Wednesday, May 26, 2010

Health ... big study well funded but what management action will result?

Dear Colleagues

IRIN has circulated an article about health written from Johannesburg titled GLOBAL: PMTCT could be key to cutting child mortality. The text of the article is copied below and the URL for the article is

The highlighted conclusion from this article is
Globally, the trend is clear - child mortality rates are going down faster than anyone anticipated. Studies like this may point way forward
The study referred to is "Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970—2010: a systematic analysis of progress towards Millennium Development Goal 4" written by the following researchers: Julie Knoll Rajaratnam PhD a, Jake R Marcus BA a, Abraham D Flaxman PhD a, Haidong Wang PhD a, Alison Levin-Rector BSPH a, Laura Dwyer BA a, Megan Costa BA a, Prof Alan D Lopez PhD b, Prof Christopher JL Murray MD a associated with (a) the Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA and (b) the School of Population Health, University of Queensland, Brisbane, QLD, Australia. The study is funded by the Bill and Melinda Gates Foundation.

The article in the Lancet is around 21 pages long and the annex to this article 219 pages ... a substantial amount of data and analysis. From an academic perspective this work is probably considered to be very good ... from a management perspective I cannot pretend to be impressed. There has been heavy use of statistical method, which is not easy to follow unless one has advanced degrees in these matters ... but little of it ends up giving clear management guidance.

Bottom line ... the question of whether or not the global health situation is being managed well or not is not addressed, even though this may be the biggest question in the modern health sector when there is so much disease and illness and a chronic shortage of resources.

Somewhere, somehow, there needs to be some good work done on how best to use scarce resources to achieve the best possible results in the healthcare sector. My sense is that the health sector is scared stiff that this will be done and it will show that the medical profession and the corporate health sector together with the funding organizations are running a high cost low performance industry ... that in spite of this, is highly profitable. This is fundamentally wrong. The scientific capacity of the modern health sector is amazing ... and no reason for the terrible amount of suffering caused by disease, poor health and dysfunction in the healthcare industry.

The question is what health outcomes should there be given the amount of fund flow that is going into global health ... and how could these outcomes being substantially improved through better organization and changing the way things are done.

Community Analytics (CA) has some preliminary conclusions including the very basic one that science and technology has progressed very impressively over the past 50 years, but value flowing into society quite modest and money profits substantial. The idea that money profits have done so well and value adding for society so limited suggests that there is some serious structural dysfunctionality in the way things are working ... notably the focus on money metrics with almost no value metrics being used anywhere.

This is not the first time I have written something like this ... and likely it will not be the last.

This IRIN article touches on an important issue ... and the Lancet study goes into great detail about some of the statistics about performance. However, moving from a big study to a big change in performance is not happening and, as far as I can see, nobody has it on their agenda.

The text of the IRIN article is below.


Peter Burgess

JOHANNESBURG, 25 May 2010 (PlusNews) - Sub-Saharan Africa is struggling to meet the Millennium Development Goal (MDG) of reducing child mortality but with greater access to prevention of mother-to-child HIV transmission (PMTCT) services, some countries are slowly catching up.

A new study by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, US, published on 24 May in the online edition of British medical journal The Lancet, compared mortality in children younger than five from 1970 to 2010 in 187 countries to chart progress towards reaching the goal.

Worldwide child mortality had declined by 52 percent since 1970, but only 31 developing countries were on track to meet the MDG target of reducing under-five mortality by two-thirds by 2015; African countries hit hard by HIV were conspicuously absent from the list.

Sub-Saharan Africa accounted for about half the global figure for child mortality under the age of five, and the region also had the slowest rates of decline in child deaths, which might be partly due to high HIV prevalence levels.

"We can see the effects of HIV in sub-Saharan Africa in the way that the declines in child mortality throughout the [19]70s and '80s stop, and start to reverse in the 1990s. This coincides with the rise of the HIV epidemic there," Dr Christopher Murray, director of the IHME, told IRIN/PlusNews.

According to UNAIDS, sub-Saharan Africa still has most of the world's HIV infections, while a regional prevalence of about 5 percent accounted for almost 70 percent of all new HIV infections in 2008.

The good news

Yet there was compelling evidence that some African countries were making significant strides in reducing child mortality, and the report's authors suggested that this could be explained by improved access to antiretroviral (ARV) drugs and PMTCT [preventing mother-to-child transmission] services.

"There has been a tremendous scale-up in ARV programmes over the past decade, and an increased emphasis on preventing mother-to-child transmission. We think both of these efforts are starting to show an effect on child mortality, and are helping to drive the child mortality rate lower," Murray noted.

"Since 2005, though, we are starting to see declines [in child mortality] again, including in countries that have been hit very hard by HIV, such as Swaziland, Botswana, and Lesotho."

The study also pointed out that southern African countries with relatively strong ARV and PMTCT programmes had notably lower under-five mortality rates than those in other regions of Africa.

Malawi, which has made substantial gains in ARV and PMTCT services, has been charting yearly declines in child mortality of more than three percent. Today, 45 percent of pregnant, HIV-positive women access PMTCT, up from just three percent five years ago, according to a recent report by the International Treatment Preparedness Coalition, a support group for people living with HIV and AIDS.

Dr Ashraf Coovadia, chair of the South African National AIDS Council's treatment and care support task team, and head of paediatric HIV services at the Rahima Moosa Mother and Child Hospital in Johannesburg, told IRIN/PlusNews that the results of improved PMTCT regimens and access were becoming evident.

"We are seeing less [HIV]-infected infants, and those that are infected we are seeing at an earlier stage," said Coovadia. Infants brought to the hospital in later stages of HIV infection tended to come from areas outside Johannesburg, where access to PMTCT services was often still problematic.

The study's authors suggested that comprehensive and accurate studies, such as this one, should be conducted more often because decreased funding levels would make the data they provided crucial to guiding aid and national health priorities.

"We need to spend more time looking in depth at what is working and what isn't working in countries where we have seen substantial progress ... What are the lessons to be learned from these countries?" Murray said.

"Globally, the trend is clear - child mortality rates are going down faster than anyone anticipated," he said. "Now, for governments and non-governmental organizations, the real work begins of identifying the best policies to build on that momentum."

Coovadia agreed, noting that further studies were needed, not only to lobby governments and funders for extended services, but also to understand why not all countries with PMTCT programmes had charted gains, like Malawi.

"We need to know where we're getting bang for our buck, especially when funding is dwindling; we need to take an evidenced-based approach to prioritising [health] interventions," he told IRIN/PlusNews.

"We also need to look at the challenges of why, in places where programmes are in place, we may not be getting the same benefits ... in many cases this is related to [weak] health systems and issues of access."

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