Tuesday, 31 August 2010


By Kate Hawkins, Communication Officer for Health and Social Change

We've published seven new briefings on "scaling up" in the health sector. Among the themes covered are improving access to health services, building sustainable health systems, and harnessing a spirit of innovation to improve equity. Photo: Shimla street scene by Liz Highleyman from Flickr (Creative Commons)

The papers follow a workshop held at IDS earlier this summer with more than 40 academics, policy makers and innovators.

The workshop aimed to explore approaches that have fostered innovation and change in the health sector. We also looked at practical ways for innovators, governments and funders to work together to enable health systems to meet the needs of the poor.

For the last couple of years, Future Health Systems and the STEPS Centre have been looking beyond traditional narratives about how poor people access health services. In fact, health systems may evolve in many different directions over time - some of which are often ignored or under-recognised.

Real world challenges

The workshop shed light on real-world challenges experienced by those working directly in the health sector.

A common challenge was how to tailor global goals, or donor expectations, to the local context. When reforms of health systems come from the international level, there is a significant transfer and allocation of resources. So these reforms are intensely political. Jeff Mecaskey of Health Partners International talked about the Partnership for Reviving Routine Immunisation in Northern Nigeria, which is working to understand and build on different political interests, and pinpointing which interests might be drivers for change.

Abbas Bhuiya, from ICDDR,B in Bangladesh, explained how scaling-up efforts need to engage with the informal sector which makes up 95 per cent of the health workforce. Informal providers earn their living by selling drugs, and over-prescription and other harmful practices are common.

The private sector was also a focus of the paper by Barun Kanjilal, of the Indian Institute of Health Management Research. Barun described how a major change in the relative roles of market and state since 1990 in India had been reflected in the health sector. India has seen a rapid spread of largely unregulated private actors, as well as an expansion of opportunities for modern medicines and innovations.

Citizen-state relations was another area of focus. The Treatment Action Campaign in South Africa supports the right of people living with HIV to access quality comprehensive prevention and treatment services and to live a healthy life. Initially, the campaign had a bio-medical focus but this led on to campaigning on a broader set of vulnerabilities and socio-economic rights, as treatment access became more widespread. Other campaigns have taken similar journeys.

A shift in focus from health care provision and access, to issues of social justice, equity and the experiences of marginalised groups was also central to the paper on indigenous people in Brazil, given by Alex Shankland of IDS.

The resulting seven briefing papers provide more information on each of the following areas:

>> Framings of scaling up
>> Large scale health interventions
>> Local innovations
>> Scaling up in context of transition
>> Information and communication technologies
>> Citizen and health system relations
>> Building evidence to support rapid change

Read more

Thursday, 12 August 2010


by Gerry Bloom, STEPS Centre Health domain convenor

On August 11 the Lancet published an article that demonstrated the emergence of a new antibiotic resistance mechanism (known as NDM-1) in India, Pakistan and the UK. The article points out that many of the UK people carrying resistant bacteria had visited the Indian sub-continent during the past year or had links with these countries. The authors warn that the spread of bacteria resistant to almost all known antibiotic drugs could pose a serious public health hazard. What's to be done?

Today, the British newspapers have responded to the issue from a number of points of view. The Daily Mail argues that “we’ve only ourselves to blame”, highlighting that people seeking inexpensive plastic surgery in India are amongst the carriers of the new bug to the UK. The Guardian contemplates "a world without antibiotics”, calling for world-wide surveillance to identify emergent resistant organisms. An editorial in the Financial Times (registered users only) emphasises the need for investment in new anti-microbial products.

This is the latest of a stream of stories about the emergence of organisms (strains of HIV, tuberculosis and malaria) resistant to existing treatments. These emergences share a common pattern: a new drug is developed, and its use spreads rapidly, including in partial doses. The problem is that in places where many people have a lowered capacity to fight infection because they are malnourished, are exposed to multiple infections through contaminated water, or have a chronic infection such as with HIV, the possibilities that a new strain of a bacterium or virus will take hold and spread are increased.

This isn't fully surprising. The Lancet article refers to a past editorial by AD Ghafur in an Indian medical journal about the availability of antibiotics in that country’s informal markets and a prediction of the emergence of resistant organisms. We need to recognise the consequences for global public health of the persistence of severe poverty and the rapid spread of health-related markets. In many parts of the world, poor people obtain most of their drugs from informal health workers or shops functioning largely outside a regulatory framework. A substantial proportion of these products are counterfeit and of low quality. People often buy several antibiotics and they do not necessarily take a full course of treatment. In this context, the rapid emergence of resistant organisms is inevitable.

What can be done?

One option is to try to protect the UK population through more effective surveillance and measures to reduce exposure of people to emergent organisms. The Lancet article, for example, opposes proposals that the British NHS refer patients to Indian hospitals as a way to save money.

A second option would be to prevent the easy movement of pharmaceuticals to localities without a well-organised health system. This would, in effect, deny many of the world’s poorest people access to effective drugs.

Neither option is politically acceptable or practically feasible in a world of increasing movement of people between countries and rapid communications, where it is almost impossible to avoid links between the very rich and poor people seeking health care in markets thousands of kilometres away.

We need to recognise the potential gravity of the problem of treatment resistant organisms. Recent efforts to make drugs widely available at an affordable cost have made a major impact on the lives of millions of people. They now need to be complemented by a similar effort to ensure that drugs are used responsibly. This cannot be achieved by simply announcing new regulations, which are unlikely to have much impact on the largely unorganised markets through which a large volume of pharmaceuticals flow.

An effective response to this problem needs to combine research on new pharmaceuticals, the creation of new global capacities for surveillance and measures to enable poor people to gain access to effective drugs while reducing the risks of resistant organisms. These measures will require a new kind of partnership between governments, pharmaceutical companies, providers of health services, participants in informal health markets and poor people, themselves, to improve access to anti-viral and anti-microbial drugs and ensure their responsible use.

Related links

>> Epidemics: Science, Governance and Social Justice, edited by Sarah Dry and Melissa Leach

>> Avian Influenza: Science, Policy and Politics, edited By Ian Scoones
>> Future Health Systems
>> Our research on Rethinking Regulation Read more

Wednesday, 11 August 2010


Photos and video of the Manifesto discussion in Beijing, held at Tsinghua University in March, are now on the website. Take a look for some top academics' takes on innovation, sustainability and development in China and across the globe.

There are lots more videos, reports and documents at www.anewmanifesto.org, which also includes the full text of the Manifesto to download or browse online. Read more