Haiti was a big focus of this year’s Global Health Council conference.

In addition to a plenary featuring Haitian Minister of Health Alex Larsen, this year’s US$1 million Gates Award was presented to Haitian NGO GHESKIO. This award recognizes that GHESKIO belongs in the same company as the London School of Hygiene & Tropical Medicine (last year’s awardee) and the Aravind Eye Care System (2008 awardee).

Founded in Haiti in 1982, GHESKIO (French acronym for: Haitian Group for Studies in Kaposi’s Sarcoma and Opportunistic Infections) was the first institution in the world dedicated solely to the fight against HIV/AIDS. GHESKIO physicians were the first to describe the characteristics of HIV/AIDS in the developing world, with their 1983 article in the New England Journal of Medicine, Characteristics of the acquired immunodeficiency syndrome (AIDS) in Haiti.

Since then GHESKIO has grown to provide antiretroviral therapy (ART) to over 9,000 HIV-positive Haitian patients – and to treat more than 500,000 Haitian patients annually. GHESKIO was selected for the award because of “its years of ground-breaking clinical service, research, and training to treat and prevent the spread of the HIV/AIDS and other related illnesses, as well as its life-saving and swift response to treat the sick and injured in the aftermath of the January 12 earthquake that devastated Haiti.” This response included continued support of its network of ARV patients when all infrastructure had collapsed. On the ground, GHESKIO staff tracked down patients on foot, by radio, and by mobile phone. GHESKIO staff did this, as Dr. Jean Pape described, even though many of them had lost loved ones in the earthquake.

The earthquake was the motivation for discussing rebuilding the health system in the plenary, After the Earthquake: Towards Building a New Haitian Health System.

The plenary participants:

• Donna Barry, Advocacy and Policy Manager, Partners in Health
• Thomas Tighe, President & CEO, Direct Relief International
• Alex Larsen, Minister of Health, Ministry of Health, Haiti
• Andre Vulcain, Faculty Liaison of the Haiti Project, Department of Family Medicine, University of Miami, Miller School of Medicine
• Dianne Jean-Francois, Haiti Country Director, Catholic Medical Mission Board, Inc.
• Moderator: Susan Dentzer, Editor-in-Chief; GHC Chair, Health Affairs Journal

While other issues were addressed, the focus of rebuilding was definitely on human resources for health:

Health worker shortage made worse: The state of New York has more Haitian physicians than all of Haiti (Minister Larsen). But the doctor shortage is only part of the problem – the shortage of nurses and mid-level professionals is even more severe. The situation before the earthquake was bad, but it was much worse afterwards, as many health workers lost their lives or were seriously injured. Consider that, as a result of the earthquake, 200,000 people died, 1.2 million were made homeless, and 600,000 left Port-au-Prince. This is why organizations such as GHESKIO had to extend beyond their core services to provide emergency care and shelter after the earthquake. (For another example, read/listen to this NPR story about 400 Cuban health workers as first responders post-quake.)

Mid-level professionals, not buildings: Minister Larsen stressed the need to focus on the health workforce over infrastructure given how many health workers were lost in the earthquake. He said that you “don’t need a building”, but people – that a hospital was of little value without the health workers to work in it. He specifically indicated the need for mid-level community health workers, nurse-midwives, and anesthesiology nurses. Jean-Francois echoed this with a description of how CMMB is focused on training and task shifting. Vulcain’s metaphor was perhaps most memorable: You have to “land the ‘beautiful plan’ in the reality of the ecosystem”. Mid-level professionals are the key to a smooth landing. “You win and lose the battles at the mid-level”.

Mental health & other “needs of the past”: Vulcain spoke of how the earthquake “exacerbated needs of the past”. In other words, the need for specific health specialties has been made more apparent in the wake of the earthquake. The two specialties that he specifically discussed were mental health and physical medicine/rehabilitation. To mental health, Barry gave the Partners in Health perspective, that they are starting to address mental health issues and that these issues need to be better addressed in Haitian health facilities. Since the earthquake, Partners in Health has brought on 50 new social workers and 15 psychologists. They are also assisting with a national plan for mental health. To rehabilitation, Jean-Francois, an amputee herself, spoke of “the plight of the Haitian amputee”. The needs go well beyond healthcare and rehabilitation – there is a need to ensure opportunities for an “active and rewarding life”.

Retention: As with many other places, Haiti suffers from the poor retention of human resources. Minister Larsen spoke to this issue. He suggested that it sometimes it feels as if programs to train health workers are in place to develop talent for later recruitment (a bit like minor league baseball in the Americas). He mentioned the US, but specifically called out Canada for its excessive recruitment of Haitian health workers. It is not only a challenge to keep resources in-country, but also to keep people working in the public sector – those that do stay in-country are drawn to NGOs and the private sector. He argued that the best solution is to train a rural person. They will be more likely to stay since “they will see see this as social promotion”. (With the caveat that no two places are the same, my experience in rural Mongolia suggests that this strategy has mixed results. Many of the young, rural recruits into the community health workforce in Mongolia are eager to migrate to urban areas, and some of them have already moved.)

Mid-level schools of public health: One of the more intriguing suggestions moving forward was from Minister Larsen, who wants to see 3-4 schools of public health for mid-level professionals in Haiti. These were already existing in Haiti at some point in the past, when he was young. (I wonder if the Cubans may be of assistance here, given their capabilities along these lines.)

Minister Larsen began his plenary remarks by describing how grateful Haiti was for the international assistance they received. In the first few days after the earthquake, the Dominicans – despite their limited means – sent assistance. Following this, assistance came from everywhere, from the Israelis and the Palestinians, from the Russians, from the Americans, from the Europeans. He said that Haiti is “forever in debt for this assistance”. The challenge now will be to ensure that the assistance translates into meaningful contributions to helping Haiti develop its human resources to help it rebuild its health system. Sara Pacqué-Margolis, who reported on this plenary from the perspective of IntraHealth’s CapacityPlus project, speaks to this very need.

As Minister Larsen said, citing a French saying: “It’s never too late to do good”.

This is a report from the Global Health Council’s annual conference in Washington, DC. This year’s conference, Dateline 2010: Global Health Goals & Metrics, was held June 14-18, 2010. GHC37 is a reference to the Twitter hashtag used for the meeting. Make sure to check out the Council’s own conference blog coverage for more depth. This is our third year covering the meeting (2008 posts, 2009 posts).

Even though the focus of the Global Health Council conference was on metrics and evaluation, we at Global Health Ideas were particularly interested in learning about new service and technology innovations. “New”, as you might imagine, is a relative word. I discovered this when asking other conference attendees for their lists of new innovations. Late in the conference, I offered my working list to Peggy Parlato of AED. Every single item on my list was old hat to her. When I asked her for an innovation, she told me about voucher schemes – which we’ve covered extensively on Global Health Ideas for more than three years.

I’m focusing on ideas that were new to me, with the hopes that these will be new to some of our readers, too:

Export human resources, import ideology. This was the topic of Lord Nigel Crisp’s (NHS UK) lunchtime talk about his new book Turning The World Upside Down: The Search For Global Health In The 21st Century. He argued that we currently do the opposite in places like the UK, that we import human resources (brain drain) and export ideology (development aid). A wild idea on paper, but one that jives with the trend towards reverse innovation and addresses critical issues around human resources for health (HRH).

Micro-competitions. Spark MicroGrants “supports community-led development by giving small grants to community members to fund locally-generated solutions”. From the card that Neal Lesh gave me. He described a story of how his team was trying to develop an SMS-based system to increase the number of mothers giving births at health facilities in Tanzania. During this process, they asked community health workers for their ideas and one suggested a much simpler solution – that they simply provide free diapers and soap as an incentive to mothers to come to the clinics. They encouraged this health worker to write up the idea. She did and US$625 later, the idea was implemented, resulting in almost immediate increases in facility births (tens more facility-based births per month at one facility). This is how the Spark Microgrants idea was born. The grants they now provide are on the order of US$3,000. The Jhpiego PRIDE project in Pakistan similarly organized a competition for health centers to apply for facility development funds. With PRIDE, the amounts were greater – on the order of US$10,000 – and the focus was less on innovation and more on basic needs (e.g., clean water systems).

Avon Lady model, exported. If you’re not familiar with the US-originated Avon model, read up on it. It’s long been expanded to international markets, but now Solar Sisters has appropriated the model to sell solar-powered lamps to poor households in Uganda.

Ultra Rice. Ultra Rice has been around for a little while, but a couple folks brought this up to me as novel, including a JSI employee that I met at a cafe across the street from the conference. Ultra Rice is a food-based solution to micronutrient problems, well-suited to cultures with rice-heavy diets. We’ve covered this in a previous conference post.

Voucher programs. Since Peggy mentioned it, we’ll include it here. Now accepted as a way to implement results-based financing (RBF), though it wasn’t always that way – previously there was not always a tie-in between vouchers and outputs (thanks to Mursaleena Islam of Abt for the historical perspective). The voucher session description, doesn’t provide an entirely clear description of what voucher schemes are or why they’re important, so if you’re new to vouchers, check out the Population Council’s Reproductive Health Vouchers site.

This is a report from the Global Health Council’s annual conference in Washington, DC. This year’s conference, Dateline 2010: Global Health Goals & Metrics, was held June 14-18, 2010. GHC37 is a reference to the Twitter hashtag used for the meeting. Make sure to check out the Council’s own conference blog coverage for more depth. This is our third year covering the meeting (2008 posts, 2009 posts).

This morning I attended the Next Steps in Health Information Systems Applications panel.

The speakers:

• Johan Saebo, Health Metrics Network, Norway: A Global Analysis of Health Information System Assessments
• Gashaw Shiferaw, Supply Chain Management System (SCMS), Ethiopia: Ethiopia’s Innovative Approach for Bigger, Better, Faster Logistics Decisions
• Anwer Aqil, John Snow, Inc., United States: Strengthening Routine Health Information System (RHIS) for Better Health Systems Outputs
• Theo Lippeveld, John Snow, Inc., United States: Case Studies Illustrating Contributions of Health Information Systems
• Moderator: Dykki Settle, IntraHealth International, United States

Two aspects of the panel deserving special attention:

ARV supply chain management in Ethiopia: Gashaw Shiferaw presented a system developed by Ethiopia for tracking ARV supplies. The system is called HCTS, or Health Commodity Tracking System. It was motivated by Ethiopia’s extremely ambitious scale up/universal coverage program. For example, Ethiopia is aiming to scale up from 220,000 patients on ART to just under 2.4 million by the end of 2010. The technical system makes use of PDAs and offline desktop applications for data entry, and a centralized web service that aggregates data, performs analysis, and produces reports. And all this of course influences the behavior of the supply chain. It’s interesting to hear about a present-day PDA example, a seemingly successful one no less. In the past 1-2 years it seems PDAs have become passe in our mHealth community – it’s all about mobile phones these days. The system has been used by the Clinton Health Access Initiative (CHAI) and FMOH medical stores for five decision cycles. Results include the following: reporting turnarounds have been reduced from 1-2 months to 3-5 days; reporting is up to 99+%, well above the 80% target, from 70%; and emergency orders due to stock outs have been reduced to 0. It is now being implemented nationwide. More information is available from the HCTS website.

Quasi-experimental RHIS studies: In 2009, HMN contracted JSI to conduct case studies in four countries examining the impact of improving HMIS on health services: Ethiopia, Haiti, Cote d’Ivoire, and Pakistan. In Cote d’Ivoire, where the focus was on HIV/AIDS prevention, they observed dramatic increases in VCT rates between 2005 and 2008. During this period there had been significant RHIS efforts that could have led to this increase. Despite results such as these (Lippeveld also presented DHIS improvements from Pakistan), there is no clear causal link between RHIS efforts and system outcomes. Lippeveld conceded that there needs to be a stronger, “more structured, more scientific” link between RHIS performance and health system performance. The MEASURE evaluation team is now developing a “linking tool” and everal quasi-experimental studies are in the works, with results expected in three years.

This is a report from the Global Health Council’s annual conference in Washington, DC. This year’s conference, Dateline 2010: Global Health Goals & Metrics, was held June 14-18, 2010. GHC37 is a reference to the Twitter hashtag used for the meeting. Make sure to check out the Council’s own conference blog coverage for more depth. This is our third year covering the meeting (2008 posts, 2009 posts).

This is the first of two posts I’ll be writing based on today. The other one probably won’t be ready until tomorrow. This one is from my attendance at an afternoon panel focused on nutrition: Nutritional Supplements and Complementary Feeding Practices.

Unfortunately, Zhang was unable to attend, so Labbok read her abstract and presented some of her own thoughts+experience on complementary feeding practices.

The session was organized around three evaluations of nutrition interventions: 1) an education and iron folate supplement program in northern Bangladesh, 2) Ultra Rice in Andhra Pradesh (India), and 3) a education program using health workers in northwest China. Ultra Rice was the primary reason I came to this session. If you don’t know, Ultra Rice is a micronutrient supplement that takes the size, shape, and other characteristics of rice. It is mixed in with regular rice at a ratio of roughly 1:100. More from PATH.

The overarching theme that I pulled from the session – as one of the few nutrition outsiders in the room – was an emphasis on what the field of nutrition needs,  in terms of interventions, research, and resources. Here’s the detailed view:

Continuum of interventions: Labbook did an excellent job of moderating, providing a global view of the presentations – including Zhang’s – throughout. She spoke of a “continuum of interventions”, which she presented in two different ways. First, in terms of target age: infants (Zhang), adolescents (Talukder), and women/children (Galloway). Second, in terms of approach: clinical – delayed cord clamping to increase the flow of nutrients to infants at birth; behavioral – via various education programs; and systemic – food-based solutions such as Ultra Rice.

Food-based solutions: In addition to Galloway (Ultra Rice), Talukder advocated for food-based solutions based on his study. Instead of iron folate tablets, he recommended food fortification, homestead food production, and dietary modifications. Talukder said, “We have to think about people and culture with interventions”, to which Galloway agreed, “We need more food-based solutions”.

Understanding behaviors (1): A Nepali in the audience asked a question about the impact of grinding Ultra Rice into rice flour (Ultra Rice Flour?) on micronutrient levels for the “end user”. This has not been studied, but it seems that it should be, particularly for areas that grind their own rice flour and use it significantly in cooking. I’m not a food expert, but I would guess that South Indian and Bengali cuisine qualify.

Understanding behaviors (2): In the Ultra Rice study, the “excess” method of boiling rice, where the extra water is poured off, resulted in levels of iron content more than 2x lower than the “absorption” method. Galloway, however, indicated that the excess method is preferred in many areas in India. The challenge becomes reconciling food culture with behavior change. (I wonder if the cookstove people and the nutrition people talk much.)

More studies: There were a variety of studies suggested by the panel and audience members that have not been conducted. Among these were rigorous, comparative studies of the various micronutrient innovations, such as Ultra Rice, Sprinkles, and Nutributter.

This is a report from the Global Health Council’s annual conference in Washington, DC. This year’s conference, Dateline 2010: Global Health Goals & Metrics, was held June 14-18, 2010. GHC37 is a reference to the Twitter hashtag used for the meeting. Make sure to check out the Council’s own conference blog coverage for more depth. This is our third year covering the meeting (2008 posts, 2009 posts).

This our first in a series of posts blogging from this year’s Global Health Council Conference in Washington, DC. This year the focus is on goals and metrics, which is of interest to us at Global Health Ideas because of the potential for technology and innovative services to improve measurement and outcomes.

Some of the more interesting themes that emerged:

The missing link is not analysis, but a need for better data collection: Rasmussen argued that we’re good at analysis, but – citing Jody Ranck – he said that data collection is abysmal. Too much of what is being done is removed from on-the-ground, day-to-day activities.  Carucci said that we “haven’t done a good enough job of collecting data in real-time” for decisions in real-time.

… but analysis can overcome some of this: While Rasmussen advocated for basic training on data collection, he also suggested that mathematical approaches can be used to successfully resolve inconsistencies/gaps/errors in data. He gave a laundry list of tools from the field of AI (artificial intelligence) that can be useful: Hidden Markov Models, BLAST (basic local alignment search tool) technology from DNA sequuencing, satisficing approaches from economics, and neo-Bayesian classifiers. For more see InSTEDD.

Systems integration is a key issue: This was brought up both by Carucci in context of mHealth and López in context of health information systems in Mexico: “The individual elements are relatively simple, one of the greatest challenges to face is the integration”. And: ”There are big mountains of data, big mountains of information”, but these are not integrated with doctors in the hospital.

Improved information can save money and improve outcomes: Stansfield presented the Belize case study, where a pharmaceutical information management system has reduced stock outs and successfully increased supply reliability. They estimate that they have saved US$500,000 (?) in a year – all this saving despite expanded procurement. With PillBox, a US HHS drug identification system designed as an alternative to traditional poison control hotlines, Hale discussed ROI (return on investment). The cost of a single call to a poison control hotline is estimated at US$50. There are more than a million of these every year. The costs of PillBox are those of running an open-access website. Both Stansfield and Carucci indicated, in response to a question from Hay, that it is less about convincing donors that better information systems are important – it’s more about convincing them that this is important relevant to other priorities. Lesson – for the time being, we should be looping cost into the discussion on outcomes.

We need to end the “command-and-control” model: From Carucci: “public health is no longer command-and-control”. By opening up the creation of data (Carucci) and the analysis of data (Hale) we can achieve much more innovation. Carucci: “Public, paticipatory, cocreation of data”. Hale: Engaging communities in open data initiatives can lead to a “virtuous cycle, where even competitors work together”. And check out this new “hacking” contest from the US government, cited by Hale.

A key question which lingered for us and I’m sure for others in the audience: What is it that connects these various efforts* beyond a superficial level? It’s essential that we find such clarity, particularly for those who don’t work in the space of health information systems.

*mHealth,  biosurveillance using noisy data, HMIS country guidelines, government open data initiatives, rural telemedicine

This is a report from the Global Health Council’s annual conference in Washington, DC. This year’s conference, Dateline 2010: Global Health Goals & Metrics, was held June 14-18, 2010. GHC37 is a reference to the Twitter hashtag used for the meeting. Make sure to check out the Council’s own conference blog coverage for more depth. This is our third year covering the meeting (2008 posts, 2009 posts).

I just heard about a cool new project that is launching this week – WWARN: the Worldwide Antimalarial Resistance Network. The about us section is really bad, so don’t bother going there (WWARN please please re-write this section). Here is what you need to know – this is a Gates funded effort to crowd source information and data from the ground up about various metrics that might provide more rapid (“real time”) signals of drug resistance to anti-malarial drugs, basically “tracking the emergence of malarial drug resistance”. What could have previously taken years (waiting for publications as proof) will hopefully now be speeded up. Browse through the website, their tool should be going live this week:

“The WWARN Explorer collates and analyzes data examining complementary aspects of antimalarial drug resistance: treatment outcomes and measures from clinical trials of drug efficacy; pharmacological profiles of antimalarial drugs across key target populations; in vitro assessment of drug susceptibility of parasite isolates; and molecular markers of parasite resistance. The preview version of WWARN Explorer links a repository of standardised data to our interactive tool, which allows users to perform custom queries of more than a hundred studies and display the results using dynamic interactive maps.”

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E-health

A large part of the conference focused on e-health implementation which could help to improve care and care management, empower patients themselves, and reduce costs. According to one of the speakers during the first e-health session, redundant procedures currently account for 1.5 BN Euros annually, and 128,000 hospitalizations occur due to preventable drug interactions. With electronic medical records much of these costs could be avoided.

One example demonstrated at the conference was the Danish national health portal. As is the case in many industries, the Scandinavians manage to do everything well. The Danish portal sundhed.dk is designed to provide decision support, information, and a communications medium for patients and health professionals. It consists of three rooms, an open room which all patients and professionals can access, a closed room for each professional, and a closed room for each patient’s interactions and information. The portal structure is simple and accessible, and usage in Denmark is high with penetration of electronic medical records at over 90%. Other countries have instituted similar portals but with less success. So the most important question is why are they so successful? The French have thrown buckets of money into trying to implement electronic medical records while making only very limited headway. The conference definitely threw out some great ideas but implementing them in other places is easier said than done.

Chronic disease management

Chronic diseases currently account for almost 40% of the burden of disease. With that kind of statistic, chronic disease management was a major focal point at the conference. Different countries have identified the need for improving access to bikes, and putting showers in offices. Prevention programs at schools and a variety of nutrition focused initiatives have also come into play.

An interesting concept brought out by Alliance Boots, a community pharmacy in the UK, is combining condition management with the local pharmacy. Their pharmacies have begun to offer vaccinations, weight management programs, smoking cessation programs, among others, all administered by specially trained personnel. In addition, the company has initiated a Web MD platform to provide better information to patients, along with a health assessment portal with an online personal health record. Many stores have also joined with general practitioner offices to increase the convenience for people – a doctor’s appointment at the same time as you pick up some new shampoo. By increasing the convenience of these care offerings, people are more likely to take advantage of them. Particularly in the case of weight management and smoking cessation, convenience is a major factor in success, even if people are required to pay their pharmacist for it. The real question though is how many people are willing to pay for such services? Is it only the richest segment of society? Or can we somehow make such facilities available to the less socio-economically privileged?

Conclusion

The different platforms and tools demonstrated at the conference certainly show promise in chronic disease management, reducing costs, and improving care quality. At the level that is visible from a presentation of course, it is difficult to translate such new learning into practice in a different location. The World Health Care Congress does of course offer networking opportunities which can perhaps be leveraged into practical implementation. The most important lesson I will take from it is a reminder of the similarities in the problems that health systems face across Europe and the world. In spite of this, local differences make it difficult to apply foreign solutions, although knowledge of external best practices may help to generate new ideas that are more customized to particular environments and societies.

A couple of weeks ago I attended the World Health Care Congress Europe event in Brussels. The event was organized as a forum for networking and discussion of the different issues and solutions being implemented around the world in the health care arena. With speakers and attendees from around Europe and the world, the presentations were generally engaging, although certain sessions were a bit jam-packed.

According to a speaker from the OECD, European health care spending is expected to double by 2050. This massive increase is attributed to ageing, the rising cost of technology, values which place a greater emphasis on health, and public health enemies such as increasing obesity. Obesity already accounts for 8-15% of the burden of disease, while high cholesterol accounts for another 5-12%. In this growing cost atmosphere, a major policy dilemma arises. How do we control health expenditures in both the short and long term, while ensuring sustainable care? The financial crisis has brought this question to the front line even more so than before. Although the conference centered on several themes such as e-health and chronic disease management, the underlying theme was how to continue to increase the quality of care while controlling costs.

Academic health science centers

One of the most interesting presentations focused on the role of academic health science centers in improving care. I’ve heard reference to a common phrase – the “valley of death” between academic research and clinical application. We’ve mapped the genome but how useful has that been in patient care? We are able to identify patients with a substantially higher risk of breast cancer, but what can they really do about it? When I asked them how to combat this valley of death, each of the panelists stressed the need to change the state of mind of scientists to be more application focused. Professor Wong from the National University of Singapore demonstrated how his team has been able to isolate a particular gene which determines whether a patient should receive chemotherapy or an alternative therapy in the case of some cancers. In the presence of this gene, the alternative therapy is effective, but without it, chemotherapy is the more effective treatment. Applications such as this are the reason that academic health science centers receive so much funding and attention; however, ensuring that such applications can occur is the tough point. Still it’s promising to note that research teams which are driven towards a specific application can sometimes have success.