid Al-Faisal recently proposed to establish a Hajj University. The University, to be established in Mecca, will provide education, training, and research to improve Hajj services. “The proposed new University can be seen as an example of Saudi Arabian global health diplomacy, which could be beneficial in sharing experience of international health system strengthening to control potential global public health hazards, such as poliovirus in Pakistan.”

31. Global Health: Science & Practice – Routine immunization: an essential but wobbly platform

Robert Steinglass;

Despite their vital role, routine immunization programs are taken for granted. Coverage levels are poor in some countries and have stagnated in others, while addition of new vaccines is an additional stressor. We need to strengthen: (1) policy processes, (2) monitoring and evaluation, (3) human resources, (4) regular delivery and supply systems, (5) local political commitment and ownership, (6) involvement of civil society and communities, and (7) sustainable financing. Rebalancing immunization direction and investment is needed.”


32. BMJ (news) – Obama announces fix for canceled health plans

Obamacare is in trouble (episode 67), but this time for real, I’m afraid, more in particular because now the president’s credibility seems badly damaged too. See this excellent ‘Obamacare analysis’ in the  Economist.


An obvious question then, is: if the implementation of Obamacare really becomes Obama’s political death sentence,  will this have implications for the global UHC momentum (in post-2015 discussions etc.), for example after a Republication victory in Congress mid-term elections?


Meanwhile, in another sign of the sorry times we’re in, Walmart asks customers for food support for its own (badly under-paid) employees, in Cleveland, Ohio.


33. FT – Global spending on drugs to exceed $1tn

Andrew Jack;

Global spending on prescription medicines will accelerate next year to exceed $1 trillion for the first time, fueled by the launch of more innovative drugs and rising health expenditure in emerging markets led by China.“. The projections were made by the IMS Institute for Healthcare Informatics. See also this BMJ  news article.


34. Lancet (World Report) – Typhoon Haiyan: Philippines faces long road to recovery

Yu-Tzu Chiu;

Homes, health infrastructure, and other essential services have been decimated in areas hit by Super Typhoon Haiyan, leaving millions of survivors vulnerable to illness. Yu-Tzu Chiu reports.


See also the Lancet editorial of this week: “It is far too simple to say that relief efforts during complex humanitarian emergencies must improve. It is imperative, however, that the global community works toward streamlining viable systems for increasing the speed and efficacy of responses during crises.”

35. Health Policy & Planning Debated – 2014: the year for every newborn

Lara Brearley;

2014 must be the year of the newborn. As care for newborns is a proxy for health system strength, the focus on newborns must be a catalyst for progress towards UHC.


Global Health podcasts & videos

Irene Agyepong talks about Health Systems Global and the symposia, in a very short video.

Meanwhile, Health Systems Global welcomes proposals for (more) thematic working groups. The next deadline is 1 December. Read more here: …



36. Lancet Global Health blog – Decision making in the midst of uncertainty

David Dowdy;

Great blog post.  “If there is a hallmark of global health decision making, it is uncertainty. Data from high-burden, resource-limited settings are often sparse, and the settings under which interventions are implemented are heterogeneous. Nevertheless, decisions regarding implementation of public health interventions must be made on short time scales and in diverse settings. Here we argue that, by focusing narrowly on the uncertainty in empirical data without considering uncertainty in translating those data to heterogeneous settings, the global health scientific community is selling itself short.”

37. Plos – Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise

Aziz Sheikh et al.;

Using a modified Delphi exercise, Aziz Sheikh and colleagues identify research priorities for patient safety research in primary care contexts.


38. Global Public Health – Cervical cancer and the global health agenda: Insights from multiple policy-analysis frameworks

Justin Parkhurst et al.;

Cervical cancer is the second leading cause of cancer deaths for women globally, with an estimated 88% of deaths occurring in the developing world. Available technologies have dramatically reduced mortality in high-income settings, yet cervical cancer receives considerably little attention on the global health policy landscape. The authors applied four policy-analysis frameworks to literature on global cervical cancer to explore the question of why cervical cancer may not be receiving the international attention it may otherwise warrant.

39. Social Science &  Medicine – Can social capital help explain enrolment (or lack thereof) in community-based health… –

Philipa Mladovsky et al.;

CBHI has achieved low population coverage in West Africa and elsewhere. Studies seeking to explain this point to inequitable enrolment, adverse selection, lack of trust in scheme management and information and low quality of health care. Interventions to address these problems have been proposed yet enrolment rates remain low. This exploratory study proposes that an under-researched determinant of CBHI enrolment is social capital.


40. International journal for equity in health – Lack of access to health care for African indigents: a social exclusion perspective

Werner Soors et al.;

Lack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. The authors explore if the analytical framework of social exclusion can contribute to the latter.

41. TMIH (Editorial) – Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

Victoria Simms et al.;

For the methodological people among you.



Oxford Martin School – Now for the long term: The Report of the Oxford Martin Commission for future generations

Must read, but if you lack time, read at least the Executive summary. The Oxford Martin Commission for Future Generations focuses on ‘the increasing short-termism of modern politics and our collective inability to break the gridlock which undermines attempts to address the biggest challenges that will shape our future’. It then offers a number of options on how to overcome the current gridlock.


See also this Project Syndicate article (by Pascal Lamy et al) for some  key messages of the report.



  • CGD published its annual development friendliness ‘Commitment to Development’ index (see this  blog post by Owen Barder or some key messages).




  • Finally, some nice reads on the post-2015 discussion & financing: ODI published a Rough guide on an emerging consensus (and divergence) for post-2015 goals ( see here); Charles Kenny wrote a blog post on the need for a 1 trillion financing package (see here), and check out what China might be up to in the post-2015 debate (see here).

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