Geneva Health Forum Archive

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An Overview of the TRREE for Africa Project

Author(s): Marie Hirtle1
Affiliation(s): 1Biotika Inc., Mont-Royal, Canada
Key issues: Ensuring the protection of persons who participate in research, especially in clinical drug trials, and promoting the highest ethical standards for research involving humans is the responsibility of many actors who participate in international collaborative research. And, while international and national regulations apply to some aspects of clinical trials, many others fall under ethical principles and processes that require interpretation and judgment to ensure subject protection and to promote highest ethical standards in concrete situations. Despite this difficult task, those involved in research involving humans receive little or no training and support to enhance their understanding and comfort level of the legal and ethical framework that applies to research involving humans.
Meeting challenges: TRREE-for Africa (Training and Resources in Research Ethics Evaluation) is a project that aims at developing a distance learning programme on research ethics for all those involved in ensuring research participant protection and in promoting highest ethical standards in international collaborative research. TRREE-for Africa will also provide a platform for a participatory website of resources that apply to research involving humans.
Conclusion (max 400 words): This presentation will describe the origins of this project, its goals, anticipated challenges and the proposed results.

A Short Overview of the KFPE and an Introduction to the Session

Author(s): Jon-Andri Lys1
Affiliation(s): 1Commission for Research Partnership with Developing Countries, KFPE, Bern, Switzerland
Key issues:

The KFPE (The Commission for Research Partnership with Developing Countries) is dedicated to promoting research partnerships with developing and transition countries. In this way, it wishes to contribute to sustainable development. The KFPE is engaged in Swiss scientific policies and is committed to promoting the interests of researchers and their affiliated institutions on both national and international levels. It furthers development-oriented research and elaborates research-strategic concepts. In this context, it ascertains that partnership principles are followed, that the quality of research is assured, and that the interests of all partners are respected. The KFPE is a commission of the four Swiss scientific Academies. This session, Research Networks in Partnership, gives an introduction and an overview of a new initiative of partnership and ethics in research called TRREE. Research partnerships and ethics are also two central topics of interest for the KFPE. TRREE (Training and Resources in Research Ethics Evaluation) for Africa will provide training in research ethics evaluation designed specifically to address the ethics of clinical trials conducted in Africa that must comply with international ethical standards. The session will highlight various aspects of such research networks in partnership, such as the challenges or pre-conditions of such networks or assessing the needs for the evaluation of ethics in research.

The Health System’s Challenge to Deliver Malaria Prevention and Treatment

Author(s): Don De Savigny1
Affiliation(s): 1Epidemiology and Public Health, Swiss Tropical Institute, Basel, Switzerland
Key issues:

Effective control of malaria in Africa faces many challenges and bottlenecks. The dramatic increase in financial resources for malaria control provided by recent Global Health Initiatives and new partnerships for financing at country level have improved the prospects of having sufficient commodities for malaria prevention (long-lasting insecticidal nets, insecticides for indoor residual spraying) and treatment (artemisinin combination therapy and other drugs). As this higher-level constraint resolves, another array of constraints are quickly becoming evident. These include large-scale procurement of commodities once financing is available, and the delivery of these commodities in programmes that actually reach the population in need. These constraints are all health system constraints. Failure of countries and donor partners to invest wisely in health systems development have resulted in the current frustration to meet Millennium Development and other international and national goals.

Objective(s): This presentation will examine the common health system weaknesses that currently impede effective national-scale malaria prevention and treatment. Under health systems dimensions of stewardship, resources, financing and programme delivery, key weaknesses revolve around: policies and guidelines; tendering and procurement; public-private partnerships; human resources, training and supervision; decentralization and ownership; national and local planning, priority setting and resource allocation; population access and targeting; provider compliance; consumer adherence; home care and household behaviours; monitoring and evaluation.
Meeting challenges: There are a number of strategies for both quickly scaling up equitable access and coverage of malaria interventions that can temporarily avoid these system constraints (e.g. campaign approaches for preventive interventions), yet help build systems for more sustainable continuous availability of quality interventions through routine systems (integration). This presentation will examine some recent successes in such approaches.
Conclusion (max 400 words): When it comes to achieving malaria control, health system strengthening is ignored at our peril. There are a number of system strengthening strategies that have been shown to work, but all require political commitment from all partners.

Home Management of Malaria

Author(s): Franco Pagnoni1
Affiliation(s): 1WHO/TDR, Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland
Key issues:

Home Management of Malaria is a strategy that aims at improving access to antimalarial treatment by making effective, pre-packaged medicines available close to the homes through trained community-based providers backed up by a communication strategy for behaviour change. It has been shown to be both feasible and effective in ensuring prompt access to appropriate treatment in the African region; a region where the mortality burden from malaria is greatest, and where the majority of children die before they ever reach health facilities (World Health Organization 2003; McCombie 2002). This strategy was initiated because the earliest recognition of uncomplicated malaria (fever) and initial treatment occur at home, often in an inadequate manner. However, most of the strategies for malaria control are limited to the health facility level. The formal health system is often used as a last resort by caregivers due to well-documented constraints such as inadequate geographical and financial access (Foster 1995; Nyamongo 2002), perceived poor quality of health services and a variance in caregiver perception of aetiology of disease (Baume et al. 2000; Ahorlu et al. 1997; Agyepong 1992) amongst others, thus reducing the ability of formal health strategies to make the desired impact on malaria morbidity and mortality. With sufficient evidence that HMM is effective (Sirima et al. 2003; Yeboah-Antwi et al. 2001; Kidane and Morrow 2000), many countries adopted the HMM strategy into their National Malaria Control Programmes (NMCP). Chloroquine has since then developed resistance levels of over 40% (Koram 2002) and as a result, the drug policy for first-line treatment of malaria in health facilities has changed to ACT (WHO 2006). However, there is scanty experience with the use of ACT beyond the health facility level and several concerns have been raised with regard to the use of ACT in the context of the HMM strategy (D’Alessandro et al. 2005; Pagnoni et al. 2005; Charlwood 2004). Concerns include the feasibility and acceptability by the communities of ACT use at the community level, the level of compliance to treatment regimen and counselling instructions by caregivers and community distributors, the potential increase in drug resistance resulting from unsupervised use of ACT, issues related to the high cost of ACT and current lack of supply. These issues are all-important and have to be addressed through implementation research. However, while recognizing these outstanding issues, we believe that current evidence suggests it is best to move forward positively for the benefit of the patients rather than to delay the introduction of new interventions to those in need. It would be wholly unrealistic to expect that the RBM (Roll Back Malaria) goal of reducing malaria mortality by half will be achieved unless access to effective medicines is vastly improved, and in most of sub-Saharan Africa, this will have to be through HMM. All efforts, both in research and financial terms, must be undertaken in making the best antimalarial drug available at all levels of the health system through the best possible operational strategy. Preliminary results from recently concluded or ongoing studies show that this is possible.

Increasing Access to Antimalaria Medicines in the Private Sector in Sub-Saharan Africa: Going Beyond Global Subsidies

Author(s): Ambrose O. Talisuna1
Affiliation(s): 1Assistant Commissioner, Department of Health Services Epidemiological Surveillance Unit, Ministry of Health, Uganda
Summary (max 100 words):

Despite considerable efforts during the last millennium to eradicate or control malaria, it is still one of the most prevalent and devastating diseases in the tropics. This pervasive situation is compounded by the widespread parasite resistance to affordable medicines (chloroquine (CQ), sulphadoxinepyrimethamine (SP) and amodiaquine (AQ). Consequently, artemisininderivative based combination therapies (ACTs) have been proposed as the only available bullet in the global effort to roll back malaria. However, ACTs are expensive, highlighting the need for a globally coordinated strategy to ensure that artemisinin derivatives and their partner drugs in combination therapy are not used as monotherapy in order to reduce the likelihood for parasite resistance to develop. In response to these concerns, the board on global health of the Institute of Medicine (IOM) has, in 2002, convened a committee to examine the economics of the alternative strategies to treat malaria, given the declining effectiveness of CQ and its immediate alternatives (SP, AQ) in malaria endemic countries. In its final report, Saving Lives, Buying Time, the committee has identified the reasons for the immediate introduction of ACTs including; the need to minimize the use of artemisinin monotherapy (which could lead to rapid resistance); and the need to reduce malaria-related deaths as a result of using ineffective antimalarial medicines. Further, the Institute of Medicine’s report has recommended the establishment of an international fund that would buy ACTs from producers at a subsidized price and resell it to malaria endemic countries at a price close to that for CQ or SP monotherapy, because this would ensure a stable demand for ACTs that could ultimately lower the price of ACTs. However, some have raised caveats that, while subsidies create substantial benefits for the individual patients, they could result in widespread use and misuse and increase selection for resistant parasites (a global public bad). In this paper, we support the Institute of Medicine’s committee recommendation that greater use of ACTs (through a global subsidy) would delay resistance and increase the useful therapeutic life of ACTs (an international public good). However, we contend that global subsidies alone are not enough and an integrated package beyond subsidies is needed, including: deliberate efforts to withdraw monotherapy (artemisinin and non-artemisinin); improved diagnosis in the private sector (through better training and use of subsidized rapid diagnostic tests); a paradigm shift in the strategies for the involvement of the private sector (new approaches for training in the private sector content, form, accredited private outlets and a focused communication strategy); a radical shift to more rigorous supervision, surveillance and monitoring (pharmacovigilance, medicine quality and efficacy monitoring); regular audits and group processes; and finally continuous operational research to update strategies. The global public goods argument for subsidies is linked to the expectation that subsidized ACTs would discourage use of monotherapy and therefore delay the emergence of resistance to ACTs. But subsidies could also limit the motivation to manufacture counterfeits in Africa (already widespread in Asia).

Integrated and Sustainable Vector Control in Sub-Saharan Africa

Author(s): Christian Lengeler1
Affiliation(s): 1Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland
Key issues:

Vector control has been the mainstay of malaria control for many decades and it has allowed to eliminate malaria transmission in much of the world. In sub-Saharan Africa, however, vector control on a large scale has been the exception rather than the rule. Since the 1990s the development of insecticide-treated nets (ITNs) has provided for the first time a feasible strategy and many large-scale programmes are now being implemented. Indoor residual spraying (IRS) is currently only done at national scale in southern African countries. We aim to review systematically the available information on efficacy, effectiveness and cost of both ITN and IRS programmes. In addition, this review discusses the main epidemiological and operational aspects relevant for the planning of vector control and discusses them in the context of the Roll Back Malaria Partnership (RBM).

Meeting challenges: Ample historical evidence is available to document the impact of IRS in sub-Saharan Africa and elsewhere. At least 2 billion people are now living in low-to-no-malaria risk as a result of intense prevention activities. For ITNs, over 110 completed trials in the 1980s and 1990s have demonstrated the large gains in child survival and important reductions in clinical attacks that can be achieved. In addition, good epidemiological evidence demonstrated that no mortality re-bound was taking place in children protected from birth by ITNs. A direct comparison of ITNs and IRS was performed in 5 settings and both approaches were similar in terms of impact and cost. Choosing between them is therefore largely a matter of operational feasibility and national strategies. With IRS few variations are possible in the way the intervention is implemented. Spraying houses with insecticide requires a well organized and structured programme, entirely supported by public resources. On the other hand, ITNs can be implemented in a number of ways: assisted commercial distribution, social marketing and different distribution models through health services. There is still scant evidence on their respective feasibility, cost-effectiveness and sustainability and each country will need to make its own strategic decisions.
Conclusion (max 400 words): Vector control has a long and successful history and the main strategies need to be deployed much more widely in sub-Saharan Africa. Literally, this has the potential to prevent one million annual deaths and improve substantially the life of all Africans.

Mainstreaming Gender-Based Analysis of the Women’s Hospital of Costa Rica

Author(s): Zully Moreno Chacón1, L. Ledesma1
Affiliation(s): 1Hospital of Costa Rica, San José, Costa Rica
Purpose: Explain how Gender-Based Analysis (GBA) helped the transformation of the Women’s Hospital in Costa Rica through the implementation of the Women’s Health Integral Attention Model Process developed since 1999.

A descriptive type investigation with a quantitative methodology was followed to build and understand learning about the Hospital’s transformation process. Also, an evaluation of three programmes directed to the attention of women’s health was conducted with a retrospective vision through GBA. This analysis was completed with a reflexive revision of the process documentation.


A transformation process of the hospital was achieved, from a traditional one to a strategic planning hospital which works with communities and women to make decisions regarding health, with the creation of programmes and projects through GBA. In relation to Sexual and Reproductive Health, new forms of attention were directed to: childbirth, abortion, integral attention to the adolescent mothers, women of the medium age, cervical-uterine health, intra-family violence, HIV/AIDS, drugs, maternal nursing and healthy lifestyles. Nine interdisciplinary teams were developed for the formulation and execution of a women’s integral health model. A base of active citizenship was created, formed by three women’s health associations and a board for women’s health. A health network was developed, composed of eleven areas that developed the Access Plan for the pathology of the uterus neck with the support of women. Evaluation and monitoring of the qualitative and quantitative attention was set up. As a result of the project, decreases were noted for delays for colposcopy consultation from six to one and a half months, and for menopause consultations from nine to three months. Training of 517 employees from the health network was carried out to improve the sensitivity of care for women, also reaching 95% of hospital members.

Conclusion (max 400 words):

GBA implementation produced profound changes in the treatment of problems and women’s health needs and enhanced: strategic planning, revision of physical infrastructure, revision of working processes and administration, distribution of spaces, challenge of management structures, allocation of budgets, new obstetrical practices, and methodologies and processes of work. GBA is beneficial for the care of women’s health.

Micro-credit Financing and Impact on Female Genital Mutilation

Author(s): Berhane Ras-Work1
Affiliation(s): 1NGO, Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, Geneva, Switzerland
Key issues:

Gender is a cross-cutting issue that determines the health and lives of women and men in different ways and at different levels. The health of the majority of women, in particular their reproductive health, is impacted by the role and status attributed to them by the society in which they live. Systematically women are affected negatively by social attitudes and practices. Gender-based violence with all its variations is a strong health determinant across the life cycle of women. The unequal power relationship between men and women both socially and economically render women vulnerable, forcing them to accept in silence and with apathy even the most gruesome forms of violence. The most brutal form of violence is perpetrated on African women in the name of preserving cultural values. Female genital mutilation is practised in at least 28 African countries. Reasons advanced for the persistence of the female genital mutilation include: religious, e.g. misconceptions; family honour, e.g. virginity; economic, e.g. bride price; aesthetic; social integration; prevention of child mortality. The benefits received by those who carry out the excision and ignorance on the part of the women are also important reasons to be considered. Although the cost of such forms of violence is high to the nations, governments tend to be silent, thus justifying this violation of Human Rights as an inevitable tradition and integral par of culture. In recent times, gender inequality and violence have been gaining international recognition. NGOs have played a crucial role in bringing the issue of violence on the agenda of the relevant bodies of the UN. A very important outcome of this lobbing is the appointment of the Special Reporter on Violence against Women. The experience of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) shows that with intensive education and information tailored to respond to the varying cultural contexts, it is possible to impact positive changes of attitudes. IAC has realized the underlying factor for gender-based violence proves to be the economic vulnerability of women as well as their ignorance. Women subject themselves and their daughters to practices such as FGM to ensure the security of marriage and the survival it provides. Empowering women through education, skills training and micro-credits can change the status of women for a better life. IAC has embarked on a micro-credit scheme with excisers to enhance alternative income generating activities. Through this experience it has been proven that excisers, once reoriented and supported, can stop their traditional practice and engage themselves in productive activities. They can also act as agents of change. Although a sufficient number of protective international and national instruments exist, the political will to fully protect women and girls is still lagging. The responsibility of civil society lies in holding governments accountable for compliance.

Meeting challenges: Changing deep-seated traditional attitudes and practices in favour of promoting the health and status of women.
Conclusion (max 400 words): Women themselves have to be continuously informed and made aware in order for them to be empowered to value themselves, including their body, and to protect their rights. The socializing system of boys and girls should be gender sensitive with built in values for equality.

Microfinance and Health Intermediation

Presenter: K. Narendar1
Author(s): V. K. Padmavathy2
Affiliation(s): 1Chief Executive, DHAN Foundation, Madurai, India, 2Kalanjiam Community Banking Programme, DHAN Foundation, Madurai, India
Key issues:

Poverty and health issues are mutually correlated. The Millennium Development Goals (MDGs) aim at achieving a dramatic reduction in poverty and a marked improvement in the health status of the poor by 2015. The majority of poor people across the world are not able to afford quality healthcare services. Creating an access to basic healthcare services and providing financial protection against health risks continue to be major development challenges. Over the last two decades, microfinance has emerged as one of the significant mechanisms to address the deep-rooted causes of poverty, inclusive of health. Evidence reveals that access to microfinance services positively enhances nutritional intake, contraceptive usage and reproductive health decisions by women. Microfinance programmes across the globe predominantly focus on women. Their access to savings and credit facilitates reduction of risks and vulnerabilities, and also improves their participation in family decision making. This enables the poor women to increase expenditure on their own well-being and that of their children, which ultimately affects the health outcomes at family level. Microfinance encompasses three major services viz., savings, credit and insurance. Appropriate savings products could be promoted for chronic health problems for which treatment can be planned well in advance. Savings products could also be a solution for addressing preventive healthcare needs such as immunisation, usage of napkins for personal hygiene, etc. Credit services and products could be extended for urgent health needs based on repayment capacity of the members. However, for higher healthcare expenditures social security measures such as health insurance must be in place. Beyond microfinance services, the social capital created out of organising the community can very well be utilised in enhancing the health status of the poor. These community-owned, controlled and managed structures act as a local demand system influencing mainstream healthcare institutions through creating sustainable linkages. Increasing access to healthcare services and behavioural changes related to health and nutrition are the core issues that need to be addressed to sustain the improved health outcomes. This paper highlights the experience of the DHAN Foundation, a professional development organisation working in India in achieving improved health outcomes through microfinance intervention.

Access to Safe Care in Developing Countries

Author(s): Stuart Whittaker1
Affiliation(s): 1Research and Information, The Council for Health Service Accreditation of Southern Africa, Pinelands, South Africa
Key issues:

Recognising the inevitability of unsafe outcomes due to high-risk processes in hospitals, this presentation introduces the concept of the Wedge Model for improving access to safe healthcare. The model comprises two separate, parallel but interdependent processes converging on unsafe care. The model has been developed in response to current events in South Africa. Rarely does a week pass without some minor or major adverse event in a hospital or healthcare facility in this country being reported in the country's media. Post-apartheid hospitals are struggling to deliver quality care to some 43 million people, particularly in the poorer, rural areas. This struggle is even more intense, given resource constraints, the impact of HIV/AIDS, a brain-drain of doctors and nurses and poor performance in both clinical and non-clinical areas. However, evidence is emerging that all countries experience the paradox of healthcare facilities providing some excellent curative care and yet posing a high risk to patients, staff and the community.

Meeting challenges:

The Wedge Model approach offers a mechanism to reduce the risk to patient, staff and community safety and at the same time improve patient care. One side of the wedge is COHSASA's standard improvement programme that aims at improving facility, clinical, management, clinical and non-clinical support and technical systems so that ultimately high levels of excellence are achieved. Work to date shows that services can be improved using QI methods based on standards compliance provided management support and essential resources are available. Clinical standards, however, show a resistance to improvement and adverse events remain a threat. The other side of the wedge is the adverse event monitoring, improving and preventing arm that aims at identifying and improving systems failures that impact on patient safety while they are being improved by the standard improvement arm.

Conclusion (max 400 words):

In this two-pronged approach, serious system failures are identified and interventions prioritised to ensure that patient safety is maximised at any given point during the ongoing quality improvement cycle, which is being implemented simultaneously. The aim is to achieve safe and effective patient care through the Wedge Model by improving systems through incremental standard compliance improvements, on one hand, and regular monitoring and improvement of serious system failures through AE monitoring, route-cause analysis and solutions, on the other hand.