Health Systems

ASTMH Kicks Off 2017 Annual Meeting by Premiering Its First Society-Level Medal Named After A Female Icon In Tropical Medicine

This blog post was written by Doug Dusik, Senior Communications Executive, American Society of Tropical Medicine and Hygiene (ASTMH)The American Society of Tropical Medicine and Hygiene, founded in 1903, is the largest international scientific organization of experts dedicated to reducing the worldwide burden of tropical infectious diseases and improving global health. The organization accomplishes this through generating and sharing scientific evidence, informing health policies and practices, fostering career development, recognizing excellence, and advocating for investment in tropical medicine/global health research. ASTMH is a 2017 Global Health Council member.

The American Society of Tropical Medicine and Hygiene (ASTMH) kicked off its 66th Annual Meeting in Baltimore on Sunday by presenting a new honor and first for the Society: the Clara Southmayd Ludlow Medal, the first named after a female icon in tropical medicine. The ASTMH Council recognized the absence of a Society-level medal named after a woman as an oversight and announced its plans at the 2016 Annual Meeting, soliciting nominations earlier this year. The new medal recognizes honorees of either gender for their inspirational and pioneering spirit, whose work represents success despite obstacles and advances in tropical medicine. The medal was named for Clara Ludlow (1852-1924), the Society’s first female member and its first non-MD member, an entomologist with scientific zeal and tenacity who battled the odds of age, gender and skepticism of women in the sciences to advance the understanding of tropical medicine.

• Front of ASTMH’s new Clara Southmayd Ludlow Medal, its first named after a female tropical medicine icon.

The medal’s first recipient selected is Ruth S. Nussenzweig, MD, PhD, of New York University of Medicine, whose extraordinary contributions forever changed malaria vaccine research at time when it was thought that a malaria vaccine was impossible. Her work, with husband and collaborator Victor Nussenzweig, showed otherwise, paving the way for today’s malaria vaccine efforts. Dr. Nussenzweig was unable to attend the awards ceremony but her son, Andre, accepted the medal on his mother’s behalf. Also in attendance were Dr. Nussenzweig’s grandsons, Julian and Samuel.

• Back of the Ludlow Medal bearing the name of its first recipient, Ruth S. Nussenzweig.

The Society was equally delighted to have two family members of Clara Ludlow: Elizabeth Thomas and Sarah Brown Blake. Elizabeth Thomas is a second-year doctoral student in the Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health in Baltimore, and Sarah Blake Brown is a Postdoctoral Scholar at the Betty Irene Moore School of Nursing at the University of California, Davis. Her professional nursing experience is rooted in community and public health with a focus on Maternal Child & Adolescent Health. Clearly, the spirit of Clara Ludlow is in their DNA.

Elizabeth and Sarah bestowed the Ludlow Medal on Andre Nussenzweig. ASTMH President and awards ceremony moderator Patricia F. Walker, MD, DTM&H, FASTMH, described it as a way of history connecting to the past.

The ASTMH Annual Meeting continues through Thursday, when National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD, will deliver a special plenary session. Other highlights included a keynote address by Paul Farmer, MD, PhD, Co-founder and Chief Strategist of Partners In Health (PIH) and a chance for attendees to give back to the global health community by receiving their annual flu shot via Walgreens’ Get a Shot. Give a Shot.® campaign through the United Nations Foundation’s Shot@Life campaign.

 

The Complex Truth of Health Tech: Why Greater Ultrasound Availability Doesn’t Always Benefit Patients

This post originally appeared on the NextBillion website. This guest post was written by Catharine Taylor, Vice President of Health Programs at Management Sciences for Health (MSH), along with fellow colleagues Dai Hozumi, Senior Director for Health Technologies and Joann Paradis, Strategic Communications Advisor. MSH is a nonprofit global health organization and Global Health Council member organization. 

A pregnant woman is given an ultrasound. (Photo Credit: Rui Pires)

Advances in health technologies have reshaped the lives of communities, families and individuals, undoubtedly contributing to better health outcomes around the world. For the most vulnerable populations, technology may significantly improve access to preventive, diagnostic, and treatment services and help increase demand for greater quality care. Yet, despite their potential, new technologies can also add new challenges, risking potential gains in quality, safety or cost. Particularly in settings where health systems are weak, the introduction of technological interventions requires thoughtful execution.

Take the case of ultrasound technology. Used during routine antenatal visits, ultrasound scans have the potential to change the scenario for many pregnant women who face complications. If combined with proper skills, knowledge and quality-assurance, this technology could help identify high-risk pregnancies and establish an accurate gestational age in order to improve obstetric care. Many low- and middle-income countries are seeing a rapid introduction of this technology into their health systems, accelerated by a dramatic rise in demand that has been driven in part by medical staff, local advertising, falling prices, and a greater availability and range of ultrasound devices.

Yet ultrasounds are not proven to lead to better outcomes for women and newborns in low-income countries, and without the proper focus on their introduction and use, we risk the efficiency and effectiveness of health systems and expose women and newborns to unnecessary technological interventions. That’s why, just last year, the World Health Organization (WHO) issued recommendations on antenatal care endorsing one scan in early pregnancy in low-income countries alongside guidance for staff training and proper use of this technology.

THE REALITIES ON THE GROUND

We recently visited a health center in the outskirts of Kampala, Uganda’s capital city, which had just introduced an ultrasound machine for antenatal care. Like many others, the doctor at this health center was looking to take advantage of this imaging technology to provide better care to his patients. Despite the guidelines calling for only one ultrasound scan in early pregnancy, a woman we met proudly shared with us four photographs she obtained through repeated scans, even though there were no abnormalities or issues identified throughout her pregnancy. We’ve encountered instances like these in several countries, bringing into question essential governance aspects including the right policies, oversight, and mechanisms for evidence-based decision-making, and highlighting potential ethical issues around the use of this technology. Was the doctor equipped with the right skills or understanding behind the proper use of ultrasound? Were there additional unnecessary costs and burdens for the woman and her family, who may have been lulled into a false sense of security that repeated scans would ensure a better outcome for mother and baby?

Given the WHO recommendation and the ubiquity of ultrasound devices, the real question becomes: How do we ensure health systems are robust enough to effectively and safely take advantage of this technology?

There appear to be major gaps in policies, planning and oversight to support the introduction of ultrasound technology, especially outside the more specialized hospital setting. At Management Sciences for Health, we support governments in their efforts to build strong adaptive systems that meet the needs of the populations they serve. The case of antenatal ultrasound highlights three specific issues:

Adequate procurement and a strong supply chain: Our experiences in helping governments improve procurement and supply chain management highlight critical issues that affect how technology takes root and delivers on its potential. Ultrasound technology has advanced to allow for different types of imaging and functionalities, ranging in price from USD $2,000 to $15,000. Determining which one meets the specific needs of a local health system requires thoughtful procurement policies and effective distribution and placement. In addition to regular supplies such as jelly, paper towels, printers, etc., the processes and costs required to maintain the accuracy and sensitivity of the ultrasound equipment, including servicing malfunctioning machines, must be carefully considered within health systems – and these are influenced by the machine specifications. Of course, power supply requirements are also important considerations for health centers that frequently experience electricity outages and voltage fluctuations.

A well-functioning referral mechanism: Because the effectiveness of this intervention relies on the ability of screened women to seek care depending on the screening results, it is also essential for a functional referral system to be in place. Health workers and sonographers must be able to support informed decision-making, and women with high-risk pregnancies must be able to reach the referral hospital – one which must be equipped to handle the level of care that screening indicates, including emergency obstetric and newborn care. The value of the ultrasound screening is diminished when this is not in place, or when women are unable to cover the additional costs of transportation and hospital care and treatment. As illustrated in a study published recently on the implementation of ultrasound technologies in the Democratic Republic of Congo, these challenges represent enormous barriers for the most vulnerable populations.

Strong governance for health: As a screening tool, the ultrasound depends on a process or a decision-making algorithm that allows health workers to adequately act on the information gathered. Nurses and midwives – the cadres who might typically perform this intervention at health centers – must have the policies, consistent training and ongoing supervision to use the technology, analyze the results and take appropriate actions. These elements, and a sound system of quality assurance and data management, will protect the health of women and newborns and prevent health workers from misdiagnosing patients.

Above all, to realize the power of technology in any setting, but most importantly in low-resource countries, we must understand their specific circumstances, and support governments to establish appropriate policies, good governance, and ethical standards as a foundation for appropriate use of technology. This requires structural changes within the health system, and partnership with businesses involved in the manufacturing and selling of ultrasound devices. Only then can we ensure that ultrasound technology – or any technology – delivers on its promise.

 

Strengthening Sierra Leone Health Systems: Applying Lessons from the 2014 Ebola Outbreak to Future Emergencies

This guest post was written by Laurentiu Stan (laurentiu_stan@jsi.com), MD,MPH, MBA, Chief of Party, Advancing Partners and Communities (APC) Project, Sierra Leone, JSI Research & Training Institute, Inc. John Snow, Inc., a member of Global Health Council (GHC), and the nonprofit JSI Research & Training Institute, Inc., are public health management consulting and research organizations dedicated to improving the health of individuals and communities in the US and around the globe.

Zainab Jalloh, holding her one-year-old daughter Khadijatu, at the Gbanti Community Health Post (CHP) on April 3, 2017 in Bombali District, Sierra Leone.

I’ve lived in Sierra Leone for almost two years, working to help this country’s long-battered health system recover from the Ebola outbreak that took the lives of more than 200 health professionals. Now the country has been affected by an epic landslide. Despite these tremendous setbacks, health systems and health indicators are improving.

Even before the Ebola Virus Disease (EVD) outbreak, Sierra Leone had the world’s highest maternal mortality ratio: 1630 of 100,000 live births (UNICEF, 2010). By 2015, the ratio had dropped to 1360, but Sierra Leone still held the top spot in this dismal measurement. Ebola compounded the problem because about 1 in every 4 women stopped coming to clinics for prenatal care and delivery. In fact, although almost 4,000 Sierra Leoneans died due to the EVD outbreak (between May 2014 and January 2016), during that same period more than 4,500 women died in childbirth.

The Ministry of Health and Sanitation (MOHS) focused its post-Ebola health recovery priorities on strengthening the health system’s capacity to safely detect and prevent diseases and respond to future epidemics in cooperation with its neighbors. It also recognized the need to contribute to global health security to improve health and economic opportunities.

A health facility water pump before APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

Between September 2015 and August 2017, under the umbrella of the USAID-funded and JSI-managed Advancing Partners & Communities (APC) project, I have helped implement a number of programs that are contributing to MOHS recovery objectives by improving primary care service delivery in the communities hardest hit by Ebola. APC has revitalized 305 primary care facilities, ensuring access to basic health services—with a focus on improving quality of maternal health services—for almost 2 million Sierra Leoneans, including the 3,400 registered Ebola-survivors.

A health facility water pump after APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

APC’s community health facility upgrades dramatically improved water and sanitation standards, installed solar power systems, provided basic equipment, and trained more than 900 health professionals and 1,500 community health workers (CHWs) on reproductive, maternal, newborn, and child health and as—importantly, given how Ebola was spread—infection prevention and control practices. Today, more than 2 million Sierra Leoneans in five districts have access to revitalized primary care and community health services in these primary care units and their catchment villages.
We know that another epidemic or emergency could come at any time, and while the Sierra Leone health system is going through significant transformations as part of the five-year recovery plan, it is better equipped now to address it.

The tragic August 14 landslide was just such an emergency—and the new systems that the U.S. government has invested in are working. The emergency coordination and resource mobilization mechanisms put in place with CDC support reacted well and fast. Mental health nurses who were trained to support Ebola survivors are providing psychosocial support to the several-thousand people who lost homes and relatives: more than 1,000 people died in the landslide. The CHWs recently trained by APC have undergone a 15-day social mobilization exercise to identify and convey messages on the prevention of cholera and other waterborne diseases to at-risk populations. With USAID and DfID support, JSI is assisting the MOHS relief efforts with emergency delivery of essential pharmaceutical and medical consumables to one area hospital and six primary care units.

This most recent tragedy has demonstrated that the country’s service delivery system has improved. One year after the outbreak ended, the MOHS data showed about a 10% positive change in uptake of facility deliveries and outpatient services in the four districts where 70% of Ebola survivors live. Now that health facilities have been revitalized, and health care workers are providing higher-quality services, we are seeing more and more Sierra Leoneans returning to their local health facilities.

There is still much to be done, of course. But Sierra Leone is on its way to a health system that meets the needs of its people—and, given the toll that Ebola took, is ready to confront the next infectious disease—be it Ebola or some other virus—with stronger, better prepared health services. And that helps us all.

Community Health Workers: A Priority for Universal Health Coverage?

This guest post was written by Colin Gilmartin, Senior Technical Officer at Management Sciences for Health (MSH), a nonprofit global health organization and GHC member organization. Gilmartin specializes in health care financing and the planning and costing of community-based services. He can be followed on Twitter, @colingilmartin. MSH’s mission is saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.

Community Health Volunteer in a remote village of Tulear, Madagascar, giving instructions to a client on the use of pregnancy tests. Image by Samy Rakotoniaina/MSH

How countries can move toward building sustainable community health programs.

Universal health coverage (UHC) is increasingly recognized as the best way to achieve the Sustainable Development Goal targets on health. But with 400 million people lacking access to essential health services and a projected shortage of 18 million health workers, it will take unprecedented effort and funding. Community health workers (CHWs) could be an important part of the solution—but without effective investments and sound planning, we will fall short of achieving UHC.

Many low- and middle-income countries rely on a robust community health workforce, but few are self-sustaining and many rely heavily on external donors. CHWs fill critical gaps while delivering quality, affordable services closer to underserved patients. Even during crises, such as West Africa’s Ebola outbreak, CHWs can ensure the continuity of services while helping to stop epidemics.

As a 2015 report shows, CHWs can also yield a sound 10-to-1 return on investment, when accounting for a healthier population’s increased productivity and formal employment and the prevention of costly health crises. Expanding access to community services could prevent up to 3 million deaths annually while substantially reducing patients’ out-of-pocket costs.

Recognizing these benefits, low- and high-income countries alike are developing and expanding CHW programs. In Ethiopia, Community Health Extension Workers (CHEWs) proved instrumental in reducing maternal and child deaths and in meeting nearly all of the country’s 2015 Millennium Development Goals on health. Countries including Ghana and Sierra Leone are training and deploying a combined 35,000 CHWs to bridge gaps. Even in American cities like Philadelphia, CHWs are delivering evidence-based health interventions to high-risk patients while reducing overall health care costs.

While CHWs are not a new concept, the recent momentum for scaling CHWs raises an important question: will they be a long-term investment or simply a palliative solution to achieve short-term results?

Amid competing funding priorities and uncertainty around foreign assistance, countries show reluctance to invest in community health systems. CHWs are often unpaid volunteers, lack a career path, and are rarely considered part of the formal health workforce. These factors, combined with growing demand for their time, contribute to high rates of attrition. Further, in the absence of proper planning, frequently there is no funding for ongoing training, program support, and supervision of CHWs. This can lead to low-quality services or, worse, a complete stoppage of services in the most challenged communities.

To achieve UHC and the health SDG targets, long-term community health planning is essential—and along with helping countries identify solutions to meet health goals, it provides an opportunity to evaluate progress and make improvements. Planning can also help countries identify the costs and resource needs to sustain CHWs, including medicines and supplies; equipment; incentives; training; as well as program management, supervision, and reporting. It also cuts down on duplicative efforts among partners.

To facilitate this process, the NGO where I work, Management Sciences for Health, partnered with UNICEF to create a Community Health Planning and Costing Tool that helps calculate the costs of delivering comprehensive community health services for up to 10 years. To-date, the tool has helped plan the long-term implementation of national community health programs in Madagascar, Malawi, and Sierra Leone.

Understanding the costs and required financing for large-scale community health programs helps governments more effectively advocate for domestic and external funding sources, including the private sector. Plus, identifying funding gaps can help countries pool different sources to ensure that health programs operate fully and consistently.

As countries move toward building and sustaining national community health programs, they should consider a few key takeaways.

First, long-term financing plans should be developed to support continuous services and funding for all elements of a community health program. While domestically-financed programs may prove unrealistic for many countries, there are opportunities to leverage existing initiatives and donor funding. For example, in Rwanda, CHWs are integrated into the country’s national performance-based financing scheme, which provides incentives to fund income-generating activities. Other countries leveraged multi-year Global Fund support to cover antimalarial medicines, rapid diagnostic tests, training, and incentives.

Community health program funding should work to strengthen health systems overall. Embedded in weak health systems, CHWs programs will be ineffective and investments will fall flat. CHWs will only succeed when all building blocks are performing. For example, programs must reinforce strong supply chains, a dynamic supervisory and management workforce, and an effective flow of health information.

As frontline health workers, the CHW role should also be institutionalized in national health systems. Along with clearly defined responsibilities, they should receive ample recognition, incentives, and professional development opportunities. By doing so, countries can improve the quality of service delivery, ensure greater accountability to their communities, and increase CHW retention.

Lastly, we must continue to demonstrate the impact of CHWs and draw lessons. To strengthen the investment case for CHWs, we must go beyond demonstrating achievements of process indicators and coverage metrics and document how effectively CHWs improve patient outcomes, reduce costs to health systems and patients, and contribute to health milestones and targets. By sharing experiences and lessons-learned, other countries might avoid shortcomings and adapt program successes to address their health priorities.

This article was originally published in Global Health NOW. Join the thousands of subscribers who rely on Global Health NOW summaries and exclusive articles for the latest public health news. Sign up for the free weekday e-newsletter, and please share the link with friends and colleagues: http://www.globalhealthnow.org/subscribe.html.

NCD Child’s Approach to Advocacy: Putting Children First

This guest post was written by, Jonathan D Klein, MD, MPH, FAAP, Executive Director, NCD Childa a global multi-stakeholder coalition championing the rights and needs of children, adolescents, and young people living with or at risk of developing non-communicable diseases (NCDs). NCD Child is a member of the Global Health Council.

NCD Child is a global multi-stakeholder coalition championing the rights and needs of children, adolescents, and young people living with or at risk of developing non-communicable diseases (NCDs).  Their message to civil society, governments, and WHO is unwavering – children are not small adults.  They require unique services, yet many national and global health policies fail to adequately account for these distinctive needs.  NCD Child actively engages and collaborates with governments, multilateral organizations (ie, WHO, UNICEF, other UN agencies), civil society, the private sector, and academic institutions to promote awareness, education, prevention, and treatment of NCDs in children, adolescents, and young people.  They support child health advocacy and policy at the global level via WHO and the UN as well as at the country-level through civil society and individual champions.  They are committed to involving youth voices across all their work, from engagement in the NCD and Sustainable Development Goal (SDG) agendas to their own governance and program activities.

Young people’s access to essential medicines and technologies for special health care needs are a particularly alarming and growing concern.  To tackle this challenge, NCD Child launched a Taskforce on Essential Medicines and Technologies during the 2017 World Health Assembly.  Whether it is insulin, an asthma inhaler, chemotherapy, heart surgery, or simple antibiotics, poor access or lack of availability to safe and appropriate medicines and technologies for children, adolescents, and young people hinders their chances of living healthy, productive and long lives.  There are several challenges to consistent, safe access to essential medicines and technologies – drug shortages, appropriate dosages for children, challenges in drug delivery, technology incompatible with systems, and products excluded from the WHO Essential Medicines for children lists.  The new taskforce, chaired by Dr. Kate Armstrong, Executive Director of CLAN (Caring & Living as Neighbors) and founding Executive Director of NCD Child, includes a diverse group of experts from government, academia, and civil society.  Kate’s vision that all children living with chronic health conditions should be afforded the same opportunities and quality of life as other children, helped NCD Child frame their mission and goals towards a rights-based approach to universal access and population health.  For the taskforce, this means addressing consistent, equitable, and affordable access to essential medicines and equipment for all children, adolescents, and young people living with NCDs – including attention to the rights and needs of all young people with special health care needs.  The initial report, scheduled for 2018, will discuss common barriers to access and propose collaborative, practical strategies to address the gaps.

Practically, this means NCD Child wants policies ensuring that the health needs of young people are always included in health systems planning and accountability.  They recognize to affect policy, governments and other advocates need to fully appreciate why it is important to include children, adolescents, and young people.  How do current policies and frameworks exclude them?  What is the potential impact of not tailoring policies, health education, and health systems?  How many lives can be saved, improved, and extended if policies addressed the needs of all ages across the entire life-course?  The taskforce will serve to amplify NCD Child’s concerns by developing resources to educate governments, help guide policy development, and contribute to the WHO Essential Medicines list.

Prevention and treatment of NCDs helps children, adolescents, and young people live life to their fullest potential. These investments are also critical to successfully addressing preventable maternal and child deaths, and to effective, sustainable development.  At the July High Level Political Forum on SDGs, Dr Nata Menabde, Executive Director of WHO at the United Nations, closed the review of the health goal by noting that “every minister should be a health minister.”  When it comes to health in all policies, “put children first” is essential to all plans, whether for health systems, NCDs, or other global goals.

For more information and to sign up for the NCD Child listserv, visit www.ncdchild.org.