Economic benefit of tuberculosis control

Tuberculosis is the most important infectious cause of adult deaths after HIV/AIDS in low- and middle-income countries. This paper evaluates the economic benefits of extending the World Health Organization's DOTS Strategy (a multi-component approach that includes directly observed treatment, short course chemotherapy and several other components) as proposed in the Global Plan to Stop TB, 2006-2015. The authors use a model-based approach that combines epidemiological projections of averted mortality and economic benefits measured using value of statistical life for the Sub-Saharan Africa region and the 22 high-burden, tuberculosis-endemic countries in the world. The analysis finds that the economic benefits between 2006 and 2015 of sustaining DOTS at current levels relative to having no DOTS coverage are significantly greater than the costs in the 22 high-burden, tuberculosis-endemic countries and the Africa region. The marginal benefits of implementing the Global Plan to Stop TB relative to a no-DOTS scenario exceed the marginal costs by a factor of 15 in the 22 high-burden endemic countries, a factor of 9 (95% CI, 8-9) in the Africa region, and a factor of 9 (95% CI, 9-10) in the nine high-burden African countries. Uncertainty analysis shows that benefit-cost ratios of the Global Plan strategy relative to sustained DOTS were unambiguously greater than one in all nine high-burden countries in Africa and in Afghanistan, Pakistan, and Russia. Although HIV curtails the effect of the tuberculosis programs by lowering the life expectancy of those receiving treatment, the benefits of the Global Plan are greatest in African countries with high levels of HIV.Health Monitoring&Evaluation,Disease Control&Prevention,Population Policies,Health Systems Development&Reform,Poverty and Health

Funders: the missing link in equitable global health research?

Global health research is mired by inequities, some of which are linked to current approaches to research funding. The role of funders and donors in achieving greater equity in global health research needs to be clearly defined. Imbalances of power and resources between high income countries (HICs) and low- and middle-income countries (LMICs) is such that many funding approaches do not centre the role of LMIC researchers in shaping global health research priorities and agenda. Relative to need, there is also disparity in financial investment by LMIC governments in health research. These imbalances put at a disadvantage LMIC health professionals and researchers who are at forefront of global health practice. Whilst many LMICs do not have the means (due to geopolitical, historical, and economic reasons) for direct investment, if those with means were to invest more of their own funds in health research, it may help LMICs become more self-sufficient and shift some of the power imbalances. Funders and donors in HICs should address inequities in their approach to research funding and proactively identify mechanisms that assure greater equity–including via direct funding to LMIC researchers and direct funding to build local LMIC-based, led, and run knowledge infrastructures. To collectively shape a new approach to global health research funding, it is essential that funders and donors are part of the conversation. This article provides a way to bring funders and donors into the conversation on equity in global health research

The quest for universal access to effective malaria treatment: how can the AMFm contribute?

Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin

Integration of priority population, health and nutrition interventions into health systems: systematic review

Objective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes. Systematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria. Of 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models. Targeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery

Essential obstetric care: Assessment and determinants of quality

This paper reports on a study to develop and to apply methods for measuring the quality of essential obstetric care (EOC) in health centers. Based on a Nigerian guideline and an international guideline, and in consultation with local experts in primary care obstetrics, norms were established for equipment, personnel, supplies and the process of EOC, focusing on critical tasks. A combination of assessment methods was used, including observation of tasks performed during intrapartum care; use of data from records of care kept by midwives during the period of observation; use of data from records kept by midwives in the calendar year preceding the period of observation; exit interviews with clients; and inventories of equipment and supplies. Twelve health centers in three Local Government Areas (LGAs) and 360 clients in labor were included in the study. Quality of care was measured quantitatively as a score, calculated for each task and for each delivery in the health center. The results show that the methods developed are useful for: identifying quality score differences among health centers, and the effects of methods of assessment on quality scores; identifying aspects of EOC requiring improvements within each health center; and identifying factors influencing the quality of care, as a basis for effective quality improvement efforts. Regression models show that the most consistent and important predictor of quality scores is the use of printed forms (i.e. routine records of labor) during intrapartum care. Printed forms served as job aids, providing prompts that reminded midwives to perform specific tasks.quality essential obstetric care maternal mortality methods Nigeria

Integration of targeted health interventions into health systems: a conceptual framework for analysis

The benefits of integrating programmes that emphasize specific interventions into health systems to improve health outcomes have been widely debated. This debate has been driven by narrow binary considerations of integrated (horizontal) versus non-integrated (vertical) programmes, and characterized by polarization of views with protagonists for and against integration arguing the relative merits of each approach. The presence of both integrated and nonintegrated programmes in many countries suggests benefits to each approach. While the terms 'vertical' and 'integrated' are widely used, they each describe a range of phenomena. In practice the dichotomy between vertical and horizontal is not rigid and the extent of verticality or integration varies between programmes. However, systematic analysis of the relative merits of integration in various contexts and for different interventions is complicated as there is no commonly accepted definition of 'integration'-a term loosely used to describe a variety of organizational arrangements for a range of programmes in different settings. We present an analytical framework which enables deconstruction of the term integration into multiple facets, each corresponding to a critical health system function. Our conceptual framework builds on theoretical propositions and empirical research in innovation studies, and in particular adoption and diffusion of innovations within health systems, and builds on our own earlier empirical research. It brings together the critical elements that affect adoption, diffusion and assimilation of a health intervention, and in doing so enables systematic and holistic exploration of the extent to which different interventions are integrated in varied settings and the reasons for the variation. The conceptual framework and the analytical approach we propose are intended to facilitate analysis in evaluative and formative studies of-and policies on-integration, for use in systematically comparing and contrasting health interventions in a country or in different settings to generate meaningful evidence to inform policy