When Implementing Universal Health Coverage, Context Matters

As the WHO’s Millennium Development Goals reach their final phase, Sara Gorman reflects on what we have learned about how political, cultural and financial contexts impact the success of universal health coverage systems. 

Image Credit: Edith Soto, Flickr

Image Credit: Edith Soto, Flickr

In May of 2013, Margaret Chan affirmed the WHO’s commitment to achieving universal health coverage worldwide, proclaiming “universal health coverage is the single most powerful concept that public health has to offer”. For Chan, public health measures such as universal health coverage represent a key component of development work in the 21st century. As the Millennium Development Goals (MDGs) begin to wind down with their 2015 expiration date looming, the WHO has turned its attention toward the next set of goals for world health. With statistics revealing that more than 100 million are pushed into poverty each year due to excessive health care costs, it seems ever more urgent to advocate for universal health coverage, spreading the costs across entire populations.
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When Retroviral Research Goes Viral

The PLOS Pathogens team reflects on their most widely shared article and the benefits and pitfalls of sharing science research on social media.

ALM_image_Pixabay

Image credit: Pixabay

Social media has taken the science world by storm. Or maybe it’s the other way around; but regardless, if you are reading this, you are likely a scientist engaging in social media (this is a science blog). Scientists are participating in all types of social media— blogs, Facebook, Twitter, reddit, Tumblr, Flipboard — showing that science discourse is not limited to conference rooms and laboratories.

Prominent and famous scientists from the Nobel prize winning climatologist Dr. Michael Mann to television-show sensation Bill Nye use social media (see famous scientists on Twitter at Business Insider as well as  scientists on the reddit Ask Me Anything Series). However, social media isn’t just for Principle Investigators in the public eye or distinguished science journalists. Scientists in any field can and are using social media on a daily, even hourly, basis— just check out Vincent Racaniello, the host of the TWiV podcast and an active twitter user. PLOS Biology has even published An Introduction to Social Media for Scientists instructing scientists why and how to showcase their research using social media and PLOS Computational Biology more recently published Ten Simple Rules of Live Tweeting at Scientific Conferences.
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Further Integration: The latest update to the MHTF & PLOS Maternal Health Collection

In November 2013, PLOS Medicine and the Maternal Health Task Force (MHTF) called for submissions to the third year of the MHTF-PLOS Collection on Maternal Health. Today we announce an exciting new update to the Year 3 Collection, including original 11 research articles and a policy forum, all recently published in PLOS.

This continued collaboration between the MHTF at Harvard School of Public Health and PLOS Medicine is reflected in this latest collection update, highlighting recently published work that ties in with the current theme, “Integrating Health Care to Meet the Needs of the Mother–Infant Pair”. 

Image credit: Jack Zalium, Flickr

Image credit: Jack Zalium, Flickr

Chosen with the aim to contribute to a better understanding of how and when to comprehensively integrate maternal and infant health care, this year’s theme includes work on conditions such as HIV, malaria, exposure to environmental risks, and other situations that have a significant impact on both maternal and infant health.

Featured work in this latest update

A policy forum by Jenny Hill and colleagues highlights the importance of prioritizing pregnant women, as a high risk group, for delivery of long lasting insecticide treated nets through antenatal clinics. Delivering free or subsidized long-lasting insecticide treated nets (or vouchers) to pregnant women is a key approach for controlling malaria and increases coverage and use by both pregnant women and their infants.
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PLOS Resources on Ebola

Virginia Barbour, Medicine & Biology Editorial Director at PLOS, on the urgent need for Open Access research into the Ebola outbreak in West Africa.

The current Ebola outbreak in West Africa probably began in Guinea in 2013, but it was only recognized properly in early 2014 and shows, at the time of writing, no sign of subsiding. The continuous human-to-human transmission of this new outbreak virus has become increasingly worrisome.

Analyses thus far of this outbreak mark it as the most serious in recent years and the effects are already being felt far beyond those who are infected and dying; whole communities in West Africa are suffering because of its negative effects on health care and other infrastructures. Globally, countries far removed from the outbreak are considering their local responses, were Ebola to be imported; and the ripple effects on the normal movement of trade and people are just becoming apparent.

There is an urgent need for research into all aspects of this Ebola outbreak.  PLOS is addressing this need today through two channels.  First is the rapid publication of important early research in PLOS Currents OutbreaksThe second is a new PLOS Collection that pulls together all the current published articles in the PLOS corpus, which are, like all our content, freely and openly available for download, use and reuse. The Collection is available on Flipboard as well as being described below.
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Who Should Contribute to Funding of Global Health R&D and How Much?

The international community recently gave WHO a mandate to advance global health R&D by creating a pooled international fund for a first set of four Demonstration Projects. Mari Grepstad, Suerie Moon and John-Arne Røttingen consider how it could be funded.

This May, the 67th World Health Assembly (WHA) made important progress on strengthening research and development (R&D) of medicines and other technologies for diseases that affect the world’s poor by agreeing to establish an international fund for R&D. The fund builds on the 2012 report of the WHO Consultative Expert Working Group on Research and Development (CEWG), which recommended a framework for more sustainable and equitable financing of R&D that aims to “de-link” innovation costs from product prices through approaches such as open knowledge innovation and prizes (see an earlier blog post).

WHO has been mandated to take forward at least four projects selected by Member States and experts to apply these new approaches to neglected diseases such as Cutaneous and Visceral leishmaniasis, present in the Americas, Middle East, Africa, Central Asia, Mediterranean and southern U.S. Seen as a step towards demonstrating the opportunities of de-linkage models, this move was warmly welcomed by international NGOs.

A recent report commissioned by the Drugs for Neglected Diseases initiative (DNDi) suggests guiding principles, policies and governance arrangements for the pilot fund. The fund would mobilize and deploy resources with assistance from independent advisory committees, and could be governed by a Board hosted by an existing organisation. The WHA asked WHO to examine the feasibility of establishing the fund at the Special Programme for Research and Training in Tropical Diseases (TDR).
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Why ICART, a New Research Center in the D.R.Congo, is Needed

An International Center for Advanced Research and Training (ICART) has been launched in Panzi, Bukavu, in the South-Kivu Province of the DR Congo. This province has suffered many wars over decades and is trying to recover. ICART is organizing its first symposium. How is scientific research of help for the recovery?

Good research usually requires well-trained scientists, infrastructure and equipment. Africa is the continent least resourced in these elements. Yet there are many issues on the continent that need the kind of solutions that come from research. Poverty and lack of research are related, one favoring the other, but it is possible to break this vicious circle. First, there are now many well-trained Africans, living either on the continent or in the diaspora, who can sustain some level of research work. Secondly, some types of research do not necessarily require great capital investment. Thirdly, international collaborations offer access to mutually beneficial shared expertise and resources. Finally, some problems in Africa can best be addressed by the unique experience of the African researchers themselves. Such problems are illustrated by the current epidemics of hemorrhagic fever or the persistent high prevalence of genital fistulae or child malnutrition.

On the scientific research front Africa displays a large diversity. There are continental superpowers such as South Africa and Egypt, which by themselves account for nearly 50% of all research output of the continent. On the other hand, there are countries, especially war-torn nations such as the DR Congo, where research activity is very low or has been declining for decades. It is a big challenge in the latter countries to embark in viable research activities. In the case of the Eastern part of the DR Congo, the war situation, administrative mismanagement and corruption have led to a disintegration of nearly all systems. Recently, increased political stability has seen efforts to help hasten the recovery from the destructions of war. In this respect, the establishment of institutions such as the Panzi Hospital or of an international research center such as ICART (International Center for Advanced Research and Training) should serve as powerful instruments to help in the recovery.
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Visceral leishmaniasis-HIV coinfection: Time for Concerted Action

As PLOS Neglected Tropical Diseases launches its Visceral Leishmaniasis-HIV Collection, Johan van Griensven discusses the importance of a multidisciplinary approach to tackling VL-HIV co-infection.

NTDs_VL HIV PR Collection Image

Image Credit: Mock et al.

In 2013, PLOS Neglected Tropical Diseases decided to dedicate a special collection to VL-HIV co-infection. With Ed Zijlstra, Asrat Hailu, and myself as guest editors, they sent out a call for papers. Today the Visceral Leishmaniasis-HIV Collection is launched, containing the first batch of submitted papers. Previously published content from across the various PLOS journals are also included. The collection will be expanded over time with novel publications published by PLOS.

VL-HIV coinfection is an emerging global problem. It is on the rise in South-America and the Indian subcontinent, which harbours more than half of the global VL burden. In North-West Ethiopia, up to 40% of patients with VL were found to be co-infected with HIV, mainly among seasonal migrant workers.

Currently, prognosis of VL-HIV coinfection is poor. In the setting where we work in Ethiopia, case fatality rates of up to 25% have been documented. Many patients do not respond to therapy, and if they do, around half relapse within the following year. To help address this problem, we founded the AfriCoLeish Consortium, supported through the European Union. Two clinical trials (one on secondary prophylaxis, one on VL combination therapy) are currently ongoing. While such initiatives are highly needed, we should move beyond.
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Venezuela: An Emerging Tropical Disease and Humanitarian Emergency?

Image Credit: Flickr, valeyoshino

At the International Congress of Parasitology (ICOPA XIII) held in Mexico City earlier this month, we learned of a very serious and dangerous tropical disease situation now unfolding in Venezuela.   The most glaring public health failure has been a sharp rise in malaria.  As also reported in Lancet last week Rodriguez-Morales and Paniz-Mondolfi found more than a doubling of the number of malaria cases in Venezuela since 2008, with almost 1,500 weekly cases reported on average this year.  Whereas the Americas overall have seen a 58 percent decrease in malaria over the last decade, Venezuela joins Guyana and Haiti as the only three countries with an increase.  However, Venezuela has a substantially higher human development index and gross national income per head than Guyana and Haiti, suggesting that factors other than extreme poverty partly account for this situation.  They include a health system in disarray (as reported recently in Science), and the unavailability of antimalarial drugs.  According to Rodriguez-Morales, who presented at ICOPA XIII, malaria is now hyperendemic in areas surrounding Venezuela’s gold mines, which has been linked to a rise in illegal mining and mismanagement.

Malaria is not the only tropical disease to re-emerge in Venezuela.  Dengue cases are increasing and there are serious concerns about chikungunya spreading from the Caribbean.  Moreover, there have been shortages in the national stockpile of antimonial drugs for treating leishmaniasis, and we learned of an unresolved problem with urban schistosomiasis caused by Schistosoma mansoni.  In 2010, Dr. Belkisyole Alarcon de Noya and her colleagues from the Instituto de Medicine Tropical, Universidad Central de Venezuela, reported on a large urban outbreak of orally acquired acute Chagas disease at a school comprised of mostly middle-class schoolchildren in Caracas. More than 100 of 1,000 exposed individuals became infected with Trypanosoma cruzi when they ingested contaminated guava juice.  More than one-half of the confirmed cases exhibited abnormalities on their ECG recordings, while 20 percent required hospitalization.  There was also one death – a five-year-old child who died of acute Chagasic myocarditis.  Subsequent T. cruzi genotyping confirmed a common source of infection.

We have used the term blue marble health to highlight the unexpectedly high prevalence and incidence rates of neglected tropical diseases in the G20 and other wealthy economies.  The term mostly applies to diseases striking concentrated areas of intense poverty in these countries.  The concepts of blue marble health certainly apply to Venezuela but we may now also be seeing a significant re-emergence of tropical infections in recent years.   In stark contrast to previous decades, when Venezuela was a leader of public health efforts in Latin America, the country now appears to be experiencing a dire public health crisis. We need a better understanding of the basis for this rise in disease prevalence and incidence, and to what extent they reflect changes in government policies versus other forces.  In the meantime, neglected tropical diseases represent a public health and humanitarian emergency in the nation of Venezuela that may require external assistance from the Pan American Health Organization and other international agencies.

Peter Hotez MD PhD and Jennifer Herricks PhD are at the National School of Tropical Medicine at Baylor College of Medicine and James A Baker III Institute for Public Policy at Rice University.  Prof. Hotez is also Co-Editor-in-Chief of PLOS Neglected Tropical Diseases.

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The Global Response to the Ebola Fever Epidemic: What Took So Long?

Mark J. Siedner of Harvard Medical School and John D. Kraemer of the O’Neill Institute for National and Global Health Law, Georgetown University, discuss the impact of the delayed global response to the Ebola epidemic.

On August 8, twenty weeks after the first suspected cases in what has become the worst hemorrhagic fever outbreak in history, the World Health Organization’s (WHO) Director-General declared the epidemic a public health emergency of international concern (PHEIC). The announcement, which signals that an epidemic constitutes a sufficient public health risk to member WHO States through the spread of disease, will ideally motivate financial and logistic support to the countries most affected. But after nearly 1,000 deaths, and for a disease where a relatively simple and coordinated public health response has extinguished prior epidemics, many are left wondering, “what took so long?”

An integral part of the WHO mission, mandated by the International Health Regulations (IHR), is to protect member states from international public health threats. The IHR were revised in 2005 after the SARS outbreak to improve responses to epidemics in an increasingly globalized world. Among the IHR’s central components is commitment from high-income countries to build capacity to prevent public health emergencies, and to provide assistance during active ones. The IHR task WHO with promptly identifying emergencies by declaring PHEICs to sound the proverbial alarm.

Timeline demonstrating course of Ebola epidemic including cumulative suspected cases, deaths, and notable events during the period (Source: CDC).

Timeline demonstrating course of Ebola epidemic including cumulative suspected cases, deaths, and notable events during the period (Source: CDC).

By most accounts, the criteria to declare a PHEIC were met months ago (Figure 1). The outbreak quickly made public health impact with its rapid pace and case fatality rates above 50% and by disproportionately affecting healthcare workers. It became an international epidemic five days after the first cases were reported when it spread from Guinea to Liberia. The epidemic is also unusual because it represents the first hemorrhagic fever epidemic in urban areas, where poverty and population density exacerbate disease spread. Only nine days after Guinea notified the WHO of the outbreak, Senegal closed its land borders with Guinea. By the end of May – 10 weeks before the PHEIC declaration – the epidemic raged on in Guinea, gained speed in Sierra Leone, and reemerged in Liberia.
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Ebola: Liberians Destined for Extinction

Liberian medical student Gondah Lekpeh gives us his perspective from the front lines of the Ebola outbreak.

On July 22 of this year, the Liberian Minister of Health informed us and the world that the Ebola hemorrhagic fever outbreak in our country is out of control. This disease is caused by the deadly Ebola virus, and the fate of infected individuals is death in 90% of cases.

The announcement followed more than a month of efforts by the Ministry of Health to contain and eradicate the virus. The Ministry is doing what it can, but with the weak health care system because of the lack of human and other resources, the Ebola outbreak has caused the system to break down. The disease continues to directly and indirectly take away lives. Indeed, our relatives, colleagues and friends are perishing daily and our survival as a people is unpredictable. Either through natural selection some will survive, or we will all be extinct. As I was writing this, a childhood schoolmate of mine, a nurse, just died this morning after contracting the disease at St. Catholic Hospital while treating a patient about two weeks ago.

Here in Liberia, the virus is spreading like wildfire, devouring the life of everyone along its path. Limited health resources, ignorance, stigmatization, denial, and cultural burial rites are fueling the spread of the disease. Ebola cases are reported in ten of the fifteen counties in our country. I do not have the space and time to elaborate on how ignorance, denial, stigmatization as well as cultural practices are spreading the virus. But regarding limited health resources, here is the tip of the iceberg. As part of control measures, everyone was advised to call the Ebola response unit for safe transfer of suspected cases and disposal of corpses from communities in and around Monrovia. There are two ambulances to transfer suspect cases to isolation center and two burial teams for Monrovia. These teams are overwhelmed and it takes about two to three days to respond to calls from communities. The relatives of suspected cases end up transporting the patient in a commercial vehicle, thereby contaminating themselves. The remains of suspected cases who died at homes spend days before the burial team can arrive. Moreover, there is only one treatment center in Monrovia. The isolation center is full to capacity and suspected cases are reportedly turned away. When will the spread and death of Ebola stop in the wake of limited resources? I do not know. But I know for sure that contact tracing is not possible and we are overstretched and exhausted.

Besides Ebola directly killing here, others are dying of treatable conditions due to closure of health facilities. Most health facilities in and around Monrovia have been closed for the past three weeks. This followed the failure of most health workers to show up on duty after the death of their colleagues. They fled due lack of equipment as simple as gloves to protect themselves. At the beginning of this week, some of these health facilities reopened. But activities currently at these hospitals are limited to training of staff on precaution measures. I do not know the fates of those with treatable conditions other than Ebola. Where the obstetric emergency cases are being managed? Where are the hundreds of children who usually present weekly at John F. Kennedy Medical Center under-five ER with diarrhea and severe dehydration and severe malaria complicated by anemia, hypoglycemia and seizure, seeking care? I do not know. But I know there are numerous corpses in homes in and around Monrovia which have overwhelmed the burial teams.

The Ebola virus is like a merciless rebel determined to annihilate his weak and feeble enemies (Liberians). Help! Help! We are drowning in the sea of Ebola.

About the author: Gondah Lekpeh is a fourth year medical student at A.M. Dogliotti College of Medicine in Monrovia, Liberia.

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