Photo by A. BlightHealth Dialogues: Ireland, MDGs and health: A drop in the ocean or a real contribution
Irish Forum for Global Health
*****************************
The Irish Forum for Global Health launched its new series of ‘Health Dialogues’ on 16th June 2010, bringing together over 30 participants from various backgrounds including health and development-related international NGOs, the health service, staff and students in higher education and research institutions, and others interested in global health.
Dr Diarmuid O’Donovan, Chair of the Irish Forum for Global Health, opened the session and reported back on the recent EU Conference on Global Health held in Brussels in June 2010. He highlighted the conclusions on the EU role in global health that were reached during the Council of the European Union meeting in May 2010 and that will have a significant impact on global health in the years to come.
Notable among these recommendations was the call to the EU and its Member States to agree policies and actions that prioritize their support to strengthening comprehensive health systems in partner countries. Particular concern was expressed about maternal health (MDG 5) in Sub-Saharan Africa where it was stressed that health systems should pay special attention to gender equality, women’s needs and rights, and to combating gender-based violence. The conclusions also made specific recommendations regarding support for Trade Related Intellectual Property (TRIPs), migration and the need to strengthen the links between food security, nutrition and health. Full conclusions are online at: http://onetec.be/global_health/doc/Council%20Conclusions%20Global%20Health%20May%202010.pdf
Dr Eilish McAuliffe, Director of the Centre for Global Health, Trinity College Dublin, gave an excellent presentation detailing findings from a multi-country study highlighting some of the gaps in maternal mortality in relation to health systems strengthening. Reminding participants that MDG 5 is to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio, Dr McAuliffe began by outlining global action to reduce maternal mortality since 2007. She cited recent debates in the Lancet in relation to the findings regarding rates of decline in maternal mortality -for the first time a significant decline in pregnancy-related deaths from 526,300 in 1980 to 342,900 in 2008 has been reported (Hogan et al, 2010). This represents a 1.5% decline per year -to reach MDG 5 target by 2015 a decline rate of 5.5% per annum is needed. She noted that while this is the case in some countries, including some southern African countries, it is not in many others. She also pointed out that there are discrepencies in the maternal mortality rates available from different sources.
She then shared some of the key findings from a study titled ‘Health Systems Strengthening for Equity’ (HSSE) among mid-level providers (non-physician clinicians) who are responsible for the provision of Emergency Obstetric Care (EMoC) in Tanzania, Malawi and Mozambique. The study assessed factors that contribute to an enabling environment from the inputs such as staff and equipment, to the processes such as supervision, management and team-working, linking these to outcomes such as job satisfaction, performance and commitment. Findings included lack of equipment and supplies as a key constraint as well as showing many gaps in drug availability, especially in the rural hospitals. The supplies most commonly missing were not the most expensive items and yet are the ones critical to infection prevention such as sterile gloves, soap and antiseptics. Findings also indicate that very few facilities are adequately equipped to deal with eclampsia/pre-eclampsia and that the lack of oxygen seems to be a constraint to managing complications in many facilities.Other key findings include that the main providers of EmOC are mid-level providers - 80% all c-sections at district level are carried out by mid-level providers. Across all three countries mid-level providers are providing all of the Comprehensive Emergency Obstetric Care (CEmOC) signal functions(although not all providers provide all of the signal functions). Mid level providers are three times more cost-effective (Mozambique) than medical doctors and there is a high retention level. The study also highlighted the strong link between supervision and job satisfaction and the lack of structured supportive supervision in many healthcare facilities.
In drafting these findings as recommendations for interventions and further research it is clear that much can be done to improve the provision of EmOC and that addressing problems in the delivery system may have more immediate effect than addressing socio-cultural issues or attempting to manage migration. Many of the interventions required to improve care are not expensive.
Rosalyn Tamming, Head of the Health Support Unit, Concern Worldwide and Lecturer Centre at the Global Health, Trinity College Dublin, made an excellent presentation that focused on the NGO’s contribution to the health MDGs by illustrating the experience of Concern Worldwide. She began by reminding the audience of MDG 4 - to reduce by two thirds, between 1990 and 2015, the under-five mortality rate. She pointed out that under-nutrition was an underlying cause of 35% of mortality in the under 5’s and went on to describe Concern’s programmes from 1968- 2009 addressing acute malnutrition and changing over time as new products and approaches became available. Notably, she highlighted the Community Management of Acute Malnutrition (CMAM) programme, first trialed in the Dowa district of Malawi, and now endorsed by the UN as the accepted method of treating acute malnutrition in children. Prevention of malnutrition remains a key strategy for preventing child mortality and more evidence and advocacy at national and international levels is needed. Rosalyn then described child survival programmes, in particular scaling up of evidence based therapeutic and preventative interventions to reduce child mortality. Based on successful results in earlier programmes in countries such as Rwanda and Bangladesh the programme was expanded and now reaches one fifth of the children less than 5 years of age in Rwanda.
She lastly described an innovative new five-year Gates-funded programme currently being developed and implemented by Concern Worldwide in Malawi, Sierra Leone and India (Orissa State). This programme will challenge the most serious barriers to maternal neonatal child health and test original, creative and innovative ideas that will then be evaluated and scaled up if successful. She finished her presentation making the point that available, feasible interventions could prevent 6 million (63%) global child deaths at a cost of $5 billion per year. NGOs can surely do more but political will and increased resources are required.
A thought-provoking presentation given by Professor Ruairi Brugha, Royal College of Surgeons in Ireland, focused on the effects of the significant rise in global finances for HIV/AIDS on health systems and the health MDGs, and specifically on how funding for HIV has impacted on non-HIV services. The presentation started with an interesting overview of the levels of funding made available in Zambia, Malawi, Ethiopia and Uganda funded by global health initiatives such as the Global Fund to Fight AIDS, TB and Malaria and the US President’s Emergency Plan for AIDS Relief (PEPFAR) Using the Health Systems Framework as an entry point for research, findings showed there was a stagnation in staff numbers delivering services in settings in Zambia and Malawi that were scaling-up HIV services such as Antiretroviral treatment (ART) and prevention of mother to child HIV transmission (PMTCT). In 29 facilities in rural and urban areas in Zambia, there was little change in the numbers of clinical staff from 2004 to 2007, despite the large level of funds injected into health services during this time and the rapid rise in numbers of clients receiving HIV services. There was an increase in demand for services in rural areas and although staff numbers did not rise in proportion, the workload of staff in rural areas increased significantly.
There was also evidence in terms of population coverage, that numbers of clients receiving maternal and child health services were increasing in the catchment areas of facilities where HIV services were also scaling up. The research went beyond showing summary improvements in service delivery to demonstrate positive associations within facilities of scale up in HIV services (ART and PMTCT) with non HIV services – Antenatal Clinic attendance and Family Planning registration. Overall, while HIV service scale-up is occurring (MDG6), and there is some evidence that other priority services (MDG4 and 5) are benefiting, this needs to be further explored and tested through mixed methods explanatory research studies. There is clear evidence however, that rural areas are being neglected and workload is increasing, which raises concerns about staff retention and equity of access to services between rural and urban areas, which policy makers need to address.
During the open floor session chaired by Dr O’Donovan, the issue of decreased funding for health was raised. For Ireland’s contribution to the Global Fund to fight AIDS, TB and Malaria this reduction translates into a drop from €25million in 2008 to €9million in 2010. While this keeps Ireland relatively high in terms of contribution in funds per capita, reducing the contribution to the Global Fund by Ireland and other donor governments, translates into pulling back on life-saving medication (ARVs) for those in need. The impact of this is already being felt in sub-Saharan Africa.
To counter-act what was termed donor-fatigue, it was suggested that academic researchers in Ireland get more involved in advocacy, where NGOs have been active for some time. It was also suggested that institutions like the UN might consider naming those donors that have defaulted on their commitments. One participant noted that pooling money in multilateral bodies is often the most difficult to sustain support for, as attribution of successes to inputs (funding) is difficult to make and it has least traction with the general public. It was suggested that this aspect of aid is not adequately championed. Another participant suggested that there was a need to look at cost effective interventions, for example water and sanitation, given that Irish Aid health funding is unbalanced and is in decline.
There was further discussion on the purpose of the Irish Forum for Global Health (IFGH) itself as a forum. Suggestions for focus included using it to create specific targeted calls and connections between different people and groups, becoming an advocacy body and facilitating networking across sectors. It was also noted how the IFGH offered an opportunity to learn from other work going on in the area of health, such as that in the presentations given that day which can improve collaboration and learning, even in a small island such as Ireland.
The meeting ended with a short description by Dr David Weakliam, Consultant in Public Health Medicine, Department of Public Health about the recent Memorandum of Agreement signed between the Health Service Executive (HSE) and Irish Aid. The agreement, signed on 4 June 2010 by Minister of State for Overseas Development, Mr Peter Power, T.D., and Health Service Executive CEO, Professor Brendan Drumm, commits both organisations to strengthening Ireland’s overall contribution to health in the developing world by sharing expertise and promoting international best practice in support to developing countries. It will enable the HSE to make some of its experts available to provide expertise and technical advice to Irish Aid on health policy, proposals and programmes. Meanwhile, Irish Aid will assist the HSE by promoting best international practice in the HSE’s initiatives to support developing countries. HSE-Irish Aid also plan to link to other groups, including this Forum. More information about the agreement online at: http://www.dfa.ie/home/index.aspx?id=83561
Ends
(IFGH would like to thank Carlos Bruen, RCSI, for his notes that contributed to this article).
Presentations
*************
All three presentations are informative and full of useful information. They are available online at: www.globalhealth.ie under ‘presentations’.
Further reading
***************
The concerns of the impact of reduced funding on ARV treatment to HIV-positive patients was raised during the forum and one participant encouraged members to read a report recently released by MSF presenting an articulate analysis of the widening funding gap for HIV/AIDS treatment in sub-Saharan Africa (online at: http://www.msf.org/source/countries/africa/southafrica/2010/no_time_to_quit/HIV_Report_No_Time_To_Quit.pdf
Another report highlighted was Rationing Funds, Risking Lives: World Backtracks on HIV Treatment, a report produced by the International Treatment Preparedness Coalition (ITPC) in April 2010, documenting early warning signs resulting from the global pull back on AIDS commitment and funding: caps on the number of people enrolled in treatment programs, more frequent drug stock outs, and national AIDS budgets falling short (online at: http://www.itpcglobal.org/images/stories/doc/ITPC_MTT8_FINAL.pdf
******************************************
For further information about this session or the Irish Forum for Global Health, please contact: info@globalhealth.ie or visit our website at www.globalhealth.ie
If you would like to join the Irish Forum for Global Health as a member and be part of our eForum, please email to: join-globalhealth@eforums.healthdev.org
Nadine Ferris France - HDN/ IFGH
Irish Forum for Global Health
*****************************
The Irish Forum for Global Health launched its new series of ‘Health Dialogues’ on 16th June 2010, bringing together over 30 participants from various backgrounds including health and development-related international NGOs, the health service, staff and students in higher education and research institutions, and others interested in global health.
Dr Diarmuid O’Donovan, Chair of the Irish Forum for Global Health, opened the session and reported back on the recent EU Conference on Global Health held in Brussels in June 2010. He highlighted the conclusions on the EU role in global health that were reached during the Council of the European Union meeting in May 2010 and that will have a significant impact on global health in the years to come.
Notable among these recommendations was the call to the EU and its Member States to agree policies and actions that prioritize their support to strengthening comprehensive health systems in partner countries. Particular concern was expressed about maternal health (MDG 5) in Sub-Saharan Africa where it was stressed that health systems should pay special attention to gender equality, women’s needs and rights, and to combating gender-based violence. The conclusions also made specific recommendations regarding support for Trade Related Intellectual Property (TRIPs), migration and the need to strengthen the links between food security, nutrition and health. Full conclusions are online at: http://onetec.be/global_health/doc/Council%20Conclusions%20Global%20Health%20May%202010.pdf
Dr Eilish McAuliffe, Director of the Centre for Global Health, Trinity College Dublin, gave an excellent presentation detailing findings from a multi-country study highlighting some of the gaps in maternal mortality in relation to health systems strengthening. Reminding participants that MDG 5 is to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio, Dr McAuliffe began by outlining global action to reduce maternal mortality since 2007. She cited recent debates in the Lancet in relation to the findings regarding rates of decline in maternal mortality -for the first time a significant decline in pregnancy-related deaths from 526,300 in 1980 to 342,900 in 2008 has been reported (Hogan et al, 2010). This represents a 1.5% decline per year -to reach MDG 5 target by 2015 a decline rate of 5.5% per annum is needed. She noted that while this is the case in some countries, including some southern African countries, it is not in many others. She also pointed out that there are discrepencies in the maternal mortality rates available from different sources.
She then shared some of the key findings from a study titled ‘Health Systems Strengthening for Equity’ (HSSE) among mid-level providers (non-physician clinicians) who are responsible for the provision of Emergency Obstetric Care (EMoC) in Tanzania, Malawi and Mozambique. The study assessed factors that contribute to an enabling environment from the inputs such as staff and equipment, to the processes such as supervision, management and team-working, linking these to outcomes such as job satisfaction, performance and commitment. Findings included lack of equipment and supplies as a key constraint as well as showing many gaps in drug availability, especially in the rural hospitals. The supplies most commonly missing were not the most expensive items and yet are the ones critical to infection prevention such as sterile gloves, soap and antiseptics. Findings also indicate that very few facilities are adequately equipped to deal with eclampsia/pre-eclampsia and that the lack of oxygen seems to be a constraint to managing complications in many facilities.Other key findings include that the main providers of EmOC are mid-level providers - 80% all c-sections at district level are carried out by mid-level providers. Across all three countries mid-level providers are providing all of the Comprehensive Emergency Obstetric Care (CEmOC) signal functions(although not all providers provide all of the signal functions). Mid level providers are three times more cost-effective (Mozambique) than medical doctors and there is a high retention level. The study also highlighted the strong link between supervision and job satisfaction and the lack of structured supportive supervision in many healthcare facilities.
In drafting these findings as recommendations for interventions and further research it is clear that much can be done to improve the provision of EmOC and that addressing problems in the delivery system may have more immediate effect than addressing socio-cultural issues or attempting to manage migration. Many of the interventions required to improve care are not expensive.
Rosalyn Tamming, Head of the Health Support Unit, Concern Worldwide and Lecturer Centre at the Global Health, Trinity College Dublin, made an excellent presentation that focused on the NGO’s contribution to the health MDGs by illustrating the experience of Concern Worldwide. She began by reminding the audience of MDG 4 - to reduce by two thirds, between 1990 and 2015, the under-five mortality rate. She pointed out that under-nutrition was an underlying cause of 35% of mortality in the under 5’s and went on to describe Concern’s programmes from 1968- 2009 addressing acute malnutrition and changing over time as new products and approaches became available. Notably, she highlighted the Community Management of Acute Malnutrition (CMAM) programme, first trialed in the Dowa district of Malawi, and now endorsed by the UN as the accepted method of treating acute malnutrition in children. Prevention of malnutrition remains a key strategy for preventing child mortality and more evidence and advocacy at national and international levels is needed. Rosalyn then described child survival programmes, in particular scaling up of evidence based therapeutic and preventative interventions to reduce child mortality. Based on successful results in earlier programmes in countries such as Rwanda and Bangladesh the programme was expanded and now reaches one fifth of the children less than 5 years of age in Rwanda.
She lastly described an innovative new five-year Gates-funded programme currently being developed and implemented by Concern Worldwide in Malawi, Sierra Leone and India (Orissa State). This programme will challenge the most serious barriers to maternal neonatal child health and test original, creative and innovative ideas that will then be evaluated and scaled up if successful. She finished her presentation making the point that available, feasible interventions could prevent 6 million (63%) global child deaths at a cost of $5 billion per year. NGOs can surely do more but political will and increased resources are required.
A thought-provoking presentation given by Professor Ruairi Brugha, Royal College of Surgeons in Ireland, focused on the effects of the significant rise in global finances for HIV/AIDS on health systems and the health MDGs, and specifically on how funding for HIV has impacted on non-HIV services. The presentation started with an interesting overview of the levels of funding made available in Zambia, Malawi, Ethiopia and Uganda funded by global health initiatives such as the Global Fund to Fight AIDS, TB and Malaria and the US President’s Emergency Plan for AIDS Relief (PEPFAR) Using the Health Systems Framework as an entry point for research, findings showed there was a stagnation in staff numbers delivering services in settings in Zambia and Malawi that were scaling-up HIV services such as Antiretroviral treatment (ART) and prevention of mother to child HIV transmission (PMTCT). In 29 facilities in rural and urban areas in Zambia, there was little change in the numbers of clinical staff from 2004 to 2007, despite the large level of funds injected into health services during this time and the rapid rise in numbers of clients receiving HIV services. There was an increase in demand for services in rural areas and although staff numbers did not rise in proportion, the workload of staff in rural areas increased significantly.
There was also evidence in terms of population coverage, that numbers of clients receiving maternal and child health services were increasing in the catchment areas of facilities where HIV services were also scaling up. The research went beyond showing summary improvements in service delivery to demonstrate positive associations within facilities of scale up in HIV services (ART and PMTCT) with non HIV services – Antenatal Clinic attendance and Family Planning registration. Overall, while HIV service scale-up is occurring (MDG6), and there is some evidence that other priority services (MDG4 and 5) are benefiting, this needs to be further explored and tested through mixed methods explanatory research studies. There is clear evidence however, that rural areas are being neglected and workload is increasing, which raises concerns about staff retention and equity of access to services between rural and urban areas, which policy makers need to address.
During the open floor session chaired by Dr O’Donovan, the issue of decreased funding for health was raised. For Ireland’s contribution to the Global Fund to fight AIDS, TB and Malaria this reduction translates into a drop from €25million in 2008 to €9million in 2010. While this keeps Ireland relatively high in terms of contribution in funds per capita, reducing the contribution to the Global Fund by Ireland and other donor governments, translates into pulling back on life-saving medication (ARVs) for those in need. The impact of this is already being felt in sub-Saharan Africa.
To counter-act what was termed donor-fatigue, it was suggested that academic researchers in Ireland get more involved in advocacy, where NGOs have been active for some time. It was also suggested that institutions like the UN might consider naming those donors that have defaulted on their commitments. One participant noted that pooling money in multilateral bodies is often the most difficult to sustain support for, as attribution of successes to inputs (funding) is difficult to make and it has least traction with the general public. It was suggested that this aspect of aid is not adequately championed. Another participant suggested that there was a need to look at cost effective interventions, for example water and sanitation, given that Irish Aid health funding is unbalanced and is in decline.
There was further discussion on the purpose of the Irish Forum for Global Health (IFGH) itself as a forum. Suggestions for focus included using it to create specific targeted calls and connections between different people and groups, becoming an advocacy body and facilitating networking across sectors. It was also noted how the IFGH offered an opportunity to learn from other work going on in the area of health, such as that in the presentations given that day which can improve collaboration and learning, even in a small island such as Ireland.
The meeting ended with a short description by Dr David Weakliam, Consultant in Public Health Medicine, Department of Public Health about the recent Memorandum of Agreement signed between the Health Service Executive (HSE) and Irish Aid. The agreement, signed on 4 June 2010 by Minister of State for Overseas Development, Mr Peter Power, T.D., and Health Service Executive CEO, Professor Brendan Drumm, commits both organisations to strengthening Ireland’s overall contribution to health in the developing world by sharing expertise and promoting international best practice in support to developing countries. It will enable the HSE to make some of its experts available to provide expertise and technical advice to Irish Aid on health policy, proposals and programmes. Meanwhile, Irish Aid will assist the HSE by promoting best international practice in the HSE’s initiatives to support developing countries. HSE-Irish Aid also plan to link to other groups, including this Forum. More information about the agreement online at: http://www.dfa.ie/home/index.aspx?id=83561
Ends
(IFGH would like to thank Carlos Bruen, RCSI, for his notes that contributed to this article).
Presentations
*************
All three presentations are informative and full of useful information. They are available online at: www.globalhealth.ie under ‘presentations’.
Further reading
***************
The concerns of the impact of reduced funding on ARV treatment to HIV-positive patients was raised during the forum and one participant encouraged members to read a report recently released by MSF presenting an articulate analysis of the widening funding gap for HIV/AIDS treatment in sub-Saharan Africa (online at: http://www.msf.org/source/countries/africa/southafrica/2010/no_time_to_quit/HIV_Report_No_Time_To_Quit.pdf
Another report highlighted was Rationing Funds, Risking Lives: World Backtracks on HIV Treatment, a report produced by the International Treatment Preparedness Coalition (ITPC) in April 2010, documenting early warning signs resulting from the global pull back on AIDS commitment and funding: caps on the number of people enrolled in treatment programs, more frequent drug stock outs, and national AIDS budgets falling short (online at: http://www.itpcglobal.org/images/stories/doc/ITPC_MTT8_FINAL.pdf
******************************************
For further information about this session or the Irish Forum for Global Health, please contact: info@globalhealth.ie or visit our website at www.globalhealth.ie
If you would like to join the Irish Forum for Global Health as a member and be part of our eForum, please email to: join-globalhealth@eforums.healthdev.org
Nadine Ferris France - HDN/ IFGH