Calling for a stronger climate and health nexus within the UNFCCC

From 1-11th June I was part of the International Federation of Medical Students Association’s (IFMSA) delegation at the UNFCCC intersessional’s in Bonn. The IFMSA has been engaging diligently in the UNFCCC process for over 5 years working to reinforce the climate and health nexus within the negotiating text. Our efforts have been greatly appreciated by delegates and the global climate policy community, as there is a relatively small health community engaging with the UNFCCC, despite the recognition that climate change is the “greatest threat to global health of the 21st century” (1). Last December, our work was rewarded in the Lima Call for Action where health was placed firmly in the preamble of the text (2). We entered these intersessionals with positive spirits, due to recent successes of the World Health Assembly, which took place in Geneva the previous week. This resulted in a resolution on the public health dangers of air pollution and the need to phase out fossil fuels in order to both tackle ill-health from pollution and reap co-health benefits of climate change mitigation (3). However, as we head towards COP21 in Paris, which aims to produce a legally binding global agreement, there is concern that the need to dramatically shorten the text will force certain issues into the side-lines. Our aim from now until Paris is to use the contacts we have made at these intersessionals and previous COPs to coordinate a larger coalition of countries that will provide a strong position on health in the new global agreement.

This was my first experience as a delegate at the UNFCCC, and despite not having particularly high expectations, I must admit that the pace of the talks was even slower than I had expected. Negotiations hardly got further than discussing commas and brackets and how these could be used to shorten the text from its former 96 pages to something more manageable. However, after day 6 they had only managed to cut this down to 86 pages, and nothing of the substance of the text had even begun to be discussed. This was frustrating for many of the organisations who had come to lobby delegates on a breadth of issues which need to be included within the text such as human rights, intergenerational equity, gender and health. Being part of the youth constituency, I found there were many barriers to prevent our voices being fully considered. From informing us of interventions less than hour before, not providing adequate translation services, giving us interventions only at the end of sessions and forcing our creative actions to be within strict rules and regulations; our opportunity to represent young people, who are going to be most impacted by the decisions, was severely restricted. The lack of representation of the Global South also made me question the legitimacy of the process. How are we supposed to go about constructing effective policy solutions when those suffering the most from climate change are not represented? Of course, this is not an issue unique to climate change policy, but to witness this stark injustice in reality was a powerful reminder of the need for change.

After spending the past year being involved with local and national action on climate change and health, the pace and level of engagement at these high level negotiations was at best disheartening. It is clear we cannot wait upon the UN to ensure effective solutions to the impending and already tangible impacts of climate change. Whilst the IFMSA and others will continue to be at the forefront of ensuring a legally binding and successful agreement that will protect and promote global health, we rely upon a forward thinking global health community to implement solutions in their own communities. This needs to go beyond acknowledging the intersections between ecology and health towards being part of the structural change needed to ensure a sustainable and healthy future.

This is a critical year for climate action and the implications of inaction on our health and our future is unprecedented. I hope to continue to work within the UNFCCC, but also to bridge the gap between this process and community action which is a key part to building climate resilience. Through attending several side events during the conference I also found that public health provided an important and coherent narrative in which to address a wide range of climate change issues from food and water scarcity, air pollution, occupational and community health surround fossil fuel extraction, transitions towards sustainable active transport and rising infectious diseases in crops, livestock and people. It was clear that health is a powerful tool to provide an anchor of agreement in the UNFCCC, as well as provide a lens to engage a breadth of people with climate change. I look forward to tracking the progress of the UNFCCC and hope that an agreement in Paris will be reached that will mobilise the diverse and collaborative movement needed to save human and ecological life on this planet.


References

Costello (2009) Managing the health effects of climate change. The Lancet [pdf] https://www.ucl.ac.uk/global-health/project-pages/lancet1/ucl-lancet-climate-change.pdf

Lima Call for Action: http://unfccc.int/files/meetings/lima_dec_2014/application/pdf/auv_cop20_lima_call_for_climate_action.pdf

World Health Organisation (2015) World Health Assembly closes, passing resolutions on air pollution and epilepsy [online] Available at: http://www.who.int/mediacentre/news/releases/2015/wha-26-may-2015/en/


ADP2.9: Last Updates from the IFMSA Delegation

ADP2.9: Updates from the ADP 2.9 United Nations Climate Change Conference

ADP2.9 – Meet the IFMSA Delegation!


 

Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.

http://www.healthyplanetuk.org/

 

Rewarding research: Social Science and Health Research in Zambia

Rewarding research: Using my ‘self’, psychotherapeutic perspectives and reflection in social science and health research in Zambia

Following a long career in the NHS in Scotland as an Art Psychotherapist and leading several projects training mental health staff in Ghana and Zambia, I embarked on an MSc in Africa and International development at the University of Edinburgh.

My MSc incorporated a work-based placement at ZAMBART[1] in Zambia where I conducted a secondary analysis of case studies of households caring for patients with TB /HIV – from a mental health perspective. This gave me the opportunity to include my ‘self’ and my professional knowledge and stance as elements which worked in dialogue with each other as to inform and shape my dissertation. .

This was no mean task and required both reflection and personal challenge – an acceptance of painful self-realisations – in order to expose the normalised assumptions endemic in my attitudes. I judged men as ‘bad men’ – when their risk taking behaviours impacted on their families. Recognising this and then understanding these behaviours from a non-judgmental psychotherapeutic stance enabled the complex systemic relationships around men’s mental health in rural Zambia to no longer be hidden in a blind spot – beginning their exposure to greater understanding and analysis.

Such fruitful discoveries from such a self-reflective approach and a psychotherapeutic stance point add to the enhanced value of practitioners engaging in research and the blending of psychotherapeutic stances with research objectives.

More detail on this aspect of my work-based placement is given in  Who Cares about Mr Mubanga

 


Lesley Hill, MSc Africa and International Development (2014)

 

References

[1] ZAMBART – a non-for profit research organisation based within the University of Zambia that is also a research collaborating centre for the London School of Hygiene and Tropical Medicine

 

Nkhoma Hospital Cervical Cancer Screening Programme: a Scottish–Nkhoma partnership

In Malawi, cervical cancer is the most frequent cancer among women of reproductive and economically important age (45.4% of female cancers) and an 80% mortality. Numbers are projected to increase over the next 2 decades as improvements in other areas of health (eg treatment for HIV) increase length of life. There is no national programme for cervical cancer prevention through immunisation or screening and many women now survive childbirth only to die later of preventable cervical cancer. Inadequate access to treatment, ostracisation of women with severe symptoms of cervical cancer, and limited palliative care services are additional features.

We received funding from the Scottish Government International Development Fund for Malawi (2013-2016) to set up a sustainable programme of cervical cancer reduction in Nkhoma Hospital and 10 surrounding health centres. The project is jointly led by Professor Heather Cubie, Consultant Clinical Scientist in NHS Lothian until recently / Honorary Professor, Global Health Academy, University of Edinburgh and by Dr Christine Campbell, Senior Research Fellow, Centre for Population Health Sciences, University of Edinburgh. The principal clinicians are Sr. Hilary Brown and Dr Graeme Walker from NHS Lothian who participated in ALSO courses (Advanced Life-Saving in Obstetrics) in Malawi a few years back and others from round Scotland have helped / are helping for short periods through sabbatical or unpaid leave.

The Scottish and Nkhoma teams, October 2013

The Scottish and Nkhoma teams, October 2013

In the first two years of the project, our Malawian colleagues have provided information on the value of cervical screening to 4 Traditional Authorities and 84 Group Village Headmen and obtained their permission to speak to around 30,000 people in the region. In addition, a potential 120,000 (50% of the population) has been reached by local radio broadcasts. Twenty-four Malawian healthcare professionals (mainly midwives and clinical officers) have been trained to provide cervical screening using a procedure called VIA (visual inspection with acetic acid) and treatment of early lesions using cold coagulation. Case load is audited and competency of each provider is assessed by Scottish clinicians using similar standards to the UK.

Talk to women to explain what would happen in VIA clinic, Nkhoma Hospital

October 2013

October 2013

In the new outside classroom, October 2014

In the new outside classroom, October 2014

 

 

 

 

 

 

 

 

Over 7000 women have had their first-ever cervical screen. Those with early signs of abnormality have been offered treatment and 75% received it the same day. At the start of the project, a number of women said they would need to ask permission from their husbands to receive treatment but this is no longer a big issue. Hopefully this is because the information messages have reached the whole population, men and women, giving women a sense of empowerment. Two-thirds have returned for follow-up visits, despite this being considered difficult to achieve.

Sadly, the VIA clinics still see too many women with cancers which are too advanced for immediate treatment. There is little Malawi can offer in terms of chemo- or radiotherapy, but the project does ensure that these women have their diagnosis fully explained and are offered surgery or palliative care where appropriate.

The project now has daily clinics in Nkhoma Hospital and weekly clinics in 5 surrounding health centres, some Government and some CHAM. Year 3 of the project will extend to weekly clinics in 5 more health centres and consolidate training to allow sustained service. We are currently looking for further funding to extend the ‘hub and spokes’ model to additional hospitals and their health centres.

 

Sustainable Programme of Cervical Cancer Screening

 


Professor Heather A Cubie  (Global Health Academy)  and Dr Christine Campbell (Centre for Population Health Sciences), University of Edinburgh

 


 

Global Health Academy

 

 

 

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.

map image web

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 (http://globalsurg.org/get-involved/). 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.

 bullet image

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

From the normal to the uncertain

An Earthquake is a massive event in every way, it quite literally shakes you out of your normal life and immediately throws you into uncertainty.

Unlike a hurricane or typhoon you can’t see it coming and you don’t know exactly when you will be in the clear. It is precisely this uncertainty that makes the union of individuals, communities ,governments and organizations in the relief efforts following an earthquake all the more remarkable.

All of those who arrived in Nepal following the quake have no certainty that they will not experience an aftershock that might again throw everything into chaos. They are putting their lives at risk just as much as those of us who experienced the quake on April 25th. They have all come together , Saudi Arabia, South Africa, Israel, France, China, the United States and many more ignoring the usual political tensions that exists between nations to work together. Despite the press the government of Nepal has received we have witnessed hundreds of government officials of all levels working tirelessly to deliver aid, to make sure the wounded receive treatment and that people have shelter.  There are also amazing local NGOs here in Nepal such as BibekSheel that alone has delivered more than 10 tons of aid to Gorkha , that’s more than most large INGOs have delivered!

All of the Nepalis who have worked non-stop during this response have left their own families and homes to help others in their country. Many have suffered damage to their own houses but have chosen to give to others. While the disaster here in the Kathmandu valley and in other districts in Nepal has been devastating, underneath that layer of debris and ruble that we see on television is : dedication, caring and a deep love for humanity from all who are here and all who have come to serve.

Let’s lift that debris off and let those values be seen both here on the ground in Nepal and in each of our lives every day.


 

Jay Evans, Regional Director , Asia for Medic Mobile
Jay Evans TH

 

 

 

 

Twitter: @jaymedicmobile

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.


adrian m a

            

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

                   Edinburgh Infectious Diseases, University of Edinburgh, UK

 

 

 


Links

 

 

 

Unhealthy investments

I have been involved with the fossil fuel divestment movement over the past year, both with the University and through Healthy Planet UK, after coming to terms with the enormity of climate change and the need for urgent action. As a medical student I am compelled by a similar duty of care towards our ecosystem, on which our health depends, and am called to respond to its current symptoms of distress. Divestment offers a way to treat one of the root causes of these symptoms – the continued burning of fossil fuels – through moving investments away from the fossil fuel industry whose business model relies upon burning reserves which currently hold over five times that which is safe to burn if we are to stay below the 2 degrees celsius limit of global warming[1] Akin to the health sector leading divestment from the tobacco industry, there is a similar narrative in the response to the health threat of climate change further weighted by tactics utilised by the fossil fuel industry to thwart climate mitigation policy and mar public perception of the reality of climate science[2]. UK universities hold around £5.2 billion worth of investments through their endowment funds in the fossil fuel industry[3]. However, divestment is not simply a matter of money, most divestment decisions have been driven by a moral case. It rests on a simple principle -if it is wrong to wreck the planet, then it is wrong to profit from that wreckage. For the medical tradition investing in fossil fuels can be seen to contradict the fundamental principle to “first do no harm”. So far 21 universities, 35 cities, 65 religious organisations and numerous other organisations from around the world including the British Medical Association have committed to divesting from fossil fuels[4].

 

Medical institutions and the health community have a unique awareness of climate change through its current and future impacts on human health, but also through the potential immense health co-benefits of tackling climate change such as reducing the disease burden of air pollution, which has been attributed to 2000 premature deaths annually in Scotland[5], and encouraging active travel through reducing our reliance on fossil fuel guzzling cars. This gives an important dimension to the divestment dialogue and the engagement of medical schools and health organisations is sure to be very valuable. On the 3rd February, Healthy Planet are publishing their report “Unhealthy Investments”, co-authored with MedAct, The Climate and Health Council, Medsin and the Centre for Sustainable Healthcare. This will be a crucial step towards further engagement on fossil fuel divestment from the health sector. It will involve a panel of expert speakers to discuss the question of whether organisations which work to improve health should continue to invest in fossil fuel extraction and production companies. Should the health sector be taking more of a lead in this issue? There is certainly great potential in engaging with the process and evaluating how best our pension and endowment funds can be invested towards a healthier and more sustainable future.

 

More information on the report launch can be found here: http://www.eventbrite.co.uk/e/unhealthy-investmentsshould-health-organisations-divest-from-fossil-fuels-tickets-15237083527


 

References

[1] http://www.carbontracker.org/

[2] http://www.greenpeace.org/usa/en/campaigns/global-warming-and-energy/polluterwatch/Dealing-in-Doubt—the-Climate-Denial-Machine-vs-Climate-Science/

[3] http://peopleandplanet.org/fossil-free

[4] http://gofossilfree.org/commitments/

[5] http://www.foe-scotland.org.uk/air-pollution


 

 

Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.

http://www.healthyplanetuk.org/

 

Global mental health – its time to pull together

The recent report from the UK’s All-Party Parliamentary Group on Global Health and Mental Health (MH) is very welcome. Not only does it describe the parlous state of MH services in many parts of the world, it presents an evidence-base for global action. It is important to acknowledge, for example, that patients can be caged, chained or subjected to abusive traditional approaches and that Western mental health services are not all bad. The report summarises the growing body of research showing that there are cost-effective solutions to mental health problems that even the poorest countries could implement and benefit from. These include improving social and economic environments, integrating mental health into general health care, using trained and non-specialist health workers to provide culturally appropriate community care, increasing access to self-help and empowering people with mental health problems to support and advocate for themselves and each other.

Further, and more specifically, the WHO (1) have previously shown that interventions such as psychosocial and antidepressant treatment are ‘very cost-effective’ interventions for panic disorder and depression throughout the world, and that psychosocial treatments plus older antipsychotic and mood stabilising drugs are ‘cost-effective’ for schizophrenia and bipolar disorder.

Another report released in November, from the Overseas Development Institute (2), gives a complimentary perspective – mental (ill) health does not receive due policy attention due to stigma and a lack of coherence across the mental health community. The time has come for the mental health community to work together to achieve shared goals such as reducing stigma and increased funding for MH services across the globe.

 

 


Professor Stephen Lawrie, Head of Psychiatry, University of Edinburgh


 

1.Chisholm D, on behalf of WHO-CHOICE. Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organisation. World Psychiatry 2005; 4: 37-44.
2. Mackenzie J. Global mental health from a policy perspective: a context analysis. Overseas Development Institute 2014.

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.

Introduction

 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

Conclusions

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


 

References

 

  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: https://www.wbginvestmentclimate.org/advisory-services/health/health-in-africa/upload/HiA-Factsheet_October-2013.pdf [Accessed: 10 May 2014].
  6. International Finance Corporation (2011a) IFC – History. [Online]. Available at: http://ifcext.ifc.org/ifcext/masterinternet.nsf/AttachmentsByTitle/ifctFS.htm/$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].

DanielleHowe_photo

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