Happy New Year to all of you, first of all! Hope you enjoyed the festivities and some “quality time” with your families – yes, that’s the first neoliberal concept I use in this new year, and it won’t be the last, I’m afraid. In case you don’t have a family (yet), I hope you did all you’re not allowed to do as public health people on New Year’s Eve.
If you are back at work by now, you probably still feel a bit rusty, like myself. So in this first IHP newsletter of the year, we won’t come up with “top 10 stories of 2013” etc. (with one exception) but will try to focus on the key global health news of the last two weeks.
In the last newsletter of 2013, we didn’t cover Uganda’s new (and outrageous) anti-homosexuality law yet for example (see here and here for some reactions from the global health community). Infuriated, business entrepreneur Richard Branson tweeted he won’t do business in Uganda anymore. Branson is a neoliberal role model whose behaviour we should all copy, presumably. Wonder whether he’s still doing business in Russia, by the way. Or India, for that matter.
On a more positive note, 2014 kicked off with some encouraging UHC news from the US and Indonesia, among others. Julio Frenk and colleagues wrote a characteristically thought-provoking viewpoint on global health in the Lancet, and Agnes Binagwaho et al did the same on tackling NCDs in LICs, post-2015, even offering a new catchy target.
In this week’s guest editorial, former colleague Jeroen De Man talks about an experience he had in an Indian private hospital in 2013. He’s very happy he’s still among us in 2014.
Enjoy your reading.
Kristof Decoster, Peter Delobelle, Basile Keugoung & Wim Van Damme
Quality of care in a high-standard private Indian hospital: a not so entertaining “field experience”
Jeroen de Man (MD)
From April to September 2013 I lived in India to mentor an action research project targeting primary health centers. The project originated from a partnership between the Institute of Tropical Medicine, Antwerp, and the Institute of Public Health, Bangalore. The study site of our project was Tumkur, a district of Karnataka.
When Indians ask a foreigner how it is to live in Tumkur, they usually want to hear his or her opinion about the food, the climate, the culture, … And overall, I have to say I was pretty happy about all these. Unfortunately, something happened I did not expect to happen to a healthy 29-year-old male researching health care in India. I had the opportunity to experience the Indian health services first hand, and count myself lucky I can still write an editorial about it, some months later.
What knocked me almost out? On August 26, 2013, I developed a very bad gastro-enteritis with diarrhea, high fever, signs of dehydration, and extreme weakness. This is a combination of symptoms that should be taken seriously said my friend, an Indian physician who advised me to go to a hospital. I decided to follow his advice and went to one of the well-established private hospitals in Tumkur. Since this hospital was rated among the better ones in India, I expected about the same quality of care as provided in a basic hospital in my own country, Belgium. This feeling of safety ended quickly when the physician in charge came to see me at the emergency department. He asked me a few questions (first in Hindi which I do not speak) and within less than two minutes he had decided I had to be hospitalized. No clinical examination had been done and when I asked the nurse to measure my temperature, she touched my underarm – a technique that does not seem very reliable to me – and confirmed that I had high fever. When I entered the general ward, things got worse. I developed a severe pain in my stomach and a nurse had to detach me from the intravenous fluids every 20 minutes to allow me to go to the bathroom. After having visited the bathroom a few times, the nurses were fed up with me and decided to put me on a diaper in front of the other 7 Indian patients who were lying in the same room. After an hour or two my diaper got saturated and started leaking. This resulted in a bed full of stool. I started to feel a little uncomfortable and asked the nurse to change my diaper. She told me that this was impossible at two o’clock in the morning since there was no housekeeper around and that I had to wait some time. I started feeling really uncomfortable and decided to pull off the blankets from my almost naked body. The nurses told me that this was disrespectful towards the other patients in the ward but they finally got the message and sent me to the bathroom with a new diaper. The next morning they brought me the bill which included several medicines that were never given to me. I protested but had to pay the bill. Luckily for me, the hospital reimbursed me the extra amount two days later. I decided to leave the hospital and the physician in charge gave me a prescription with antibiotics.
However, my misfortune wasn’t over yet. After having swallowed the tablets during the evening of the same day, I developed a life-threatening allergic reaction which is called “anaphylaxis” in medical jargon. During such a reaction, you develop a very quick and heavy swelling of your face and throat. And indeed, my face grew twice as big as usual, I was not able to speak anymore and breathing became very difficult. As an emergency physician I knew that this was a dangerous condition which requires an immediate injection of epinephrine (a medicine to decrease the swelling). Therefore, I returned as fast as possible to the same hospital. When I arrived, I managed to utter the word “anaphylaxis”. The physician confirmed my diagnosis – it was not difficult since it was a classic example – and I was expecting prompt administration of epinephrine. Strangely enough, instead of treating me, the physician went to see another patient. I was being monitored and I saw on the monitor that the oxygen level of my blood was slowly falling because of the difficulties with my respiration. Ten minutes after my arrival at the hospital, I still had not received the medicine I was hoping for and I was getting afraid. I gave a sign to my friends who understood that something had to be done, at least if they didn’t want me to end up in the mortality stats. Finally the nurse injected me an antihistaminic, a medicine that can be given for limited allergic reactions but which was certainly not the first choice in my case. Fortunately, I was among the lucky ones so I’m still able to reproduce this story.
Studies about quality of care in public hospitals in India report room for improvement (see for example, Rao et al, 2006; Puri et al, 2012 ). Peer reviewed literature on private hospitals is scarce, but some stories from the grey literature suggest that my experience was not an isolated one (see for example here, here and here). Private hospitals seem to be highly heterogeneous in terms of quality and poorly regulated by the government (see here for example). To uniformly increase the quality in these facilities, more stewardship from the government seems warranted.
Meanwhile, I wish you all a happy New Year! ( and glad I’m still here!)
Post-MDGs & UHC
1. Lancet (Viewpoint) – From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence
Julio Frenk et al.;
Julio Frenk, with some thinking about global health, post-2015,… need I say more? If the “Tony Blair of global health” is involved, you know you better pay attention. A must-read for the visionaries among you (and everybody else).
In a related blog post (on D+C), Andreas Wulf argues health is a global public good – and providing good health care is an international responsibility.
2. Lancet (Comment) – 80 under 40 by 2020: an equity agenda for NCDs and injuries
Agnes Binagwaho et al.;
In May 2013, the WHA approved a global monitoring and evaluation framework for prevention and control of NCDs. This framework calls for a 25% reduction in deaths from cardiovascular diseases, chronic respiratory diseases, cancer, and diabetes in individuals aged 30—70 years by 2025, or “25 × 25”. The authors of this Lancet Comment applaud this effort, but do not feel that it adequately addresses the specific health and economic burdens affecting low-income countries, nor those of poor people in middle-income countries. So they propose a complementary agenda to reduce premature mortality from all NCDs and injuries (including neuropsychiatric disorders) by 80% in individuals younger than 40 years by the year 2020, or “80 × 40 × 20”. (apparently advanced math skills will be needed to understand the post-2015 agenda)
3. Lancet (Comment) – Surgery and global health: a Lancet Commission
John G Meara et al.;
“Surgery has now reached a crucial juncture in global health. A Lancet Commission on Global Surgery is timely. A commission is needed to acknowledge surgical care delivery as a core component of health systems, and to embed surgical care within present global health initiatives and the post-2015 global health agenda. The Lancet Commission on Global Surgery will engage experts across the global health community to define the best strategies for provision of surgical care with a focus on low-income and middle-income health systems, while also recognising the major issues related to equitable delivery of high-quality surgical care in areas of conflict, disaster, and in high-income settings. The Commission will provide advocacy for definitive action and an impetus for implementation of surgical health system reform.”
4. Lancet (Editorial) – Indonesia strides towards universal health care
On Jan 1, Indonesia began the roll-out of its plan to provide UHC, the Badan Penyelenggara Jaminan Sosial (BPJS). “Their brand of coverage will draw together existing insurance services and initially provide comprehensive care to 180 million people, expanding to cover all citizens by 2019.” This Lancet editorial assesses the situation, the challenges and the prospects.
5. JAMA (Viewpoint) – Realizing the Promise of the Affordable Care Act—January 1, 2014
John E. McDonough;
Obama’s ACA finally got some good news, recently, with a few million people signing up. And January 1st was of course an important day, as this JAMA viewpoint explains in more detail.
As for UHC in India in 2014, you might want to read this short comment by K. Srinath Reddy (on UHC Forward).
6. Lancet (Correspondence) – Universal health coverage and health laws
Amir Attaran et al.;
“Rifat Atun and colleagues (July 6, p 65) described the development of universal health coverage in Turkey. Yet a transcendent point in Turkey’s achievement is easily overlooked: all the foundational reforms of the health system that made universal health coverage possible were changes prescribed by law. Simply put, law reform preceded health reform, which would have been impossible without it.”
The authors of this Letter argue: “In Turkey and elsewhere, law reform is an essential precondition for restructuring of the health-care system, especially for UHC. … For more countries to follow Turkey’s example, they will need to embrace the use of health law to expand universal health coverage. We call on WHO to renew its collection of health laws and to provide targeted advice on legal best practices to attain universal health coverage.”
This week quite some Lancet Correspondence is also dedicated to the health care reform in Turkey.
7. ODI (publication) – Future diets
Should the world go on a diet in 2014 ? There has been a dramatic increase in the numbers of overweight or obese people in the past 30 years, this new ODI publication shows. Previously considered a problem in richer countries, the biggest rises are in MICs and the developing world. ‘Future Diets’ traces how the changes in diet – more fat, more meat, more sugar and bigger portions – have led to a looming health crisis. It also looks at how policy-makers have tried to curb our eating excesses – with mixed results.
For an assessment of this ODI publication, see Mark Tran in the Guardian.
Health policy & financing
8. WHO Bulletin – January issue
The new WHO Bulletin issue has plenty of interesting stuff. In editorials, Laura A Krech et al. introduce a database for tracking the quality of medicines, and R Rampatige et al. question the validity of causes of death assigned in hospitals. In news articles, Priya Shetty reports on global efforts to halt female genital mutilation and Menelaos Tsafalios interviews Aris Sissouras on how the Greek health system is adapting to an ongoing economic crisis.
Check out also the following article in the Bulletin, ‘Principles for designing future regimens for multidrug-resistant tuberculosis’, by Grania Brigden et al. “For the first time in over 50 years, new drugs have been developed specifically to treat tuberculosis, with bedaquiline and potentially delamanid expected to be available soon for treatment of MDR cases. However, if the new drugs are merely added to the current treatment regimen, the new regimen will be at least as lengthy, cumbersome and toxic as the existing one. There is an urgent need for strategy and evidence on how to maximize the potential of the new drugs to improve outcomes and shorten treatment. We devised eight key principles for designing future treatment regimens to ensure that, once they are proven safe in clinical trials, they will be clinically effective and programmatically practicable.”
9. Economist – The new drugs war
Arguments over drug pricing are rising once again, more than a decade after the HIV medicines fight. The Economist offers some of the latest examples, and says the Trans-Pacific Partnership ( TPP ) is the biggest battlefield. No surprises what option the journal advocates. See also here.
10. Scidev.net – Activists fear trade deal’s impacts on the Pacific rim
During the Christmas holidays, I watched a couple of ridiculous Hollywood action blockbusters with my teenage son, one of them being ‘Pacific Rim’ – “think Transformers versus Sea Monsters”. The movie had, of course, a happy end.
Whether the TPP will have a happy end is far from clear, though, this Scidev.net article argues (perhaps because far more cunning lawyers are involved?).
11. NEJM (Review article ) – Global Effects of Smoking, of Quitting, and of Taxing Tobacco
Prabhat Jha et al.;
In the NEJM global health review series, this is the latest instalment, a neat review article of the global impact of smoking, quitting & taxing tobacco.
12. Plos – Editors’ Wishes for an Illuminated Season and an Open New Year
In their editorial for December 2013, the PLOS Medicine Editors reflect on recent advances in open access to medical research and identify challenges to be addressed in 2014.
In a Plos Systematic Review of systematic reviews, Maira Bes-Rastrollo and colleagues examine whether financial conflicts of interest are likely to bias conclusions from systematic reviews that investigate the evidence for the relationship between sugar-sweetened beverages and weight gain or obesity. The answer seems yes. (see also a BMJ news article on this paper).
13. TMIH – Sleeping with the enemy: the United Nations Development Programme and its position on the non-communicable disease epidemic
Anil J. Jacob et al.;
“The United Nations Development Programme’s position on NCDs is undermined by a key issue at the global institutional level. Fundamentally, the nature of the relationship between international development agencies and the tobacco industry is at odds with the professed public health priorities of the former.” The authors identify an array of conflicts of interest.
In other potential ‘sleeping with the enemy’ news, a NYT op-ed (by Adam P. Coutts et al) asks some awkward questions about the WHO in Syria. “There are very real challenges for United Nations staff members working in Syria, but the World Health Organization must respond to the claims that it refused to test the Deir al-Zour polio samples, explain why it took three months to confirm a suspected case in July 2013 and give a better account of why the area was excluded from its vaccination drive.”
14. NEJM – Asia’s Ascent — Global Trends in Biomedical R&D Expenditures
Justin Chakma et al.;
I have to say geopolitical trends are more than a bit confusing these days: “Africa is rising”, Asia is still rising too (see here on the global trends in biomedical R&D), and apparently developed countries will be back too in 2014, if economists can be believed. You need to have Robert D. Kaplan-style skills to see through all of it, these days.
Richard Horton discusses (laments?) a related topic in his weekly Offline contribution, zooming in on the fact that Europe seems to have fallen out of love with science. He also offers a solution.
15. Yale journal of Medicine & Law – The ethics of pharmaceutical testing in the developing world
Anand explores the ethical issues around the outsourcing of clinical trials to developing countries.
16. Aidspan – South Africa government under fire for failure to end drug stockouts
An article from just after the ICASA conference in Cape Town: “The great progress in South Africa’s fight against AIDS will be undermined by its inability to resolve the problems caused by drug stockouts at health facilities around the country, Treatment Action Campaign has warned. In launching the campaign group’s review of South Africa’s national strategic plan for HIV, STI and TB, Mark Heywood used the 2013 ICASA conference in Cape Town to demand swift and deliberate action by the government to end stock-outs.”
17. Scidev.net – Viral load tests ‘could transform HIV treatment failure’
In other news from the ICASA conference, MSF called for an increased use of viral load monitoring to improve treatment outcomes of HIV patients, in its latest study on testing in Africa. (check out also what our ITM colleague Lut Lynen had to say about the “implementation cascade”).
18. Global Fund – updated info on the New Funding Model
See here for the latest info on the NFM.
19. Journal of Health Services & Policy – Are we ready to build health systems that consider the climate?
Susannah Mayhew, Sara Van Belle, Michael Hammer;
This essay considers the political landscape, possible leaders and why it is necessary for health systems’ professionals to move beyond the health sector in order to secure support for health and health care systems development in a post-MDG development framework that will be defined by climate change.
20. UNAIDS – UNAIDS Board calls on UNAIDS to support countries in setting revised national targets for antiretroviral treatment access
At a UNAIDS Board meeting in the second half of December, The Board called on UNAIDS to support on-going country and international processes to set revised national targets for universal access to HIV treatment.
21. Lancet Global Health (Comment) – Global prevalence of age-related macular degeneration
Jost B Jonas;
http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70163-3/fulltext Jonas discusses the global prevalence of age-related macular degeneration, based on a new study in the Lancet Global Health.
Podcasts & videos
WHO released this ‘Happy New Year’ video, with a review of 2013 global health highlights.
22. Health Policy & Planning – An alternative mechanism for international health aid: evaluating a Global Social Protection Fund
Sanjay Basu et al.; http://heapol.oxfordjournals.org/content/29/1/127.full.pdf
Several public health groups have called for the creation of a global fund for ‘social
protection’—a fund that produces the international equivalent of domestic tax
collection and safety net systems to finance care for the ill and disabled and related
health costs. All participating countries would pay into a global fund based on a
metric of their ability to pay and withdraw from the common pool based on a metric
of their need for funds. The authors of this article assessed how alternative strategies and metrics by which to operate such a fund would affect its size and impact on health system financing.
This article was part of the January issue of HP&P
23. Health Policy & Planning – Coherence between health policy and human resource strategy: lessons from maternal health in Vietnam, India and China
Tim Martineau et al.;
“The failure to meet health goals such as the MDGs is partly due to the lack of appropriate resources for the effective implementation of health policies. The lack of coherence between the health policies and human resource (HR) strategy is one of the major causes. This article explores the relationship and the degree of coherence between health policy—in this case maternal health policy—processes and HR strategy in Vietnam, China and India in the period 2005–09.”
24. Social Science & Medicine – Health sector priority setting at meso-level in lower and middle income countries: Lessons learned, available options and suggested steps
David B. Hipgrave et al.;
Setting priority for health programming and budget allocation is an important issue, but there is little consensus on related processes. It is particularly relevant in low resource settings and at province- and district- or “meso-level”, where contextual influences may be greater, information scarce and capacity lower. Although recent changes in disease epidemiology and health financing suggest even greater need to allocate resources effectively, the literature is relatively silent on evidence-based priority-setting in LMICs. The authors conducted a comprehensive review of the peer-reviewed and grey literature on health resource priority-setting in LMICs, focussing on meso-level and the evidence-based priority-setting processes (PSPs) piloted or suggested there.
25. Journal of Public Health in Africa – Adolescent health, global guidelines versus local realities: the Sub-Saharan Africa experience
Kudakwashe Dube, Marc Van der Putten, Nitaya Vajanapoom;
“As the field of adolescent sexual and reproductive health (ASRH) evolves, further discussion and documentation of national policy and aspects of its implementation is needed to ensure effectiveness of interventions. Further research is required to foster beneficial shifts in policy advocacy, including resource allocation, and in the prioritization of adolescent programs in health and education systems, in communities and in workplaces. Adolescents are exposed to diverse interventions across all the countries under discussion; however there exist obstacles to realization of ASRH goals. In some countries, there exists a conflict of interest between national laws and global policy guidelines on ASRH; moreover national laws and policies are ambiguous and inconsistent. In addition, there have been strong negligence of vulnerable groups …” As adolescent health is rising on the agenda, this seems an important read.
26. BMC Health services research – A systematic review of barriers to and facilitators of the use of evidence by policymakers
Kathryn Oliver et al.;
The gap between research and practice or policy is often described as a problem (or worse). To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, the authors updated a systematic review.
If you want to get a feel of the EV2013 venture in Cape Town, in December 2013, check out this blog post by Conrad Tonoukouen (on the IHP blog ). He considers the programme comprised four main advantages. With plenty of action pictures !
- The Broker has some nice articles on tackling inequality to achieve inclusive growth and social protection as a global challenge.
- For some of the latest info on the SDG negotiations, check out this blog post: Every country for itself or leave no one behind? (by NYU’s Center on International Cooperation)