Innovative spending in health: what should money be spent on to make global health innovations more effective in developing countries?

Background Delivering effective healthcare to people in developing countries is a perennial challenge, hence the unending search for, and implementation of creative or innovative ways of spending money and other resources that are available for health. Objectives This paper presents and discusses some innovations in health-spending from South Africa and Zimbabwe. The presentation will also ask a number of inter-related theory, policy and practice questions, among others, how such innovations get embedded in health systems, how they can be/are cushioned from internal and external shocks, whether there are any back-up mechanisms, and who is liable when such innovations fail? Methods This paper is based on an on-going three-year project and is drawing on evidence emerging from interviews with key stakeholders located at various points within and around health systems in South Africa and Zimbabwe, observations and document reviews. Result From creation of policy and practice space for medical facilities run separately or collectively by public, private and civil society stakeholders; generation, consolidation and use of disease surveillance data at district, provincial and national levels; to empowering rural communities in shaping health delivery options, there is abundant evidence in the two countries of innovative efforts to do more with less. Conclusion This paper confirms the need for agile and innovative approaches to ensuring that the health needs of marginalised populations are met. In addition to reflecting on the utility and effectiveness of some approaches already in use, the paper also brings to the fore some hitherto unreported innovations in health spending in South Africa and Zimbabwe

Socio-economic impact of GMOs on African consumers

The debate surrounding genetically modified organisms (GMOs) remains an important one for consumers and consumer organisations the world over, and is characterized by strong views for, and against the technology. The debate is of particular interest to Africa, where the countries are yet to embrace the new technology and where food security challenges tend to amplify the dilemma faced by decision-makers. Consumers, represented through the work of consumer organizations, are a very active and vocal constituency in this debate, as it unfolds in Africa.The objective of this paper is to inform the reader on how the consumer movement has contributed to the GMO debate in Africa in the past few years and to highlight the potential socio-economic impacts on African consumers. Firstly, the paper summarises the consumer movement and its work with the Joint Advocacy Project on GMOs; and secondly looks at the potential social, ethical and cultural impacts. Economic and environmental impacts are also discussed. The Socio-Economic Impact Assessment tool is highlighted as one of several tools to guide bio-safety decision-making policy. A few recommendations and policy implications are given at the end of the paper

Can options be used to enhance equity returns: evidence from Australia

The start of the 21st century witnessed the rejuvenation of structured financial products that date back to the early 1970s. Since 2000, the derivatives market has experienced significant growth as interest in structured financial products has increased substantially. Despite this strong growth, both in Australia and globally, recent evidence shows a lack of interest from investment managers in utilising derivatives. To this effect, the Australian Stock Exchange has undertaken a number of initiatives to raise the awareness of opportunities for investors in the options market. This thesis aims to contribute to the literature on structured financial products and assist investors in examining opportunities in the Australian options market. This thesis investigates a number of structured financial products in particular: the buy–write strategy and extreme portfolio trading strategies. It first examines the performance of the buy–write option strategy on the Australian Stock Exchange and analyses whether such an investment opportunity violates the efficient market hypothesis on the basis of its risk and returns. The study investigates the relation between buy–write portfolios returns and past trading volume and other fundamental financial factors, including dividend yield, firm size, book-to-market ratio, earnings per share, price earnings ratio, and value stocks within these portfolios. It also tests the profitability of the buy–write strategy during bull and bear markets. The thesis next examines extreme portfolio trading strategies. It investigates the profitability of equity, call, and put option-based extreme portfolio trading strategies on the Australian Stock Exchange and analyses whether they generate consistent abnormal returns. It also analyses the relation between equity- and option-based extreme portfolio returns and different financial fundamentals, as well as the performance of extreme portfolio trading strategies during different market conditions. As far as the buy–write strategy is concerned, the results of this study are consistent with the literature. This thesis determines that the buy–write strategy offers superior risk-adjusted returns for low levels of out-of-the-moneyness; however, it notes contrary evidence for deeper out-of-the-money portfolios. In line with other Australian buy–write strategy studies, this study also finds an Australian preference for options with a maturity of around three months. It shows that quarterly rebalancing periods offer better returns for the buy–write strategy. This study’s empirical results on extreme portfolio trading strategies are consistent with the literature, demonstrating that applying options in extreme portfolio strategies is profitable in Australia and that options can be used to enhance equity contrarian strategy profits

Nitrogen effect on zinc biofortification of maize and cowpea in Zimbabwean smallholder farms

Agronomic biofortification of crops with zinc (Zn) can be enhanced under increased nitrogen (N) supply. Here, the effects of N fertilizer on grain Zn concentration of maize (Zea mays L.) and cowpea (Vigna unguiculata L.) were determined at two contrasting sites in Zimbabwe over two seasons. All treatments received soil and foliar zinc‐sulphate fertilizer. Seven N treatments, with three N rates (0, 45, and 90 kg ha−1 for maize; 0, 15, and 30 kg ha−1 for cowpea), two N forms (mineral and organic), and combinations thereof were used for each crop in a randomized complete block design (n = 4). Maize grain Zn concentrations increased from 27.2 to 39.3 mg kg−1 across sites. At 45 kg N ha−1, mineral N fertilizer increased maize grain Zn concentration more than organic N from cattle manure or a combination of mineral and organic N fertilizers. At 90 kg N ha−1, the three N fertilizer application strategies had similar effects on maize grain Zn concentration. Co‐application of N and Zn fertilizer was more effective at increasing Zn concentration in maize grain than Zn fertilizer alone. Increases in cowpea grain Zn concentration were less consistent, although grain Zn concentration increased from 39.8 to 52.7 mg kg−1 under optimal co‐applications of N and Zn. Future cost/benefit analyses of agronomic biofortification need to include information on benefits of agro‐fortified grain, complex farmer management decisions (including cost and access to both N and Zn fertilizers), as well as understanding of the spatial and site‐specific variation in fertilizer responses

Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings

WHO 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe: Modeling Clinical Outcomes in Infants and Mothers

The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002-2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens.Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using "Option A" (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO "Option B" (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) "Option B+:" lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4-6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected.Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years).Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes

Quantification of T-cell dynamics in health and disease : Mathematical modeling of experimental data

An essential branch of the adaptive immune system is formed by T cells which are produced in the thymus. The absence of T cells can be detrimental to the host as is the case in acquired immuno-deficiency syndrome (AIDS). The goal of this thesis is to gain insights into the dynamics of different T-cell subsets in healthy as well as disturbed situations. This information is important not only in understanding how the immune system is regulated normally, but also in guiding therapeutic strategies when the immune system gets disturbed. By combining mathematical modeling with experimental data, this thesis demonstrates how the two can complement each other in quantifying the kinetics of T cells , and in resolving some of the discrepancies in previous kinetic estimates and in the mechanisms of T-cell maintenance in mice and men. In young adult mice, we estimate that naive CD4 and CD8 T cells have expected life spans of 48 and 91 days, while CD4 and CD8 memory T cells have expected life spans of 12 and 17 days, respectively. Our analyses show that throughout life, naive T cell production in mice almost exclusively occurs in the thymus, which implies that in the event of lymphopenia in mice, thymic output is central to successful immune reconstitution. In contrast, studies based on T-cell receptor excision circles (TRECs) have suggested that in humans T-cell proliferation plays a key role in naive T-cell maintenance during adult life. Our results therefore highlight an important qualitative difference in T-cell dynamics between mice and humans. Extrapolation of experimental results from mice to humans should hence be done with caution. Recent work using deuterium labeling from our group indicated that in human adults naive T cells are kinetically homogeneous and very long-lived. This is in contrast to the current consensus that recent thymic emigrants (RTEs) form a separate short-lived sub-population of naive T cells. In several studies described in this thesis, we find no evidence that RTEs in either mice or men form a kinetically separate sub-population of naive T cells. The typical decline in CD4+ T-cell numbers that is observed during HIV infection is accompanied by a shift in the kinetics of both naive and memory CD4 and CD8 T cells to faster turnover rates compared to healthy controls. Our analyses show that in HIV-infected individuals, naive CD4 and CD8 T cells have a 3.3-12 fold shorter expected lifespan, and CD4 and CD8 memory T cells a 2.8-3.1 fold shorter expected lifespan compared to healthy controls. The increased T-cell loss rates in HIV infection are accompanied by higher per capita production rates of both naive and memory T cells. In naive T cells , this increased turnover can explain our observation that longitudinal TREC dynamics after infection are biphasic. In this case, HIV triggers a massive recruitment of naive T cells into the effector/memory compartment where they are quickly lost. We also predict shortening of naive T cell telomeres after HIV infection contrary to previous findings that telomeres are normal in HIV patients. This discrepancy can be attributed to the effect of individual variations when extrapolating cross-sectional data to longitudinal dynamics. We show that changes in thymic output, and T-cell death and proliferation rates tend to affect average TREC contents and telomere lengths similarly. Especially when naive T-cell life spans are affected, as is the case in HIV infection, the observed TREC dilution can only be explained by increased proliferation rates. Reduced thymic output could however add to the observed decline of naive T cells. Indeed, our mouse model of HIV-independent chronic immune activation shows that chronic immune activation is sufficient to cause severe naive T cell depletion, while decreased thymic output aggravates the naive T-cell loss. This suggests that therapeutic strategies for HIV infection that are aimed at boosting thymic function may fail to reconstitute the CD4 T cell pool if immune activation is not simultaneously kept under control

Societal beliefs, scientific technologies and HIV/AIDS in Africa: facing the challenge of integrating local communities in Kenya and Zimbabwe

Of the many challenges that Africa is facing, the HIV/AIDS pandemic ranks amongst the most threatening. This article draws attention to local community settings and focuses on village set-ups, probing into the nature of the approaches to combat the pandemic. Given the issues surrounding the spread of the virus, including, for example, stigmatisation/discrimination, sexuality, modes of transmission, cultural beliefs and practices, trauma, health-care services, aid organisations as well as governance issues, we raise questions that cut across the societal belief terrains on the one hand, and scientific/technological advancements on the other. The article explores questions relating to: the extent to which cultural practices are part of the unbreakable barriers in the effort to combat the pandemic; the extent to which cultural contexts of local communities are understood or misunderstood; how focus on participatory approaches and not diagnostic measures can help; and how best a sustainable integration of scientific and social aspects can be achieved in the search for solutions. To address these and other related questions, the argument will be informed by examples from Kenya and Zimbabwe, looking at how particular 'scientific' and 'local' communities have strived to integrate their efforts to combat HIV/AIDS

Hot and cold strategies: Australian evidence

This study explores a high-frequency tactical asset allocation strategy. In particular, we investigate the profitability of momentum trading strategies and contrarian investment strategies for equities listed on the Australian Stock Exchange (ASX). This paper takes into consideration the short-selling restrictions imposed by the ASX on the stocks used in these two strategies. We look at the relationship between stock returns and past trading volume for these equities within our sample portfolios. This research also investigates the seasonal aspects of contrarian portfolios and observes an April effect. We report significant contrarian profits for the period investigated and show that contrarian profit is a persistent feature for the strategies examined. We also document that contrarian portfolios earn returns as high as 6.54% per day for portfolios with no short-selling restrictions, and 4.71% on the restricted model. The results also support the view that volume traded affects stock returns and shows that market imperfections such as short-selling restrictions affect investors' retur