Geography and global health

In the wake of the report of the World Health Organisation's Commission on the Social Determinants of Health, Closing the gap in a generation (Marmot 2008), this invited commentary considers the scope for geographical research on global health. We reflect on current work and note future possibilities, particularly those that take a critical perspective on the interplay of globalisation, security and health.

[International financing for cooperation to develop health in Latin America and the Caribbean]

The purpose of this study is (a) to examine the ways in which Latin America and the Caribbean (LAC) have benefited from increases in international development assistance for health (DAH) at the global level and whether the trend observed after the Millennium Summit has also applied to the Region; (b) to determine whether there are differences in the distribution of this assistance, based on the gross per capita income of each country; (c) to identify the possible effects of the 2008 international financial crisis on official bilateral assistance; and (d) to compare trends in public health expenditure in relation to DAH before and after the Millennium Summit. The study has found that DAH in LAC follows a very different pattern than in other regions of the world. The period from 1997 to 2008 was one of fluctuating stagnation, with average annual disbursements of US$ 1 200 million. Multilateral financial institutions accounted for 79% of the average disbursements in the upper-middle income countries between 2002 and 2008, while official bilateral assistance held the greatest share (61%) in the low- and lower-middle income countries. Bilateral assistance grew at an annual rate of 13% during this period, but in the year after the crisis, disbursements fell to US$ 20 million. Sixty-four percent of bilateral assistance came from the United States, Spain, and Canada, with 29% of it being directed to HIV/AIDS and sexually transmitted diseases. After the Millennium Summit DAH channeled to governments decreased 30% in the period 2001-2006, and its share of public health expenditure in the region was 0.3% for the same period, with an equally marginal proportion in relation to total health expenditure for 2008 (0.37%; US$ 2 per capita). The study concludes that after the Millennium Summit, DAH in LAC did not grow nor did it equal the trends prior to 2000, and public health expenditure followed its historical growth trend, without further increases in relation to the regional gross domestic product. Given these realities and the fact that LAC is the world's most unequal region, but not its poorest, it is imperative to reconsider the concepts, management, and delivery of cooperation in the development of health, using innovative approaches and alternative financing mechanisms that respond more effectively to the realities of the region.

The politics of assessment: water and sanitation MDGs in the Middle East

The Middle East and North Africa (MENA) is generally considered to be making adequate progress towards meeting Target 10 of the Millennium Development Goals (MDGs), which calls for halving the proportion of the population with inadequate access to drinking water and sanitation. Progress towards achieving Target 10 is evaluated by the Joint Monitoring Programme (JMP), run by UNICEF and WHO. This article shows that the assessment methodologies employed by the JMP significantly overstate coverage rates in the drinking water and sanitation sectors, by overlooking and ‘not counting’ problems of access, affordability, quality of service and pollution. The authors show that states in MENA often fail to provide safe drinking water and adequate sanitation services, particularly in densely populated informal settlements, and that many centralized water and sanitation infrastructures contribute to water pollution and contamination. Despite the glaring gap between the MDG statistics and the evidence available from national and local reports, exclusionary political regimes in the region have had few incentives to adopt more accurate assessments and improve the quality of service. While international organizations have proposed some reforms, they too lack incentives to employ adequate measures that gauge access, quality and affordability of drinking water and sanitation services.

Quantifying the impoverishing effects of purchasing medicines: a cross-country comparison of the affordability of medicines in the developing world

BACKGROUND

Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability.

METHODS AND FINDINGS

Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines.

CONCLUSIONS

Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems. Please see later in the article for the Editors' Summary.

HIV testing for children in resource-limited settings: what are we waiting for?

Scott Kellerman and Shaffiq Essajee argue that the time has come to increase access to HIV testing for children, especially in sub-Saharan Africa.

Global health: challenges and opportunities for Singapore

Over the past decade, global health has evolved from a buzzword to a discipline, attracting interest from governments, academic institutions and funding organisations. Global health centres, institutes and initiatives in Western countries have increased in both size and number, aided primarily by institutional backing and supportive funding mechanisms. As the rise to prominence of global health on the public health agenda also coincides with shifts in global balances of power, Asia, as well as Singapore, has an expanded role to play in supporting global health teaching and research, both in the region and throughout the world. Foundations, universities, government agencies, statutory boards and the private sector all have an important role to play in moving the global health agenda forward in Singapore. Rigorous global health training and increased funding for global health research are now timely and essential in order for global health, as a discipline, to develop within Singapore and have an impact within the region.

Trade and health: an agenda for action

The processes of contemporary globalisation are creating ever-closer ties between individuals and populations across different countries. The health of a population, and the systems in place to deliver health care, are affected increasingly by factors beyond the population and health system. The Lancet's Series on trade and health has provided an overview of these links between international trade, trade liberalisation, and health, and raised the key issues that face the health community. In this final paper in the Series, we call for a substantial and sustained effort by those within the health profession to engage with issues of trade, to strengthen institutional capacity in this area, and to place health higher on the agenda of trade negotiations. The rapid rise of trade agreements and treaties, as well as trade that occurs beyond these institutional boundaries, means that further action is required by a range of actors, including WHO, the World Bank, the World Trade Organization (WTO), regional agencies, foundations, national governments, civil society, non-governmental organisations, and academics. The stewardship of a domestic health system in the 21st century requires a sophisticated understanding of how trade affects, and will affect, a country's health system and policy, to optimise opportunities to benefit health and health care while minimising the risks posed though the assertion of health goals in trade policy. To acheive this will place a premium on all those engaged in health to understand the importance of trade and to engage with their counterparts involved in trade and trade policy. We hope that this Series has prompted the reader to become involved in these efforts.

WHO's budgetary allocations and burden of disease: a comparative analysis

BACKGROUND

Ministers of health, donor agencies, philanthropists, and international agencies will meet at Bamako, Mali, in November, 2008, to review global priorities for health research. These individuals and organisations previously set health priorities for WHO, either through its regular budget or extra-budgetary funds. We asked what insights can be gained as to their priorities from previous decisions within the context of WHO.

METHODS

We compared the WHO biennial budgetary allocations with the burden of disease from 1994-95 to 2008-09. We obtained data from publicly available WHO sources and examined whether WHO allocations varied with the burden of disease (defined by death and disability-adjusted life years) by comparing two WHO regions-Western Pacific and Africa-that are at differing stages of epidemiological transition. We further assessed whether the allocations differed on the basis of the source of funds (assessed and voluntary contributions) and the mechanism for deciding how funds were spent.

FINDINGS

We noted that WHO budget allocations were heavily skewed toward infectious diseases. In 2006-07, WHO allocated 87% of its total budget to infectious diseases, 12% to non-communicable diseases, and less than 1% to injuries and violence. We recorded a similar distribution of funding in Africa, where nearly three-quarters of mortality is from infectious disease, and in Western Pacific, where three-quarters of mortality is from non-communicable disease. In both regions, injuries received only 1% of total resources. The skew towards infectious diseases was substantially greater for the WHO extra-budget, which is allocated by donors and has risen greatly in recent years, than for the WHO regular budget, which is decided on by member states through democratic mechanisms and has been held at zero nominal growth.

INTERPRETATION

Decision makers at Bamako should consider the implications of the present misalignment of global health priorities and disease burden for health research worldwide. Funds allocated by external donors substantially differ from those allocated by WHO member states. The meeting at Bamako provides an opportunity to consider how this disparity might be addressed.

Sex and the global fund: how sex workers, lesbians, gays, bisexuals, transgender people, and men who have sex with men are benefiting from the Global Fund, or not

The Global Fund to Fight AIDS, Tuberculosis and Malaria has allowed countries to bring their response to HIV/AIDS to an unprecedented scale, resulting in innovative projects that reach otherwise underserved communities with HIV prevention, treatment, and care. But in regions and countries where sex workers, men who have sex with men, or lesbian, gay, bisexual, and transgender persons are criminalized or stigmatized, organizations that are led by or work with these groups face challenges participating in Global Fund processes and accessing funding. This article explores the potential of the Global Fund to create space for the participation of these groups in decision-making and to increase their access to resources; examines barriers that hinder their participation; and proposes measures to overcome them.

[Tuberculosis and malaria global prophylaxis in the light of decisions of the Big Eight]

At the present time about two million people, one third of the Earth's population, are carriers of tuberculosis agent. Though tuberculosis is curable disease, it continues to take away lives of about 4400 persons; most of them are young and are in the most productive age. The most active incidence rate of tuberculosis occurs in the countries of Africa to the south of Sahara (29% of all cases of tuberculosis per head); half of new cases of tuberculosis fall on Asian countries: Bangladesh, China, India, Indonesia, Pakistan, Philippines. The governments of Big Eight maintain activities that have stabilized morbidity of tuberculosis on a world scale. Over 11 years (1995 - 2006) World Health Organization (WHO) implemented the DOTS strategy (Directly Observed Treatment with Short course of chemotherapy) in 183 countries and tested it on 26 millions patients with tuberculosis. Global data acquisition in 2005 found out morbidity of tuberculosis in 59% (the aim is 70%) and successful cure in 84% cases (the aim is 85 %). In 2006 WHO started realization of the Global Plan "Stop tuberculosis" (2006 - 2012). At the present time Global Fund use about 17% its resources to finance programs against tuberculosis. These funds help to reveal 5 millions extra cases of tuberculosis and cure 3 millions patients in the network of DOTS.

The World Health Organization, the drugs company, and the $10,000 funding offer

The World Health Organization faces allegations that it attempted to secure a $10,000 donation from a pharmaceutical company by asking a patients' group to act as a covert channel for the funds, an arrangement that would break the WHO's own rules on accepting money from the pharmaceutical industry. The WHO denies attempts to bend its donation rules.

Who's funding WHO?

WHO guidelines state that it will not accept money from drug companies, but how rigorous is it in enforcing this? Michael Day investigates

[Pentavalent vaccine and vaccination coverage in children aged less than one in Colombia 2000-2003]

OBJECTIVE

Determining the impact of including pentavalent vaccine in third-dose immunisation coverage for children aged less than 1 (2002 and 2003) by geographic cluster.

MATERIALS AND METHODS

This was an ecologic study using department, province, municipality and capital city as analysis units. It compared third-dose coverage, desertion index, number of places having more than 80% immunisation coverage and the number of children being immunised before and after vaccination was introduced. Having more than 80% immunisation coverage was compared to the number of children or places having unsatisfied basic needs, the presence of armed conflict or municipal category.

RESULTS

Immunisation coverage increased from 23% to 26%, mainly for Hib3. Desertion index was 9.3-31.7% in 2000 and 0.3% in 2003. The number of municipalities having more than 80% immunisation coverage increased from 265 in 2000 to 627 in 2003. 462,000-584,000 third-doses were applied in 2000 and 805,000-813,000 in 2003. More municipalities having more than 80% coverage had high unsatisfied basic needs, low socioeconomic income or conflict.

CONCLUSIONS

The introduction of the vaccine affected immunisation coverage. Financing should be sought for the vaccine to ensure its continuity and to implement studies for new vaccines or introducing combination vaccines.

Open letter to the incoming director general of the World Health Organization: time to refocus

Ruth Levine argues that WHO needs to concentrate on confronting global health risks, improving the health of poor people, and marshalling technical expertise