Navigating silos–reflections on 20 years of health policy advocacy and programme implementation in Southeast Asia

By Chris Vickery (Biography below)

The establishment of Global Health Initiatives (GHIs) has seen a massive increase in funding for, depending on how one saw it, either health system-distorting, unintegrated vertical disease control programmes, or problem-focused, results-based strategic investments in key public health interventions. Tuberculosis (TB) was among the diseases that received attention and was tackled through a vertical disease control strategy led by the Stop TB Partnership, with disease-specific country level targets, independent funding streams and separate information systems for monitoring TB indicators.

The new TB supplement in Health Policy and Planning

The supplement by Khan and colleagues, ‘Evidence to improve global tuberculosis control strategies: lessons from Southeast Asia’, which critically examined the progress and pitfalls of the global TB control strategy in Southeast Asia, resonated with me as I considered my experiences of working closely with international donors either implementing or advising on large health programmes in Cambodia over the past 20 years. The studies provide new and important evidence on ways to overcome the challenges posed by disease control programmes working in silos; this is a problem that is often levelled at countries but seldom at donor partners. In this blog, I reflect on the role of donor partner and technical advisors in creating and perpetuating silos, and share my observations on how this has had an impact on health systems.

Donor partners and silos

In the first decade of the new millennium, bilateral donors, caught up with the millennial momentum and scale of the vision of GHIs such as The Global Fund to Fight TB, HIV and malaria, GAVI – The Global Alliance Vaccine Initiative and U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) began to allocate increasing resources to vertical disease control initiatives. In Cambodia, these new resources were like steroids for the nascent post-conflict state’s national disease control programmes, which soon became largely independent of the mainstream Ministry of Health and over which the Ministry of Economy and Finance (MEF, the Treasury) had, until very recently, little or no say. A similar situation in terms of donor funding flooding into, and possibly overwhelming the strategic planning and implementation capacity of domestic institutions, is reported in the situational analysis on Myanmar. Recently, in Cambodia, the Ministry of Economy and Finance has assumed the role of Principal Recipient for the GF TB and HIV grants from the National Programmes. The importance of this step towards integration should not be underestimated. MEF has keen interest in value for money, and a clear understanding that this implies verifiable service quality.

In Cambodia, the funding pendulum soon began to swing back leaving bilateral donors with a dilemma. Many had their budgets cut after the 2008 financial crash. Often with fewer staff and fewer country programmes, a strategy of awarding fewer but larger grants became administratively attractive. The dilemma bilateral donors faced was the relative convenience of continuing to fund GHIs globally, whilst their partners and advisors were arguing at country-level for closer institutional integration of national programmes into national health systems. This has led to a situation in Cambodia and other countries in the region where in discussions and negotiations with Ministries of Health, bilateral and multilateral donors now rarely use the word “integration”. Its repetition too stridently and for too long has effectively stifled meaningful debate on this issue with Government. “Closer linkages” has become the preferred euphemism for “integration”. It is easy to see why; the donors required the establishment of these systems in the first place, they continue to fund them, and any integration of large and established semi-autonomous systems, managing millions of dollars annually, into the mainstream Ministry of Health would be a gigantic exercise in civil service engineering. The scale of such reforms is underestimated by donor partners. To say the National Programmes are empires is overstating the case, but in Cambodia as everywhere, budget control means  power and for many years it was received wisdom that the National Programmes would not relinquish their PR role (the “turkeys don’t vote for Christmas” argument). Increasing interest from MEF towards National Programme budgets that they had been barely aware of is changing the political economy.

Although the studies by Khan and colleagues provide evidence from China, Cambodia and Myanmar that a more holistic approach considering access to and quality of health services broadly is essential for improvements in TB control, there are both political economy and practical challenges in moving away from the siloed status quo. In relation to the former, the laudable Global Fund principle of country-led decision making by the Country Coordination Mechanisms (CCM) has led to an unintended consequence. Key stakeholders sitting on Country Coordination Mechanisms tend not to favour a disempowering of the vertical disease control programmes that have become the norm, so there has been an inbuilt bias towards the status quo. In Cambodia things seem to be changing with the CCC (Cambodia’s CCM) agreeing to the PR role shifting to MEF for TB and HIV. The reasons for this shift are complex, but include; MEF’s interest in service quality, National Programmes becoming increasingly weary with onerous GF reporting requirements and Donor Partner advocacy with both the National Programmes and the Global Fund.

Cambodia’s Health Equity Fund (HEF), which exempts some 3.2m poor people[1] from public health facility fees, provides an example some of the practical challenges with integration in terms of service delivery and financing. The poor are pre-identified by the Ministry of Planning and health facilities at all levels are required to waive the user fees they are entitled to charge, and invoice the HEF monthly for these exemptions. This includes all TB and HIV services that are not funded by the National Programmes, such as drugs for people awaiting confirmation of a diagnosis, but principally the waived consultation fee. However, the well-meant messaging over the years from the National Programmes, and amplified by politicians, that all HIV and TB services are provided “free” has had an unintended effect. A recent assessment[2] has shown that many health workers do not feel that they are allowed to invoice the HEF for poor people receiving these services. So, in this environment, many health workers fear the “contagion” of money being associated with any aspect of TB and HIV services because they are “free”. Health facilities where such views prevail do not invoice the HEF for providing HEF beneficiaries with TB or HIV services not covered by the National Programmes therefore they generate no revenue for these facilities. Thus there is a subtle disincentive to providing TB and HIV services to poor HEF beneficiaries’ patients, and to improving early case detection and contact screening

Conclusion

For an advisor and practitioner with responsibilities for policy advocacy, and planning strategies to navigate challenges such as the one I have described with HEFs in Cambodia, research that acknowledges political economy considerations not just as “who to speak to in MoH?”, but as a central issue in addressing health system challenges is hugely useful. It is central. As one of the studies in the supplement demonstrates though, research that address the broad issues that are relevant to policymakers and programme planners is rare. Indeed, impacts of the disease-specific, siloed approach that the global health community has embarked upon are far reaching, often influencing research agendas towards focused questions that do not consider the wider implications of disease control strategies.


[1]Who have been identified as poor by the Ministry of Planning.

[2] The relationship between HEF, TB and HIV services, URC, USAID June 2016.

Dr Chris Vickery has extensive experience in Cambodia and elsewhere in South East Asia and South Asia in the design and governance of aid instruments and strengthening health systems, notably in Health Financing. He has engaged in policy advocacy and assisted policy formulation in many low income countries. His consultancy work in Cambodia stretches back 20 years, covering pre-HSSP1, HSSP1, HSSP2 and more recently H-EQIP design and implementation. Until recently he was resident in Cambodia for six years working for several bilateral and NGO development agencies. 

Image credit: Patient Care Technician

$2.1M Investment is UK’s ‘biggest ever investment into physical causes of ME/CFS’

Written by the CureME team at the London School of Hygiene & Tropical Medicine

The CureME team at The London School of Hygiene & Tropical Medicine is delighted to announce the award of $2.1m (£1.57m) of grant funding from the United States National Institutes of Health (NIH).

The grant will fund a longitudinal study that will measure changes in the immune system and genetic profile of individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).

The new award is a renewal of an initial project, which began in 2013, also made possible by funding from the NIH. The new funding will enable the current project, which is searching for biomarkers (measurable biological characteristics) of the disease, to be extended until 2021.

Dr Luis Nacul, who leads the CureME team at LSHTM and is also responsible for overseeing the UK ME/CFS Biobank, which has been built and maintained by charity support and the funding from America, welcomed the new funding and added:

“The new grant from the NIH (US) will enable, for the first time, comprehensive prospective assessments of cases of ME/CFS at regular intervals. This greatly enhances the chances of a breakthrough in the understanding of the pathophysiology of this complex disease and the identification of much-needed biomarkers for the diagnosis of different sub-groups of patients. We very much look forward to continuing our partnership with the patient community, which has been key to the success of our research so far.”

The grant will enable the collection and storage of blood samples and clinical data from a greater number of people with ME/CFS, to add to the existing resources donated by participants with ME/CFS and multiple sclerosis, as well as healthy controls.

The Biobank is the only resource in the world that includes samples from those most severely-affected – the house-bound or bed-bound – and is the premier resource outside of the United States for the study of the disease. All participants are examined by a clinician, and must conform to the Biobank’s rigorous protocols before donating tissue samples and data.”

The UK charity, The ME Association, has been a long-time supporter of the Biobank and provides funding to support its development. Dr Charles Shepherd, the charity’s medical adviser, and chair of the Biobank steering committee, said:

“This is the biggest ever investment into the physical causes of ME and represents a significant and vital sum of money that will help scientists unravel the mysteries of this devastating illness.

The fact that the NIH has decided to provide another major grant is an important endorsement of the ME/CFS Biobank, and we would like to congratulate all the staff who have been involved in setting up and developing what has become a vital new part of the biomedical research infrastructure here in the UK.

We hope that other research groups will now start to make use of this unique resource to achieve desperately-needed breakthroughs into the cause and treatment of ME/CFS.”

The CureME team would like to thank the many participants who have contributed to the project thus far.

The research is supported by the National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) under Award Number R01AI103629. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Please see her for full details of the NIH grant, and the existing project.

Find out more about ME/CFS on the Alumni Blog.

Visit the CureME and ME Association websites for further information about CureME at the London School of Hygiene & Tropical Medicine and the ME Association involvement.

Feature image courtesy of the CureME team – picture of the CureME team in 2016.

Announcing the WHO Headquarters Leadership Team

On 3 October the World Health Organization (WHO) announced the senior officials who would form the WHO Headquarters Leadership Team under LSHTM alumnus and Honorary Fellow, Director-General Dr Tedros Adhanom Ghebreyesus. The team represents all WHO regions, and we are proud to say that two out of the fourteen new appointees are LSHTM alumni.

The new appointees are:

Dr Soumya Swaminathan, Deputy Director-General for Programmes

Jane Ellison, Deputy Director-General for Corporate Operations

Dr Peter Salama, Executive Director of Health Emergencies Programme

Dr Bernhard Schwartländer, Chef de Cabinet

Dr Naoko Yamamoto, Assistant Director-General for Universal Health Coverage and Health Systems Cluster

Professor Lubna A. Al-Ansary, Assistant Director-General for Metrics and Measurement

Dr Svetlana Akselrod, Assistant Director-General for Noncommunicable Diseases and Mental Health

Ambassador Michèle Boccoz, Assistant Director-General for External Relations

Dr Ranieri Guerra, Assistant Director-General for Special Initiatives

Dr Ren Minghui, Assistant Director-General for Communicable Diseases

Dr Mariângela Batista Galvão Simão, Assistant Director-General for Drug Access, Vaccines and Pharmaceuticals

Dr Princess Nothemba (Nono) Simelela, Assistant Director-General for Family, Women, Children and Adolescents

Mr Stewart Simonson, Assistant Director-General for General Management

Dr Joy St John, Assistant Director-General for Climate and Other Determinants of Health

ranieri-guerra-100MSc Community Health in Developing Countries alumnus, Dr Ranieri Guerra who has been appointed Assistant Director-General for Special Initiatives is a physician from Italy with more than 30 years of public health experience. Since 2014, he has served as Director-General for Preventive Health and Chief Medical Officer of the Italian Ministry of Health. He previously served as director of the WHO Collaborating Centre, and was a Medical Director of the United Nations Relief and Works Agency. He has also worked with several multilateral organizations and the Italian Ministry of Foreign Affairs. Dr Guerra has published extensively on humanitarian and emergency operations and health reform in developing and transitional countries.

princess-nothemba-nono-simeDr Princess Nothemba (Nono) Simelela, a distance learning alumna from South Africa who studied for a Postgraduate Certificate in Global Health Policy, has been appointed Assistant Director-General for Family, Women, Children and Adolescents. Dr Simelela has more than 30 years of experience as an obstetrician, academic, advocate and government official and has served in several senior leadership roles. Her most recent position was as Special Advisor to the Deputy President, including on national strategic plans concerning noncommunicable diseases. Previously, she has served as the CEO of the South African National AIDS Council, Director of Technical Knowledge and Support for the International Planned Parenthood Federation (IPFF) and Cluster Manager for HIV, TB and Sexually Transmitted Infections for the South African Department for Health. She has also sat on a number of committees and boards, including the Executive Board of the WHO, representing IPPF from 2004 to 2009 and the WHO technical committee for the development of guidelines for the prevention of mother-to-child transmission of HIV.

Read more about the other twelve new appointees on the WHO website.

Images courtesy of the World Health Organization.

Giving Tuesday 2017 is coming!

Save the date – 28 November 2017

 

#GivingTuesday is celebrated worldwide as a day to support the charities and causes that are important to you. It falls on the Tuesday after (US) Thanksgiving, Black Friday and Cyber Monday and is used as a way to give back after all the shopping and indulgence.

The London School of Hygiene & Tropical Medicine loves taking part in Giving Tuesday as a way to get the whole School community informed of and involved in the School’s LSHTM Fund; raising money for scholarships for the future leaders of global health

GTlogoThis year, you can be involved wherever you are in the world. There will be a bake sale in London, and plenty to like, share and get involved with on our Twitter, Facebook and Instagram! Look out for more details near the time, but if you want to me involved (bake a cake for our sale, for example), please contact

We can’t wait to show you what we have planned!

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Books for World Mental Health Day

October 10th is World Mental Health Day.   LSHTM Library has items on mental health classified at UJ – currently shelved in the front left corner of the Barnard Room.

Global Mental Health comprehensive booksSome books from the collection:

Global Mental Health : Principles and Practice, edited by Vikram Patel, Harry Minas, Alex Cohen, Martin J. Prince (2014).

Furthers the scientific basis of global mental health and offers practical ways of implementing programs.

And three of the editors are LSHTM professors!

Library shelfmark: UJ.S 2014

 

21st Century Global Mental Health, edited by Eliot Sorel (2013).

Epidemiology and diagnostic systems; determinants of mental health; mental health of populations; evaluating and strengthening systems; human rights, stigma, policy and the media.

Library shelfmark: UJ.RX.09 2013

 

Essentials of Global Mental Health, edited by Samuel O. Okpaku (2014).

A broad range of topics – setting up integrated mental health systems, advocacy and reduction of stigma, special populations such as child soldiers, depression and suicide and more. 

Library shelfmark: UJ.S 2014


A little more specialised:

Specialised mental health booksMental Health and Disasters, edited by Yuval Neria, Sandro Galea, Fran H. Norris (2009).

Psychopathy, resilience, interventions and case studies.

Library shelfmark: UJR 2009

 

Suicide : Global Perspectives from the WHO World Mental Health Surveys, edited by Matthew K. Nock, Guilherme Borges, Yutaka Ono (2012).

Epidemiology of non-lethal suicide behaviour with data from 100,000 study participants.

Library shelfmark:  UJXS 2012

 

Migration and Mental Health, edited by Dinesh Bhugra and Susham Gupta (2011).

A resource for improving cultural competence in clinical and policy-making settings.

Library shelfmark:  UJ.S.ZR 2011

 

Global Mental Health Trials, edited by Graham Thornicroft, Vikram Patel (2014).

Practical information on conducting randomised controlled trials evaluating care in low-resource settings.

Library shelfmark: UJ.S 2014

 

Where There is No Psychiatrist : a Mental Health Care Manual, by Vikram Patel (2003).

From LSHTM’s Professor Vikram Patel, empowering healthcare workers in under-resourced communities to build mental health care into existing services.

Library shelfmark: UJ.R.03 2003


 

Ten years on: Content, Cadres and Costs for Community Based Maternal Newborn Care

By Ninha Silva, MARCH Centre Blog Editor (MSc Public Health Candidate)

On the 3rd of October, the MARCH centre celebrated the culmination of ten years of an intervention programme on Community Based Maternal and Newborn Care (CBMNC). The occasion was marked with the launch of a series of eight papers in the last supplement of the Health Policy and Planning journal.

The eight papers that constitute this supplement are the result of a multi-country analysis of costs and health systems conducted in Ethiopia, Tanzania, Uganda, South Africa, Malawi and Bolivia. Led by the London School of Hygiene and Tropical Medicine, the South African Medical Research Council (MRC), Save the Children, UNICEF and the Makarere Centre of Excellence for Maternal Newborn & Child Health, the papers are result of a collaborative work between 38 authors, from 17 institutions.

The event, held at John Snow Lecture Theatre (Keppel Street), was chaired by Professor Joy Lawn, Director of the MARCH Centre and one of the authors of the eight papers. Joining Professor Lawn on the podium and providing an overview of the study, were Dr Emmanuelle Daviaud, lead health economist within the Health Systems Research Unit at South African MRC, Diana Barger, researcher in systems and economics at the University of Bordeaux, and Dr Tedbabe Degefie, researcher at UNICEF New York.

Since 2005, the time of design of this multi-country study, to the present date, the world has observed a considerable shift away from home births towards more facility births. However, research shows that to achieve universal health coverage and a continuous reduction in maternal and newborn mortality, there is a need for health systems to focus community contact points during pregnancy and postnatally.

Implemented in different settings, these research studies included cluster Randomised Control Trials (cRCTs) and two before and after studies. The study team explored the impact, affordability and commodities variations of CBMNC, with the aim to inform policy makers and scale up.

The primary aim of the programme was to analyse costs of the Community Based Maternal and Newborn Care from a provider perspective. To ensure comparability between countries, the study team developed the excel based Cost of Integrated Newborn (COIN) Care tool.

Dr Emmanuelle Daviaud explains that results of the study show that routinely implementing this model of care would translate to an additional annualized financial cost of health expenditures as low as $1 per capita total population in Ethiopia, Uganda and Bolivia. She continues explaining that countries such as Malawi and Tanzania, where “health expenditure per capita is very low, that percentage [of additional health expenditures] looks much higher”.

With more than 5000 Community Health Workers (CHW) trained or assessed throughout the ten years of intervention, results suggest that fixed costs of the programme (such as training, supervision, incentive, and kits) represent “at least 97% of financial costs in four countries and 63% in South Africa”.

Additionally, the authors argue that for the programme to be highly cost-effective, all countries studied would need to avert less than one additional neonatal death per 1000 live births, with exception to Uganda where the requirement would be 1.5 additional averted deaths per 1000 live births.

The launch of the HPP supplement provided space for panellists Dr Josephine Borghi, Dr Claudia Hanson and Dr Donat Shamba to contribute to the discussion and results of the multi-country study.

The Editor in Chief of the journal, Sandra Mournier Black, also marked her presence in the event explaining that the supplement not only “fits with the ambition of the journal”, but also brings “important policy and health research practice and evidence to policy makers”.

If you have missed the launch of the Health Policy and Planning supplement, you can listen to the recording here and find infographic here.

OA Week Competition: Emoji Your OA Research

To help celebrate Open Access Week, we are running a competition to find the best emoji-based tweet about open access LSHTM research. To have a chance of winning a £25 Amazon.co.uk voucher, tweet a summary of your research only using emojis.

For example the following represents the School’s RDM Policy, which can be found in Research Online http://researchonline.lshtm.ac.uk/612422:-

 emojicomp

Eligibility: Your research must be available in LSHTM Research Online, and your tweet must include the LSHTM Research Publication Team’s Twitter handle (@LSHTMopenaccess), the OA Week handle (#OAWeek) and a link to your open access paper in LSHTM Research Online.

In addition, you must be a current LSHTM staff member or student, and tweets must be made from your own Twitter account before 10am (BST) on Friday 27th October 2017. During Open Access Week we will retweet some of our favourites and we will pick one winner, to be announced via our Twitter page on Friday afternoon.

Open Access Week 2017

The International Open Access Week is held annually to celebrate and further promote the principles of the open access movement. Local events and online activities are organized by a variety of organizations, including universities, publishers and societies. This year’s theme is “Open in order to…”, which asks us to think about the concrete benefits of making research available open access. These benefits may include reaching a wider audience (which may include non-academics), boosting the academic and societal impact of scholarly work, and making it more likely that research findings are adopted in to policy and practice.

oa week

Image: openaccessweek.com, available under a CC BY 4.0 license

To help celebrate Open Access Week 2017 (23-29th October), the Library’s Research Publication Team invite you to participate in a variety of online and in-person events. There will also be plenty going on around London, so be sure to follow the #OAWeek hashtag on Twitter.

 

Film Screening: The Internet’s Own Boy: The Story of Aaron Swartz 

The Internet’s Own Boy presents the life of Aaron Swartz, the computer programmer, writer and activist who campaigned for a free and open internet. This film is particularly pertinent in its exploration of access to information, as Swartz was indicted by US courts on various charges relating to accessing scholarly articles. It features interviews with key figures and colleagues, as well as his friends and family, telling the story of his work, campaigns and legal battles up to the end of his life at age twenty-six.

The film will be shown between 12-2pm in the John Snow Lecture Theatre (Keppel St.) on Friday 27th October. All welcome. Please register here: bit.ly/2xW8iiX

 

Competition: Emoji Your OA Research 

To help celebrate Open Access Week, we are running a competition to find the best emoji-based tweet about open access LSHTM research. To have a chance of winning a £25 Amazon.co.uk voucher, tweet a summary of your research only using emojis. See more details and rules here.

 

Open Access Drop-In 

Members of the Research Publications Team and the Research Data Manager will be available in the Dean’s Office in the Faculty of Public Health and Policy, Tavistock Place, between 10am-12pm on Tuesday 24th.

We will be available to answer any questions about open access and open data, including securing funding for open access fees (“gold open access), and how to make your work open access if you do not have funding available (“green” open access). We will also be able to provide information on related issues like promoting your research online and ORCID.

 

Marketplace Stand 

During the LSHTM new staff induction day on Thursday 26th between 1.45pm-2.45pm, members of the Research Publications Team and the Research Data Manager will be able to answer questions on open access for new staff.

 

Blog and Twitter 

Visit our blog during International Open Access Week to read a range of views from the Research Publication Team and others on the various benefits and impacts of open access. We will explain how open can help you to better promote your own research, improve the scientific process, and better research non-academic audiences. We will also present some of our favourite tools and resources to help promote and disseminate your open access work.

Universities, research organisations and publishers around London tend to hold free-to-attend events during open access week. So also visit our Twitter (@LSHTMopenaccess), where we will retweet some of the international goings-on, as well as local events and news you may be interested in.

2 – 8 October 2017

A study led by Ajay Aggarwal that finds surgical cancer units invest heavily in unproven technologies to attract patients was reported by the Daily Mail and The Times (£). Quoted by the Daily Mail, Ajay said: “We have to accept there is a market within the NHS. People are choosing and providers are providing. But they are not given the evidence that what they are choosing is any better.”

Val Curtis is interviewed live on BBC World TV’s Talking Business on the hygiene of banknotes, coins and cards: “Don’t be worried about these [banknotes], be very worried about people who don’t wash their hands after they’ve been to the toilet…but banknotes aren’t going to make you sick.”

Val also speaks to Ireland’s NewsTalk Radio on the human evolution on the emotion of disgust and feelings of revulsion.

Andrew Bastawrous provides comment to SciDev.net on a new study that shows sub-Saharan African and South Asia have the highest percentage of blind older people worldwide: “Governments need to prioritise good vision for all the population, help develop novel treatments, and boost research to understand the barriers and solutions in a wide variety of systems.”

Peter Piot is quoted by Drug Delivery Business News and Pharmacy Choice on a $45m funding award to Janssen Pharmaceutical, support the development of an Ebola vaccine: “These ongoing outbreaks demonstrate the importance of disease surveillance and management, the value of strong health systems, and the need to finish the job of developing safe and effective vaccines.”

Database of Social Protection & Disability in Asia-Pacific & Africa

In 2015, a review was undertaken of social protection programmes to identify those that were either disability targeted or had some element of disability inclusion within their design. The review covered social assistance, social insurance and labour market programmes in Asia-Pacific and in Africa, and used a two-stage process:

– In the first stage, countries were screened for inclusion, using set criteria (e.g. population size, social protection coverage, presence of formal social security disability benefits). 

– In the second stage, programmes in countries selected were identified using regional and global social protection databases and other key sources, such as State Party Reports to the Committee on the Rights of Persons with Disabilities. 

Data was extracted based upon a standardised set of themes and sub-themes, including both general programme information and disabilty specific data (name and type of programme, benefits provided, number of beneficiaries with disabilities etc). 

The full database is available here.

This work was funded by DFAT.

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