The Environmental Cost that Living in this World Puts on Our Health

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

View fullsize

Source: Environmental Health, World Health Organization (WHO)

As revolting as it sounds, there are places in the world where the chances of consuming one’s neighbours’ faeces are quite high if one is not vigilant regarding sanitation and hygiene. That being the condition of many areas in low and lower-middle income countries does not mean that high and higher-middle income countries are exempt from any environmental conditions that are harmful to health.

But, what is environment health? The World Health Organization (WHO) defines the term as, “All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours”. It, however, excludes genetics and the social and cultural environment.

In low-income settings, concerns for environmental health may arise in the context of sanitation and hygiene, as well as indoor and outdoor pollution. In high-income countries, many chronic diseases like diabetes and cardiovascular disease, are associated with sedentary lifestyles. While these might be attributed to behaviour, one must consider that such behaviours can arise from changes in the environment. Over 80% of communicable and non-communicable diseases can be attributed to environmental hazards.  Overall, conservative estimates indicate that about one quarter of the total global burden of disease is owing to this cause (WHO, 2011). Furthermore, the biggest killers of children under 5 years are all environmental-related diseases, including diarrhoea, respiratory infections, and malaria.

Other diseases of concern are helminthic infections, trachoma (a bacterial eye infection), Chagas disease, leishmaniosis, onchocerciasis, and dengue fever. All of which are associated with impoverished conditions and can be mitigated by improving sanitation, hygiene, and housing. Although conflicts and natural disasters might be catastrophic for any country, struggling economies tend to suffer more because disasters worsen the poor conditions which directly affect sanitation and hygiene practices, creating conducive conditions for various infectious diseases, and ultimately feeding into the vicious cycle of poverty.

Many interventions are underway to address these conditions, including Water, Sanitation and Hygiene (WASH) initiatives, Integrated Vector Management, Programme on Household Air Pollution, International Programme on Chemical Safety, Health and Environment Linkages Initiative, and Intersun Programme for the effects of UV radiation. The acknowledgement of the effects of the environment has grown. One of the Millennium Development Goals (MDGs) was, “To ensure environmental sustainability.” The Sustainable Development Goals (SDGs) are more extensive and thorough in placing focus on the environment. Goal 1 is to end poverty, goal 6 is to make provision of clean water and sanitation possible, and goal 13 is to stop climatic change resulting in floods and drought (United Nations, 2014).

View fullsize

The Sustainable Development Goals. Source: United Nations System Staff College

It is encouraging to see steps being taken to control environmental hazards; however, the journey to measuring and eradicating such conditions still remains a challenge, which will hopefully be overcome through future endeavours.

References:

United Nations (2014). Sustainable Development Goals. doi:10.1017/CBO9781107415324.004

World Health Organization (2011). WHO Public Health & Environment Global Strategy Overview

Aid Dependency: The Damage of Donation

~Written by Victoria Stanford, University of Edinburgh (Contact: vstanford@hotmail.co.uk)

"The Culture of Aid Dependency Need to Change," David Sengeh, Sierra Leone. Photo Credit: www.engineeringforchange.org

Aid has long been the response of richer countries to the imbalance of economic development seen across the globe. In the last two decades however, relatively non-intrusive in-kind giving has been re-branded and intensified to the point where aid today is arguably used as a strategic force in increasingly interventionist global development policy. The aid industry has seen a rapid expansion, characterised by an increase in the number of organisations, amounts of funding and geographical reach (Collinson and Duffied, 2013). The question of aid dependence is an important one; many argue that international assistance paradoxically poses a barrier to recipient country development and sustainable economic growth (Moyo, 2009).

Recent rhetoric surrounding aid dependency is clear- it is an unwelcome and unfortunate side effect of aid and its diminishment is high on the aid policy agenda (Thomas et al., 2011). What is becoming increasingly clear however is that there is an emerging type of aid-related dependency that does not refer to economic or financial factors, but political. Cases of corruption in recipient country governments have been met with the development of more complex modes of donation, including direct programme funding, conditionalities, tied aid, and grants, which give donors more control over the direction and ultimate use of their funds. This often means that those providing aid are increasingly entwined in political processes. This combined with aid uncertainty, questionable sustainability, and a tendency of top-down approaches to political involvement, create a situation where countries in need of aid are dependent upon foreign agendas.

How has aid caused dependency?

Aid dependency refers to the proportion of government spending that is given by foreign donors. Since 2000 this has in fact decreased by one third in the world’s poorest countries, exemplified by Ghana and Mozambique where aid dependency decreased from 47% to 27% and 74% to 58% respectively (3). Aid is not intrinsically linked to dependency; studies have shown that dependency is influenced by many factors, mostly length and intensity of the donation period, and 15-20% has been identified as the tipping point where aid begins to have negative effects (Clemens et al., 2012). What causes dependency is when aid is used, intentionally or not, as a long-term strategy that consequently inhibits development, progress, or reform. Food aid is particularly criticised for this; increasing dependency on aid imports disincentivises local food production by reducing market demand. This is compounded when declining aid is replaced with commercial imports rather than locally-sourced food, either because of cheaper prices or a lack of recipient country food production capacity because of long-term aid causing agricultural stagnation (Shah, 2012). This is exemplified in the situation of Haiti, which is dependent on cheap US imports for over 80% of grain stocks even in a post-aid era, or countries such as the Philippines where aid dependency has forced an over-reliance on cash crops. Dependency relates not only to commodities but also technical expertise and skills which donors often bring to specific aid schemes and projects, which when not appropriately coupled with education create an over-reliance on donors (Thomas et al., 2011).

A more concerning type of dependency

The nature of aid almost intrinsically causes what is increasingly known as ‘political dependency’ by encouraging donor intervention in political processes. Donors need to satisfy the interests, values and incentives of the home country, whilst also providing them with expected results in order to maintain the cash flow. This has resulted in donors either bypassing and therefore destabilising government service provision processes to establish donor projects, a strategy often favoured by USAID and the World Bank (Bräuntigam and Knack, 2004), or intervening directly in policy-making and implementation (Bräutigam, 2000).

The involvement of donors, either foreign governments or international agencies, in recipient country political processes has been shown to reduce the quality of governance (Knack, 2001). It reduces leader accountability; the government is “playing to two audiences simultaneously”- the donors and the public (Hayman, 2008). This means the direction of accountability is between government and donor rather than the public, risking government legitimacy and delaying the progress of political reform and development (Bräutigam, 2000). This is particularly damaging in countries where the need for aid stems from political upheaval or civil unrest such as the Democratic Republic of Congo or Zimbabwe, which have a lengthy history of aid dependence (Moss et al., 2006). The risk here is that donors have political leverage, thus decisions and planning become reliant on donor involvement whose motivation and values may not necessarily align with those of the public or government.

Furthermore, ‘earmarking’ is a strategy favoured by many international donors who fear corruption in recipient governments, therefore ‘earmark’ direct sector or programme funding rather than general government budget support (Foster and Leavy, 2001). This not only shifts the agenda-making power to donors who have the authority to set priorities and direct funds accordingly, but also creates patchy and unsustainable development where some sectors outperform others.

An additional significant problem of dependency upon international agenda-making for countries receiving aid is that globally recommended ‘best practice’ policies often lack appropriate contextualisation to cultural, religious, or social values. A top-down, uniform approach to policy implementation by donors also has logistical barriers whereby local infrastructure is incapable of carrying out donor projects effectively and producing satisfactory results. A good example of this is the widely-disseminated policy encouraging syndromic management of sexually transmitted diseases, which was coercively incorporated into aid channels in Mozambique, despite the clear lack of the technical expertise and human resource capacity that such a robust policy requires (Cliff et al., 2004). This then perpetuates aid dependency because donors do not receive satisfactory project results and may consequently reduce funding without actually solving the problem, thus the poverty cycle continues and aid is required once again.

Demolishing aid dependency

Ending or preventing aid dependency will be contingent on affirmative action from both donors and recipients. Botswana is a key example of recipient-led aid policy that effectively resulted in rapidly reducing aid and therefore dependency. Botswana began receiving aid shortly after gaining independence in 1966 (Bräutigam and Botchwey, 1999). Of primary importance here is that Botswana largely decided the direction and use of funding; areas of priority were identified and donors were matched accordingly, thus avoiding reliance on donor ideas and agendas. Only projects that the predicted government capacity could absorb once aid was reduced in the long-term were undertaken, which ensured sustainability. In contrast, the relative ‘success story’ of Taiwan can be explained by donor-led project planning. Taiwan received much aid from the US in the early 1960’s which focused mainly on building infrastructural capacity-docks, railways, factories-with the aim to increase trading systems and boost the economy. In fact, this scheme was so effective that the US eventually withdrew aid for fear of creating competition (Chang, 1965).

It seems evident that recipient-led schemes and projects are more effective and reduce the risk of dependency. Technically speaking, some argue that aid should only ever be in the form of general government budget support rather than selective sector or project aid because it reduces donor involvement in political processes. It is also less bureaucratic, is less influenced by donor missions who need to produce and report results, and avoids the risk of uneven service provision (Moss et al., 2006). Ideologically speaking, the aid industry today is at risk of forming a novel kind of colonialism where ‘Western’ ideas of development and progress are used to influence and hold power over governments of countries receiving aid.

Concluding thoughts

The aid industry must respond to the problem of economic and political dependence. Coordinated efforts to more effectively monitor donor-recipient relationships, using a widely implemented human rights-based legal and moral framework for aid policy should be the ultimate, collective goal (Ooms and Hammonds, 2008). The reality is however that with increasingly complex humanitarian disasters and the destructive forces of climate change looming, the aid industry will be called upon to increase capacity and intensity which may perhaps re-direct focus from implementing ideological change. Nevertheless, the opportunity to ‘get things right’ in aid policy and practice persists, and it is a moral imperative that the industry and its participants make the attempt.

References:

Bräutigam D and Botchwey K (1999) The institutional impact of aid dependence on recipients in Africa. Chr. Michelsen Institute;Working Paper 1.

Bräutigam, D. (2000). Aid dependence and governance, Almqvist & Wiksell International;Stockholm pp.14.

Bräuntigam D and Knack S (2004) Foreign aid, institutions and governance in Sub-Saharan Africa, Economic Development and Cultural Change, Vol 52;2, pp.255-285.

Chang D (1965) US Aid and Economic progress in Taiwan, Asian Survey, Vol 5;3, pp.152-160.

Clemens MA, Radelet S and Bhavnani R (2012) Counting Chickens when they Hatch: Timing and the Effects of Aid on Growth, The Economic Journal, 122(561), 590-617.

Cliff J, Walt G and Nhatave, I (2004) What's in a Name? Policy transfer in Mozambique: DOTS for tuberculosis and syndromic management for sexually transmitted infections. Journal of Public Health Policy, 25;1, p.38-55

Collinson S and Duffied M (2013) Paradoxes of Presence:Risk Management and aid culture in challenging environments, Humanitarian Policy Group, Overseas Development Institute [Online] Available at: http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/8428.pdf [Accessed 02 January 2015].

Foster M and Leavy J (2001) The choice of financial aid instruments. London: Overseas Development Institute, pp.4.

Hayman R (2008) Rwanda: milking the cow. Creating policy space in spite of aid dependence. The Politics of Aid, 156.

Knack S (2001) Aid dependence and the quality of governance: cross-country empirical tests, Southern Economic Journal, 310-329.

Moss T, Pettersson G andVan de Walle, N (2006) An aid-institutions paradox? A review essay on aid dependency and state building in sub-Saharan Africa, Centre for Global Development; Working paper No. 74.

Moyo D (2009) Dead Aid, Penguin; London, pp.12

Ooms G and Hammonds R (2008) Correcting globalisation in health: transnational entitlements versus the ethical imperative of reducing aid-dependency. Public Health Ethics, 1(2), 154-170.

Shah A (2012) Food aid, Global Issues [Online] Available at: URL: http://www. globalissues. org/article/748/food-aid [Accessed January 02 2015]

Thomas A, Viciani L and Tench J et al (2011) Ending Aid Dependency, Action Aid; London.

Investing in Healthcare to Put a Dent in Poverty

~Written by Hussein Zandam (Contact: huzandam@gmail.com; Twitter: @zandamtique)

View fullsize

Poverty and Healthcare, Two halves. Photo credit: Our Africa

Health and poverty are intricately related. Evidence suggests that there is a positive correlation between health and poverty. People with limited resources in low- and middle-income countries (LMICs) are reported to have limited access to healthcare compared to their wealthier counterparts (Wagstaff, 2002). However, other evidence has shown that health expenditure can push households into poverty (Kruk et al, 2009). Tackling either is a priority for governments to improve the welfare of people. The poor are more likely to need healthcare for many reasons including a lack of safe drinking water, a balanced diet, adequate shelter, and protection against harsh environmental conditions. Because of the increased need for healthcare, the poor incur increased spending on already limited resources, and are likely to experience catastrophic expenditure. Reducing healthcare expenditure by the poor has the potential to be a viable mechanism against deepening of poverty.

Reducing extreme poverty is a major goal of the Millennium Development Goals (MDGs) and was also considered in the formulation of the post-2015 agenda. Countries all over the world are grappling with measures to reduce income inequality and poverty. In developing countries, this is more apparent through the increase of micro credit schemes, subsidies, and social safety nets for the most vulnerable. However, evidence has shown that in spite of efforts from nations and development partners, more needs to be done to eradicate extreme poverty (Laterveer et al. 2003). Poverty and access to healthcare have been subjects of research and policy. Poverty can be viewed not only as a conception of material and income deprivation (Deaton and Zaidi, 2002) but also as the lack of opportunities for an individual to lead a life he/she values (Sen, 1999). Using this concept, empowering people to live healthy lives can be seen as an initiative to overcome poverty. However, when poverty is viewed as a deprivation of income and assets, initiatives are channeled that directly improve household expenditure; when in relation to health, initiatives that lower expenditure on health to avoid catastrophic expenditure.

The World Health Organization (WHO; 2000) has advocated for health financing measures that provide financial protection from catastrophic health expenditure. Catastrophic expenditure is a leading cause of impoverishment in many countries. Efforts to prevent catastrophic expenditure oh health have been primarily through insurance. However, in many LMICs it is not effective and/or is beyond the reach of the poor either by being too costly or by not providing adequate coverage (McIntyre, 2006). Thus, the world health report (WHO, 2010) advocated for universal public finance (UPF) as a strategy to promote universal health coverage. UPF means that governments finance interventions for people regardless of who receives it and who provides it. UPF has been in practice in many high-income countries where many necessary interventions are covered. In LMICs however, UPF is limited by targeting a set of interventions tagged as the essential health package, which means many services are excluded and require user payments at the point of care.

For example, extended cost-effectiveness analysis (EECA) was used to assess the effectiveness and reduction in financial risk afforded by a public package of interventions initiated by the government of Ethiopia (Verguet et al, 2015). The interventions examined included services for vaccination, treatment of some conditions, caesarean section surgery, and tuberculosis DOTS. Their analysis focused on UPF where there is no out-of-pocket expenditure to cover costs incurred for each of the nine interventions. They estimated the annual number of deaths averted and the annual total financial protection afforded by the reduction in out-of-pocket expenditure associated with each intervention. The results for intervention costs, health gains and financial protection varied across the interventions but it was concluded that the interventions were cost-effective and prevented cases of poverty among those at lowest income level. Such evidence can be used to convince governments to increase funding of health services with the objective of improving health status of citizens and eradicating extreme poverty among the population.

References:

Deaton, A. and Zaidi S. 2002. Guidelines for Constructing Consumption Aggregates for Welfare Analysis. World Bank. https://openknowledge.worldbank.org/handle/10986/14101. 

Kruk et al. 2009. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff. 28: 1056–66.

Laterveer et al. 2003. Pro-poor health policies in poverty reduction strategies. Health Policy Plan. 2: 138–145.

Mcintyre et al. 2006. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc. Sci. Med. 4: 858–865.

Sen, A. (1999). Development as Freedom, Oxford University Press, Oxford, 1999.

Verguet et al. (2015): Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. Lancet Glob Health 2015; 3: e288–96.

Wagstaff, A. 2002. Poverty and health sector inequalities.Bull. World Health Organ. 80: 97–105.

WHO (2000). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2000.

WHO (2010). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2010.

Health Issues on the African Horizon for 2015

~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich 

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.

Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.

Values and Global Health Governance: Lessons from the Ebola 2014 Outbreak

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Values are critical in shaping the global health (GH) dialogue and landscape. Values and the actions that arise from them (virtues) underlie the policies that ensure universal access to necessary health services, adequate responses to health emergencies and resource allocation. Similarly, the values of health governing bodies can create chasms between people and their health necessities. This truth has been unfolding poignantly on an international level during the handling of the Ebola virus disease (EVD) outbreak in West Africa. 
 

What values did the actions or inaction of the international GH community endorse in handling the current EVD outbreak? Although the uniqueness of the outbreak in terms of location and challenges in diagnosis should be considered, many experts agree that the greatest force contributing to the rapid spread of EVD was inaction (1-4). In June 2014, signs that EVD was spiraling out of control throughout Guinea were flashing brightly but the response from the international community remained slow. The exception was Doctors without Borders (MSF), whose staff was already on the ground, helped to diagnose the first case and pleaded for a more robust response from international health governing bodies (3). 
 

Criticisms of health regulatory bodies grew stronger when EVD entered rich countries, which appeared to produce a marked increase in global support efforts. It is hard to say unequivocally, whether this heightened interest and commitment was inevitable or whether the cases in the US and Europe were the impetus. But it is fair to say that many mistakes were made in terms of prioritizing EVD eradication and surveillance. It may also be accurate to say that major economies responded when EVD was perceived as an immediate threat to their economy. This, I believe, is inevitable in a GH system that is built upon a market-driven approach.
 

Can a GH agenda that is framed around economics prioritize the eradication of emerging diseases and neglected diseases of poverty? Although there are compelling arguments for why high-income countries should help to combat EVD and similar diseases, it is unlikely that great achievements will be made without a values shift (5). 
 

A market driven approach inherently prioritizes the need of a few versus the need of many. This model enables the interests of major economies to outweigh the greater good of the whole, if left unchecked. The most important consequence of this approach is that it undermines international health regulatory bodies, whose actions and budgets are heavily influenced by larger economies. This is a problem which, when combined with poor health systems, harmful microbes and permeable borders will inevitably lead to threats in local communities and global security. More importantly, with the movement of people forming a major characteristic of this era, the market driven approach is an unsustainable value upon which to build GH interventions. 
 

View fullsize

There are many points worth considering (schematic above). Major questions moving forward should consider creating a GH model that is more oriented toward equity, security and creativity. Resolutions that create a space in which poor nation states help to set the GH agenda without being threatened by the loss of aid from larger economies must be discussed. Additionally, addressing ways in which the GH dialogue can be re-framed to include stakeholders that currently operate based on virtues stated above should be considered. For example, is there a way to ensure a more official decision-making role for organizations like MSF?

What is next for GH governance and what will the values shift towards? EVD 2014 is a strong indicator of the limits of theoretical values, political indifference and passivity in achieving health and well-being for all. But the stories emerging from West Africa provide an opportunity for EVD 2014 to serve as a “meaning making” event in GH. It provides an impetus for changing priorities from passive verbiage of values of human dignity to a model of creativity, equity and accountability which proactively contextualizes GH policies, innovation and interventions. 

References
1. Gostin LO and Friedman EA 2014 Ebola: a crisis in global health leadership. The Lancet, 384; 1323-1324. 
2. Cohen J 2014.Ebola vaccine: Little and late. Science, 345 (6203): 1441-1442. 
3. Ebola: Massive Deployment Needed to Fight Epidemic in West Africa: http://www.doctorswithoutborders.org/news-stories/press-release/ebola-massive-deployment-needed-fight-epidemic-west-africa
4. Farrar JJ and Piot P 2014. The Ebola Emergency-Immediate Action, Ongoing Strategy N. Engl J Med 371(16):1545-1546.
5. Rid, A., & Emanuel, E. J. (2014). Why Should High-Income Countries Help Combat Ebola? JAMA, 312(13), 1297-1298.

Global Health and Post-2015 Agenda: Making a Case for Vulnerable Populations

~Written by Hussain Zandam, Health Systems and Policy Researcher (Contact: huzandam@gmail.com) 

The health-related Millennium Development Goals (MDGs) has made relative progress in improving access to essential healthcare. The next step, as suggested by many professionals in the development arena, is to consolidate on the gains and address the existing wide gap in quality healthcare among populations, especially in LMICs.  This can be tackled by addressing the challenges faced by a range of vulnerable populations. Vulnerable groups are defined as social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality. The group is represented by different categories of people including; women, children, elderly people, ethnic minorities, displaced people, people suffering from illnesses, people with disabilities and others. Together, these groups makes up a very significant population. For example, according to World Bank’s report on disability, PWDs makes up about 20% of world population equivalent to over billion people.

There is ample evidence confirming that access to effective health care is a major problem in the developing world. Many millions of people suffer and die from conditions for which there exist effective interventions. Vulnerable populations make up majority of these people. While some challenges are similar across different vulnerable people, others are specific to a particular vulnerable group. Selected factors to categorize groups should reflect specific subgroups of the population - such as poor rural women, or members of an ethnic minority - that require particular awareness due to their underlying social characteristics, which afford them less opportunity to be healthy than their more privileged counterparts. As a group, they also tend to be the least healthy and most probably have the most to benefit from health care. The fact that those most in need make least use of health care is widely considered inequitable.

Insufficient resources, inappropriate allocation, and inadequate quality are major impediments to the delivery of effective health care that reaches this group. The access problem cannot be solved without tackling each of these deficiencies. Even with limited resources, services should aim for equity, emphasizing the individual and their dignity rather than their merits, economic circumstances or ethnicity. Equitable access has been defined as ‘‘care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographical location and socio-economic status.  Adequate access is also linked to timeliness and the quality of services.

According to Organization for Economic Cooperation and Development/World Health Organization (OECD/WHO) DAC guidelines, the development of equitable financing through increasing pre-payment and risk pooling is one of four priorities for the development of a pro- poor health system delivering quality, accessible health services to the poor. The extension of health insurance cover is a long-term goal. At low levels of development, a more feasible policy is to maintain reliance on out-of-pocket payments but to grant exemptions to groups, principally the poor, for which price is a major deterrent to use. Policy initiatives can accelerate the process, however it is important for health policies to include not only commitments to core concepts of human rights ‘for all’, but also whether for vulnerable groups in a way which takes account of their ‘vulnerabilities’.

A general strategy can be defined at the global level, while policy measures should be heterogeneous, varying with the local conditions in which they are implemented. Finally, as nations and the entire world accept more and more responsibility for the health of human beings, the discussion on ‘‘universal health coverage’’ as the successor to health-related millennium development goals, global health should have a strong focus on the health of the poor and vulnerable.

Malnourishment: A Growing Concern - Food as a Weapon

~Written by Mike Emmerich, Specialist Emergency Med & ERT Africa Consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich

The number of hungry people has fallen by over 200-million since 1992, so says the 2014 Hunger Map and a report titled “The State of Food Insecurity in the World: Strengthening the Enabling Environment for Food Security and Nutrition” jointly prepared by World Food Programme (WFP), the Food and Agriculture Organisation (FAO) and the International Fund for Agricultural Development (IFAD).

They go on to say that 805 million people, or one in nine of the world’s population, go to bed hungry each night. But in Sub-Saharan Africa, this is even worse, with one in four people suffering from undernourishment. The report says that sub-Saharan Africa faces the most severe challenges in securing its food; mainly due to sluggish income growth, high poverty rates and poor infrastructure, which hampers physical and distributional access.

It states: “In general, in Africa, there has been insufficient progress towards international hunger targets, especially in the sub-Saharan region,”

The report also says limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities, while the region continues to face challenges in improving dietary quality and diversity, particularly for the poor. I did some work in the Southern DRC (based out of Lubumbashi in 2006) and we noted then that dehydration, was the leading cause of death in children under the age of 5. Dehydration as the result of diarrhoea, caused by unsanitary drinking water. For those who survive they are then in turn faced with stunted growth, which is made worse by poor food nourishment.

This report just published confirms that the situation has not changed in the past 8 years, limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities. In fact the report notes, that progress has been so poor, that the WFP target of halving the number of undernourished people by 2015, will not be realised.

The report highlights the following to move forward:

1. Sustained political commitment at the highest level

2. Placing food security and nutrition at the top of the political agenda

3. Creating an enabling environment for improving food security and nutrition through adequate investments

4. Better policies, legal frameworks and stakeholder participation

5. Institutional reforms are also needed to promote and sustain progress.

Plus an integrated plan focussing on:

1. Public and private investments to raise agricultural productivity

2. Better access to inputs, land, services, technologies and markets

3. Measures to promote rural development

4. Social protection for the most vulnerable (persons and countries)

5. Including strengthening their resilience to conflicts and natural disasters

6. Specific nutrition programmes, especially to address micro-nutrient deficiencies in mothers and children under five.

As reports go it is a very good piece of work tackling many complex issues and outlining clear broad action plans. As with most reports though, I take issue with their expected outcomes, to broad, not specific and in my opinion, to broad. Its like position papers from government departments or even aid agencies. It does not tackle the problem head stating what is at fault and what needs to be done in clear action plans; to do that will require stepping on toes or worse – maybe even naming names!

Regional conflicts, greedy power hungry warlords all demanding access to food, how it is priced and distributed. This can affect when and if crops are planted, and who gets the produce, and they who sells it. Food can be and is used as a weapon, to control people or even to get votes, Zimbabwe and South Africa are cases in point.

The cost of food is then another key factor, Lester Brown wrote in 2011's “Food Issue” of the Foreign Policy magazine:/ Americans generally spend less than 10% of their income on food, but there are 2 billion people who live in poverty around the globe who spend 50 to 70 percent of their income on food/. A slight increase in the cost of food for these persons could be life or death, and the costs when they do escalate, are beyond the control of the consumer, at times manipulated by external forces, for their own (political or economic) gain.

On a sad and macabre note, Saudi Arabia, South Korea and China ventured beyond their borders in 2008 to grow grain in cheaper regions, such as Ethiopia and Sudan, where, of course, people where starving and did not get any of the planted grain.

So where to from here; I think if we cast our eyes to Burkina Faso, we might see a way out, People Power. The people need to speak and speak loudly in the only way the politicians and regional leaders will listen.