Misfinancing global health: a case for transparency in disbursements and decision making

Challenges and the Way Forward in Demand-Forecasting Practices within the Ethiopian Public Pharmaceutical Supply Chain

This study delves into the challenges of pharmaceutical forecasting within the Ethiopian public pharmaceutical supply chain, which is vital for ensuring medicine availability and optimizing healthcare delivery. t It aims to identify and analyze key hindrances to pharmaceutical forecasting in Ethiopia, employing qualitative analysis through semi-structured interviews with stakeholders. Thematic analysis using NVIVO 14 software reveals challenges including finance-related constraints, workforce shortages, and data quality issues. Financial challenges arise from funding uncertainties, causing delayed procurement and stockouts. Workforce shortages hinder accurate forecasting, while data quality issues result from incomplete and untimely reporting. Recommendations include prioritizing healthcare financing, investing in workforce development, and improving data quality through technological advancements and enhanced coordination among stakeholders.

The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.

U.S. global health aid policy and family planning in sub-Saharan Africa

The Trump administration reinstated and expanded the Mexico City Policy (MCP) in 2017 as the Protecting Life in Global Health Assistance (PLGHA) policy, forbidding international organizations receiving all U.S. health assistance from promoting abortion. Existing evidence suggests that abortion rates rise under the MCP, but the direct effect of U.S. funding restrictions on supply and use of family planning has received less attention. By studying PLGHA's impact on health service delivery providers and women in eight sub-Saharan African countries, we are able to fill this gap. We find that health facilities provide fewer family planning services, including emergency contraception, and that women are less likely to use contraception and more likely to have given birth recently under the policy. These findings suggest that PLGHA has important unintended consequences that are detrimental to reproductive health and the autonomous decision-making of health service providers and women.

Challenges in international health financing and implications for the new pandemic fund

BACKGROUND

The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing.

METHODS/RESULTS

The article outlines eight challenges associated with global health financing instruments and development aid for health within the global health literature. These include misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Using available information about the Pandemic Fund, the article positions the Pandemic Fund against these challenges to determine in what ways the financing instrument recognizes, addresses, partially addresses, or ignores them. The assessment argues that although the Pandemic Fund has adopted a few measures to recognise and address some of the challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed.

CONCLUSION

It remains unclear how the Pandemic Fund is explicitly addressing challenges widely recognized in the global health financing literature. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers four sets of policy recommendations for how the Pandemic Fund and the PPR financing architecture might respond more effectively to the identified challenges.

Exploring health promotion efforts for non-communicable disease prevention and control in Ghana

Noncommunicable diseases (NCDs) are a growing public health challenge in Ghana. Health promotion can provide useful avenues to reduce the incidence of NCDs in the country. We used the Ottawa Framework to assess health promotion efforts for the prevention and control of NCDs in Ghana. Data were collected using key informant interviews and documentary sources. A content analysis approach was adopted for data analysis using Nvivo 11 Software. We found a strong policy framework for NCD prevention in Ghana with the ratification of several international protocols and resolutions and the development of national and specific NCD-related policies. Implementation of these policies, however, remains achallenge due to limited resources and the overconcentration on communicable diseases. Attempts have been made to create a supportive environment through increased access to NCD services but there are serious challenges. Respondents believe the current environment does not support healthy eating and promotes unhealthy use of alcohol. The Community-based Health Planning and Services (CHPS) program engenders community participation in health but has been affected by inadequate resources. Personal skills and education programs on NCDs are erratic and confined to a few municipalities. We also found that NCD services in Ghana continue to be clinical and less preventative. These findings have far-reaching implications for practice and require health planners in Ghana to pay equal attention in terms of budgetary allocations and other resources to both NCDs and communicable diseases.

Multi-period vaccine allocation model in a pandemic: A case study of COVID-19 in Australia

While the swift development and production of a COVID-19 vaccine has been a remarkable success, it is equally crucial to ensure that the vaccine is allocated and distributed in a timely and efficient manner. Prior research on pandemic supply chain has not fully incorporated the underlying factors and constraints in designing a vaccine allocation model. This study proposes an innovative vaccine allocation model to contain the spread of infectious diseases incorporating key contributing factors to the risk of uninoculated people including susceptibility rate and exposure risk. Analyses of the data collected from the state of Victoria in Australia show that a vaccine allocation model can deliver a superior performance in minimizing the risk of unvaccinated people when a multi-period approach is employed and augmenting operational mechanisms including transshipment between medical centers, capacity sharing, and mobile units being integrated into the vaccine allocation model.

Good Financial Grant Practice: A Tool for Developing and Demonstrating Institutional Financial and Grant Management Capacity in Global Health

The administration and governance of grant funding across global health organizations presents enormous challenges. Meeting these challenges is crucial to ensuring that funds are used in the most effective way to improve health outcomes, in line with the United Nations' Sustainable Development Goal 3, "Ensure healthy lives and promote well-being for all at all ages." The Good Financial Grant Practice (GFGP) Standard (ARS 1651) is the world's first and, currently, only international standard for the financial governance and management of grant funding. Through consensus building and global harmonization between both low- and middle-income and high-income country players, the GFGP Standard has achieved a leveling impact: GFGP applies equally to, and can be implemented by, all types of organization, regardless of location, size, or whether they predominantly give or receive funding. GFGP can be used as a tool for addressing some of the challenges of the current funding model. Here, we describe our experiences and lessons learned from implementing GFGP across 4 diverse research institutions in India, Nigeria, Colombia, and the Philippines as part of our National Institute for Health Research Global Health Research Unit on Genomic Surveillance of Antimicrobial Resistance.

Donor Commitments and Disbursements for Sexual and Reproductive Health Aid in Kenya, Tanzania, Uganda and Zambia

Background: Sexual and Reproductive Health and Rights (SRHR) investments are critical to people's well-being. However, despite the demonstrated returns on investments, underfunding of SRHR still persists. The objective of this study was to characterize donor commitments and disbursements to SRH aid in four sub-Saharan countries of Kenya, Tanzania, Uganda and Zambia and to compare trends in donor aids with SRH outcome and impact indicators for each of these countries. Methods: The study is a secondary analysis of data from the Organization for Economic Co-operation and Development's Assistance creditor reporting system and SRH indicator data from the Global Health Observatory and country demographic health surveys for a 16-year period (2002-2017). We downloaded and compared commitments to disbursements of all donors for population policies, programs and reproductive health for the four African countries. SRH indicators were stratified into health facility level process/outcome indicators (modern contraceptive prevalence rate, unmet need for family planning, antenatal care coverage and skilled birth attendance) and health impact level indicators (maternal mortality ratio, newborn mortality rate, infant mortality rate and under five mortality rate). Results: Donor commitments for SRH aid grew on average by 20% while disbursements grew by 21% annually between 2002 and 2017. The overall disbursement rate was 93%. Development Assistance Cooperation (DAC) countries donated the largest proportion (79%) of aid. Kenya took 33% of total aid, followed by Tanzania 26%, Uganda 23% and then Zambia (18%). There was improvement in all SRH outcome and impact indicators, but not enough to meet targets. Conclusion: Donor aid to SRH grew over time and in the same period indicators improved, but improvement remained slow. Unpredictability and insufficiency of aid may be disruptive to recipient country planning. Donors and low- and middle-income countries should increase funding in order to meet global SRHR targets.

Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda

Most Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program's inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.

The value proposition of the Global Health Security Index

Infectious disease outbreaks pose major threats to human health and security. Countries with robust capacities for preventing, detecting and responding to outbreaks can avert many of the social, political, economic and health system costs of such crises. The Global Health Security Index (GHS Index)-the first comprehensive assessment and benchmarking of health security and related capabilities across 195 countries-recently found that no country is sufficiently prepared for epidemics or pandemics. The GHS Index can help health security stakeholders identify areas of weakness, as well as opportunities to collaborate across sectors, collectively strengthen health systems and achieve shared public health goals. Some scholars have recently offered constructive critiques of the GHS Index's approach to scoring and ranking countries; its weighting of select indicators; its emphasis on transparency; its focus on biosecurity and biosafety capacities; and divergence between select country scores and corresponding COVID-19-associated caseloads, morbidity, and mortality. Here, we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the importance of scoring and ranking; (4) describe the robust methodology underpinning country scores and ranks; (5) highlight the GHS Index's emphasis on transparency and (6) articulate caveats for users wishing to use GHS Index data in health security research, policymaking and practice.

Comparative financing analysis and political economy of noncommunicable diseases

The pandemic of chronic non-communicable diseases (NCDs) poses substantial challenges to the health financing sustainability in high-income and low/middle income countries (LMICs). The aim of this review is to identify the bottle neck inefficiencies in NCDs attributable spending and propose sustainable health financing solutions. The World Health Organization (WHO) introduced the "best buy" concept to scale up the core intervention package against NCDs targeted for LMICs. Population- and individual-based NCD best buy interventions are projected at US$170 billion over 2011-2025. Appropriately designed health financing arrangements can be powerful enablers to scale up the NCD best buys. Rapidly developing emerging nations dominate the landscape of LMICs. Their capability and willingness to invest resources for eradicating NCDs could strengthen WHO outreach efforts in Asia, Africa, and Latin America, much beyond current capacities. There has been a declining trend in international donor aid intended to cope with NCDs over the past decade. There is also a serious misalignment of these resources with the actual needs of recipient countries. Globally, the momentum towards the financing of intersectoral actions is growing, and this presents a cost-effective solution. A budget discrepancy of 10:1 in WHO and multilateral agencies remains in donor aid in favour of communicable diseases compared to NCDs. LMICs are likely to remain a bottleneck of NCDs imposed financing sustainability challenge in the long-run. Catastrophic household health expenditure from out of pocket spending on NCDs could plunge almost 150 million people into poverty worldwide. This epidemiological burden coupled with population ageing presents an exceptionally serious sustainability challenge, even among the richest countries which are members of the Organization for Economic Co-operation and Development (OECD). Strategic and political leadership of WHO and multilateral agencies would likely play essential roles in the struggle that has just begun.

The World Bank & financing tuberculosis control, 1986-2017

Background: Tuberculosis is among the leading contributors to global mortality and morbidity from infectious diseases and has had a major socioeconomic cost in recent history. The World Bank is a leading institution for global health governance and financing, but little research has concentrated on the role of the World Bank in global tuberculosis control. Methods: We tracked the development of the World Bank’s policies and associated financial flows for tuberculosis control. First, we performed a scoping review of both published and grey literature. Second, we used the World Bank’s Projects & Operations database to construct a dataset of all World Bank projects with funding allocated to the “Tuberculosis” theme from 1986 to 2017.  Finally, we analysed the World Bank’s funding patterns alongside wider funding for tuberculosis using the Institute of Health Metrics and Evaluation’s Development Assistance for Health database. Results: We identified four periods in the World Bank’s involvement in global tuberculosis control, from the recognition of tuberculosis as a global health issue to the creation of a global coalition against tuberculosis. Between 1986 and 2017 the World Bank undertook 79 projects with financing from its core lending divisions with a tuberculosis control theme or focus. Within the 79 projects, the World Bank committed 19.6% of funding, or $0.9bn, towards tuberculosis control. The World Bank has invested significantly into Direct Observation of Treatment, Short-course chemotherapy (DOTS). After the formation of private-public partnerships against tuberculosis in 2002 such as the Global Fund to Fight HIV/AIDS, TB and Malaria, the World Bank’s core financing decreased and private-public partnerships provided increasing levels of substitutive financing for tuberculosis control. Conclusions: The World Bank has been pivotal in leading global financing, garnering advocacy and creating widespread coalition in the battle against tuberculosis control in recent decades.

Implementing health system strengthening projects at USAID: Findings from five cases using an integrated framework

Evidence on the implementation of health systems strengthening (HSS) interventions is scarce. Donors need this information to prioritise investments and lobby for continued financial support. To develop a deeper understanding of the implementation dynamics of robust HSS interventions, we retrospectively compared five USAID-supported projects in the Dominican Republic, Ethiopia, Kazakhstan, Rwanda, and Zambia. A document review and key informant interviews (n = 44) were conducted, coded, and analysed in each of the five cases using an integrated implementation framework. The framework was organised by four phases of implementation. For the pre-condition phase, data-driven HSS interventions were nested in a range of political contexts and with differing levels of financial support. In pre-implementation, cases relied on diverse teams that created a data-informed, inclusive, and transparent project ethos for implementation. Implementation was located at multiple tiers of the health system, used interventions as catalysts for government initiatives, supported governance/accountability initiatives, and responded nimbly to contextual changes in the implementation climate. There was less evidence of maintenance and evolution but all cases were designed with an eye towards sustainability. This research yields important insights about the dynamics of HSS, identifying ways donors can better support countries to achieve universal health coverage.

Developing a Sustainable Long-Term Ageing Health Care System Using the DANP-mV Model: Empirical Case of Taiwan

Most of the baby boomers born after the Second World War (WWII) have passed the age of 65, meaning they have gradually lost their social functions and positions, and are facing the need for care. In Taiwan, the lack of a long-term care mechanism is having a certain degree of impact on society as a whole, and thus, it is important to have a mechanism to take care of the elderly. In order to make this system sustainable, sufficient funds and continuous improvement are important factors. In the past, in order to avoid the illegal transfer of benefits, the social welfare mechanism avoided the use of for-profit organizations. However, as the economic environment declines, the role of for-profit organizations should be considered. This study defines the long-term ageing health care system using five major dimensions and 20 criteria. The DANP-mV model was used to analyze Taiwan's current system and identify problems, and then to develop a continuous improvement strategy from the perspective of the source of the problem in order to improve long-term ageing health care.

How to use relevant data for maximal benefit with minimal risk: digital health data governance to protect vulnerable populations in low-income and middle-income countries

Globally, the volume of private and personal digital data has massively increased, accompanied by rapid expansion in the generation and use of digital health data. These technological advances promise increased opportunity for data-driven and evidence-based health programme design, management and assessment; but also increased risk to individuals of data misuse or data breach of their sensitive personal data, especially given how easily digital data can be accessed, copied and transferred on electronic platforms if the appropriate controls are not implemented. This is particularly pertinent in low-income and middle-income countries (LMICs), where vulnerable populations are more likely to be at a disadvantage in negotiating digital privacy and confidentiality given the intersectional nature of the digital divide. The potential benefits of strengthening health systems and improving health outcomes through the digital health environment thus come with a concomitant need to implement strong data governance structures and ensure the ethical use and reuse of individuals’ data collected through digital health programmes. We present a framework for data governance to reduce the risks of health data breach or misuse in digital health programmes in LMICS. We define and describe four key domains for data governance and appropriate data stewardship, covering ethical oversight and informed consent processes, data protection through data access controls, sustainability of ethical data use and application of relevant legislation. We discuss key components of each domain with a focus on their relevance to vulnerable populations in LMICs and examples of data governance issues arising within the LMIC context.

Tracking donor funding towards achieving the Global Vaccine Action Plan (GVAP) goals: A landscape analysis (1990-2016)

Efforts driving universal coverage have recently been strengthened through implementation of the Global Vaccine Action Plan (GVAP) where cost estimates for immunization support were developed totaling US$40 billion of donor assistance by 2020. In addition to resource mobilization, there has been an increasing focus on improving both vaccine access and delivery systems. We track donor assistance for immunization by funding objective and channel from 1990 to 2016, and illustrate projections through 2020 to inform progress of the GVAP. Using available data from development agencies supporting immunization, we categorize funding by vaccine and quantify support for systems strengthening. We split time into four periods including the post universal childhood immunization era (1990-1999) and Gavi's three funding phases between 2000 and 2015, during which annualized funding changes are estimated. Lastly, we perform a linear extrapolation through 2020 to predict the success of stipulated resource mobilization targets. Double counting was eliminated and results presented in real 2017 US dollars. Over the last 27 years, funding for immunization increased by 10.5% annually, with non-Gavi funding increasing by 7.1% and Gavi funding by 23.6% in the last 17 years. Gavi disbursements targeting vaccines and health system improvements increased uniformly at 15%, compared to 22.5% for vaccines and 11.7% for system strengthening from non-Gavi channels. Funding fluctuated for non-Gavi channels with disbursements declining before 2000 and during Gavi funding phase II, while Gavi disbursements continued to grow relative the previous phase. New and underused vaccines were prioritized by Gavi whereas non-Gavi channels focused on elimination efforts. Projected funding targets were estimated to be on track for Gavi contrary to non-Gavi support which was estimated to remain 40% below the stipulated target. Renewed assessments for funding requirements need to be undertaken, while strengthening existing resource efficiencies in order to achieve current global universal coverage targets.

The World Bank & financing tuberculosis control, 1986-2017

Background: Tuberculosis (TB) is among the leading contributors to global mortality and morbidity from infectious diseases and has had a major socioeconomic cost in recent history. The World Bank is a leading institution for global health governance and financing, but little research has concentrated on the role of the World Bank in global tuberculosis control. Methods: We tracked the development of the World Bank’s policies and associated financial flows for tuberculosis control. First, we performed a scoping review of both published and grey literature. Second, we used the Bank’s Projects & Operations database to construct a dataset of all World Bank projects with funding allocated to the “Tuberculosis” theme from 1986 to 2017.  Finally, we analysed the World Bank’s funding patterns alongside wider funding for tuberculosis using the Institute of Health Metrics and Evaluation’s Development Assistance for Health database. Results: We identified four periods in the World Bank’s involvement in global tuberculosis control, from the recognition of tuberculosis as a global health issue to the creation of a global coalition against tuberculosis. Between 1986 and 2017 the World Bank undertook 79 projects with financing from its core lending divisions with a tuberculosis control theme or focus. Within the 79 projects the Bank committed 19.6% of funding, or $0.9bn, towards tuberculosis control. The World Bank has been involved in increasingly vertical programming with a growing proportion of project funding invested into tuberculosis control over time. However, after the formation of private-public partnerships against tuberculosis in 2002 such as the Global Fund to Fight HIV/AIDS, TB and Malaria, the Bank’s core financing decreased and private-public partnerships provided increasing levels of substitutive financing for tuberculosis control. Conclusions: The World Bank has been pivotal in leading global financing, garnering advocacy and creating widespread coalition in the battle against tuberculosis control in recent decades.

Additional Insights Into Problem Definition and Positioning From Social Science Comment on "Four Challenges That Global Health Networks Face"

Commenting on a recent editorial in this journal which presented four challenges global health networks will have to tackle to be effective, this essay discusses why this type of analysis is important for global health scholars and practitioners, and why it is worth understanding and critically engaging with the complexities behind these challenges. Focusing on the topics of problem definition and positioning, I outline additional insights from social science theory to demonstrate how networks and network researchers can evaluate these processes, and how these processes contribute to better organizing, advocacy, and public health outcomes. This essay also raises multiple questions regarding these processes for future research.

Research priority-setting: reproductive health in the occupied Palestinian territory

BACKGROUND

Occupied Palestinian territory (oPt) is an authority with limited resources. Therefore, research conducted in such a setting should be prioritized and coordinated to follow a national research agenda. This study aims to produce a research agenda for reproductive health in the oPt that can be utilized by reproductive health stakeholders and contribute to the development of policy-based evidence to guide health practice.

METHODS

In the current study, we followed research prioritization methods developed by the World Health Organization-Child Health and Nutrition Research Initiative. Research questions were obtained from reproductive health experts in the oPt. The questions were then grouped into thematic areas which were prioritized by the reproductive health experts. Scores were calculated and sorted to define the top priority research areas.

RESULTS

A total of 232 research questions were prioritized by 30 reproductive health experts. Health system issues were the most addressed in the top 50 research questions. They included questions on the quality of services and health professionals' knowledge and continuous professional training. Adolescents' sexual and reproductive health and gender-based violence were rarely mentioned in the top 50 questions. The number of questions related to safe motherhood was around 50% followed by questions related to health system. Questions related to elderly women and menopause as well as reproductive system cancers were also within the top 50 ranked questions.

CONCLUSIONS

Priority research areas in reproductive health were identified for the oPt, which should be utilized by researchers with a focus on the high priority areas. Policy makers and funders should coordinate their efforts to ensure the production of research with value to the Palestinian context, in the most efficient way possible.

Assessing global, regional, national and sub-national capacity for public health research: a bibliometric analysis of the Web of Science(TM) in 1996-2010

BACKGROUND

The past two decades have seen a large increase in investment in global public health research. There is a need for increased coordination and accountability, particularly in understanding where funding is being allocated and who has capacity to perform research. In this paper, we aim to assess global, regional, national and sub-national capacity for public health research and how it is changing over time in different parts of the world.

METHODS

To allow comparisons of regions, countries and universities/research institutes over time, we relied on Web of Science(TM) database and used Hirsch (h) index based on 5-year-periods (h5). We defined articles relevant to public health research with 98% specificity using the combination of search terms relevant to public health, epidemiology or meta-analysis. Based on those selected papers, we computed h5 for each country of the world and their main universities/research institutes for these 5-year time periods: 1996-2000, 2001-2005 and 2006-2010. We computed h5 with a 3-year-window after each time period, to allow citations from more recent years to accumulate. Among the papers contributing to h5-core, we explored a topic/disease under investigation, "instrument" of health research used (eg, descriptive, discovery, development or delivery research); and universities/research institutes contributing to h5-core.

RESULTS

Globally, the majority of public health research has been conducted in North America and Europe, but other regions (particularly Eastern Mediterranean and South-East Asia) are showing greater improvement rate and are rapidly gaining capacity. Moreover, several African nations performed particularly well when their research output is adjusted by their gross domestic product (GDP). In the regions gaining capacity, universities are contributing more substantially to the h-core publications than other research institutions. In all regions of the world, the topics of articles in h-core are shifting from communicable to non-communicable diseases (NCDs). There is also a trend of reduction in "discovery" research and increase in "delivery" research.

CONCLUSION

Funding agencies and research policy makers should recognise nations where public health research capacity is increasing. These countries are worthy of increased investment in order to further increase the production of high quality local research and continue to develop their research capacity. Similarly, universities that contribute substantially to national research capacity should be recognised and supported. Biomedical journals should also take notice to ensure equity in peer-review process and provide researchers from all countries an equal opportunity to publish high-quality research and reduce financial barriers to accessing these journals.

Critical factors influencing the establishment, maintenance and sustainability of population-based cancer control programs

Developing and maintaining a comprehensive cancer control program are two distinct entities. Key issues related to building and sustaining cancer control programs include how to integrate initiatives and efforts across multiple constituencies addressing components of the implementation of cancer control and non-communicable disease programs, the processes used in different resource settings to achieve effective drug budgeting, health technology assessment and health economics, and how countries can support public and societal engagement. There are promising examples in both resource-rich and resource-challenged countries of constituencies that have developed programs which can contribute to comprehensive cancer control. Some take advantage of newer technology and information services, while others are more people and patient focused.

Critical issues and factors for establishing and maintaining population-based comprehensive cancer control programs are identified and reviewed.

Critical evaluation of international health programs: Reframing global health and evaluation

Striking changes in the funding and implementation of international health programs in recent decades have stimulated debate about the role of communities in deciding which health programs to implement. An important yet neglected piece of that discussion is the need to change norms in program evaluation so that analysis of community ownership, beyond various degrees of "participation," is seen as central to strong evaluation practices. This article challenges mainstream evaluation practices and proposes a framework of Critical Evaluation with 3 levels: upstream evaluation assessing the "who" and "how" of programming decisions; midstream evaluation focusing on the "who" and "how" of selecting program objectives; and downstream evaluation, the focus of current mainstream evaluation, which assesses whether the program achieved its stated objectives. A vital tenet of our framework is that a community possesses the right to determine the path of its health development. A prerequisite of success, regardless of technical outcomes, is that programs must address communities' high priority concerns. Current participatory methods still seldom practice community ownership of program selection because they are vulnerable to funding agencies' predetermined priorities. In addition to critiquing evaluation practices and proposing an alternative framework, we acknowledge likely challenges and propose directions for future research.

Activity-based costing of health-care delivery, Haiti

Objective

To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti.

Methods

Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators.

Findings

Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit.

Conclusion

Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated.

A systematic approach to injury policy assessment: introducing the assessment of child injury prevention policies (A-CHIPP)

Introduction

This study presents a systematic approach—assessment of child injury prevention policies (A-CHIPP)—to assess and track policies on effective child injury interventions at the national level. Results from an initial pilot test of the approach in selected countries are presented.

Method

A literature review was conducted to identify conceptual models for injury policy assessment, and domains and indicators were proposed for assessing national injury policies for children aged 1–9 years. The indicators focused on current evidence-supported interventions targeting the leading external causes of child injury mortality globally, and were organised into a self-administered A-CHIPP questionnaire comprising 22 questions. The questionnaire was modified based on reviews by experts in child injury prevention. For an initial test of the approach, 13 countries from all six WHO regions were selected to examine the accuracy, usefulness and ease of understanding of the A-CHIPP questionnaire.

Results

Data on the A-CHIPP questionnaire were received from nine countries. Drowning and road traffic injuries were reported as the leading causes of child injury deaths in seven of these countries. Most of the countries lacked national policies on interventions that address child injuries; supportive factors such as finance and leadership for injury prevention were also lacking. All countries rated the questionnaire highly on its relevance for assessment of injury prevention policies.

Conclusion

The A-CHIPP questionnaire is useful for national assessment of child injury policies, and such an assessment could draw attention of stakeholders to policy gaps and progress in child injury prevention in all countries.

The relationship between burden of childhood disease and foreign aid for child health

Background

We sought to examine the relationship between child specific health aid (CHA) and burden of disease. Based on existing evidence, we hypothesized that foreign aid for child health would not be proportional to burden of disease.

Methods

In order to examine CHA and burden of disease, we obtained estimates of these parameters from established sources. Estimates of disability adjusted life years (DALYs) in children (0–5 years) were obtained from the World Health Organization for 2000 and 2012. The 10 most burdensome disease categories in each continent, excluding high-income countries, were identified for study. Descriptions of all foreign aid commitments between 1996 and 2009 were obtained from AidData, and an algorithm to designate the target diseases of the commitments was constructed. Data were examined in scatterplots for trends.

Results

The most burdensome childhood diseases varied by continent. In all continents, newborn diseases, vaccine-preventable diseases (lower respiratory diseases, measles, meningitis, tetanus, and pertussis), and diarrheal diseases ranked within the four most burdensome diseases. Infectious diseases such as malaria, tuberculosis, and HIV were also among the ten most burdensome diseases in sub-Saharan Africa, and non-communicable diseases were associated with much of the burden in the other continents. CHA grew from $7.4 billion in 1996 to $17.7 billion in 2009 for our study diseases. Diarrheal diseases and malnutrition received the most CHA as well as the most CHA per DALY. CHA directed at HIV increased dramatically over our study period, from $227,000 in 1996 to $3.4 billion in 2008. Little aid was directed at injuries such as drowning, car accidents, and fires, as well as complex medical diseases such as leukemia and endocrine disorders.

Conclusion

CHA has grown significantly over the last two decades. There is no clear relationship between CHA and burden of disease. This report provides a description of foreign aid for child health, and hopes to inform policy and decision-making regarding foreign aid.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2540-5) contains supplementary material, which is available to authorized users.

World Bank's financing, priorities, and lending structures for global health

In the first article of a series, Devi Sridhar, Janelle Winters, and Eleanor Strong describe how the World Bank has used its influence to catalyse change in global health

Donor funding health policy and systems research in low- and middle-income countries: how much, from where and to whom

BACKGROUND

The need for sufficient and reliable funding to support health policy and systems research (HPSR) in low- and middle-income countries (LMICs) has been widely recognised. Currently, most resources to support such activities come from traditional development assistance for health (DAH) donors; however, few studies have examined the levels, trends, sources and national recipients of such support - a gap this research seeks to address.

METHOD

Using OECD's Creditor Reporting System database, we classified donor funding commitments using a keyword analysis of the project-level descriptions of donor supported projects to estimate total funding available for HPSR-related activities annually from bilateral and multilateral donors, as well as the Bill and Melinda Gates Foundation, to LMICs over the period 2000-2014.

RESULTS

Total commitments to HPSR-related activities have greatly increased since 2000, peaked in 2010, and have held steady since 2011. Over the entire study period (2000-2014), donors committed a total of $4 billion in funding for HPSR-related activities or an average of $266 million a year. Over the last 5 years (2010-2014), donors committed an average of $434 million a year to HPSR-related activities. Funding for HPSR is heavily concentrated, with more than 93% coming from just 10 donors and only represents approximately 2% of all donor funding for health and population projects. Countries in the sub-Saharan African region are the major recipients of HPSR funding.

CONCLUSION

Funding for HPSR-related activities has generally increased over the study period; however, donor support to such activities represents only a small proportion of total DAH and has not grown in recent years. Donors should consider increasing the proportion of funds they allocate to support HPSR activities in order to further build the evidence base on how to build stronger health systems.

Does published research on non-communicable disease (NCD) in Arab countries reflect NCD disease burden?

Objectives

To review trends in non-communicable (NCD) research output in the Arab region, in terms of quantity and quality, study design, setting and focus. We also examined differences by time and place, and assessed gaps between research output and NCD burden.

Methods

A scoping review of a total of 3,776 NCD-related reports published between 2000 and 2013 was conducted for seven Arab countries. Countries were selected to represent diverse socio-economic development levels in the region: Regression analyses were used to assess trends in publications over time and by country. Research gaps were assessed by examining the degree of match between proportionate literature coverage of the four main NCDs (CVD, cancer, DM, and COPD) and cause-specific proportional mortality rates (PMR).

Results

The annual number of NCD publications rose nearly 5-fold during the study period, with higher income countries having the higher publication rates (per million populations) and the most rapid increases. The increase in the publication rate was particularly prominent for descriptive observational studies, while interventional studies and systematic reviews remained infrequent (slope coefficients = 13.484 and 0.883, respectively). Gap analysis showed a mismatch between cause-specific PMR burden and NCD research output, with a relative surplus of reports on cancer (pooled estimate +38.3%) and a relative deficit of reports on CVDs (pooled estimate -30.3%).

Conclusion

The widening disparity between higher and lower-income countries and the discordance between research output and disease burden call for the need for ongoing collaboration among Arab academic institutions, funding agencies and researchers to guide country-specific and regional research agendas, support and conduct.

Health Aid Is Allocated Efficiently, But Not Optimally: Insights From A Review Of Cost-Effectiveness Studies

Development assistance from high-income countries to the health sectors of low- and middle-income countries (health aid) is an important source of funding for health in low- and middle-income countries. However, the relationship between health aid and the expected health improvements from those expenditures--the cost-effectiveness of targeted interventions--remains unknown. We reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV; malaria; tuberculosis; noncommunicable diseases; and maternal, newborn, and child health. We measured the alignment between health aid and cost-effectiveness, and we examined the possibility of better alignment by simulating health aid reallocation. The relationship between health aid and incremental cost-effectiveness ratios is negative and significant: More health aid is going to disease categories with more cost-effective interventions. Changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements. The greatest improvements in the alignment would be achieved by reallocating some aid from HIV or maternal, newborn, and child health to malaria or TB. We conclude that health aid is generally aligned with cost-effectiveness considerations, but in some countries this alignment could be improved.

Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda

BACKGROUND

Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors.

OBJECTIVE

Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda.

DESIGN

Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers' progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression.

FINDINGS

At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified.

CONCLUSION

The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.

Approaches to Sustainable Capacity Building for Cardiovascular Disease Care in Kenya

Cardiovascular diseases are approaching epidemic levels in Kenya and other low- and middle-income countries without accompanying effective preventive and therapeutic strategies. This is happening in the background of residual and emerging infections and other diseases of poverty, and increasing physical injuries from traffic accidents and noncommunicable diseases. Investments to create a skilled workforce and health care infrastructure are needed. Improving diagnostic capacity, access to high-quality medications, health care, appropriate legislation, and proper coordination are key components to ensuring the reversal of the epidemic and a healthy citizenry. Strong partnerships with the developed countries also crucial.

Past and Future Performance: PEPFAR in the Landscape of Foreign Aid for Health

This review traces the course of the US President's Emergency Plan for AIDS Relief (PEPFAR) as a foreign aid program. It illustrates how the epidemiologic and geopolitical environments of the early 2000s influenced PEPFAR's early directions and contributed to its successes. In addition to scaling up infrastructure and care delivery platforms, PEPFAR led to large increases in the number of people receiving antiretroviral therapy and reductions in mortality. These successes, in turn, have brought its principal challenges-its outsized budget, narrow focus, and problem of entitlement-into sharp relief. PEPFAR's recent evolution, then, has been in response to these challenges. This review suggests that PEPFAR's early formulation as an emergency response relieved it from a need to articulate clear goals, and that this freedom is now leading to new challenges as it struggles to identify priorities in the face of expectations to do more with a flat budget.

Tracking official development assistance for reproductive health in conflict-affected countries: 2002-2011

OBJECTIVE

To provide information on trends on official development assistance (ODA) disbursement patterns for reproductive health activities in 18 conflict-affected countries.

DESIGN

Secondary data analysis.

SAMPLE

18 conflict-affected countries and 36 non-conflict-affected countries.

METHODS

The Creditor Reporting System (CRS) database was analyzed for ODA disbursement for direct and indirect reproductive health activities to 18 conflict-affected countries (2002-2011). A comparative analysis was also made with 36 non-conflict-affected counties in the same 'least-developed' income category. Multivariate regression analyses examined associations between conflict status and reproductive health ODA and between reproductive needs and ODA disbursements.

MAIN OUTCOME MEASURES

Patterns of ODA disbursements (constant U.S. dollars) for reproductive health activities.

RESULTS

The average annual ODA disbursed for reproductive health to 18 conflict-affected countries from 2002 to 2011 was US$ 1.93 per person per year. There was an increase of 298% in ODA for reproductive health activities to the conflict-affected countries between 2002 and 2011; 56% of this increase was due to increases in HIV/AIDS funding. The average annual per capita reproductive health ODA disbursed to least-developed non-conflict-affected countries was 57% higher than to least-developed conflict-affected countries. Regression analyses confirmed disparities in ODA to and between conflict-affected countries.

CONCLUSIONS

Despite increases in ODA for reproductive health for conflict-affected countries (albeit largely for HIV/AIDS activities), considerable disparities remains.

TWEETABLE ABSTRACT

Study tracking 10 years of aid for reproductive aid shows major disparities for conflict-affected countries.

An analytical perspective of Global health initiatives in Tanzania and Zambia

BACKGROUND

A number of Global health initiatives (GHIs) have been created to support low and middle income countries. Their support has been of different forms. The African Region has benefitted immensely from GHIs and continues to register an increase in health partnerships and initiatives. However, information on the functioning and operationalisation of GHIs in the countries is limited.

METHODS

This study involved two country case studies, one in Tanzania and the other one in Zambia. Data were collected using a semi-structured questionnaire. The aims were to understand and profile the GHIs supporting health development and to assess their governance and alignment with country priorities, harmonisation and alignment of their interventions and efforts, and contribution towards health systems strengthening. The respondents included senior officers from health stakeholder agencies at the national and sub-national levels. The qualitative data were analysed using thematic content analysis in MAXQDA software.

RESULTS

Health systems in both Tanzania and Zambia are decentralised. They have benefitted from GHI support in fighting the common health problems of HIV/AIDS, tuberculosis, malaria and vaccine-preventable diseases. In both countries, no GHI adequately made use of the existing Sector-wide Approach (SWAp) mechanisms but they largely operate through their unique structures and committees. GHI efforts to improve general health governance have not been matched with similar efforts from the countries. Their support to health system strengthening has not been comprehensive but has involved the selection of a few areas some of which were disease-focused. On the positive side, however, in both Tanzania and Zambia improved alignment with the countries' priorities is noted in that most of the proposals submitted to the GHIs refer to the priorities, objectives and strategies in the national health development plans and, GHIs depend on the national health information systems.

CONCLUSION

GHIs are important funders of health in low and middle income countries. However, there is a need for the countries to take a proactive role in improving the governance, coordination and planning of the GHIs that they benefit from. This will also maximise the return on investment for the GHIs.

Acute coronary syndromes in low- and middle-income countries: Moving forward

Cardiovascular disease remains the leading cause of death worldwide, particularly in low- and middle-income countries (LMICs), with substantial mortality from acute coronary syndromes. These deaths, when compared against high-income countries, occur at younger ages, and, beyond the lives lost, often result in economic privation for families deprived of a breadwinner and indebted by the oftentimes catastrophic cost of inpatient medical care. This burden will likely grow in scale in the years ahead as more countries pass through the epidemiologic transition. Billions around the world are beginning to experience the comforts that even modestly increased incomes can provide, including diets high in fats and sugars, more sedentary lifestyles, and tobacco and alcohol use and abuse. Health care systems in many of these countries are ill-equipped to prevent the harms caused by these lifestyles, as well as treat the acute coronary syndromes that result from them-including insufficient access to appropriate facilities and medications, difficulties with transport, and low awareness of the symptoms and need for emergent evaluation.

Building Sustainable Capacity for Cardiovascular Care at a Public Hospital in Western Kenya

Cardiovascular disease deaths are increasing in low- and middle-income countries and are exacerbated by health care systems that are ill-equipped to manage chronic diseases. Global health partnerships, which have stemmed the tide of infectious diseases in low- and middle-income countries, can be similarly applied to address cardiovascular diseases. In this review, we present the experiences of an academic partnership between North American and Kenyan medical centers to improve cardiovascular health in a national public referral hospital. We highlight our stepwise approach to developing sustainable cardiovascular services using the health system strengthening World Health Organization Framework for Action. The building blocks of this framework (leadership and governance, health workforce, health service delivery, health financing, access to essential medicines, and health information system) guided our comprehensive and sustainable approach to delivering subspecialty care in a resource-limited setting. Our experiences may guide the development of similar collaborations in other settings.

Structure, function and five basic needs of the global health research system

Background

Two major initiatives that were set up to support and co–ordinate global health research efforts have been largely discontinued in recent years: the Global Forum for Health Research and World Health Organization's Department for Research Policy and Cooperation. These developments provide an interesting case study into the factors that contribute to the sustainability of initiatives to support and co–ordinate global health research in the 21st century.

Methods

We reviewed the history of attempts to govern, support or co–ordinate research in global health. Moreover, we studied the changes and shifts in funding flows attributed to global health research. This allowed us to map the structure of the global health research system, as it has evolved under the increased funding contributions of the past decade. Bearing in mind its structure, core functions and dynamic nature, we proposed a framework on how to effectively support the system to increase its efficiency.

Results

Based on our framework, which charted the structure and function of the global health research system and exposed places and roles for many stakeholders within the system, five basic needs emerged: (i) to co–ordinate funding among donors more effectively; (ii) to prioritize among many research ideas; (iii) to quickly recognize results of successful research; (iv) to ensure broad and rapid dissemination of results and their accessibility; and (v) to evaluate return on investments in health research.

Conclusion

The global health research system has evolved rapidly and spontaneously. It has not been optimally efficient, but it is possible to identify solutions that could improve this. There are already examples of effective responses for the need of prioritization of research questions (eg, the CHNRI method), quick recognition of important research (eg, systems used by editors of the leading journals) and rapid and broadly accessible publication of the new knowledge (eg, PLoS One journal as an example). It is still necessary to develop tools that could assist donors to co–ordinate funding and ensure more equity between areas in the provided support, and to evaluate the value for money invested in health research.

Improving health aid for a better planet: The planning, monitoring and evaluation tool (PLANET)

Background

International development assistance for health (DAH) quadrupled between 1990 and 2012, from US$ 5.6 billion to US$ 28.1 billion. This generates an increasing need for transparent and replicable tools that could be used to set investment priorities, monitor the distribution of funding in real time, and evaluate the impact of those investments.

Methods

In this paper we present a methodology that addresses these three challenges. We call this approach PLANET, which stands for planning, monitoring and evaluation tool. Fundamentally, PLANET is based on crowdsourcing approach to obtaining information relevant to deployment of large–scale programs. Information is contributed in real time by a diverse group of participants involved in the program delivery.

Findings

PLANET relies on real–time information from three levels of participants in large–scale programs: funders, managers and recipients. At each level, information is solicited to assess five key risks that are most relevant to each level of operations. The risks at the level of funders involve systematic neglect of certain areas, focus on donor’s interests over that of program recipients, ineffective co–ordination between donors, questionable mechanisms of delivery and excessive loss of funding to “middle men”. At the level of managers, the risks are corruption, lack of capacity and/or competence, lack of information and /or communication, undue avoidance of governmental structures / preference to non–governmental organizations and exclusion of local expertise. At the level of primary recipients, the risks are corruption, parallel operations / “verticalization”, misalignment with local priorities and lack of community involvement, issues with ethics, equity and/or acceptability, and low likelihood of sustainability beyond the end of the program’s implementation.

Interpretation

PLANET is intended as an additional tool available to policy–makers to prioritize, monitor and evaluate large–scale development programs. In this, it should complement tools such as LiST (for health care/interventions), EQUIST (for health care/interventions) and CHNRI (for health research), which also rely on information from local experts and on local context to set priorities in a transparent, user–friendly, replicable, quantifiable and specific, algorithmic–like manner.

The lack of a non-communicable disease curriculum threatens the relevance of global public health education

BACKGROUND

Non-communicable diseases (NCDs) such as cardiovascular diseases (CVDs), cancer, lung disease and diabetes are major public health challenges for emerging economies. However, Masters of Public Health (MPH) curricula in the USA do not provide germane coursework.

METHODS

To assess the availability of global NCD courses in MPH curricula, we searched the websites of the 50 schools accredited by the Council on Education for Public Health as of 1 July 2013. Our questionnaire queried availability of a global or international health department or track, availability of an NCD track, and the presence of courses on NCD, NCD risk factors, CVD or global NCDs as well as global health infrastructure.

RESULTS

All schools had online course coursework available. Thirty-one schools (62%) offered a global/international health track or certificate; 38 (76%) offered an NCD course but only 4 (8%) offered a global NCD course. Of the schools with a global health program, none required an NCD course but all offered courses on global health economics or infrastructure.

CONCLUSION

For public health schools to be aligned with global realities and to retain a leadership role, curricular initiatives that highlight the NCD epidemic and its societal complexities will need new emphasis.

Financing the response to HIV among gay men and other men who have sex with men: Case studies from eight diverse countries

Despite reductions in the number of new HIV infections globally, the HIV epidemic among men who have sex with men (MSM) is expanding. This study characterises financing of HIV programmes for MSM and the impact of criminalisation on levels of funding, using data from five countries that criminalise same-sex sexual practices (Ethiopia, Mozambique, Guyana, India and Nigeria) and three that do not (China, Ukraine and Vietnam). For each country, all publicly available documents from the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved HIV/AIDS grants in Rounds 5-9 and Country Operational Plans detailing investments made through the President's Emergency Plan for AIDS Relief (PEPFAR) from US fiscal year (FY) 2007-2009 were examined. Eleven of 20 HIV proposals to the Global Fund contained programmes for MSM totalling approximately $40 million or 6% of proposed budgets. In six countries providing activity-level data on MSM programming, PEPFAR funding that served this population and others ranged from $23.3 million in FY2007 to $35.4 million in FY2009, representing 0.5-25.9% of overall, non-treatment funding over this period. Countries that criminalise same-sex sexual practices spend fewer resources on HIV programmes serving MSM. However, they also show consistent underfunding of programmes serving MSM regardless of context or geography.

Spillover effect of HIV-specific foreign aid on immunization services in Nigeria

BACKGROUND

Health aid to Nigeria increased tremendously in the last decade and a significant portion of the funds were earmarked for HIV-associated programs. Studies on the impact of HIV-specific aid on the delivery of non-HIV health services in sub-Saharan Africa have yielded mixed results. This study assessed if there is a spillover effect of HIV-specific aid on childhood vaccinations in Nigeria.

METHODS

Multivariate logistic regression models were used to estimate the effect of aid disbursements in a previous year on the receipt of vaccines at the individual level in a given year. Estimations were done for approximately 11 700 children using data from demographic and health surveys conducted in Nigeria in 2003 and 2008.

RESULTS

US$1 increase in HIV aid per capita was associated with a decrease in the probability of receipt of vaccines by 8-31%: polio first dose decreased by 8%; polio final dose by 9%; diphtheria-pertussis-tetanus (DPT) first dose by 11%; DPT final dose by 19%; measles by 31%; final doses of polio and DPT plus measles vaccine by 8%.

CONCLUSIONS

HIV-specific aid had a negative spillover effect on immunization services in Nigeria over the study period. Donors may need to rethink their funding strategies in favour of more horizontal approaches.

Non-Communicable Chronic Diseases: Winning on Facts but Losing on Passion

Abstract-For the past ten years, there has been an extensive analytical effort attempting to convince policy makers to invest in the prevention and treatment of non-communicable chronic diseases (NCDs) in low- and middle-income countries. From an analytical perspective, it has been an impressive decade of data gathering and presentations culminating in the United Nations high-level meeting on NCDs in September 2011. On the other hand, funding for NCDs has remained at very low levels compared to the burden of disease associated with NCDs. An important question, therefore, becomes why has all this important analytical work so far been unable to generate significantly more additional funding for NCDs? There are many possible explanations for the lack of appreciable additional funding, but perhaps the most important reason is a lack of passion or grass roots advocacy for preventing and treating NCDs by the general public. Until the politicians and policy makers see some urgency from the general public, the funding situation is unlikely to fundamentally change. However, there are many different actions that can be taken by researchers and funders while the funding levels remain low. In addition, many highly cost effective programs should be highlighted.