Payment-by-results in International Development: the elixir or the poison?

This week, Jason Calvert (MPH) – a development and health economist with PwC – explores the benefits limitations of a Payment-by-Results approach to international development.

Flickr / epSos.deAs the concept of Payment-by-Results (PbR) gains momentum in the international development sector, it hasn’t taken long for it to turn into somewhat of a ‘dirty’ word – particularly among not-for-profits. In some ways, its reputation can be justified but not entirely. PbR is a payment mechanism where delivery organisations will only get all or part of their payment upon the delivery of some form of ‘result’. This differs from other payment mechanisms where payments may be made upfront or on the delivery of inputs or intermediate outputs rather than results. As such, it is much more controversial.

Taking the approach of trying to improve value-for-money during times of belt-tightening on government spend makes sense. We’ve seen this in other public sectors such as healthcare and criminal justice – both of which have experimented with forms of PbR. However, in healthcare, this led to a scenario where incentives to focus on preventative care were eroded, as payments would be made based on results in the form of curing illness. To be fair, it’s much easier to measure illness cured as opposed to illness prevented. In criminal justice, PbR was trialled in offender rehabilitation programmes. It was found that this led providers to ‘cherry-pick’ clients that would be easier to rehabilitate – leaving out potentially those most in need of services, but who would be more difficult to rehabilitate.

The provision of core public services such as health, education and justice faces many challenges in a developed-country context. It’s usually even more complex in developing countries. Unwieldy PbR contracts could potentially further complicate matters, and place pressure on implementing organisations to spend more time focussing on reporting burdens as opposed to implementation. This is at odds with using PbR to improve value-for-money by shifting the focus to results. But in order to financially penalise a delivery organisation with the PbR stick it is necessary to have solid evidence underpinning the decision to do so (or risk being sued). Whilst this will (hopefully) drive improvements in the quality of monitoring and evaluation we see in international development projects, some results are much harder to measure than others. The costs of measuring tricky outcomes (like measuring improved community attitudes towards injecting drug users in rural Kenya), and attributing these to one particular programme, could often outweigh the benefits of a PbR contract. However, it could be argued that in the context of poor information and difficult measurement, there is even more risk of money being misspent or results not being achieved.

Other PbR challenges relate to the assumption that not-for-profits respond to financial incentives the same way for-profits would. The potential for cherry-picking and avoiding the most marginalised individuals, and the possibility that by focussing on narrowly-defined results, valuable but hard-to-measure activities might not take place (such as community advocacy).

Flickr / DFID - UK Department for International DevelopmentPbR does have the potential for benefits – but only if implemented in a very careful manner on carefully selected projects. In such cases, it has the potential to align incentives between funders and implementers to focus on core results rather than inputs, incentivise greater focus on refining theories of change to suit clear goals, improve transparency and accountability, weed out wasteful activities, and drive greater professionalism in the sector. But as a sector, we need to stop thinking that PbR is a panacea or that it’s going to solve many of the inherent problems in the aid sector. PbR isn’t going to disappear, but I’m convinced that over time we will realise that it is only suited to certain development sectors where measurement of results is not overly contentious (such as infrastructure projects). Rather than thinking PbR will solve all our issues, we should be focussing on improving the way we undertake evaluations and make use of the results: shifting them away from being ‘tick-box’ exercises, to making them true lesson-learning tools that don’t end up gathering dust on a shelf at the donor office.

As a sector, we’ve catapulted ourselves high in our ambitions regarding PbR and value-for-money. Only time will tell where we land.


jason-calvertJason Calvert is a development and health economist with PwC, experienced in the monitoring, evaluation, and assessment of value-for-money in international development programmes, with a particular focus on human development projects. He has experience with payment-by-results mechanisms, both in international development contexts and broader contexts such as domestic health and social welfare.

Jason currently leads the monitoring and evaluation workstream on DFID’s Girls’ Education Challenge – a £300m fund of 38 projects across 18 countries aiming to educate up to a million girls. He has previously worked with the World Health Organization’s Regional Office for Europe on strengthening their evaluation and appraisal methods.

This article was co-blogged with PwC.

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A quick experiment: removing barriers to fruit in the retail environment, will more of us buy them?

This week on PLOS Blog Translational Global Health, a short post from our colleagues in Peru on the role and effects of the retail environment in behaviour change for NCDs.

Everybody knows that eating fresh vegetables and fruits is good for you. At least, let’s assume, the majority of people do. But does this translate into action? We also know that knowledge is not enough. More importantly, does everybody react in the same manner to the same information? Who is more likely to make more concrete moves towards action? All these questions are relevant, because in practice, it will determine “how it works and under what context” for many interventions.

Nourishing Framework from WCRF International.

Nourishing Framework from WCRF International.

Fruit and vegetable intake is essential in a healthy diet and this has been translated into ‘5 servings per day, 7 days a week’ campaigns worldwide. On the scoping and wider policy side, WCRF’s has developed the NOURISHING framework, a policy framework to promote healthy diets & reduce obesity. But, given our human nature, as behavioural economist Dan Ariely  points out, there is certain irrationality in not doing the ‘right thing’.

Despite being an agrarian country, an Andean study in Peru showed that approximately one-third of the population had low fruit and vegetable intake (defined as less than 3 days per week). Insufficient local data at an individual level impedes to monitor the patterns of diet in this population as well as the consumption of healthy and unhealthy food. Moreover, little is known about the personal reasons that lead someone to prefer fruit over an unhealthy snack, and what changes —i.e. an intervention to promote a healthy diet— may be effective in influencing peoples’ decisions.

A research team led by members of the CRONICAS Center of Excellence in Chronic Diseases at Universidad Peruana Cayetano Heredia, based in Lima, Peru, made a quick, on-the-go, hypothesis-driven, unfunded —as usual, fun studies are the unfunded ones— experiment to test if some strategies are more effective to increase fresh fruit purchasing at a university cafeteria.

Here is the experiment.

Three different scenarios were established sequentially, each stage lasted 3 weeks. In a first stage, fruit was positioned over 3 meters away from the point of purchase and price was PEN 1.50 ($US 0.57) per fruit unit with no advertisement. In the second stage, the price remained the same but fruit was positioned next to the point of purchase with an advertisement promoting fruit consumption. The advertisement was displayed in Spanish and showed the unit price and the following message: “Consuming five fruits and vegetables per day prevents many illnesses” as stated by the World Health Organization. Finally, for the third stage, fruit price lowered to PEN 1.00 ($US 0.38) and all the other changes remained as the previous stage. Cafeteria staff participated with daily recording of indicators. A simple approach, using pen, paper and eyes: we needed to know age group (above/under 20), gender and number of fruits sold.

So what was the outcome?

Flickr / Denim Dave

Flickr / Denim Dave

The analyses of the registered information showed an increase in fruit purchasing when comparing fruit sales from the first and the last stage. This is good news, but it is not all. Take home message one: break accessibility barriers for healthier products, and consumption increases. A study, published in Public Health Nutrition  journal, showed that simple marketing strategies such as enhancing visibility, adding information and lowering price do also work for increasing fruit consumption. Interestingly, by the third phase, people reacted to it and more fruits were sold.

However, besides the most salient (and significant) results, here is the beauty of being able to disclose your weaknesses, which makes it much more interesting. For context, this cafeteria caters for approximately 200 students per day and most of them have just completed high school and are preparing to enter into university.

Interestingly, the baseline scenario is so challenging: median sales of fruit at the cafeteria are remarkably low, just 1 to 2 fruits per day over each of the 3-week period tested. This is a huge challenge! Second, the human factor is not constant, females do better than males, they buy more fruits, as did the ‘older’-adults —just to be clear, our own research team was banned from buying fruits. Third, as usual — although we would like to claim this, but technically we can’t— we do not know if it was the change of place (availability) or the lowering of price (costs) the biggest driver in increasing sales, because of our ‘bundled’ intervention. Fourth, a further challenge, was that we were not able to explore if fruit sales reduced expenditures in junk-food or if unhealthy sales remained constant.

Last but not least, we were excited to figure out more about the complexities of human nature. We know that this is a small study from “darkest Peru.” Now, when we hear that the target of “5 servings per day” is a simple one to aim for, we will say, it ain’t that simple.

J. Jaime Miranda is Research Professor at the Department of Medicine, School of Medicine and Director of the CRONICAS Center of Excellence in Chronic Diseases, both at Universidad  Peruana Cayetano Heredia (UPCH) in Lima, Peru. 

Maria Kathia Cárdenas works as health economist at CRONICAS Center of Excellence in Chronic Diseases. She studied a Master in Epidemiological Research at Universidad Peruana Cayetano Heredia (UPCH) through a Fellowship supported by The National Heart, Lung and Blood Institute.

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Podcast Interview with Young Cancer Survivor and Advocate, Mexico City

abishThis week, the latest in our series of podcasts from around the world. Sandro interviews Abish Romero, a young cancer survivor and advocate living and studying in Mexico City. 









Abish Romero is an MPH student at the National Institute of Public Health of Mexico. She became a cancer advocate after being diagnosed with breast cancer when she was 24 years old. Her experience with the disease made her realize how important social protection is in developing countries; and how governments can strengthen health systems by improving the quality of multidisciplinary care and treatment. As she has seen, these actions are key in avoiding impoverishment in families caused by catastrophic expenditures.

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Human rights and Ebola: the issue of quarantine

The Ebola virus is posing challenging questions around the human rights of patients and health workers alike – and this isn’t the first time such questions have arisen. This week on PLOS TGH, Doctor/Lawyer and Harvard MPH Candidate Fiona Lander explores the issues that have arisen around quarantine.

When Kaci Hickox, a nurse working in Sierra Leone, returned home to the United States on Friday October 24, she clearly anticipated being screened for Ebola. After all, she had just returned from an area of the world where the virus is currently spreading out of control.

Having no symptoms suggestive of infection, however, she evidently did not expect to be put into compulsory quarantine. CNN reported that Ms Hickox was put into an isolation tent inside University Hospital in Newark, although she had twice tested negative for the virus.

As reported this week in the New England Journal of Medicine, the virus is generally not detectable prior to the onset of symptoms, so Ms Hickox’s negative tests were far from an ‘all clear’. However, as was also reported, the virus is not contagious prior to the onset of symptoms. The NEJM and the U.S. Center for Disease Control both conclude that asymptomatic healthcare workers can safely monitor their own temperature and other parameters upon their return home, provided they alert officials immediately if they develop symptoms.

Accordingly, the utility of mandatory hospital-based quarantine in Ms Hickox’s case was limited, and represented a curtailment of her rights; in particular, her right to freedom of movement. Ms Hickox was ultimately released from quarantine in New Jersey on Monday 27 October, and having travelled to Maine, continued to defy requests by the Governor of that State to voluntarily quarantine herself. A Maine court subsequently issued orders (in compliance with CDC protocols) that allow Ms Hickox to go outside, but which stipulate that she must stay away from public transit and workplaces, and that she must not to leave the town of Fort Kent without informing public health authorities.

Following a storm of criticism, New York’s Governor Andrew Cuomo relaxed the strict quarantining protocols that had previously been announced jointly with Governor Christie. However, Governor Christie has insisted on retaining the protocols in New Jersey on the basis that a voluntary system of quarantine is not reliable, apparently because of how serious this outbreak is. Some might argue, alongside Mr Christie, that the nature of the Ebola epidemic demands such stringent action, even if such protocols result in breaches of individual healthcare workers’ rights. However, this ignores the lessons of the recent past.  

Learning from history: a human rights-based approach to epidemicsHIV ribbon
This is not the first time that quarantine requirements have been imposed without evidence to support their imposition. A classic example is that of the AIDS epidemic in the 1980s, where quarantine was utilized in an attempt to stop the spread of the virus, but ended up causing greater stigma, subsequently fuelling spread of the disease.

It is for this reason that the Ebola quarantine policies announced in the U.S. have drawn opposition from HIV activists, who have seen the pernicious effects of imposing quarantine when evidence suggests it is unnecessary. There is no doubt that Ebola is more readily transmissible than HIV, but the same legal principles in relation to compulsory quarantine apply in both cases.

The Siracusa principles outline the circumstances within which restriction of human rights are justified. In order for a restriction like compulsory quarantine to accord with the Siracusa principles:

  1. It must be provided for, and carried out, in accordance with the law;
  2. It must be in the interest of a legitimate objective of general interest;
  3. It must be strictly necessary to achieve the objective, in a democratic society;
  4. There should be no less restrictive/intrusive means through which the same objective can be achieved;
  5. The restriction must be based on scientific evidence, and not imposed arbitrarily or in a discriminatory way.

It is also vital that such restrictions be of limited duration, and subject to appeal and/or review.

Clearly, containment of the Ebola virus is a legitimate objective, and for a confirmed case, quarantine within a health facility is justified. The arguments for compulsory quarantining of asymptomatic health workers, however, are dubious.

The quarantine protocols put in place by Governor Christie appear to be unnecessary and discordant with scientific evidence. It is likely that the objective of the protocols can be achieved in a less restrictive manner, as borne out by the U.S Center for Disease Control guidelines referenced above; it is also likely that the protocols are also not strictly necessary to achieve the stated objective.

There are other compelling arguments against compulsory quarantine. As well as being of little utility and imposing on their right to freedom of movement, compulsory quarantining of asymptomatic health care workers has the potential to create stigma and fear around the very people whose skills are essential in the fight against Ebola. In addition, it would seem reasonable to assume that healthcare workers returning from East Africa are acutely aware of the risks that they pose to a community, should they be infected with the virus, and are likely to report to authorities promptly if they experience a fever or any other symptoms.

Freedom of movement is a human right and can only be legally curtailed in extreme circumstances. Compulsory quarantine of a patient suspected to have an infectious illness should be a measure of last resort, and only after voluntary measures to isolate the patient have failed.  

The rights of patients

Different circumstances exist in relation to quarantine within West African countries where the epidemic continues to spread. Amongst the media storm concerning quarantine of healthcare workers in the U.S., it can be easy to forget that all three of the countries that have been worst hit by the virus – Liberia, Guinea and Sierra Leone – have imposed quarantines at various points in time, in an attempt to control further spread of the virus.

For example, Sierra Leone imposed a three-day quarantine in late September, confining individuals to their homes while healthcare workers toured affected areas searching for infected individuals who had not yet been identified as having the virus. The New York Times reported that the Sierra Leone quarantine met with mixed responses – some deeming the measures harsh but necessary, others (including representatives of Médecins Sans Frontières) expressing concerns that such quarantines could jeopardize trust between patients and healthcare practitioners.

The Siracusa Principles clearly anticipate the restriction of certain human rights, through measures such as quarantine, in situations such as the current Ebola outbreak in West Africa, where there is an enormous threat to health and security. However, such measures still need to be proportionate and adherent to international standards.

Human Rights Watch has expressed concern that quarantines imposed during the Ebola epidemic have not met these standards, noting that they have “not been based on scientific evidence, have been applied arbitrarily, and been overly broad in implementation”.

Keep calm…and don’t unnecessarily restrict human rights
As the epidemic continues, it will be increasingly necessary for human rights advocates to closely monitor the measures imposed to control spread of the virus, to ensure that the rights of individuals are not unnecessarily restricted.

The hysteria around the Ebola virus is, to some extent, understandable. We currently lack a vaccine or specific treatment for this virus. The mortality rate remains high – estimated at between 50 to 70% – and those who are infected will likely die without appropriate medical treatment. However, this does not mean that there is no treatment. Supportive therapy such as aggressive fluid resuscitation may improve chances of survival.

Moreover, for those outside West Africa, the situation is not as grim as it may seem. The odds of an epidemic occurring in a high-income country such as the U.S. are negligible – the U.S. Center for Disease Control has clearly stated that Ebola poses no substantial risk to the U.S. general population.

Although the West African epidemic demands stringent measures to prevent further spread of the virus – which may include imposition of quarantine protocols that comply with international law – it is fair to say that the quarantine protocols for returning health workers introduced in New Jersey, amongst other States, are not justifiable under international law, and are not supported by scientific evidence. –

Dr Fiona Lander is a medical doctor and lawyer, and a Frank Knox Fellow at Harvard University, where she is currently completing a Masters in Public Health, specializing in Law and Public Health. Dr Lander has previously worked in Mumbai, India, as Senior Officer assisting the United Nations Special Rapporteur on the Right to Health. 

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The greatest health threat you’ve never heard of, but need to know about.

If you have a conversation with someone about the leading cause of global deaths, discussions will usually turn to Ebola, HIV or TB. Even more so, when we think of the biggest killers in the world’s poorer nations, we tend to think of infectious pandemics, under-nutrition or problems resulting from a lack of clean water and sanitation.

At the same time, when we think of challenges like diabetes, heart disease, obesity and cancers, we tend to think of lazy, aged populations living with too much, in rich communities.

But in reality, both of these statements are completely false – and both insidious yet widespread myths have dire consequences on the health of our populations.

This is where a new conversation around the facts becomes crucially important for Global Health. So what are the facts?

In 2014, three out of five people around the world die from one of a group of diseases called Non-Communicable Diseases (NCDs). Literally meaning a disease one cannot catch from another person, NCDs include diabetes, heart disease, cancers, chronic lung conditions and mental illness. Most people in today’s world don’t and won’t die of too little food, or a virus – but from preventable, chronic illnesses. Half of them will die before they’re 70.

Flickr /

Flickr /

NCDs are not diseases of the rich either, in fact the poorest at home in the USA – and globally – are among those worst affected. These are not diseases of laziness, or stupidity, or simply the outcomes of poor choices. NCDs are diseases with complex, shared risk factors and deeply linked to the built and social environment around us. The major drivers include poor diet often resulting from a food system geared towards overconsumption of poorer quality foods; the consumption of alcohol; tobacco use, particularly in low and middle-income nations which have become the new target for the global tobacco industry; and a lack of physical exercise, in part resulting from a rapidly urbanising and mechanising world.

In short, this group of diseases is largely a reflection of the technological and economic progresses we have achieved over the past few centuries and yet now kills approximately 36 million people per year – equating to 60% of global deaths. Affecting an individual over a long period, with high levels of suffering and sometimes pain, these diseases cause, result from and entrench poverty – with 80% of deaths occurring in developing nations. “NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty” says Ban Ki-moon, Secretary-General of the United Nations, “More than a quarter of all people who die from NCDs succumb in the prime of their lives. The vast majority live in developing countries. Millions of families are pushed into poverty each year when one of their members have become too weak to work. Or when the costs of medicines and treatments overwhelm the family budget. Or when the main breadwinner has to stay home to care for someone else who is sick.”

So why does this matter to you and I, and why should we care? Well, these myths are not just frustrating for a medical doctor or Global Health academic like myself; they are also dangerous to us all. First, missing the link between NCDs and poverty means that the major killers in our poorest communities are largely left off the development and social security agendas. The Millennium Development Goals heralded a major success for global cooperation on poverty reduction and economic development, but largely failed to recognise and address NCDs. With 15 years passing since these goals were adopted and enacted, this was a major missed opportunity for our global community – with serious life costs. In the dawning of a replacement development agenda looking set to include targets on NCDs, the missing NCD-poverty link has never been more crucial.

Flickr/  Vox Efx

Flickr/ Vox Efx

The second outcome of these myths is that we continue to blame individuals for developing these diseases, rather than seeing the structural and social determinants that cause them. Rhetoric falls to persecution of the sick, rather than their human rights. As Richard Horton, Editor-in-Chief of The Lancet stated, “addressing chronic disease is an issue of human rights – that must be our call to arms.” Instead, we entertain dangerous rhetoric that previously termed ‘adult onset diabetes’ in children is simply an outcome of poor parenting, instead of seeing the pernicious and predatory marketing by soft-drink companies, an urban environment built for cars and not people, and a food system designed to maximise profit and consumption, rather than health and wellbeing. I could go on.

Put simply, Non-Communicable Diseases are the greatest health threat you have never heard of, but need to know about. It’s time we all set the record straight.

With this in mind and together with a group of young designers, communicators and public health thinkers from around the world, this week we launched a new campaign called The Face of NCDs. Focused on a crowd-sourced, online community, #TheFace aims to move the discussion past these myths and put a true narrative to these leading global killers. Led by our Melbourne based global, social movement NCDFREE and partnering with Remedy Healthcare and a host of organisations from around the world, we are crowd-sourcing faces and stories from people affected by an NCD in some way, or working to address them. We believe in the power of people and know that personal narrative is a strong catalyst for new discussion and innovative thinking. So in addition to disseminating information to the public, #TheFace is harnessing the possibilities of social media to encourage people to drive this new conversation themselves.

“If we come together to tackle NCDs, we can do more than heal individuals – we can safeguard our very future” says Ban Ki-moon.

This is a new conversation, long overdue. This is NCDs.

This article was co-published with Australian Health Blog, Croakey. For more on The Face of NCDs and to support those living with, or working in NCDs, head to today. This campaign is run by the not-for-profit social movement NCDFREE with no financial gain or conflicts of interest.

Dr Alessandro Demaio (MBBS MPH PhD) is Co-Founder of NCDFREE. He is also a Postdoctoral Fellow in Global Health at the Harvard Global Equity Initiative, Harvard Medical School and an Assistant Professor at the University of Copenhagen.



The Conversation

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Mental Health Reflection – You are not weak.

This week, guest blogger Ashley Ng writes a reflective piece and poem on Mental Health, as Mental Health Day rolls by. Ashley is a PhD student at Deakin University and lives with diabetes.

safe_imageNCDFREE have recently launched their global campaign called #TheFace of NCDs. NCDs or Non-Communicable Diseases are health conditions that are non-infectious and cannot be passed from one person to another. They include chronic diseases such as diabetes, mental illness, heart disease. Sadly, there are a lot of negative connotations and stereotypes associated with these health conditions. #TheFace aims to dispel the myths, ignorance and misinformation about these NCDs but also urging people to share their story. Coinciding with mental health week, I would like to share the message that no matter what you are going through and what you are feeling right now, you are not alone. Your feelings and experiences may be unique, but rest assured that there are many others who are willing to give you a helping hand or even just a cuddle along the way.


For mental health week,
here’s a reminder that the world is never always bleak.

Many people suffer in silence,
while the health professionals call it non-compliance.

Do they ever ask or even remember,
to look beyond the number.

Sometimes it feels this way with my silent disease,
the highs and lows of diabetes I wish would cease.

Life with diabetes can be tough at times,
definitely tougher than coming up with rhymes.

Diabetes has made me a stronger person,
More resilient and determined to survive each season.

I reconnected with my passion of helping others,
and found my DOC friends, I now call my D sisters and brothers.

Every time I’m having a bad day,
the DOC cheers me up with what they have to say.

Please don’t struggle alone in the dark,
there will be others who see your spark.

Know that no one can survive in this world alone,
the online community never sleeps so there’s always someone on their phone.

Speak up, be brave and share your story,
It could be the end of someone’s worry.

Let them know they’re not alone,
together, the myths and ignorance around NCDs can be blown.

Let’s make life a better place,
tell your tale here and be #theface.


This article is reposted Diabetes Blog, Bitter Sweet Diagnosis.

TheFace Facebook TC

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Is There a Role for PPPs in Cancer Control?

This week, Harvard graduate and World Bank consultant Toni Kuguru writes on the role of Public-Private Partnerships in cancer control, focusing on resource-poor settings.

Pan Africa Life Cancer Challenge 2014

In July, nearly 500 people ascended onto the grounds of the Nakuru Athletic Club to receive free cancer screening.  Spread across six counties in Kenya, this was the third of six free screenings conducted as part of the Pan Africa Life Cancer Challenge 2014.  While cancer is the third leading cause of death in Kenya only after infectious and cardiovascular diseases[1], routine cancer screening – a cost-effective preventative measure – is alarmingly low throughout the country.  Therefore to raise awareness of cancer and the importance of routine screening and early detection, Pan Africa Life has partnered with the Africa Cancer Foundation, Philips Healthcare and public, private, semi-private health providers to offer one day of free cancer screening in six counties. In three cancer screenings, a total of 1,820 men and women were screened for prostate, cervical and breast cancer.

Patients waiting to be screened at the Nakuru Athletic Club

Patients waiting to be screened at the Nakuru Athletic Club

Cancer in Kenya – a few facts

The three most prevalent cancers are cervical, breast and prostate cancers and these three are responsible for almost a quarter of all cancer-related deaths[2].    This year alone, an estimated 2,461 women will die from cervical cancer, 1,969 women will die from breast cancer, and 2,048 men will die from prostate cancer[3].  Late presentation is one of the primary reasons for the high mortality rate amongst cancers that are largely treatable (if detected early).  According to the Ministry of Health (MOH), 80% of people with cancer present late-stage when palliative care is the only form of treatment that can be offered[4].

Importance of screening and early detection

For any cancer patient, early detection is critical to achieving a favorable outcome and could very well mean the difference between life and death. What’s more, early detection also leads to more affordable treatment options, which is particularly significant in a country like Kenya. Here, almost half of the population (46%) lives below the poverty line, access to health insurance is beyond the reach of most with only 10% of the population covered, and household out-of-pocket spending for healthcare remains high at 25% of total health expenditure [5],[6],[7],[8].

The MOH has identified cancer screening as the primary preventative measure against cancer.  This can be seen in the national cancer prevention and treatment policies including the national cancer management guidelines.   Yet, pap smear coverage amongst women aged 18 – 69 is unacceptably low at 3.2% or 4% in urban areas and 2.6% in rural areas[9],[10].  Mammography and breast screening coverage is even more dismal at 0.6% in urban areas and 0.7% in rural areas[11].

The escalating numbers of cancer mortality amongst preventable and treatable (if diagnosed early stage) cancers such as cervical, breast or prostate cancer suggest that 1) routine screening is not a priority of overburdened, under-staffed, and under-resourced public health facilities; 2) there is a general lack of public awareness of cancer screening, both the availability and benefits of routine screening; 3) late stage diagnosis is all too common; and 4) barriers to treatment are prohibitively high[12].  What this means is that we need solutions that address both the supply-side and demand-side issues of prevention and early detection.

The role of PPPs

Constrained by limited resources, many developing countries like Kenya are turning to public-private partnerships (PPP) to bolster government efforts at strengthening the health system and service delivery. PPPs can add value to quality health service delivery particularly in rural areas and amongst marginalized populations where infrastructure is underdeveloped and health worker density is low.  In fact, Kenya’s Vision 2030 proposed a reduced role of the government in health service delivery and the promotion of partnerships with the private sector to deliver quality health services.  Earlier this year, the MOH held a consultative cancer stakeholder meeting whereby PPPs were discussed as a welcome strategy for cancer care and control in Kenya.  Current examples in cancer prevention and control are the partnership between the MOH, Futures Group and IBM which aims to improve cervical cancer awareness and screening by strengthening cancer data collection and the integration into the national health information systems or Pink Ribbon Red Ribbon® which is a collaboration between NGOs, public and private partners including PEPFAR, UNAIDS, Merck and GlaxoSmithKline committed to reducing the number of deaths due to cervical and breast cancer by promoting early detection, vaccination, screening and awareness.

While the Pan Africa Life Cancer Challenge 2014 is a one-time event and part of the company’s CSR, the overwhelming response to the initiative highlights the need for cancer screening and demonstrates how private and public healthcare providers and corporate partners can work together to make cancer screening accessible and early detection possible.  Over the next few years, as the government attempts to reign in the ever-burgeoning public sector and NCDs radically change the landscape of the disease burden in Kenya, we can expect to see the government look to the private sector for expertise and financial resources resulting in [optimistically] more innovative and sustainable public-private partnerships strengthening health service delivery along the cancer care continuum.





[1] MOMS & MOPHS.  National Cancer Control Strategy 2011 – 2016.

[2] WHO.  Globocan 2012:  Estimated Cancer Incidence, Mortality and Prevalence Worldwide 2012.

[3] WHO.  Globocan 2012:  Estimated Cancer Incidence, Mortality and Prevalence Worldwide 2012.

[4] MOH data.

[5] World Bank:  World Development Indicators (2005)

[7] Chuma, Jane.  Viewing the Kenyan Health System Through an Equity Lens:  Implications for Universal Coverage.  2011.

[8] MOMS & MOPHS.  National Health Accounts 2009/10.

[9] MOMS & MOPHS.  National Cervical Cancer Prevention Program Strategic Plan 2012 – 2015.

[10] WHO.  World Health Survey Reports Kenya.  2013.

[11] WHO.  World Health Survey Reports Kenya.  2013.

[12] Rositch, Anne, et al.  Knowledge and Acceptibility of Pap Smears Self-Sampling and HPV Vaccination Among Adult Women in Kenya.  2012. – pone.0040766-National1.

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Climate Summit 2014 – live update from New York City

This week’s post comes from Dr Alessandro Demaio who is postdoctoral fellow in Global Health and NCDs at Harvard Medical School and an Assistant Professor at the Copenhagen School of Global Health.


Groundbreaking pledges of funding from the French, 120+ heads of state attending, famous faces calling for greater action and less talk. It’s all happening this week in New York City, where I join the UN Climate Summit. Hosted by Secretary-General Ban Ki-Moon today, it has been a ‘hit the ground running’ week leading up to this unprecedented event – with building expectation (some would say desperation) that this is where we might see major commitments from governments and an uprising of the public in favour of real climate action.


Tuesday morning in New York City and here is what we have seen so far:

  • More than 310,000 people took to the streets of the Big Apple calling for real action on this global threat on Sunday;
  • Barack Obama, David Cameron and Dilma Rousseff are among leaders in NY today – Australia is a conspicuously absent;
  • France pledged US$1B towards a Green Climate Fund;
  • Strong words from Austria, calling for a “universal, binding agreement” on climate to come from before the 2015 Conference of the Parties to the UNFCCC, Paris;
  • Chile has committed to a 20% reduction of CO2 by 2020 in addition to renewable sources already contributing 45% of national electricity and having a tax on CO2 emissions;
  • Japan’s prime minister says that his country has delivered the US$16bn in ‘climate aid’ that it promised over three years;
  • Leonardo DiCaprio sported a hipster beard to call governments on meaningless climate rhetoric and denial – “none of this is rhetoric, none of this hysteria, this is fact”.

Climate and Health.

But importantly, climate change is not just about polar bears, this is about you and me too. An important message emerging.

With the world watching, the rhetoric on climate is rapidly changing from one solely focused on the environment, to one firmly focused on global human health too. Hence my attendance.

Leading a charge in this space, the Global Climate and Health Alliance (GCHA) provides thought leadership regarding the overlap and interdependacies between climate with health – I have covered this before . But importantly, they also outline three actions for the health and public health communities for co-mitigation on climate and health.

1. Climate change must become a mainstream public health concern.

“Put simply, we will have no health on a dead planet” – says the Stockholm Resilience Centre’s Johan Rockstrom. A hotter, more polluted world in which food scarcities, weather extremes, polluted air/water/land and greater geopolitical instability poses a major risk to global and local public health.

We must continue to work to make these links known.

The World Health Organization head states “climate change, and all of its dire consequences for health, should be at centre-stage… whenever talk turns to the future of human civilizations. After all, that’s what’s at stake”.

2. Clean energy and active transport can save lives, carbon and money.

“Dramatic health benefits and associated cost savings would result from a global transition to clean energy, avoiding millions of early deaths each year through improved air quality” says GCHA. Urban areas are home to half the world’s population, but generate around 80% of global economic output, and around 70% of global energy use and energy-related greenhouse emissions. Air pollution is a growing burden to human health and already kills an estimated 7 million people each year.

Rapid transition to active transport and cleaner energy alternatives will be a major focus of the Summit this week – hopefully with commitments and actions.

3. We need to make investment choices which benefit health.

Following an historic announcement by Hesta in Australia last week to pull any coal investments from their $26B retirement fund, this is a hot topic this week. Divestment is the concept of pulling invested funds away from companies or stocks which contribute to environmental damage – think big oil, gas and coal burners. Using investments as a political tool for change. The American billionaire family, the Rockerfellers joined more than 180 institutions — including philanthropies, religious organisations, funds and governments — pledging to sell assets tied to fossil fuel companies from their portfolios. This is seen as a momentous move and a powerful tool for forcing innovation and private-sector change.

Following live.

Combined with the United Nations General Assembly week here in New York City, this is set to be a very big day for climate change. We can only hope that it is.

To follow live from home or your smart phone, use #climate2014.

Above all – get involved, stay informed… this is our future.

Follow Alessandro on Twitter via @SandroDemaio

The Conversation


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Alcohol: breaking up is hard to do.

There are many absurdities in society that we overlook or come to accept. For me, there are few though more absurd than our relationship with alcohol. Addictive, harmful, carcinogenic and associated with a raft of social, economic and health consequences – we continue to accept its role as a social lubricant, a mark of celebration, a sign of manhood and a reflection of sophistication.

I have talked a lot about this before.

The public health community has long worked to address this issue. But facing an incredible force from the alcohol industry, limited progress has been made. We need to think outside the box.

With this in mind, in 2014 NCDFREE is hosting bootcamps for the brightest emerging minds from all sectors.

With just 2 hours on the clock and the challenge to ‘start a conversation around our relationship with alcohol’ through a short 1-minute film, this is what they came up with.

“It’s not me. It’s you.”

To learn more about NCDFREE, head to

Follow me on Twitter via @SandroDemaio

This film was sponsored by Remedy Healthcare.

The Conversation



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Part 2: Prevention and Control of Rheumatic Heart Disease in Kenya: Progress is on the horizon

This week on PLOS TGH – we hand over to Dr Duncan Matheka and his group, for their second post on Rheumatic Heart Disease in Kenya.


Rheumatic heart disease (RHD) has been long neglected in the developing countries – yet a ‘preventable’ disease that is easy to manage only if detected early. We hereby highlight a number of multi-sectoral initiatives mainly targeted at the Kenyan communities towards combating RHD.


1. RHD Family Support Clubs

RHD Family Support Clubs are a useful way of promoting holistic RHD care in Kenya. Kenya launched the Nairobi RHD Patient Support Club on Saturday 8th March 2014 at the School of Medicine, University of Nairobi. The club has adapted a person-centred model that has been effectively used by CLAN (Caring and Living as Neighbours – an Australian NGO) to improve quality of life for children and adolescents living with a range of chronic health conditions in low-income settings in the Asia Pacific region. CLAN utilizes a rights-based, community development framework for action, and focuses multisectoral, internationally collaborative action on five key pillars:

(1) Affordable access to medicine (monthly penicillin) and equipment (echocardiography) (2) Education (of children with RHD and their families, health care professionals, policy makers and the national and international community), research and advocacy
(3) Optimal Medical Management (through primary, secondary and tertiary prevention)
(4) Establishment and development of Kenyan RHD family support clubs
(5) Reducing financial burdens on and promoting financial independence of families living with RHD.

Support clubs offer material, moral, and psychological support within a cost-effective, strategic, sustainable, health system strengthening, multi-disciplinary approach. Successful engagement of a broad network of national and international multi-sectoral organizations around the Kenyan RHD support club launch of 8th March 2014 established the Kenyan RHD Community as a visual hub for ongoing person-centred health care in the country. The many and varied stakeholders engaged around the RHD Club meeting took up roles to support and work in partnership with the RHD community over the longer term, to ensure no affected child will: go without their monthly injection of penicillin; be lost to follow-up; miss out on education due to this disease; have their life cut short because they cannot access medical services; or suffer unnecessarily because of a lack of understanding of the best ways to manage RHD. Moreover, it offers an impetus for more sustained national action to reduce the prevalence of RHD in Kenya.

Early indications suggest support clubs as modelled in the Asia Pacific region have potential for empowering families and communities in Kenya to engage with a broad range of partners around a united vision of improved quality of life for children who are living with RHD in Kenya. Moreover, the club offers the members an opportunity to advocate for their needs collectively, while encouraging and supporting each other.


2. Education and Creating awareness

Health professionals have been travelling nationally to provide talks to primary school-going children in Kenya. In one program, student education utilized innovative technology (an interactive digital module) so as to optimally engage the children and promote learning about RHD (Kozicharow et al, 2013). The module developed by WiRED international (a US-based non-profit organization working in Kenya) had simplified animated presentations linking sore throat, rheumatic fever, and RHD, as well as prevention strategies. The module also introduced questions throughout the presentations to students and provided instant feedback to reinforce key concepts. WiRED promotes the vision that educating children at an early age has long-term benefits, because most children will retain key messages as they grow older, and pass the messages on to their families and peers during school holidays (Céspedes et al., 2013, Kozicharow et al, 2013). Teachers are also targeted during the training sessions so that they can act as reference points for the students who are in constant contact with them.

In Kenya, the Kenyan Heart National Foundation has also used its School-based ‘Talking Walls’ campaign to educate school-going children on prevention and control of RHD (Kenyan Heart website).


3. Screening and early diagnosis

Mater Hospital in Nairobi, Kenya runs a school-based rheumatic fever and RHD prevention outreach program which offers diagnostic, preventive, educational and curative services to primary and secondary school children in various parts of the country (Jowi, 2012).


 4. Advocacy and Streamlining Healthcare Infrastructure

As part of Non-Communicable Disease (NCD) prevention and care activities in Kenya, the Kenyan Ministry of Health (MOH) in collaboration with World Health Organization (WHO), World Heart Federation and NCD Alliance Kenya (NCDAK), is holding a stakeholders forum to work out best modalities of incorporating RHD within healthcare services in Kenya. The purpose of holding this forum is to increase awareness of the continuing burden of RHD and the need to specifically include RHD prevention and control as part of broader NCD initiatives. RHD prevention and control needs specific initiatives not addressed in the common risk factors approach by global and Kenyan NCD action plans, nor the current Kenyan National Health Sector Strategic plan.


5. Opportunity with healthcare decentralization

Kenya is currently undergoing decentralization of government functions, including healthcare, which means that there is a renewed opportunity to integrate RHD care into other regions of the country and build an overall healthier Kenya. As 47 counties of Kenya absorb the healthcare mandate, it is expected that greater community involvement will result in tailored healthcare for each region. Devolution will facilitate more straight-forward avenues for advocacy on NCDs at the county-level, as the decision-makers in government will be more localized and have so far demonstrated themselves as easier to communicate with. County health policymakers are usually also native to the communities that they serve and have a more vested interest in improved health outcomes in their designated regions, than the previous national level decision-makers – hence more community involvement, empowerment and development.


6. Role of multi-sectoral partnerships

For both healthcare devolution and expanded care for RHD, there is a push to build private-public partnerships. Both public and private healthcare providers must have a seat at the policy table and work together, as multi-sectoral action will have the biggest impact within communities. Yet, the need to safeguard public health (using a rights-based approach) must be emphasized and the terms of such partnerships critically evaluated and monitored. For instance, the World Heart Federation is partnering with Kenyan organizations (Kenyan Heart National Foundation, Kenya Cardiac Society, etc) to streamline healthcare provision for RHD patients.


In conclusion, besides the foregoing, there is need for more initiatives to combat RHD in Kenya by increasing community awareness and involvement and ensuring better healthcare infrastructure – thus promoting primary and secondary prevention of rheumatic fever and RHD.



  1. Kozicharow A, Ghuman S. Rheumatic heart disease project in Kenya tests WiRED training program. Available from: [cited 22 October 2013].
  2. Céspedes J, Briceño G, Farkouh ME, Vedanthan R, Baxter J, Leal M, et al. Targeting preschool children to promote cardiovascular health: cluster randomized trial. Am J Med 2013; 126: 27–35.
  3. Kenyan Heart Website:
  4. Jowi Christine Awuor. 2012. “African Experiences of Humanitarian Cardiovascular Medicine: A Kenyan Perspective.” Cardiovascular Diagnosis and Therapy 2 (3): 231–39. doi:10.3978/j.issn.2223-3652.2012.07.04.



Dr. Duncan M. Matheka is a Kenyan Medical Doctor and Public Health Researcher. He is the African Representative of Young Professionals Chronic Disease Network (YPCDN) and the Nairobi RHD Club Coordinator. Twitter @duncoh1

Dr. Laura Musambayi is a Kenyan Medical Doctor and the Nairobi RHD Club Assistant Coordinator.

Mohamed A. Omar is a fourth year medical student at the University of Nairobi, Kenya.

Dr Kate Armstrong is the Founder and President of CLAN (Caring & Living As Neighbours) and the Executive Secretary of NCD Child (a global coalition committed to integrating children and adolescents within the global NCD, health and development discourse). Twitter @ncdchild



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