Archive for Measuring and prioritising health interventions and impact.

The Lancet Commission On Global Surgery

Surgeons have long felt that the importance of surgery has been lost in past efforts to impact on global health issues. The Lancet Commission on Global Surgery seeks to address deficiencies in surgical and anaesthetic care, provide evidence and solutions for achieving health, as well as welfare and economic development through the strengthening of surgical health systems in Low and Middle income Countries (LMIC).

Twenty five commissioners have worked for almost 2 years consulting extensively in over 100 countries in 6 continents. Their report may not please all but is a significant achievement. Surveys, epidemiological studies, estimates, audits and mapping programmes helped to provide evidence and to highlight further disparities in surgical care through 5 key messages at their recent London and Boston launches:

  • 5 billion people lack access to safe affordable surgical services when needed. Nine of ten people in low-income and lower-middle-income countries cannot access basic surgical care.
  • 143 million additional surgical procedures are needed each year to save lives and prevent disability. Only 6% of 313 million procedures that are undertaken worldwide annually, are performed in the poorest countries.
  • 33 million individuals face catastrophic health expenditure to pay for surgical services.
  • Investment in surgical and anaesthetic services saves lives, is affordable and promotes economic growth.
  • Surgery is an indispensible part of health care and should be an integral component of a national health system in countries at all levels of development.

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The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

The Commission’s stated targets for 2030 are daunting:

  • A minimum of 80% coverage of essential surgical and anaesthesia services per country.
  • 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians, per 100,000 population.
  • 100% of countries tracking surgical volume, a minimum of 5000 procedures per 100,000 population.
  • 100% of countries tracking perioperative mortality.
  • 100% protection against impoverishment from out of pocket payments for surgical care.
  • 100% protection against catastrophic expenditure from out of pocket payments for surgical care.

Some might see these as challenging for some developed countries so how can these objectives be met in developing countries where increasing funding of health care still results in disparities.

We know that targeting specific health care issues through philanthropic support in the developing world has brought about mixed success. Numerous philanthropists and charities have stumbled in attempting to deliver sustainable solutions when investing in facility or service. Outreach programmes from well intended overseas surgical teams may actually impact adversely on the very environment that they hope to support. Essential emergency provision of surgical care may be compromised when, for example, limited facility is set aside for the orchestrated elective missionary surgery. The conditions or surgical pathology targeted or technology being shared may seem entirely appropriate to the visiting team but may be largely irrelevant to the needs of the local population.

Investment in infrastructure may seem to produce a tangible legacy for the donor but it is challenging to maintain such quality facilities when these are seen by some as a source of material to be plundered to support their families in desperate financial need. Furthermore, some initiatives have been been criticized for focusing too narrowly on the capacity of science and in neglecting the importance of economic, social, and political factors. Such surgical initiatives require significant funding and need to be considered in parallel with improvements in public health, education and the health system. Pressurised surgical services dealing with trauma in the developing world might rather welcome greater health and safety regulation, improvements in street lighting, better maintained roads and greater driver regulation.

So where to start? Records often do not exist so reliable surgical audits or death rate statistics for surgery do not exist in LMIC. Investment in information technology is limited in most developing countries but finance is required to obtain key information that would identify clearly the needs of surgical services in the LMIC. GlobalSurg is a collaboration supported by Clinical Surgery at the University of Edinburgh ( The group is currently using an international network of training and qualified surgeons to study variation in outcome of emergency intra-abdominal surgery across various clinical settings. It will determine whether globally relevant quality improvement strategies are needed within acute surgical units. This project would serve to provide much needed information in an area of acute surgical care and will allow development of regional, national and international surgical networks. The group recently published on the benefits of these networks in the Lancet. There is no reason why the group cannot establish key global studies, including the opportunity for randomised trials.

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The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

Humanitarian and global surgical outreach programmes have been supported by surgical colleagues in Edinburgh at considerable personal social and psychological sacrifice. Such direct support has undoubtedly had significant impact on the lives of those affected by conditions including those arising from complications of obstructed labour. The social stigmata attached to this condition are considerable and the repair transforms the patient’s existence. And yet, the procedure to correct a vesicovaginal fistula is categorized as a ‘can do’ rather than a ‘must do’ surgical procedure. Where should the priorities lie when the challenge is so immense? How can such outreach programmes deliver a legacy in a developing country?

The target set by the Commission that 100% of countries should have at least 20 surgical, anaesthetic, and obstetric physicians per 100,000 population is formidable. We have experience supporting surgical training in Malawi which produces some 100 medical graduates per year. However, for a population of 17 million people, there are currently only some 15 trained surgeons in practice since many move overseas when they are exposed to the opportunities that exist for well-trained doctors in the developed world. The Lancet Commission requirement by 2030 is projected at 60 specialists per 100,000 population. It is difficult to imagine where the additional 10,000 or so specialists will emerge for Malawi without substantial investment.

Scotland has a strong tradition of investing in education on Africa. Gordon Brown as UN Special Envoy for Global Education, and through the Office of Gordon and Sarah Brown, has promoted and initiated education programmes in Africa. Edinburgh University has invested strongly in postgraduate educational initiatives that have benefited LMIC. The huge success of our own surgical distance learning programmes has allowed us to support more trainees from these countries.

Our surgical Masters programmes currently have over 450 students enrolled in 40 different countries. In 2009, the Scottish Government and J&J/Ethicon supported the University of Edinburgh and the Royal College of Surgeons of Edinburgh to deliver free postgraduate educational support to training surgeons in Malawi. Since then, the first three students have graduated from the three-year distance learning course which supports the educational and professional needs of the young training surgeon. Six more Malawian trainees are currently in the programme. Surgical trainees have been supported without the need to remove them from the area of greatest need. The programme content adds value to their in-the-workplace training and allows the young surgeon to attend to local service needs. We are also aware that educational resource has been extended to medical assistant practitioners who are a vital link in the surgical care chain.

The Lancet Global Commission has ensured that surgery can no longer be overlooked as a health need for the world’s poorest people. The Commission has set itself ambitious targets but no one initiative will address the current unmet need. Better global surgical and anaesthesia care will only be realised through increased investment in human and physical resources. Early and urgent domestic and external investment in surgical and anaesthesia care is needed to realise these returns. Our group sees itself as being in a strong position to invest in the postgraduate education of the surgical workforce in these countries.

Similarly, research, monitoring, and assessment will have to play an increasing and crucial part in the future of global surgical and anaesthesia care. There is a paucity of scientific rigor around implementation science, and an absence of globally accepted surgical metrics which have contributed to past neglect of surgical and anaesthesia care within global health. A commitment to better understand the problems and solutions should be a priority for those dedicated to improvement of surgical and anaesthesia care worldwide. We will continue to invest primarily in the training surgeons in these LMIC through postgraduate education. In this way, we should empower the very body that can engineer change locally so that we might yet see some practical light at the end of a very long tunnel.

Professor O James Garden, Regius Professor of Clinical Surgery and Honorary Consultant Surgeon, University of Edinburgh

Why it is critical to genotype the causative agents of tuberculosis

Sun Tzu, a Chinese military philosopher in the 6th century BC, said “ if you know your enemy and yourself, you will not be imperiled in hundred battles”.

If not taken in literal terms, it would suggest that learning more about the humanity and livestock’s arch enemy Tuberculosis (TB), with whom we have been battling for millennia, can only arm us all the better for the fight.  As part of this battle, The University of Edinburgh has long been contributing to the research and development arm of the World Health Organisation’s “Stop TB Global Strategy”. 

The WHO has achieved the 2015 Millennium Goal of halting and reversing the incidence of the disease.  Despite this great acheivement, in 2013 alone the WHO registered 9 million cases of TB, half a million of which succumbed to the disease.  Horrifyingly this latter number loosely translates to four super jumbo jets crashing every day for the entire year.  Going forward to 2035, the WHO has set yet more ambitious goals to end the global TB epidemic with corresponding targets of 95% and 90% reduction in TB deaths and incidence respectively.

Knowing your enemy

In order to achieve this mighty aim, now more than ever, it is critical for the definitive diagnostics to not only reveal the mycobacterial species but also the genotype.  The majority of cases of human TB are caused by Mycobacterium tuberculosis, however a small, but significant geographically-limited, proportion is due to Mycobacterium bovis the causative agent of bovine tuberculosis. The latter is what is commonly referred to as zoonotic tuberculosis. The current statistics shows that when considered as a proportion of the global TB burden, zoonotic tuberculosis accounts for a small proportion however, if reported in absolute terms it translates to between 95,000 and 150,000 cases of which 15% succumb to this disease form globally. It is noteworthy that 9 out of the 22 high-burden TB countries are responsible for ~70% of the global zoonotic TB cases.

Vaccination as a defence against infection

In general, vaccination is an effective method of controlling infectious diseases.  The BCG vaccine, developed agianstM. bovis, is the most widely administered TB vaccine in the world.  However its varied efficacy globally has always been a challenge to the TB control strategy.  If the endemic population of infective bacteria is different from that contained in the vaccine, this can lead to vaccine failure.  Vaccines that target a narrow range of phenotypes may not offer sufficient prevention against infections in settings where multiple different strains of the infective agent may be present.

This is particularly relevant to areas where several different strains of M. bovis are prevalent, and where the TB burden is correspondingly high. It is also reasonable to argue that some of the TB treatment failures in these areas are likely due to species and genotypes un-accounted for in the treatment protocols.  Thus it is critical to document the diversity of M. bovis, and use this data to increase the phenotypic range in novel vaccines, thereby improving patient immunity.

Sequencing the genomes of the bacteria that cause TB

The currently documented genotypes of M. bovis in high-burden settings lack “granularity” because they are based on PCR methods that target less than 0.005% of the genome.  It is therefore likely that niche and host-specific polymorphisms that are critical for population-based vaccine implementation, are left unused in determining these genotypes.

This disparity in genotype diversity and breadth of target phenotype is likely part of the reasons why the efficacy of BCG vaccination is lowest in Africa.  A solution to this comes in the form of whole genome SNPs based genotyping, which offers high definition genotyping power capable of revealing subtle niche and host specific diversity.

Large international collaboration fighting the disease

Researchers from the University of Edinburgh are now part of a large international collaboration that will sequence and genotype 254 isolates of Mycobacterium bovis from eight African high burden countries.

They will be working alongside colleagues from eight African research institutions, and from the United States Department of Agriculture, Colorado State University, the University of Georgia, the University of Tromsø, theNorwegian Veterinary Institute, and the Norwegian University of Life Sciences.

The new data the team generates will be made freely available for researchers and industry involved in TB vaccine, diagnostics and therapeutics development.  By piecing together more and more information about the strains of Mycobacteria causing TB in different areas, researchers will generate the ammunition needed to finally defeat TB.

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                    Adrian Muwonge (DVM, MSc, PhD), Research Fellow, Roslin Institute, 

                   Edinburgh Infectious Diseases, University of Edinburgh, UK








Reflections from the HIV, Human Rights and Development (HHRD) Network on World AIDS Day, December 1, 2014

The Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014) Report “Fast-Track: Ending the AIDS epidemic by 2030” provides more than a beacon of hope on World AIDS Day 2014.

It states boldly that “The world is embarking on a Fast-Track strategy to end the AIDS epidemic by 2030”.

It envisages that if the world scales up its HIV prevention and treatment programmes and reaches certain fast-track targets or goals, it will manage to prevent almost 28 million new infections and more crucially “end the AIDS epidemic as a global health threat by 2030”.

The report points to a number of “fast-track targets” that need to be achieved in the next five years by 2020. These optimistic targets include: attaining a 90-90-90 target, i.e. 90 percent of people with HIV knowing their status, 90 percent of those who know their status being on treatment, and then 90 percent of those on treatment suppressing the virus. For the year 2030, this goal goes up to 95-95-95. New infections will be reduced by 75 percent to 500,000 by the year 2020, and then to 200,000 by 2030. And, it points to the overarching goal of zero discrimination and zero tolerance for both years—2020 and 2030.

However, to achieve this monumental, yet attainable goal, the report cautions that “countries will need to use the powerful tools available, hold one another accountable for results and make sure that no one is left behind”.

We at the HHRD Network believe that the commitment to human rights will provide the bedrock of the AIDS response, and that human rights will need to remain in the fore front of all efforts. Moreover, that there is a need for a sustained and continued investment to build and promote the capacity of health systems all over the world, but particularly in the context of developing countries and forced migration. We need to consider on how best we can attain the theme of World AIDS Day 2014 to “Focus, Partner, Achieve: An AIDS-free generation – to highlight the need to for governments and health officials, NGOs and individuals to address AIDS prevention and treatment”. And, finally, the “fast-track targets” need to be held closely by all players across the globe if we are to not just bend the epidemic trajectory, but to break it irreversibly”.


Dr George Palattiyil and Dr Dina Sidhva

Joint Convenors, HIV, Human Rights and Development Network

Critically Analysing the IFC’s Health in Africa initiative’s opportunistic strategy to reach the poor.


 In September 2014 Oxfam released a report entitled: Investing For the Few: The IFC’s Health in Africa Initiative. Their report highlights the lack of transparency within the International Finance Corporation’s (IFC) Health in Africa (HiA) strategy and the overall lack of monitoring and evaluative (M&E) institutions.1 Concluding that the IFC has done little to demonstrate the role of the private health sector in pro-equity health system strengthening.1

Earlier in 2014, I had completed my own research attempting to answer: To what extent has the IFC’s HiA initiative improved financial protection and access to quality health goods and services for the poor?

My research objectives were to map the IFC’s HiA activities by workstream, then use peer-reviewed and grey-literature (including World Bank monitoring and evaluation data) to investigate the extent to which HiA interventions (from analysis, to policy, to type of investment) improved health outcomes for the Sub-Saharan Africa’s poor.

This proved to be a difficult endeavour, as the IFC’s lack of transparency in HiA’s operational strategy, access/publication of information, and results frameworks, made it difficult to understand how the IFC was taking an opportunistic approach in HiA’s analytic, policy, and investment interventions to improve financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.

Lack of Transparency

In Spring 2014 I had requested (via the World Bank and the IFC’s online information request portals) the following documents: (1) A country/client specific operational plans and corresponding Results Measurements Frameworks; and (2) HiA’s Equity Investments Framework. These M&E institutions were chosen for request, as the nature of these documents fall under SECTION III, Information Routinely Made Available by IFC, in IFC’s (2012) Access to Information Policy.2 Within a week of the request, the World Bank responded with directions to forward this request through the IFC portal. Unfortunately the IFC has yet to respond, although had initially promised a response within 30-working days of a request.

Interesting to note, Oxfam (2014) has reportedly requested HiA’s Results Framework, only to be unsuccessful in their request as well. Oxfam (2014) and the Health in Africa Mid-Term Report (MTR) (2012) have both commented on the lack of transparency within the IFC and their trouble with defining HiA’s anticipated results. Leading to difficulties in understanding, measuring, and evaluating HiA’s opportunistic pathway in order to measure the extent to which the HiA initiative is reaching the poor.1,3 The Independent Evaluation Group (2014) have also recognized this lack of transparency and how little the IFC is engaged with creating M&E institutions.4

In line with my own findings, both Oxfam and the MTR have recognized the difficulties in measuring the extent to which HiA was improving financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.1,3

HIA performing Poorly

Overall, the HiA initiative is implemented over three workstreams (Analyses, Policy, and Investment) to: provide analytic products on Sub-Saharan Africa’s public and private health sectors, assist governments with health policy, and to improve access to credit for private health small- to medium-sized enterprises through equity funds, debt financing and technical assistance.5 In 2011, foreign direct investments were included/added in the HiA Factsheet as a new component of HiA’s investment workstream.6

Research revealed HiA’s Analytic workstream failed to provide a direct analysis linking the IFC’s private health sector interventions with improved health outcomes for the poor.2 Failure to provide this analytic link prompted the IFC to take an opportunistic operational strategy to understand which pathway (from analysis, to policy, to type of investment) works best to meet the IFC’s stated HiA development objectives.7

Consequently, the IFC’s HiA analytic and policy workstream activities were implemented based on the opportunistic strategy that they would create a sustainable investment climate and encourage a socially responsible private health sector to facilitate investments and help meet the estimated US$11-20billion in demand for private health goods and services.8 My findings, however, revealed that the IFC’s HiA investment activities have so far demonstrated little to no capacity to achieve the IFC’s stated HiA development objectives.

Additionally, without any of the IFC’s M&E institutions available (either publicly or upon request) I was unable to understand how the IFC was taking an opportunistic approach to find the best pathway/mechanism (from analysis to policy to type of investment) best improved financial protection and access to quality health goods and services for the poor.

Based on these findings, I question how the IFC is investing its resources for future HiA activities. Without available M&E institutions, the workstream activities which fail to improve financial protection or fail to improve access to health services may be insufficiently monitored and could potentially be continued and/or built-upon. Thus without published M&E institutions, it is possible for HiA activities to weaken Sub-Saharan Africa’s health systems and consequentially move it away from improving financial protection and access to quality health goods and services for the poor.9


If the IFC had adequate evidence to suggest it was improving health outcomes for the underserved through the HiA initiative, this would provide insight into the positive role of the private health sector in pro-equity health system strengthening. However, the evidence presented in my report suggested HiA is performing poorly to achieve the IFC’s stated HiA development objectives. Until M&E institutions are released, research will be unable to understand the extent to which HiA is increasing financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor. 

Publishing the IFC’s Health in Africa activities to Date




  1. Oxfam (2014) Investing for the Few – The IFC’s Health in Africa initiative. London: Oxfam Great Britain.
  2. International Finance Corporation (2012e) IFC Access to Information Policy. Washington: Office for International Finance Corporation World Bank Group.
  3. Brad Herbert Associates (2012) Health in Africa Mid-term Evaluation Final Report. Maryland: Office of Brad Herbert Associates prepared for the International Finance Corporation.
  4. Independent Evaluation Group (2014) World Bank Group Support to Health Financing for Improving Health Systems Performance FY03-FY12.Washington: World Bank.
  5. International Finance Corporation (2013) The Health in Africa Initiative – Improving the Role of Private Sector in Healthcare. Washington: Office for the International Finance Corporation World Bank Group. [Online]. Available at: [Accessed: 10 May 2014].
  6. International Finance Corporation (2011a) IFC – History. [Online]. Available at:$FILE/ifctFS.htm [Accessed: 30 May 2014].
  7. World Bank Group (2012) World Bank Group Management Response: Health in Africa Independent Mid-Term Evaluation. Washington: Office for International Finance Corporation World Bank Group.
  8. International Finance Corporation (2007a) The Business of Health in Africa – Partnering with the Private Sector to Improve People’s Lives. Washington: Office for the International Finance Corporation World Bank Group.
  9. Kutzin, J. (2013) Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization, 91(8), p.602-611. PubMed Central [Online]. DOI: 10.2471/BLT.12.113985 [Accessed: 26 May 2014].


Danielle Howe is a recent graduate from the University of Edinburgh MSc in Global Health and Public Policy

What are the long-term consequences of deworming programmes?

Dr Francisca Mutapi, University of Edinburgh

What happens afterwards? This apocalyptic question is one that is integral to all forms of intervention in human and animal diseases. This is particularly important in cases where the intervention occurs at a national scale. My research group has been asking this question in relation to the current global efforts to control worm (helminth) infections which significantly impact on the health and development of children. Specifically, we work on bilharzia (urinary schistosomiasis) an important, but neglected infectious disease caused by the blood fluke Schistosoma haematobium. Although we hear occasional reports of tourists infected during visits to resorts in endemic areas, bilharzia is typically a disease of poverty due its association with poor sanitation and unsafe water. People become infected when they come into contact with the infective stage in freshwater after it has been released by freshwater snail- hence the other name of the disease- snail fever. The disease affects over 100 million people, mainly in Africa.  Children carry the heaviest burden of infection; as a result, they experience bladder and kidney disorders, stunted growth and poor development.

Current global initiatives from Partners of Parasite Control including the World Health Organization (WHO), Bill and Melinda Gates Foundation, UNICEF, Schistosome Control Initiative and the World Bank are advocating regular school-based de-worming interventions to reduce the development of morbidity, promote school-child health and improve cognitive potential of the children. Children are treated with the antihelminthic drug praziquantel. Over the past decade, there has been a concerted global effort to control bilharzia, galvanised initially by the Millennium Development Goal (MDG) 6 to combat HIV/AIDS, malaria and other diseases by 2015 and the World Health Assembly resolution 54.19 to treat at least 75% of all school-age children at risk of schistosomiasis by 2010. The most recent schistosomiasis resolution, World Health Assembly resolution WHA65.21 passed in 2012 is advocating for the elimination of schistosome transmission and the WHO Schistosomiasis Strategic Plan 2012-–2020 sets out its vision of for a world free from schistosomiasis. This represents a real drive at the global scale not previously seen, to control this important disease of childhood.

Millions of school children in Africa are currently being treated with this drug resulting in significant health improvements. In several countries where the control programmes are currently being implemented, they are typically running for 5 years. The questions we are asking is what will happen to 1) the children who have been treated, 2) the rest of the population that has not been treated and 3) the parasites? The overall, long-term outcome of these treatment programmes for human health is believed to be good- but what evidence do we have for this? In my research group, we are interested in the long-term consequences of praziquantel treatment. Our studies and those of others have shown that the effects of praziquantel treatment go beyond the transient reduction of infection intensity and morbidity. Treatment with the antihelminthic also reduces future pathology and induces immune responses protective against re-infection by the parasites. What will be the effect of the 5-year treatment programmes on the host immune system and overall health?  Experimental studies of the regulation of the immune system suggest that treatment of helminth infection results in susceptibility/worsening of immune disorders (explained through the hygiene hypothesis). What is the relevance of these studies to human helminth infection? What are the long-term health implications in children treated through these national treatment programmes? Similar to malaria, people exposed to schistosome parasites develop natural acquired immunity to the parasites following repeated infection with the parasites. What is the consequence of praziquantel treatment on schistosome immunity and disease, decades after cessation of the control programmes? Providing answers to these questions is critical for informing strategic planning for ministries of health and prioritisation of resources as well as formulating /directing global health policy.

These really interesting scientific questions and the potential impact of the findings for human health are the drivers of research for Dr Francisca Mutapi and her group, the Parasite Immuno-epidemiology Group, at the University of Edinburgh.



Hepatitis E Virus – An Emerging Infection in Scotland?


Globally, liver disease caused by hepatitis A, B, C, D and E viruses is estimated by the World Health Organisation (WHO) to cause the death of around 1.4 million individuals annually. On World Hepatitis Day, 28 July 2014, the WHO underlines the recent resolution of its World Health Assembly directing its 194 Member States to ensure they have national policies in place to address the challenge of viral hepatitis in a manner that builds on local, national and international expertise and experience with a view to combat the hepatitis viruses successfully.

Worldwide, hepatitis E virus (HEV) is an emerging infection with a current estimate of around 20 million infections occurring annually – with >3 million acute cases and around 57,000 deaths (WHO data). The virus is transmitted primarily through the faecal-oral route causing mostly asymptomatic infection but HEV acquisition may also develop into overt hepatitis and fulminant hepatic failure. Although HEV prevalence is highest in East and South Asia, it is now clear that the infection is a global challenge that does not require travel to such high prevalence areas. Instead, autochthonous (locally acquired) hepatitis E is now a recognised component of UK HEV epidemiology with an increase in HEV cases having been observed in the British nations. In particular, recent collaborative research between NHS Lothian and the University of Edinburgh has highlighted the situation within the Lothian health board. Equally, Health Protection Scotland (HPS) has observed a substantial national increase in laboratory reports of HEV infection rising from 15 cases in 2011 to 95 reports in 2013. Although no HEV outbreaks have been reported in Scotland, greater awareness of autochthonous HEV has led to a general increase in HEV testing with identification of cases.

As a result of the above, NHS Scotland is collaborating closely with the University of Edinburgh and other Scottish research institutions with a view to forge a national approach to the prompt identification and management of HEV infection as well as delineating some of the research required to further our understanding of the virus and its pathogenesis thereby supporting the WHO in its efforts to combat viral (HEV) hepatitis.


Ingólfur Johannessen, Specialist Virology Centre, Department of Laboratory Medicine, the Royal Infirmary of Edinburgh (University of Edinburgh)

Thinking about the post-MDG era

In 2015, the current eight Millennium Development Goals (MDGs) will expire. Results will be mixed, some will be met and some will not. What is clear, however, is that the MDGs have shaped the way we think about development, and our priorities and approaches to alleviating poverty.

The MDGs gave new prominence to the health issues affecting the poor; although their focus was restricted and derived from a top-down process of deliberation, rather than informed by inclusive analysis and a thorough prioritisation of development needs. Subsequently, the narrowly focused and largely sector-specific MDGs left gaps in coverage and failed to realise synergies between the foci covered by the goals (education, health, poverty, and gender). MDG 6 in particular—“combat HIV/AIDS, malaria and other diseases”—sidelined many of the communicable and non-communicable diseases that perpetuate the cycle of poverty in developing countries. And yet, the very act of naming HIV/AIDS and malaria raised the profile of these diseases immeasurably, stimulating increased funding, focused policy and dedicated institutions and programmes.

In response to the narrowness and specificity of the MDGs networks, alliances and lobby groups have emerged to argue for other priorities, perspectives and approaches. One of the most vocal examples – and the focus of the article – is the alliance arguing for Neglected Tropical Diseases (NTDs), a cluster of diseases of the bottom billion that are underserved with regards to research, treatment and control, to be included in the set of Goals that will replace the MDGs after 2015. At the moment it is looking increasingly likely that NTDs will be name-checked and specifically included in the “new” MDGs. This will be no mean feat.

The case for including NTDs in the post-2015 agenda has been building since their omission from MDG 6, which served as a call to arms for a group of concerned stakeholders, who have since contributed to a series of landmark initiatives that have placed NTDs firmly on the international agenda.

One “advantage” that the NTDs may have in a more enlightened and nuanced post-MDG era (with regards to development as well as to health), is that, by their very nature, they “undermine healthy lives” and cut across and threaten to undermine multiple silos of MDGs. This suggests a potentially fruitful bifurcated approach where focusing on NTDs can help make concrete inroads into reaffirmed or tweaked post-2015 MDGs, or NTDs can be used to articulate a set of goals that do not represent silos as targets to be met, but rather represent the strengthening of the institutions we need to manage the complex social, economic, environmental, and health systems that interact to shape future development.

Controlling NTDs in a post MDG era

MDGs and NTDs: Reshaping the Global Health Agenda

INZI Project (Investigating Networks of Zoonosis Innovation)


James Smith

Professor James Smith, Director, Global Development Academy, University of Edinburgh

Emma Michelle Taylor

Dr Emma Michelle Taylor, Research Fellow, INZI Project, Centre for African Studies, University of Edinburgh