Part II-Prototypes Bring Ideation to Life

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Welcome to the second installment of our blog series on human centered design. In our introductory post we broke down what human centered design means for designers and implementers of international development projects. Our most recent post gave a case example of how we’re building empathy with health workers in Nepal. This post will share a case example of how we’re prototyping different iterations of a monitoring and evaluation (M&E) dashboard for our staff in Benin.

Once you have worked with your project partners to determine what you want to design or test, the most effective way to get useful feedback from the people you’re designing for is to prototype what you want to test.

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Sam facilitating the feedback session on VaxTrac monitor

Prototyping allows you to get feedback on something concrete rather than abstract. It is the difference between asking someone to describe their perfect cup of coffee versus giving them three different cups of coffee to critique. They will have a better grasp of what you are trying to design, and you will get more specific and useful feedback.

Prototyping also gives you the flexibility to test a variety of unique ideas without spending the resources on a project that might not work the first time.

The Problem
Our team in Benin needed a new, more efficient way to monitor our project. As we trained new health workers to use VaxTrac and added an entirely new health zone to our scope of work, our field team had to process more data than ever before.

Each field supervisor had devised his own method of monitoring how health workers use the tablets, what bugs occur in the software, and how to compare tablet-based reporting to paper-based reporting. Meanwhile, back in DC, our Learn team stayed busy exporting data from CommCare reports and spending a lot of time converting data into a more useful format.

It quickly became clear that we needed a more efficient way of tracking data so that our field-based team could spend less time entering data into spreadsheets and more time responding to health worker needs, prioritizing resources and tracking progress over time.

Prototyping Solutions to Test the Best Ideas
To solve this problem, we have been working with our team to design a monitoring tool that will allow our field supervisors to monitor the project more easily. After a series of feedback sessions interspersed with a variety of paper monitoring tool prototypes, we decided the best solution would be to design a web-based data dashboard that can automatically populate with data from CommCare, such as when a form is submitted, the time it takes to complete a form, when a child is fully immunized, among other pieces of data. We are also working to incorporate additional pieces of data such as, data use, battery level of the tablet and the last time the tablet had an internet connection.

In order to get feedback from our team in Benin, we designed a live prototype of a monitoring and evaluation (M&E) dashboard:
 

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M&E Dashboard Prototype

Our DC staff brought the prototype to our Benin staff during a trip to Benin a couple weeks ago. We held a focus group and asked our team questions about the types of data they want to monitor on the dashboard, how data should be grouped, how data should be displayed and how they would use the dashboard.

By providing a concrete example of an M&E dashboard, we were able to elicit specific and useful feedback from our team in Benin. The designing of the dashboard is an ongoing project. We will continue to get feedback and iterate on our designs until we come up with a solution that meets everyone’s needs.

Check out the final post in our series about human centered design, where we’ll give examples of how we keep iterating on our projects even after we implement.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources.

Water Risk Perception and the Use of Water Bottles

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Source: http://cbwa.info/

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

It is important to examine how social, organizational and cultural factors of the environment interact to influence health (Laverack, 2014). This has become increasingly evident as water quality and quantity is assessed to determine its impacts on the health of a community. As water is vital to human health, access to clean tap water is important; however, bottled water is often seen as a better alternative to tap water; especially in less developed regions. Many people in low-resources countries, such as Lebanon and Jordan, believe that bottled water is better than their tap water (Massoud, et al., 2013). However, the bottled water is not always effectively monitored for safety, and many are still at risk for various waterborne diseases. Thus, citizens face economic strain to pay for water that is perceived to, but may not be cleaner (Massoud et al., 2013).

Even when bottled water is cleaner than the local tap water, the poor are often unable to afford it, which further increases the gap between the different social classes (Massoud et al., 2013). Citizens should not have to pay for something that is a human right (Parag & Roberts, 2009). Encouraging the use of tap water pushes NGOs and government agencies to improve infrastructure that would make water available to all regardless of social class (Massoud et al., 2013)..

Although tap water in developed regions such as Canada is clean and reliable, bottled water is still popular as it is often purchased for convenience (Mikhailovich & Fitzgerald, 2014). Although the socio-economic implication of using plastic water bottles may not be as severe in such settings, there are still negative environmental consequences (Parag & Roberts, 2009). Manufacturing, packaging, transporting and disposing plastic water bottles is an inefficient use of resources and creates a large amount of waste (Parag & Roberts, 2009). This can have a negative impact on the ecosystem, as this waste can influence plants, animals, minerals and water (Parag & Roberts, 2009). As these systems interact with humans they eventually have a negative impact on the health of a population (Parag & Roberts, 2009). Thus, encouraging the use of re-usable water bottles encourages environmental awareness.

Nevertheless, non-reusable plastic water bottles have been beneficial for emergencies when clean water is not easily available (Canadian Bottled Water Association). With the gradual discontinuation of these bottles, alternative methods need to be determined to ensure that clean water is distributed during emergencies.

Overall, clean water is vital for human health, and easy accessibility is crucial. Thus, clean tap water must be made available and plastic bottles should be phased out in order to allow for greater use of re-usable bottles. This would be a lower burden on the environment, and decrease wealth inequality, consequently, having a positive impact on the health of citizens. 

References:

Laverack, G. (2014). A-Z of health promotion. UK: Palgrave Macmillan.

Massoud, M. a., Maroun, R., Abdelnabi, H., Jamali, I. I., & El-Fadel, M. (2013). Public perception and economic implications of bottled water consumption in underprivileged urban areas. Environmental Monitoring and Assessment, 185, 3093–3102. doi:10.1007/s10661-012-2775-x

Mikhailovich, K., & Fitzgerald, R. (2014). Community responses to the removal of bottled water on a university campus. International Journal of Sustainability in Higher Education, 15(3), 330–342. doi:10.1108/IJSHE-08-2012-0076

Parag, Y., & Roberts, J. T. (2009). A Battle Against the Bottles: Building, Claiming, and Regaining Tap-Water Trustworthiness. Society & Natural Resources, 22(7), 625–636. doi:10.1080/08941920802017248

Recent Therapeutic Advancements in Combating Dengue and Glioma

~Written by Kate Lee, MPH (Contact: kate@recombine.com)

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Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit: European Pharmaceutical Review

Infectious and chronic diseases are some of the top priorities in global health. Abundant funding, both from the government and private sector, is poured into therapeutics research to help decrease morbidity and mortality from both types of diseases. For example, recent news has highlighted two promising therapies with the potential to alleviate the global burden of two diseases: dengue fever, an infectious disease, and glioblastoma, a chronic disease.

After 20 years of research, Sanofi, a French pharmaceutical company, developed Dengvaxia, a vaccine to prevent dengue. Mexico is the first country to approve the vaccine for use in children over the age of nine and adults under the age of 45. A clinical trial last year found the vaccine to have an effectiveness of 60.8% against four strains of the virus[1]. Sanofi bypassed European and US regulations and sought regulatory approval for Dengvaxia in dengue-endemic countries. According to their press release, the vaccine, “will be priced at a fair, affordable, equitable, and sustainable price... and may be distributed for free in certain countries”[2].

Dengue is a febrile viral illness that is spread via the bite of an infected mosquito, and is endemic to tropical and sub-tropical climates. According to the World Health Organization (WHO), about 400 million people globally are infected with the dengue virus each year. Prevention has been limited to effective mosquito control and appropriate medical care[3]. These measures are often either ineffectively implemented, or there are limited, or no available medical resources in the community. Dengvaxia has the potential to reduce the burden of dengue, especially in developing countries that are particularly hard-hit with the disease. Future research could be directed towards making the vaccine more effective in children, as severe forms of dengue are the leading cause of illness and death in children in Asian and Latin American countries[3].

As one tropical virus is being prevented, another virus is being used to combat brain cancer. Researchers at Harvard and Yale have teamed up to use vesicular stomatitis virus (VSV) and Lassa virus, to search for and destroy cancer cells in mice[4]. Lassa is a febrile illness, usually transmitted by rodents, and is endemic to tropical and subtropical regions of the world[5]. VSV has been studied for many years and is generally effective in killing cancer cells; it becomes deadly to the patient when it reaches the brain[4,6]. Interestingly, including Lassa virus appears to make VSV safe for cancer therapy in the brain.

Researchers created a Lassa-VSV chimera, an organism that includes the genetic codes of two different organisms, to target glioma, one of the deadliest forms of brain cancer, which accounts for more than 80% of primary malignant brain tumors[7]. Glioblastoma is the most common form of glioma and is associated with poor survival, making this chimeric treatment a potential life saver for many patients. The next step in the treatment development process is primate research to evaluate safety. This is still a long way from the initiation of human trials, and eventual market, but promising nevertheless, for the millions of people globally who are affected by brain cancer.

Dengvaxia and the Lassa-VSV chimera represent recent advancements in therapeutics with potentially significant global impact for brain cancer and dengue respectively - diseases that affect populations in many nations.

References:

1.     Sanofi's Dengvaxia, World's First Dengue Vaccine, Approved For Use In Mexico. International Business Times. http://www.ibtimes.com/sanofis-dengvaxia-worlds-first-dengue-vaccine-approved-use-mexico-2219515. Published December 10, 2015. Accessed December 20, 2015.

2.     World’s First Dengue Vaccine Approved After 20 Years of Research. Bloomberg Business. http://www.bloomberg.com/news/articles/2015-12-09/world-s-first-dengue-vaccine-approved-after-20-years-of-research. Published December 9, 2015. Accessed December 20, 2015.

3.     Dengue and severe dengue. World Health Organization. http://www.who.int/mediacentre/factsheets/fs117/en/. Updated May 2015. Accessed December 20, 2015.

4.     Using a deadly virus to kill cancer: Scientists experiment with new treatment. The Washington Post. https://www.washingtonpost.com/national/health-science/using-a-deadly-virus-to-kill-cancer-scientists-experiment-with-new-treatment/2015/12/07/7d30bc5a-9785-11e5-8917-653b65c809eb_story.html. Published December 7, 2015. Accessed December 20, 2015.

5.     Lassa fever. World Health Organization. http://www.who.int/mediacentre/factsheets/fs179/en/. Updated March 13, 2015. Accessed December 20, 2015.

6.     Viral Therapy in Treating Patient with Liver Cancer. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01628640. Updated July 2015. Accessed December 20, 2015.

7.     Schwartzbaum J A, Fisher J L, Aldape K D, Wrensch M. Epidemiology and molecular pathology of glioma. Nature Clinical Practice Neurology (2006) 2, 494-503. doi:10.1038/ncpneuro0289

We Can End Rabies Together

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

Rabies is a neglected viral disease that is found on all continents except Antarctica and is endemic in 150 countries and territories. While rabies can be found almost everywhere, 95% of cases occur in Africa and Asia. Rabies is almost always fatal following the onset of symptoms. However, rabies is vaccine-preventable and can be eliminated. The World Health Organization (WHO) in conjunction with the Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE), and the Global Alliance for Rabies Control is raising awareness about rabies. September 28th is World Rabies Day and this year’s theme is “End Rabies Together”.

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Figure 1. Worldwide map of rabies indicating level of risk by country, 2011. Courtesy of the World Health Organization. http://www.who.int/rabies/Global_distribution_risk_humans_contracting_rabies_2011.png?ua=1

Rabies is usually transmitted to humans from the deep bite or scratch of an infected animal. Domestic dogs are responsible for more than 99% of human rabies cases throughout the world. According to the WHO, “while infected domestic dogs cause human rabies deaths in Africa and Asia; in the Americas, Australia and Europe, bats are the primary source of human rabies infections.” Children are disproportionately affected by rabies. Forty percent of people who are bitten by suspected rabid animals are children under 15 years of age.

No tests are available to determine if a person is infected with rabies before they show clinical symptoms. Once a person begins to show clinical symptoms of rabies, the disease is almost always fatal. There have been a few cases of people developing rabies symptoms and surviving, with the use of the Milwaukee Protocol. In 2004, a Wisconsin teenager was bitten by an infected bat. She did not seek medical treatment and did not receive PEP. Dr. Willoughby, an infectious disease specialist at the Children’s Hospital of Wisconsin near Milwaukee, tried an experimental treatment that included an induced coma and antiviral medication. The teen survived with few lasting complications. However, many experts caution that the Milwaukee Protocol is not the cure for rabies, at least not yet. The first 43 human rabies cases where doctors attempted to replicate the Milwaukee Protocol resulted in only five survivors. Admittedly, five survivors are pretty good for a nearly always fatal disease, but not enough to say that the Milwaukee Protocol is a cure for human rabies.

Vaccinating dogs is the most cost effective way to prevent human rabies deaths because it results in a decrease in the global deaths attributable to rabies and a decrease in the need for post-exposure prophylaxis (PEP). Post-exposure prophylaxis is the administration of rabies immunoglobulin and rabies vaccine to an exposed person immediately after exposure, in order to prevent infection. Timely PEP can prevent the onset of rabies symptoms and death. However, PEP is expensive and not widely available in many of the resource poor settings with high rabies burden. Eighty percent of dog-mediated rabies deaths occur in rural areas that lack awareness about, and access to, PEP.

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Figure 2. The 2015 World Rabies Day logo. Courtesy of the Global Alliance for Rabies Control. http://logos.rabiesalliance.org.s3-website-us-east-1.amazonaws.com/englishweb.jp

Rabies elimination is achievable for many of the countries with a high burden of dog-mediated rabies cases. Achieving a dog vaccination rate of at least 70% is accepted as the most effective way to prevent human rabies deaths. Rabies transmitted by dogs has been eliminated in many Latin American countries including Chile, Costa Rica, Panama, Uruguay, most of Argentina, the states of Sao Paulo and Rio de Janeiro in Brazil, and large parts of Mexico and Brazil. A Bill and Melinda Gates Foundation project, led by WHO, has made great strides against human rabies cases in the Philippines, South Africa and Tanzania. Furthermore, many countries in WHO South-East Asia Region have begun elimination campaigns with the goal of meeting the 2020 target for regional rabies elimination. Bangladesh, for example, launched an elimination program in 2010 and has seen human rabies deaths decrease by 50% during 2010-2013.

While there are still challenges in achieving a high vaccination rate in some areas of the world, such as vaccine availability and community support, some countries have been able to achieve rabies elimination. Events like World Rabies Day help draw attention to the high burden of rabies in resource poor settings and help to highlight the work being done to eliminate rabies.

Climate Change and Health, Part 2: Droughts, Food Insecurity and Culture

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

In my last blog post, I highlighted how climate change has impacted the frequency, severity and onset of floods, thus, have various impacts on the health and well-being of flood victims. In this blog, I will be discussing how food security will be impacted by climate change.

Overall, an increase in temperature would lead to a decrease in nutrient acquisition in crops and could disturb general nutrient cycling (St.Clair & Lynch, 2010). This would also cause an increase in the decomposition of soil organic matter, thus, reducing the fertility of soil and possibly impacting crop nutrition (St.Clair & Lynch, 2010).

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"Representation of the 11 Signs of Climate Change." Source: A Students Guide to Global Climate Change, Environmental Protection Agency (EPA)

Borana, Ethiopia is one region where droughts have been severe (Megersa et al., 2013). In this area, cattle ownership not only provides milk, an important part of the diet, but also indicates attaining the socio-cultural status set by the community. With an increase in temperatures, rangelands in this area have dried up. As there is less land for grazing, there has been a great loss in the number of cattle, and a reduction of milk produced by surviving cattle. This has led to negative health consequences as stunting has become more prevalent among children (Megersa et al., 2013). There has also been an increase in physical ailments among adults (Megersa et al., 2013). With this, 77 percent of households have claimed to be food insecure for over five months per year (Megersa et al., 2013).

As revealed in the above example, issues of food security can be closely associated with cultural norms, as diet is often influenced by the local tradition. Thus, when there is a decrease in what is considered to be a staple-food in the region, a diversification in diet can help alleviate food insecurity (Megersa, Markemann, Angassa, & Valle Zárate, 2013). However, adapting to dietary changes can be a difficult process, especially when diets are so deeply rooted in traditions (St.Clair & Lynch, 2010). Cultural norms also influence how vulnerable populations are impacted by food insecurity. For example, issues of food insecurity related to climate often leads to more issues for women and children because they are already lower on the “food hierarchy” (Watts et al., 2015).

The recent article on climate change and health published by the Lancet discussed many potential options for adaption (Watts et al., 2015). For example, efforts should be made to improve ecosystem management (Watts et al., 2015). Investments should also be made in agricultural research in order to increase food security for the long-term (Watts et al., 2015). Furthermore, early warning systems and food reserves also need to increase in order to potentially avoid issues of nutritional deficiencies (Watts et al., 2015).

As often, this issue is complicated, and there are several questions that can be asked. For example, how can policies be formed to alleviate the impacts on the most vulnerable populations? Furthermore, should those in high-resourced countries be concerned about how those in low-resource regions could be impacted by an increase in droughts? Or even how those living in developed countries could also be impacted by these droughts? 
Or is the problem maybe too far from home to be a concern in the first place?


References:
Megersa, B., Markemann, A., Angassa, A., & Valle Zárate, A. (2013). The role of livestock diversification in ensuring household food security under a changing climate in Borana, Ethiopia. Food Security, 6(1), 15–28. doi:10.1007/s12571-013-0314-4

St.Clair, S. B., & Lynch, J. P. (2010). The opening of Pandora’s Box: climate change impacts on soil fertility and crop nutrition in developing countries. Plant and Soil, 335(1-2), 101–115. doi:10.1007/s11104-010-0328-z

Watts, N., Adger, W. N., Agnolucci, P., Blackstock, J., Byass, P., Cai, W., … Costello, A. (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15). doi:10.1016/S0140-6736(15)60854-6

Lessons, Impact, and the 'Fearonomics' of the Ebola Outbreak in Nigeria

~Written by Sulzhan Bali, PhD (Contact: sulzhan.bali@twigh.org) 

Also published on the DGHI Diaries From the Field Blog

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Passport Sticker with Ebola Symptoms and National Helpline. Photo Credit: Sulzhan Bali, PhD

24th of July.

The day Macchu Picchu was discovered in 1911.

The day Apollo XI returned to the Earth after the first successful mission of taking humans to the moon in 1969. 

Yet, in Nigeria, that day in 2014 will always be marked as the day Patrick Sawyer—the index patient of Ebola—died and set an outbreak in motion in one of the most populated cities in Africa. Patrick Sawyer was a Liberian-American citizen and a diplomat who violated his Ebola quarantine to travel to Nigeria for an ECOWAS convention. His collapse at the airport, coupled with an ongoing strike by Nigerian doctors in public hospitals, landed him at a private hospital in Obalende, where he infected eight other people. 

Patrick Sawyer’s death marked the beginning of an Ebola epidemic in Lagos, a city of 21 million. Lagos is a major economic hub in Africa and one of its biggest cities. An uncontrolled Ebola epidemic would have a far-reaching economic impact beyond the borders of the city, its country, and even its continent.

A recent study has shown that Ebola virus remains active in a dead body for more than a week. Add to this that the body is most infectious in the hours before death, and it is a "virus bomb" waiting to happen if handled incorrectly. West Africa, especially Nigeria, has a strong funeral culture. This Ebola-infected Liberian diplomat’s body was transported and incinerated in accordance with the WHO and CDC protocol. This feat was achieved despite immense political and diplomatic pressure to return the body for funeral rites. It represents one of the many cases of collaboration and "clinical system governance" that are at the heart of the successful containment of Ebola in Nigeria. It is one of the many stories that I'm hoping to highlight in my research on the role of the private sector in Nigeria’s successful Ebola containment.

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One of Many Ebola Information Posters Around Lagos. Photo Credit: Sulzhan Bali, PhD

As part of my research, I am looking at 10 different economic sectors to understand how the Ebola outbreak impacted the private sector and how the private sector dealt with the challenges that the Ebola outbreak posed. My hope is that this research will lead to lessons for the private sector on how, in times of an epidemic, they can help the government to mitigate the disease’s economic impact. I also hope that the resulting report will help governments engage with the private sector more effectively in times of emergencies.

With many outbreaks, especially of highly fatal diseases such as Ebola, fear is the biggest demon. This fear has led to the crippling of economies of Ebola-affected countries. This fear has cost Sierra Leone, Guinea, and Liberia 12 % of their GDP in foregone income and unraveled the years of progress made by these countries. However, this fear is not just a phenomenon limited to West Africa. I had a very personal encounter with this fear recently, when I was quarantined for a few hours in the United States (despite Nigeria being declared Ebola free since October 2014). 

It has been a humbling experience so far, as I try to understand how this fear and the hysteria around Ebola can lead to significant behavioral changes—some of them necessary but some extreme. Everyone I speak to has a story to share. Some people tell of how they bought more than two bus tickets to prevent sitting next to other people. Others tell of hospitals resembling "ghost buildings" as people avoided hospitals and doctors like the plague. Many tell of the "Ebola elbow-shake" that replaced the usual handshake or hug. The reality is that although the Ebola outbreak infected 21 people in Nigeria, it actually affected the lives of 21 million people in Lagos alone, in one way or another. I have come to realize that there is a thin line between precaution and hysteria. Maintaining the equilibrium between the two is the key to controlling the disease and mitigating its economic impact.

As I wrap up my interviews, a few questions resonate with me time and time again from these sessions.

“Are we prepared for the next time?” 

“Ebola is back in Liberia. What can we do to prevent Ebola from coming back to Nigeria?” 

 For the doctors who died in Nigeria’s fight against Ebola:

“Can we truly say our country is a safer place after their sacrifice?” 

And for myself:

“How will your report help Nigeria?”

These are the questions that keep me going. Although my report may not be able to answer all of the aforementioned questions, I do hope it will at least get policy makers, students, and advocacy groups talking about how countries can be better prepared for the next big outbreak and how public-private collaboration can lead a country out of an epidemic and on a path of recovery.

To end on a positive note, 24th July, 2015 also marked one year since the last polio case in Nigeria—an achievement that clearly shows what collaboration in global health can achieve.

(To learn more about my research or to contribute/collaborate in my study, please contact me.)

Investing in Healthcare to Put a Dent in Poverty

~Written by Hussein Zandam (Contact: huzandam@gmail.com; Twitter: @zandamtique)

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Poverty and Healthcare, Two halves. Photo credit: Our Africa

Health and poverty are intricately related. Evidence suggests that there is a positive correlation between health and poverty. People with limited resources in low- and middle-income countries (LMICs) are reported to have limited access to healthcare compared to their wealthier counterparts (Wagstaff, 2002). However, other evidence has shown that health expenditure can push households into poverty (Kruk et al, 2009). Tackling either is a priority for governments to improve the welfare of people. The poor are more likely to need healthcare for many reasons including a lack of safe drinking water, a balanced diet, adequate shelter, and protection against harsh environmental conditions. Because of the increased need for healthcare, the poor incur increased spending on already limited resources, and are likely to experience catastrophic expenditure. Reducing healthcare expenditure by the poor has the potential to be a viable mechanism against deepening of poverty.

Reducing extreme poverty is a major goal of the Millennium Development Goals (MDGs) and was also considered in the formulation of the post-2015 agenda. Countries all over the world are grappling with measures to reduce income inequality and poverty. In developing countries, this is more apparent through the increase of micro credit schemes, subsidies, and social safety nets for the most vulnerable. However, evidence has shown that in spite of efforts from nations and development partners, more needs to be done to eradicate extreme poverty (Laterveer et al. 2003). Poverty and access to healthcare have been subjects of research and policy. Poverty can be viewed not only as a conception of material and income deprivation (Deaton and Zaidi, 2002) but also as the lack of opportunities for an individual to lead a life he/she values (Sen, 1999). Using this concept, empowering people to live healthy lives can be seen as an initiative to overcome poverty. However, when poverty is viewed as a deprivation of income and assets, initiatives are channeled that directly improve household expenditure; when in relation to health, initiatives that lower expenditure on health to avoid catastrophic expenditure.

The World Health Organization (WHO; 2000) has advocated for health financing measures that provide financial protection from catastrophic health expenditure. Catastrophic expenditure is a leading cause of impoverishment in many countries. Efforts to prevent catastrophic expenditure oh health have been primarily through insurance. However, in many LMICs it is not effective and/or is beyond the reach of the poor either by being too costly or by not providing adequate coverage (McIntyre, 2006). Thus, the world health report (WHO, 2010) advocated for universal public finance (UPF) as a strategy to promote universal health coverage. UPF means that governments finance interventions for people regardless of who receives it and who provides it. UPF has been in practice in many high-income countries where many necessary interventions are covered. In LMICs however, UPF is limited by targeting a set of interventions tagged as the essential health package, which means many services are excluded and require user payments at the point of care.

For example, extended cost-effectiveness analysis (EECA) was used to assess the effectiveness and reduction in financial risk afforded by a public package of interventions initiated by the government of Ethiopia (Verguet et al, 2015). The interventions examined included services for vaccination, treatment of some conditions, caesarean section surgery, and tuberculosis DOTS. Their analysis focused on UPF where there is no out-of-pocket expenditure to cover costs incurred for each of the nine interventions. They estimated the annual number of deaths averted and the annual total financial protection afforded by the reduction in out-of-pocket expenditure associated with each intervention. The results for intervention costs, health gains and financial protection varied across the interventions but it was concluded that the interventions were cost-effective and prevented cases of poverty among those at lowest income level. Such evidence can be used to convince governments to increase funding of health services with the objective of improving health status of citizens and eradicating extreme poverty among the population.

References:

Deaton, A. and Zaidi S. 2002. Guidelines for Constructing Consumption Aggregates for Welfare Analysis. World Bank. https://openknowledge.worldbank.org/handle/10986/14101. 

Kruk et al. 2009. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff. 28: 1056–66.

Laterveer et al. 2003. Pro-poor health policies in poverty reduction strategies. Health Policy Plan. 2: 138–145.

Mcintyre et al. 2006. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc. Sci. Med. 4: 858–865.

Sen, A. (1999). Development as Freedom, Oxford University Press, Oxford, 1999.

Verguet et al. (2015): Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. Lancet Glob Health 2015; 3: e288–96.

Wagstaff, A. 2002. Poverty and health sector inequalities.Bull. World Health Organ. 80: 97–105.

WHO (2000). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2000.

WHO (2010). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2010.

Sustaining the Fight against Malaria

~ Written by Randall Kramer, PhD, M.E. (Professor of Environmental Economics and Global Health, Duke University) & Leonard Mboera, PhD, MSc (Chief Scientist, Tanzania National Institute for Medical Research)

*Also published on the Duke Global Health Institute Website 

On World Malaria Day, April 25, there’s much to celebrate and acknowledge when it comes to the fight against malaria. Over the past 15 years, we’ve seen a huge ramp-up of international funding, and the latest statistics show impressive progress—a 46% decrease in malaria infections among children in sub-Saharan Africa and an estimated 4.3 million deaths averted globally over time.

One of the most effective malaria control measures has been the free distribution of several hundred million insecticide-treated mosquito nets that protect people from mosquitoes while sleeping. In 2004, only 3% of at-risk people in sub-Saharan Africa had an insecticide-treated mosquito net available to them, compared to 49% in 2014 after an international campaign.

The U.S. government is among the major funders of malaria control, and it’s one of the few international assistance programs that has garnered bipartisan support through the Bush and Obama terms. But despite the upsurge in spending and the laudable success of these programs, malaria remains one of the leading causes of death in poorer and tropical parts of the world.

The need for continued support is critical; it’s estimated that eliminating malaria as a major global disease threat would require double the current $3 billion invested annually in malaria control. But in the face of so many other pressing needs, why should we continue to invest in malaria?

In the last year, nearly 200 million people suffered from malaria, and its death toll—more than 500,000—was 50 times greater than that of the widely publicized outbreak of Ebola in West Africa. And malaria takes a particularly devastating toll on the young. More than 80% of the deaths from malaria are in children under five, and those who manage to survive the illness often suffer lasting effects on development, school performance and lifetime earnings.

Because malaria is such a resilient killer, we can expect to see these malaria losses continue and potentially rise in the absence of continued financial support. In fact, with temperatures steadily increasing throughout the world as a result of global warming, malaria-transmitting mosquitoes have begun to take residence in new regions, raising the specter of malaria spreading far beyond its current boundaries.

In addition to the physical suffering malaria causes, the disease stunts national economic progress.

Studies by Columbia University economist Jeffrey Sachs suggest that, if not for malaria keeping children out of school and agricultural workers out of the fields, the rate of economic development in sub-Saharan Africa would have been much higher in the past few decades.

And lastly, we can’t underestimate the goodwill generated by our investments in mosquito nets and other malaria-defeating approaches in recipient countries. As one community member told our research team in rural Tanzania, “Mosquito nets have been a great help to us. The day when mosquito nets were distributed, people were very happy, because many people in our community could not afford to buy the mosquito nets.”

The malaria parasite, a resilient and opportunistic pest, has successfully co-inhabited with humans for thousands of years, and it continues to adapt and evolve, damaging populations and economies across the globe. We now have the knowledge, technology and health systems to significantly reduce its devastating human impacts. But putting these assets into action will require renewed political will and financial commitment from rich and poor countries around the globe—including the U.S.

Motor Vehicle Accidents - A Growing Public Health Burden

~ Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za

https://twitter.com/MikeEmmerich

“Road Traffic Crashes do not just happen! They are caused by Fatal Moves (actions) by a driver. The message is simple - DON'T DO FATAL MOVES!”@FatalMoves https://twitter.com/FatalMoves* 1990 to 2010: Deaths from road traffic injuries increased by almost half.*

The largest category of fatal events are transport related. In 1990, according to Global Burden figures, these were the 10^th leading global killer. By 2013, they were fifth! Ahead of malaria, diabetes, chronic obstructive pulmonary disease, cirrhosis or any kind of cancer. In part, this is because of progress against these diseases. But it also because as incomes have risen worldwide, more people are buying, and crashing, motorbikes and cars.

Most global road traffic deaths occur in low and middle-income countries and are rapidly increasing because of the growth in motorisation. Mortality rates caused by traffic related injuries are increasing in low and middle-income countries and they account for 48 percent of the world’s vehicles but more than 90 percent of the world’s road traffic fatalities. Pedestrians are most often affected, followed by car occupants and motorcyclists. Alcohol plays a key factor in the drivers and pedestrians, notably in South Africa, where as many as 65% of all pedestrians have increased blood alcohol levels. Conversely, traffic deaths are decreasing in high-income countries, Sweden is an excellent case study that we will review further on in this article.

10 countries are responsible for 600,000 road traffic deaths annually (see this link to see if your country is on the list). Each year, 1.3 million people die in car accidents, so these 10 countries are responsible for nearly half of all road deaths! India tops the list for the highest overall number of road deaths, followed by China and the U.S. If public health leaders are to catch up on accident prevention, the Global Burden of Disease study (Lancet links below) findings can help them see where and how. “Now that somebody’s done the work and we recognize that there’s a difference we may not have seen before, we can go to work and ask why,” said Dr. Schauben

Besides the rapidly rising fatalities we must also take cognisance of the rising number of injured persons and their cost on the (Global) health burden. Road-traffic crashes were the number one killer of young people and accounted for nearly a third of the world injury burden, a total of 76 million DALYs (Disability Adjusted Life Years) in 2010, up from 57 million in 1990. Most of the victims were young, and many had families that depended on them, who know have to rely on other sources of support, in most instances, the state.

What does the current research then tell us about this rapidly rising burden on global public health; transport injury prevention shows that collective action is as important as individual efforts. Motorcycle helmets, car seatbelts and sober drivers are important, but so are safe vehicles, consistent law enforcement and a reliable infrastructure. Thanks to a combination of insufficient, nonexistent or poorly enforced safety laws, poor infrastructure and a lack of enforcement and corrupt enforcers, the bulk of the countries globally keep aiding and abetting in the deaths of over 1.3 million persons annually! Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all five risk factors (speed, drunk driving, helmets, seat-belts and child restraints). Over a third of road traffic deaths in low and middle-income countries are among pedestrians and cyclists. However, less than 35% of these countries have policies in place to protect their road users.

India has the dubious distinction of registering the highest number of road fatalities in the world (250,000), despite the fact that its population is much smaller than neighboring China and there are more vehicles on the roads in the USA than in India. "A large proportion of these deaths can be prevented by simple measures. The most important of these is strict enforcement of traffic rules, which is conspicuous by its absence in our cities as well as on highways," says the Times of India, and this would be true of the top 10, and also of the country where I reside, South Africa, where 47 persons die each day!

Further compounding the cost of the traffic fatalities is the actual real cost impacting on the affected countries economies; many who cannot afford to have the extra burden on their already strained public health budgets. The economic cost of road collisions to low and middle income countries is at least $100 billion a year! The risk of dying as a result of a road traffic injury is highest in the African Region (24.1 per 100 000 population) It's such a big problem, in fact, that the U.N. feels it needs an entire decade to fix it. In 2011, the U.N. launched a "Decade of Action" that aims to “stabilize and then reduce” global road traffic fatalities by 2020.

Is there any good news? Sweden is one success story, in 2013 only 264 people died in road crashes, a record low. How have they done this? Planning has played the biggest part in reducing accidents. Roads in Sweden are built with safety prioritised over speed or convenience. Low urban speed-limits, pedestrian zones and barriers that separate cars from bikes and oncoming traffic have helped. Globally we need to reduce human error, or eliminate the opportunity for drivers to make fatal moves; human error can even further be reduced, for instance through cars that warn against drunk drivers via built-in breathalysers and making the implementation of safety systems, such as warning alerts for speeding or unbuckled seatbelts/child-seats, compulsory on all new vehicles, built in any factories across the globe.

Individually we need to be aggressive in safe and sober driving habits and not allow our friends and family to place themselves, their passengers and fellow pedestrians at risk by not looking kindly on their unsafe driving practises. Bad and drunk driving should become as unpopular as using a cellphone while driving.

References:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961682-2/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext

http://www.worldlifeexpectancy.com/cause-of-death/road-traffic-accidents/by-country/ http://apps.who.int/gho/data/node.main.A997 http://apps.who.int/gho/data/node.main.A998 http://mikebloomberg.com/BloombergPhilanthropiesLeadingtheWorldwideMovementtoImproveRoad_Safety.pdf