Bethesda, MD -- Eliminating polio everywhere will require global cooperation on several fronts, including lowering the cost for poor countries to vaccinate with inactivated polio vaccine (IPV), says a leading global health researcher in the July/August Health Affairs thematic issue on global health.
Eradicating the wild polioviruses was supposed to have been achieved by 2000, but the effort to fight the disease is still ongoing. Polio cases reached an all-time high this century --1,997 cases -- in 2006. In 2008 there were more than 1,600 cases identified in 18 countries. For polio eradication efforts to succeed, countries must focus on several "weak links" to sustain population immunity from the virus, argues Scott Barrett, an economics professor at Columbia University in New York City.
Barrett's paper is one of many articles on global health in the new Health Affairs issue, which is supported by a grant from the Bill and Melinda Gates Foundation. Other issue highlights include a discussion of an innovative new international approach to providing affordable antimalarial drugs; an examination of the extent to which people, particularly in low- and middle-income countries, are forced to borrow money or sell assets to afford health care; a study of whether donor funding supplements or substitutes for health care spending by governments in developing nations; and a discussion of diplomatic efforts to combat a boycott of polio immunization. A full table of contents follows, and all articles are available to reporters upon request.
Papers Examine Challenges Of Eradicating Polio
Barrett describes the "weakest links" that must be strengthened if the world is to eliminate the spread of polio. Barrett says global health leaders need to focus on the following:
- Stopping the transmission of the wild polioviruses in countries such as Afghanistan and Pakistan, where war and the resulting upheaval hinder efforts to control the virus, and regions such as the northern Indian states of Uttar Pradesh and Bihar, where the presence of other health conditions appears to weaken the ability of certain forms of polio vaccine to stimulate immunity;
- Making sure that wealthy countries and private foundations continue financing anti-polio initiatives;
- Coordinating use and eventual termination of the oral polio vaccination among countries because weakened live virus strains in the oral vaccine can occasionally mutate and circulate as vaccine-derived poliovirus;
- Securing stocks of wild poliovirus stored in laboratories all over the world;
- Promoting effective surveillance and reporting of polio outbreaks; and
- Making sure countries are prepared to respond to outbreaks even after the wild polioviruses have been eradicated.
If poor countries could get access to IPV more cheaply and eventually stop use of the oral vaccination, many of the post-eradication "weakest links" would fall away, Barrett argues.
"Although the world's attention today is understandably focused on eradicating the wild viruses, the ultimate success of the initiative will depend as much on the steps being taken now to improve the economics of inactivated polio vaccination," he concludes.
In a related paper, Judith Kaufmann and Harley Feldbaum, of the Global Health and Foreign Policy Initiative of the Johns Hopkins School of Advanced International Studies, examine the diplomatic actions taken by the Global Polio Eradication Initiative, the United Nations, and the U.S. government to address the 2003-2004 northern Nigeria boycott of polio vaccination. The boycott had a strong political component and was fueled by rumors that the polio vaccine was contaminated with antifertility drugs intended to sterilize young Muslim girls. This boycott led to a global outbreak of polio, with cases spreading to 20 countries across Africa, the Middle East, and Southeast Asia, and it eventually cost more than $500 million to control.
Kaufmann and Feldbaum examine the diplomatic actions used to resolve this global health crisis, and draw conclusions about the processes and importance of health diplomacy.
"Flexibility, coordination among multiple actors and a willingness to mix politics, public health, and diplomacy were all a part of the effort. All must be part of the toolbox to address future global health challenges," they conclude.
A New Approach To Delivering Antimalarial Treatments
The global fight against malaria faces the ongoing challenge of making effective medicine affordable in developing countries. Growing resistance to traditional antimalarial drugs has made treatment more difficult, and newer, artemisinin-based medications -- the only drugs to which resistance has yet to develop -- are at least 10 times more costly than older, less effective drugs. In developing countries, most antimalarial medication is purchased at small drug stores in rural villages -- places where conventional development assistance and public-sector channels do not reach.
In 2001, in an effort to delay resistance, the World Health Organization issued a recommendation that artemisinins be used only in combination with another effective antimalarial -- as artemisinin-combination therapies (ACTs) -- for the treatment of malaria. However, artemisinin monotherapies continue to be used widely around the world. In their paper, Ramanan Laxminarayan and Hellen Gelband of Resources for the Future discuss a global subsidy that uses the distribution channels of the public and private sectors to make effective drugs accessible to those who need them while simultaneously reducing the risk of the development of resistant strains of malaria.
Laxminarayan and Gelband describe the barriers to creating such a subsidy, which challenged "orthodoxies of development assistance and medical care." "By recognizing that perfect systems would not be built in time to save malaria patients or artemisinins, the [Affordable Medicines Facility - malaria] AMFm carved out an alternative path for effective drugs to get to patients in the meantime," they write.
"The most lasting indicator of success is that with stronger public health systems, the success of malaria elimination, and lower-cost ACTs through technological innovation, the need for the AMFm will disappear," they conclude.
Borrowing And Selling To Pay For Care
Health care costs burden families all over the world, but a new study shows that people in low- and middle-income countries are hit especially hard. Out-of-pocket payments account for 70 percent of health financing in low-income countries, compared to 14.9 percent in high-income countries. In an analysis of data from the World Health Survey, Margaret Kruk of the University of Michigan and colleagues found that one in four families in these countries borrow money or sell assets to pay for health services. Survey respondents represented 40 countries and a combined population of 3.66 billion, or 58 percent of the world's population.
Kruk and colleagues suggest that by using prepayment systems -- such as tax-based health financing and social insurance -- to increase spending on health services, governments can protect families from economic hardship due to health care-related expenses.
Donor Funding And Government Spending
Donor funding from government and private sources of health aid to developing countries has increased significantly in the last two decades, reaching $13.7 billion in 2006. In a new study of donor spending in low- and middle-income countries, researcher Marwa Farag of Brandeis University and colleagues found that a 1% increase in donor funding was associated with a 0.19% decrease of government health spending in low-income countries, holding everything else constant. Donor funding is thereby partly replacing, rather than simply supplementing, government health spending, as "donors seem to regard the health sector as more important than governments do." This can have negative long-term consequences if donor funding is reduced or stopped and governments have committed their resources elsewhere.
Farag and colleagues point to how this funding substitution "requires the agencies responsible for donor coordination to pay special attention to what happens to the government share of health funding and to understand the influence of their efforts on national health systems."
The whole issue or any articles are available to reporters on request.
Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. Copies of the July/August 2009 issue will be provided free to interested members of the press. Address inquiries to Christopher Fleming at Health Affairs, 301-347-3944, or via e-mail, cfleming@projecthope.org.
TABLE OF CONTENTS:
From the Editor
946 The Devilish Details of Delivering on Global Health Susan Dentzer
Tools & Technologies
948 PROLOGUE: Spreading Tools and Technologies
949 A Global Subsidy: Key to Affordable Drugs For Malaria? A global subsidy could well have joined the "graveyard of good ideas" had it not been for an international environment of openness. Ramanan Laxminarayan and Hellen Gelband
962 Creating Access To Health Technologies In Poor Counties Rarely can access problems be solved simply by providing more money. Laura J. Frost and Michael R. Reich
974 Improving Health R&D Financing For Developing Countries: A Menu Of Innovative Policy Options New financing mechanisms could speed up development of health technologies for neglected diseases. Robert Hecht, Paul Wilson, and Amrita Palriwala
986 Pathways Of Health Technology Diffusion: The United States And Low-Income Countries In the absence of organized markets, health technologies require a steward to promote diffusion. A.K. Nandakumar, Joanne Beswick, Cindy Parks Thomas, Stanley S. Wallack, and Daniel Kress
Care Delivery
996 PROLOGUE: Improving Care Delivery
997 REPORT FROM THE FIELD: Dying To Give Birth: Fighting Maternal Mortality In Peru Simple innovations can mean the difference between life and death for Peruvian mothers-to-be. Nellie Bristol
1003 The Rural Hospital In Ecuador Improving rural secondary care is an essential expansion of the primary care strategy in many lower- and middle-income countries. David P. Gaus
1011 Innovations In Health Services Delivery From Transition Economies In Eastern Europe And Central Asia Despite myriad challenges, many formerly Eastern Bloc countries reformed their health systems while moving to market economies. Armin Fidler, Caryn Bredenkamp, and Sally Schlippert
1022 An Unhealthy Public-Private Tension: Pharmacy Ownership, Prescribing, And Spending In The Philippines Physicians who are linked to pharmacies do not prescribe more-costly medicines, but they do persuade patients to use those pharmacies. Chris D. James, John Peabody, Orville Solon, Stella Quimbo, and Kara Hanson
Public Spending
1034 PROLOGUE: Raising Public Spending
1035 Lessons From Taiwan's Universal National Health Insurance: A Conversation With Taiwan's Health Minister Ching-Chuan Yeh Fourteen years of experience with national health insurance have produced important results that other countries might find of interest. Tsung-Mei Cheng
1045 Does Funding From Donors Displace Government Spending For Health In Developing Countries? If governments substitute donor funds for their own financing, dire consequences can result for developing countries. Marwa Farag, A.K. Nandakumar, Stanley S. Wallack, Gary Gaumer, and Dominic Hodgkin
1056 Borrowing And Selling To Pay For Health Care In Low- And Middle- Income Countries One in four households in forty developing countries resort to "hardship financing" to pay for health care. Margaret E. Kruk, Emily Goldmann, and Sandro Galea
1067 Public Views Of Health System Issues In Four Asian Countries Respondents complain that those running their health systems do not solicit citizens' input or consider their views when making decisions. Mrigesh Bhatia, Ravi Rannan-Eliya, Aparnaa Somanathan, Mohammed N. Huq, Badri Raj Pande, and Batbayar Chuluunzagd
Polio
1078 PROLOGUE: Battling Polio
1079 Polio Eradication: Strengthening The Weakest Links Eradicating polio depends as much on improving the economics of vaccine manufacture as on vaccination itself. Scott Barrett
1091 Diplomacy And The Polio Immunization Boycott In Northern Nigeria With scientific evidence and pressure from political allies and religious authority figures, a Nigerian polio vaccine boycott was brought to an end. Judith R. Kaufmann and Harley Feldbaum
Brazil
1102 PROLOGUE: Spotlight On Brazil
1103 AIDS Treatment In Brazil: Impacts And Challenges Brazil's accomplishments in treating AIDS are unprecedented and have profoundly influenced global AIDS and health policy. Amy Stewart Nunn, Elize Massard da Fonseca, Francisco I. Bastos, and Sofia Gruskin
1114 Public-Private Partnerships And Public Hospital Performance In São Paulo, Brazil Innovations in public hospital management in this Brazilian state present a model for other developing countries struggling with the same set of problems. Gerard M. La Forgia and April Harding
1127 The Health Effects Of Decentralizing Primary Care In Brazil When ambulatory care facilities are turned over to local control, a locality's infant mortality rate appears to improve. Frederico C. Guanais and JamesMacinko
Health Tracking
1136 MARKETWATCH: The Political Economy Of U.S. Primary Care The singular lack of balance between primary and specialty care has serious consequences for health care in the United States. Lewis G. Sandy, Thomas Bodenheimer, L. Gregory Pawlson, and Barbara Starfield
1145 MARKETWATCH: High-Deductible Health Insurance Plans: Efforts To Sharpen A Blunt Instrument Deductibles can create powerful yet potentially indiscriminate and blunt incentives for consumers to alter their care-seeking behavior. Mary Reed, Vicki Fung, Mary Price, Richard Brand, Nancy Benedetti, Stephen F. Derose, Joseph P. Newhouse, and John Hsu
1154 MARKETWATCH: Outlier Payments For Cardiac Surgery And Hospital Quality High quality of care is strongly associated with low rates of compensatory payments for cardiac surgery. Onur Baser, Zhahoui Fan, Justin B. Dimick, Douglas O. Staiger, and John D. Birkmeyer
Narrative Matters
1161 PREFACE: Narrative Matters Turns Ten
1163 On The Southern Front Caring for elderly parents across borders and cultures and languages. Julia Alvarez
1171 In The Midst Of Sickness In the story of AIDS in Botswana, there are themes of human kindness and of people and nations not walking away from suffering. Alexander McCall Smith
1177 A Touch Of Sense Patients and physicians connect through touch and trust. Abraham Verghese
1183 Still Closing The Gap Years after the Civil Rights movement, how is it that health care in the United States remains separate and lethally unequal? Fitzhugh Mullan
DataWatch
1189 Composite Measures For Predicting Surgical Mortality In The Hospital A simple measure—based on hospital case counts and number of deaths—can explain variations in hospital mortality rates. Justin B. Dimick, Douglas O. Staiger, Onur Baser, and John D. Birkmeyer
1199 Use Of Beta-Blockers During Aortic Aneurysm Repair: Bridging The Gap Between Evidence And Effective Practice To use a procedure-specific guideline such as this one effectively, it is necessary to evaluate the data as they apply to each patient's procedure risk. Benjamin S. Brooke, Francesca Dominici, Martin A. Makary, and Peter J. Pronovost
GrantWatch
1210 ESSAY: What Do We Really Know About Foundations' Funding Of Mental Health? The sheer breadth of the mental health field sometimes obscures its visibility to funders. Ruth Tebbets Brousseau and Andrew D. Hyman
1215 Outcomes The Kaiser Family Foundation's new Web "gateway" on U.S. global health policy; foundation-funded projects on long-term care; how a foundation helped a New Orleans health center get federally qualified health center (FQHC) designation; and key personnel changes at foundations.
Book Reviews
1219 Poisoned Profits: The Toxic Assault On Our Children Philip Shabecoff and Alice Shabecoff [Reviewed by Parmeeth M.S. Atwal]
1221 Is There A Doctor In The House? Market Signals And Tomorrow's Supply Of Doctors Richard M. Scheffler [Reviewed by John K. Iglehart]
1223 The Innovator's Prescription: A Disruptive Solution For Health Care Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang [Reviewed by J.D. Kleinke]
1225 BookMarks
Journal
Health Affairs