Interactions between Global Health Initiatives and country health systems: the case of a neglected tropical diseases control program in Mali

A Mixed-Methods Evaluation of Mainstreaming Mass Drug Administration for Schistosomiasis and Soil-Transmitted Helminthiasis in Four Districts of Nigeria

In Nigeria, mass drug administration (MDA) for schistosomiasis (SCH) and soil-transmitted helminthiasis (STH) has often been coordinated with other programs that receive greater external funding. As these programs reach stop MDA milestones, SCH and STH programs will likely need to transition implementation, or "mainstream," to domestic support. A mixed-methods study was conducted in four districts before (2021) and after (2022) mainstreaming to evaluate its impact on MDA coverage. Household surveys were done in 30 villages per district pre- and post-mainstreaming. All selected communities were eligible for STH treatment; around a third were eligible for SCH treatment. Mass drug administration was primarily conducted in schools. A total of 5,441 school-aged children were included in pre-mainstreaming and 5,789 were included in post-mainstreaming. Mass drug administration coverage was heterogeneous, but overall, mebendazole coverage declined nonsignificantly from 81% pre-mainstreaming to 76% post-mainstreaming (P = 0.09); praziquantel coverage declined significantly from 73% to 55% (P = 0.008). Coverage was significantly lower among unenrolled children or those reporting poor school attendance in nearly every survey. For the qualitative component, 173 interviews and 74 focus groups were conducted with diverse stakeholders. Respondents were deeply pessimistic about the future of MDA after mainstreaming and strongly supported a gradual transition to full government ownership. Participants formulated recommendations for effective mainstreaming: clear budget allocation by governments, robust and targeted training, trust building, and comprehensive advocacy. Although participants lacked confidence that SCH and STH programs could be sustained after reductions in external support, initial results indicate that MDA coverage can remain high 1 year into mainstreaming.

Integrating health intervention into existing program structure of the neglected tropical diseases: lessons learned from Yobe and Ebonyi states

Background

Nigeria has a national policy on neglected tropical diseases (NTD) which is coordinated by the Federal Ministry of Health and integrated into the health system at all government levels. A network of grassroots mobilizers, named community drug distributors (CDDs), deliver NTD drugs and commodities to rural and hard-to-reach communities throughout Nigeria.

Methods

Interviews with state and local government coordinators of Nigerian NTD programs and focus group discussions with CDDs in Yobe and Ebonyi states were conducted to understand the working modalities of NTD programs in Nigeria to identify the potential of leveraging the NTD structure for additional health interventions such as COVID-19 vaccine rollouts. Collected data was coded and managed on NVivo version 12 using content analysis.

Results and discussion

The study found that the NTD committee had the following: a structured planning and coordination process, a community mobilization approach for the effective delivery of routine Mass Administration of Medication (MAM) activities. Challenges encountered included little or no incentives for the CDDs, insecurity, transportation and logistics, and lack of equipment and drug commodities. Nigerian NTD health structures have a wide reach, with a presence in all states and local government areas (LGAs), and this has previously been leveraged to deliver commodities and interventions to rural and hard-to-reach communities for non-NTD health programs and could thus be used similarly for COVID-19 vaccination programs. The enablers of integrating health interventions into the NTD structure are increased availability of finances and manpower, while lack of financial incentives and partners' buy-in were identified as possible. challenges.

Conclusion

The study suggests that integrating COVID-19 interventions into the NTD program in Nigeria would be a significant accomplishment, as the existing structure can support future interventions. The study also highlights the efficiency of the NTD program's modalities and processes, indicating that an organized structural system for public health interventions can. increase the services of existing interventions while allowing for the integration of future interventions.

Delivery strategies for malaria vaccination in areas with seasonal malaria transmission

BACKGROUND

Seasonal vaccination with the RTS,S/AS01E malaria vaccine given alongside seasonal malaria chemoprevention (SMC) substantially reduces malaria in young children. The WHO has recommended the use of RTS,S/AS01E, including seasonal vaccination, in areas with seasonal malaria transmission. This study aimed to identify potential strategies to deliver RTS,S/AS01E, and assess the considerations and recommendations for delivery of seasonal malaria vaccination in Mali, a country with highly seasonal malaria.

METHODS

Potential delivery strategies for RTS,S/AS01E in areas with seasonal malaria were identified through a series of high level discussions with the RTS,S/AS01E plus SMC trial investigators, international and national immunisation and malaria experts, and through the development of a theory of change. These were explored through qualitative in-depth interviews with 108 participants, including national-level, regional-level and district-level malaria and immunisation programme managers, health workers, caregivers of children under 5 years of age, and community stakeholders. A national-level workshop was held to confirm the qualitative findings and work towards consensus on an appropriate strategy.

RESULTS

Four delivery strategies were identified: age-based vaccination delivered via the Essential Programme on Immunisation (EPI); seasonal vaccination via EPI mass vaccination campaigns (MVCs); a combination of age-based priming vaccination doses delivered via the EPI clinics and seasonal booster doses delivered via MVCs; and a combination of age-based priming vaccination doses and seasonal booster doses, all delivered via the EPI clinics, which was the preferred strategy for delivery of RTS,S/AS01E in Mali identified during the national workshop. Participants recommended that supportive interventions, including communications and mobilisation, would be needed for this strategy to achieve required coverage.

CONCLUSIONS

Four delivery strategies were identified for administration of RTS,S/AS01E alongside SMC in countries with seasonal malaria transmission. Components of these delivery strategies were defined as the vaccination schedule, and the delivery system(s) plus the supportive interventions needed for the strategies to be effective. Further implementation research and evaluation is needed to explore how, where, when and what effective coverage is achievable via these new strategies and their supportive interventions.

Evaluating a capacity development intervention in health economics among producers and users of evidence in Nigeria: a case study in Getting Research Into Policy and Practice (GRIPP) in Anambra State

BACKGROUND

The use of research evidence to inform policy and practice cannot be overemphasized especially in low and middle-income countries (LMICs). To promote the use of research evidence in the provision of health services for enhanced effective control of communicable diseases in developing countries, the World Health Organization (WHO) in collaboration with the Health Policy Research Group (HPRG) commissioned a capacity development workshop in health economics among producers and users of research evidence in the healthcare system of Anambra state, south east Nigeria. This study was aimed to evaluate the impact of the workshop training on selected stakeholders on the use of health economics evidence to inform health policy and practice in the state.

METHODS

Participants were purposively selected based either as producers and users of evidence at various levels of healthcare decision making in Anambra state, comprising mostly senior managers and executives from the ministry of health, the academic and health institutions in the state. A two-day capacity development workshop was conducted to train the participants on the use of economic evidence to inform health policy and practice. Pre-post test approach and group exercises were used to assess the knowledge and impact of the training exercises on the participants regarding the use of health economics evidence. Analysis was based on the framework of process-output-outcome-impact approach using the pre-post test and scores technique to assess the impact of the training programme.

RESULTS

Pretest average scores varied from 39.7% to 60.5% while posttest scores varied from 47.6% to 65.7%, showing big differences in individual scores among participants, between the producers and users of evidence both prior to and after the training. The significant differences between the test scores indicated success in increasing the knowledge of participants on the use of health economics evidence. Results corroborated participants' perceptions that the workshop impacted positively on their ability to apply the knowledge of health economic evidence to inform decision making in their respective practices.

CONCLUSION

Findings underscored the need for regular upgrade of stakeholders in the health system for enhanced uptake and sustainability of the programme to achieve the desired goal of getting research into policy and practice in the state applicable to other settings.

Assessing the effects of disease-specific programs on health systems: An analysis of the Bangladesh Lymphatic Filariasis Elimination Program's impacts on health service coverage and catastrophic health expenditure

This study presents a methodology for using tracer indicators to measure the effects of disease-specific programs on national health systems. The methodology is then used to analyze the effects of Bangladesh’s Lymphatic Filariasis Elimination Program, a disease-specific program, on the health system. Using difference-in-differences models and secondary data from population-based household surveys, this study compares changes over time in the utilization rates of eight essential health services and incidences of catastrophic health expenditures between individuals and households, respectively, of lymphatic filariasis hyper-endemic districts (treatment districts) and of hypo- and non-endemic districts (control districts). Utilization of all health services increased from year 2000 to year 2014 for the entire population but more so for the population living in treatment districts. However, when the services were analyzed individually, the difference-in-differences between the two populations was insignificant. Disadvantaged populations (i.e., populations that lived in rural areas, belonged to lower wealth quintiles, or did not attend school) were less likely to access essential health services. After five years of program interventions, households in control districts had a lower incidence of catastrophic health expenditures at several thresholds measured using total household expenditures and total non-food expenditures as denominators. Using essential health service coverage rates as outcome measures, the Lymphatic Filariasis Elimination Program cannot be said to have strengthened or weakened the health system. We can also say that there is a positive association between the Lymphatic Filariasis Elimination Program’s interventions and lowered incidence of catastrophic health expenditures.

Evidence to understand the interactions between disease specific programs and the health system is insufficient and largely based on opinion. This study presents a methodology for using tracer indicators to measure the effect of a disease-specific program, the Bangladesh Lymphatic Filariasis Elimination Program, on its health system. The Composite Coverage Index and incidence of catastrophic health expenditures are well-established tracer indicators for measuring the strength of a health system. In this study, they were calculated, before the program started in 2000 and after it ended in 2015, using data from Demographic and Health Surveys and Household Income and Expenditure Surveys, respectively. Using the Composite Coverage Index to measure the effects of the Lymphatic Filariasis Elimination Program revealed that it did not negatively or positively affect health service coverage rates. We can also say that there is a positive association between the program interventions and lowered incidence of catastrophic health expenditures.

Country perspectives on improving technical assistance in the health sector

Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA's two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study.   Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.

30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation

Introduction

The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.

Methods

We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.

Results

Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.

Conclusion

It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate. 

Resource tracking for neglected tropical disease programmes: the first step for developing a sustainable financing strategy

The adequacy of resources for programme implementation is a premise for achieving the targets set in the road map for neglected tropical diseases (NTDs) 2021–2030. During the decade 2010–2020, international health aid and pharmaceutical donations have driven progress to control and eliminate NTDs. In the next decade, domestic financing will be critical to sustain NTD control and elimination programmes. Tracking domestic resources for NTD programmes through country health accounts, a relatively mature health system resource tracking platform, could be the first step in raising the visibility of NTDs in the discussion of national health resource allocation.

Understanding hard-to-reach communities: local perspectives and experiences of trachoma control among the pastoralist Maasai in northern Tanzania

As progress to eliminate trachoma is made, addressing hard-to-reach communities becomes of greater significance. Areas in Tanzania, inhabited by the Maasai, remain endemic for trachoma. This study assessed the effectiveness of Mass Drug Administration (MDA) through an ethnographic study of trachoma amongst a Maasai community. The MDA experience in the context of the livelihoods of the Maasai in a changing political economy was explored using participant observation and household interviews. Factors influencing MDA effectiveness within five domains were analysed. 1) Terrain of intervention: Human movement hindered MDA, including seasonal migration, domestic chores, grazing and school. Encounters with wildlife were significant. 2) Socio-cultural factors and community agency: Norms around pregnancy led women to accept the drug but hide refusal to swallow the drug. Timing of Community Drug Distributor (CDD) visits conflicted with livestock grazing. Refusals occurred among the ilmurrani age group and older women. Mistrust significantly hindered uptake of drugs. 3) Strategies and motivation of drug distributors: Maa-speaking CDDs were critical to effective drug delivery. Maasai CDDs, whilst motivated, faced challenges of distances, encounters with wildlife and compensation. 4) Socio-materiality of technology: Decreases in side-effects over years have improved trust in the drug. Restrictions to swallowing drugs and/or water were relevant to post-partum women and the ilmurrani. 5) History and health governance: Whilst perceptions of the programme were positive, communities questioned government priorities for resources for hospitals, medicines, clean water and roads. They complained of a lack of information and involvement of community members in health care services. With elimination in sight, hard-to-reach communities are paramount as these are probably the last foci of infection. Effective delivery of MDA programmes in such communities requires a critical understanding of community experiences and responses that can inform tailored approaches to trachoma control. Application of a critical social science perspective should be embedded in planning and evaluation of all NTD programmes.

Building the capacity of users and producers of evidence in health policy and systems research for better control of endemic diseases in Nigeria: a situational analysis

Background

There is a current need to build the capacity of Health Policy and Systems Research + Analysis (HPSR+A) in low and middle-income countries (LMICs) as this enhances the processes of decision-making at all levels of the health system. This paper provides information on the HPSR+A knowledge and practice among producers and users of evidence in priority setting for HPSR+A regarding control of endemic diseases in two states in Nigeria. It also highlights the HPSR+A capacity building needs and interventions that will lead to increased HPSR+A and use for actual policy and decision making by the government and other policy actors.

Methods

Data was collected from 96 purposively selected respondents who are either researchers/ academia (producers of evidence) and policy/decision-makers, programme/project managers (users of evidence) in Enugu and Anambra states, southeast Nigeria. A pre-tested questionnaire was the data collection tool. Analysis was by univariate and bivariate analyses.

Results

The knowledge on HPSR+A was moderate and many respondents understood the importance of evidence-based decision making. Majority of researcher stated their preferred channel of dissemination of research finding to be journal publication. The mean percentage of using HPSR evidence for programme design & implementation of endemic disease among users of evidence was poor (18.8%) in both states. There is a high level of awareness of the use of evidence to inform policy across the two states and some of the respondents have used some evidence in their work.

Conclusion

The high level of awareness of the use of HPSR+A evidence for decision making did not translate to the significant actual use of evidence for policy making. The major reasons bordered on lack of autonomy in decision making. Hence, the existing yawning gap in use of evidence has to be bridged for a strengthening of the health system with evidence.

Developing governance models and funding mechanisms of state-civil society partnerships for HIV/AIDS treatment and prevention based on lessons from Ghana

The contribution of civil society organisations (CSOs) to national HIV/AIDS responses in sub-Saharan African countries, with Global Health Initiatives' (GHIs) funding channelled through National AIDS Commissions (NACs), is well researched. Less well understood are the governance models and funding mechanisms being used to successfully engage CSOs in the HIV/AIDS response. Using data from government, donor, CSO and documentary sources, this article characterises the organisational principles and practices and unique funding models adopted by the Ghana AIDS Commission (GAC) to effectively and efficiently engage CSOs in the HIV/AIDS response. It found four major governance principles and practices that target: 1) strategic planning for service delivery; 2) focussed expressions of interest; 3) competitive tendering and contracting for service delivery; and 4) adoption of results-based management. It also identified three predominant funding models that illustrate the application of these guiding principles to harness the inherent strengths of CSOs to more effectively respond to HIV/AIDS, namely: 1) direct funding of locally-based CSOs; 2) funding international and national NGOs to engage local CSOs in partnership; and 3) funding umbrella organisations. These findings are significant for Ghana but they may also have relevance for other low- or middle-income countries (LMICs) that have limited experience delivering HIV/AIDS services through state-civil society partnerships, as well as broader debates on the role of donors, governments and CSOs working in partnership to fight HIV/AIDS.

Impact of measles supplementary immunisation activities on utilisation of maternal and child health services in low-income and middle-income countries

Background

Measles supplementary immunisation activities (SIAs) are an integral component of measles elimination in low-income and middle-income countries (LMICs). Despite their success in increasing vaccination coverage, there are concerns about their negative consequences on routine services. Few studies have conducted quantitative assessments of SIA impact on utilisation of health services.

Methods

We analysed the impact of SIAs on utilisation of selected maternal and child health services using Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 28 LMICs, where at least one SIA occurred over 2000–2014. Logistic regressions were conducted to investigate the association between SIAs and utilisation of the following services: facility delivery, postnatal care and outpatient sick child care (for fever, diarrhoea, cough).

Results

SIAs do not appear to significantly impact utilisation of maternal and child services. We find a reduction in care-seeking for treatment of child cough (OR 0.67; 95% CI 0.48 to 0.95); and a few significant effects at the country level, suggesting the need for further investigation of the idiosyncratic effects of SIAs in each country.

Conclusion

The paper contributes to the debate on vertical versus horizontal programmes to ensure universal access to vaccination. Measles SIAs do not seem to affect care-seeking for critical conditions.

Elimination of lymphatic filariasis: current perspectives on mass drug administration

Following the London declaration on neglected tropical diseases (NTDs) in 2012 and inspired by the WHO 2020 roadmap to control or eliminate NTDs, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) intensified preventive chemotherapy and management of morbidity as the two main strategies to enhance progress towards the elimination of lymphatic filariasis (LF). This paper focuses on current perspectives of mass drug administration (MDA) towards the elimination of LF. The goal of MDA is to reduce the density of parasites circulating in the blood of infected persons and the intensity of infection in communities to levels where transmission is no longer sustainable by the mosquito vector. Three drugs, diethylcarbamazine, albendazole, and ivermectin are currently available for LF treatment, and their effectiveness and relative safety have opened the possibility of treating the entire population at risk. Currently, almost all LF endemic countries rely on the single-dose two-drug regimen recommended by the GPELF to achieve elimination. The 4th WHO report on NTDs has indicated that considerable progress has been made towards elimination of LF in some countries while acknowledging some challenges. In this review, we conclude that the 2020 elimination goal can be achieved if issues pertaining to the drug distribution, health system and implementation challenges are addressed.

Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs)

BACKGROUND

Community drug distributors or neglected tropical disease (NTD) volunteers have played a crucial role in ensuring the success of mass drug administration (MDA) programs using preventive chemotherapy (PC) for lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil transmitted helminths. In recent years however, a noticeable decline in motivation of some of these volunteers has been perceived, potentially negatively impacting the success of these programs. Potential hypotheses for this change in motivation include the long duration of many MDA programs, the change in sociocultural environments as well as the changes to the programs over time. This literature review identifies factors that affect NTD volunteer performance and motivation, which may be used to influence and improve future programming.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic search was conducted to identify studies published between January 1995 and September 2016 that investigate factors pertaining to volunteer motivation and performance in NTD drug distribution programs. Searches from several databases and grey literature yielded 400 records, of which 28 articles from 10 countries met the inclusion criteria. Quality assessment of studies was performed using the Critical Appraisal Skills Programme(CASP) checklist. Data pertaining to motivation, performance, retention and satisfaction was extracted and examined for themes. Recurring themes in the literature included monetary and material incentives, intrinsic motivation, gender, cost to participate, and health systems and community support. Of these, community support and the health system were found to be particularly impactful. Very few studies were found to explicitly look at novel incentives for volunteers and very few studies have considered the out of pocket and opportunity costs that NTD volunteers bear carrying out their tasks.

CONCLUSIONS/SIGNIFICANCE

There is currently great interest in incorporating more attractive incentive schemes for NTD volunteers. However, our results show that the important challenges that volunteers face (cultural, health systems, financial and community related) may have less to do with financial incentives and may actually have a larger impact on their motivation than has previously been understood. Further integration of NTD programs into existing health systems is expected to improve the NTD volunteer working environment. Relevant community engagement related to the MDA program should also provide the supportive environment needed in the community to support NTD volunteers. Programs need to consider these issues to improve working conditions for NTD volunteers.

RUMOURS, RIOTS AND THE REJECTION OF MASS DRUG ADMINISTRATION FOR THE TREATMENT OF SCHISTOSOMIASIS IN MOROGORO, TANZANIA

In 2008 in Morogoro region, Tanzania, mass drug administration (MDA) to school-aged children to treat two neglected tropical diseases (NTDs) - urinary schistosomiasis and soil-transmitted helminths - was suspended by the Ministry of Health and Social Welfare after riots broke out in schools where drugs were being administered. This article discusses why this biomedical intervention was so vehemently rejected, including an eyewitness account. As the protest spread to the village where I was conducting fieldwork, villagers accused me of bringing medicine into the village with which to 'poison' the children and it was necessary for me to leave immediately under the protection of the Tanzanian police. The article examines the considerable differences between biomedical and local understandings of one of these diseases, urinary schistosomiasis. Such a disjuncture was fuelled further by the apparent rapidity of rolling out MDA and subsequent failures in communication between programme staff and local people. Rumours of child fatalities as well as children's fainting episodes and illnesses following treatment brought about considerable conjecture both locally and nationally that the drugs had been either faulty, counterfeit, hitherto untested on humans or part of a covert sterilization campaign. The compelling arguments by advocates of MDA for the treatment of NTDs rest on the assumption that people suffering from these diseases will be willing to swallow the medicine. However, as this article documents, this is not always the case. For treatment of NTDs to be successful it is not enough for programmes to focus on economic and biomedical aspects of treatment, rolling out 'one size fits all' programmes in resource-poor settings. It is imperative to develop a biosocial approach: to consider the local social, biological, historical, economic and political contexts in which these programmes are taking place and in which the intended recipients of treatment live their lives. If this is not done, the world's poor will continue to be neglected.

DEWORMING DELUSIONS? MASS DRUG ADMINISTRATION IN EAST AFRICAN SCHOOLS

Recent debates about deworming school-aged children in East Africa have been described as the 'Worm Wars'. The stakes are high. Deworming has become one of the top priorities in the fight against infectious diseases. Staff at the World Health Organization, the Gates Foundation and the World Bank (among other institutions) have endorsed the approach, and school-based treatments are a key component of large-scale mass drug administration programmes. Drawing on field research in Uganda and Tanzania, and engaging with both biological and social evidence, this article shows that assertions about the effects of school-based deworming are over-optimistic. The results of a much-cited study on deworming Kenyan school children, which has been used to promote the intervention, are flawed, and a systematic review of randomized controlled trials demonstrates that deworming is unlikely to improve overall public health. Also, confusions arise by applying the term deworming to a variety of very different helminth infections and to different treatment regimes, while local-level research in schools reveals that drug coverage usually falls below target levels. In most places where data exist, infection levels remain disappointingly high. Without indefinite free deworming, any declines in endemicity are likely to be reversed. Moreover, there are social problems arising from mass drug administration that have generally been ignored. Notably, there are serious ethical and practical issues arising from the widespread practice of giving tablets to children without actively consulting parents. There is no doubt that curative therapy for children infected with debilitating parasitic infections is appropriate, but overly positive evaluations of indiscriminate deworming are counter-productive.

NEGLECTED TROPICAL DISEASES IN BIOSOCIAL PERSPECTIVE

The term 'neglected tropical diseases' (NTDs) points to the need for a biosocial perspective. Although 'diseases' are widely understood as biological phenomena, 'neglect' is inherently social. Social priorities, social relations and social behaviour profoundly influence the design, implementation and evaluation of control programmes. Yet, these dimensions of neglect are, themselves, neglected. Instead, emphasis is being placed on preventive chemotherapy - a technical, context-free approach which relies almost entirely on the mass distribution of drugs, at regular intervals, to populations living in endemic areas. This article reflects on the processes which have enabled an NTD 'brand' identity to emerge, and it comments on a disquieting disengagement with some of the more critical insights about the consequences of mass drug administration. Building on the work of biosocial scholars studying other aspects of health and disease, a more adequate, evidence-based approach is delineated. Developing such an approach is an iterative process, requiring on-going engagement with both biological and social insights as they emerge. Considerable theoretical, methodological and political challenges lie ahead, but it is essential they are overcome, if the sustainable control of NTDs is to become a reality.

Dedicated health systems strengthening of the Global Fund to Fight AIDS, Tuberculosis, and Malaria: an analysis of grants

BACKGROUND

This study aims to understand the determinants of the Global Fund to Fight AIDS, Tuberculosis, and Malaria's dedicated channel for health systems strengthening (HSS) funding across countries and to analyze their health system priorities expressed in budgets and performance indicators.

METHODS

We obtained publicly available data for disease-specific and HSS grants from the Global Fund over 2004-2013 prior to the new funding model. Regression analysis was employed to assess the determinants of dedicated HSS funding across 111 countries. Documents for 27 dedicated HSS grants including budgets and performance indicators were collected, and activities were analyzed by health system functions.

RESULTS

HSS funding per capita is significantly associated with TB and HIV funding per capita, but not per capita income and health worker density. Of 27 dedicated HSS grants, 11 had line-item budgets publicly available, in which health workforce and medical products form the majority (89% or US$132 million of US$148 million) of funds. Yet these areas accounted for 41.7% (215) of total 516 performance indicators.

CONCLUSIONS

Health worker densities were not correlated with HSS funding, despite the emphasis on health workforce in budgets and performance indicators. Priorities in health systems in line-item budgets differ from the numbers of indicators used.

One year of campaigns in Cameroon: effects on routine health services

BACKGROUND

Targeted campaigns have been reported to disrupt routine health services in low- and middle-income countries. The objective of this study was to evaluate the average effect of public health campaigns over 1 year on routine services such as antenatal care, routine vaccination and outpatient services.

METHOD

We collected daily activity data in 60 health facilities in two regions of Cameroon that traditionally undergo different intensities of campaign activity, the Centre region (low) and the Far North (high), to ascertain effects on routine services. For each outcome, we restricted our analysis to the public health centres for which good data were available and excluded private health facilities given their small number. We used segment-linear regression to account for the longitudinal nature of the data, and assessed whether the number of routine activities decreased in health facilities during periods when campaigns occurred. The analysis controlled for secular trends and serial correlation.

RESULTS

We found evidence that vaccination campaigns had a negative impact on routine activities, decreasing outpatient visits when they occurred (Centre: -9.9%, P = 0.079; Far North: -11.6%, P = 0.025). The average negative effect on routine services [outpatient visits -18% (P = 0.02) and antenatal consultations -70% [P = 0.001]) was most pronounced in the Far North during 'intensive' campaigns that usually require high mobilization of staff.

DISCUSSION

With an increasing number of interventions delivered by campaigns and in the context of elimination and eradication targets, these are important results for countries and agencies to consider. Achieving disease control targets hinges on ensuring high uptake of routine services. Therefore, we suggest that campaigns should systematically monitor 'impact on routine services', while also devising concrete strategies to mitigate potential adverse effects.

Integrated Healthcare Delivery: A Qualitative Research Approach to Identifying and Harmonizing Perspectives of Integrated Neglected Tropical Disease Programs

Background

While some evidence supports the beneficial effects of integrating neglected tropical disease (NTD) programs to optimize coverage and reduce costs, there is minimal information regarding when or how to effectively operationalize program integration. The lack of systematic analyses of integration experiences and of integration processes may act as an impediment to achieving more effective NTD programming. We aimed to learn about the experiences of NTD stakeholders and their perceptions of integration.

Methodology

We evaluated differences in the definitions, roles, perceived effectiveness, and implementation experiences of integrated NTD programs among a variety of NTD stakeholder groups, including multilateral organizations, funding partners, implementation partners, national Ministry of Health (MOH) teams, district MOH teams, volunteer rural health workers, and community members participating in NTD campaigns. Semi-structured key informant interviews were conducted. Coding of themes involved a mix of applying in-vivo open coding and a priori thematic coding from a start list.

Findings

In total, 41 interviews were conducted. Salient themes varied by stakeholder, however dominant themes on integration included: significant variations in definitions, differential effectiveness of specific integrated NTD activities, community member perceptions of NTD programs, the influence of funders, perceived facilitators, perceived barriers, and the effects of integration on health system strength. In general, stakeholder groups provided unique perspectives, rather than contrarian points of view, on the same topics. The stakeholders identified more advantages to integration than disadvantages, however there are a number of both unique facilitators and challenges to integration from the perspective of each stakeholder group.

Conclusions

Qualitative data suggest several structural, process, and technical opportunities that could be addressed to promote more effective and efficient integrated NTD elimination programs. We highlight a set of ten recommendations that may address stakeholder concerns and perceptions regarding these key opportunities. For example, public health stakeholders should embrace a broader perspective of community-based health needs, including and beyond NTDs, and available platforms for addressing those needs.

Neglected tropical diseases are a group of parasitic, viral, and bacterial diseases that are often co-endemic in low resource settings. Five of these diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminths, and trachoma) are addressed specifically through a method called mass drug administration, where entire at risk populations are targeted with preventative drug treatments. Because of the geographical and interventional overlap between these diseases, many experts recommend program integration as a method for accelerating their control or elimination. However the optimal approaches for operationalizing integrated programing has not been systematically assessed. We undertook a cross sectional qualitative research study with neglected tropical disease stakeholders to understand different stakeholder approaches to and perspectives on program integration. The stakeholders highlighted different definitions of the term “integration”, the differential effectiveness of specific activities when integrated, the influence of integration on community member engagement, the influence of funders on integrated programming, facilitators and barriers to effective integration, and the effects of integration on health system strength. Our analysis suggests that there are three types of integration to consider: structural, process, and technical. We use these categories to make ten recommendations to stakeholders that might be used to improve integrated neglected tropical disease programming moving forward.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa. Similar to other developing areas throughout the world, this region's dearth of skilled health providers renders Western-style primary care efforts to address such diseases unrealistic. Consequently, many countries rely on their corps of nurses and community health workers to engage with underserved and hard-to-reach populations in order provide interventions against these maladies. This article attempts to cull together recent literature on the impact that nurses and community health workers have had on neglected tropical diseases.

METHODS

A review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses' and community health workers' responsibilities for neglected tropical disease control within their respective countries' health systems.

RESULTS

A total of 59 articles were identified that fit all inclusion criteria.

CONCLUSIONS

Successful disease control requires deep and meaningful engagement with local communities. Expanding the role of nurses and community health workers will be required if sub-Saharan African countries are to meet neglected tropical disease treatment goals and eliminate the possibility future disease transmission. Horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies-benefits that vertical programs are not able to attain.

Ambiguous Capture: Collaborative Capitalism and the Meningitis Vaccine Project

The primary health care approach advanced at Alma Ata to address social determinants of health was replaced by selective health care a year later at Bellagio. Subsequently, immunization was endorsed as a cost-effective technical intervention to combat targeted infectious diseases. Multilateral efforts to collaborate on immunization as a universal public health good ambiguously capture the interests of the world's governments as well as private, public, and not-for-profit institutions. Global assemblages of scientists, governments, industry and nongovernmental organizations now work in public-private partnerships to develop and make essential vaccines accessible, with vaccines marketed as single fix solutions for global health. Drawing from ethnographic fieldwork in France and Burkina Faso that followed the development, regulation, and implementation of the group A meningococcal conjugate vaccine for sub-Saharan Africa, in this article I describe events during and after the development of MenAfriVac. A technological success narrative steeped in collaborative capitalist rhetoric disguises neglected health care systems.

When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India

OBJECTIVE

Disease-specific programmes have had a long history in India and their presence has increased over time. This study has two objectives: first, it reports on the interaction between local health systems and key disease-specific programmes in India—National AIDS Control Program (NACP) (HIV/AIDS), Revised National Tuberculosis Control Program (RNTCP) (TB) and National Vector Borne Disease Control Program (NVBDCP) (Malaria), and second, it examines which factors create an enabling environment for disease-specific programmes to strengthen health systems.

METHODS

A total of 103 in-depth interviews were conducted in six states in 2009 and 2010. Key informants included managers of disease control programmes and health systems, central and state health ministry and staff from peripheral health facilities. Analytical themes were derived from the World Health Organization (WHO) building block and the Systems Rapid Assessment framework.

FINDINGS

Disease-specific programmes contribute to strengthening some components of the health system by sharing human and material resources, increasing demand for health services by improving public perceptions of service quality, encouraging civil society involvement in service delivery and sharing diseasespecific information with local health system managers. These synergies were observed more frequently in the RNTCP and NVBDCP compared with the NACP.

CONCLUSIONS

Disease-specific programmes in India are widely regarded as having made a substantial contribution in disease control. They can have both positive and negative effects on health systems. Certain conditions are necessary for them to have a positive influence on health systems—the programme needs to have an explicit policy to strengthen local health systems, and should also be embedded within the health system administration.

Extent of Integration of Priority Interventions into General Health Systems: A Case Study of Neglected Tropical Diseases Programme in the Western Region of Ghana

BACKGROUND

The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration.

METHODOLOGY/PRINCIPAL FINDINGS

The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes-across health system functions-stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system-national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00-1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48-0.68; however it was higher at the district compared to the national and regional levels.

CONCLUSIONS/SIGNIFICANCE

To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration.

Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding

BACKGROUND

This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS

Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS

Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS

Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.

Diagnosis of neglected tropical diseases among patients with persistent digestive disorders (diarrhoea and/or abdominal pain ≥14 days): Pierrea multi-country, prospective, non-experimental case-control study

Background

Diarrhoea still accounts for considerable mortality and morbidity worldwide. The highest burden is concentrated in tropical areas where populations lack access to clean water, adequate sanitation and hygiene. In contrast to acute diarrhoea (<14 days), the spectrum of pathogens that may give rise to persistent diarrhoea (≥14 days) and persistent abdominal pain is poorly understood. It is conceivable that pathogens causing neglected tropical diseases play a major role, but few studies investigated this issue. Clinical management and diagnostic work-up of persistent digestive disorders in the tropics therefore remain inadequate. Hence, important aspects regarding the pathogenesis, epidemiology, clinical symptomatology and treatment options for patients presenting with persistent diarrhoea and persistent abdominal pain should be investigated in multi-centric clinical studies.

Methods/Design

This multi-country, prospective, non-experimental case–control study will assess persistent diarrhoea (≥14 days; in individuals aged ≥1 year) and persistent abdominal pain (≥14 days; in children/adolescents aged 1–18 years) in up to 2000 symptomatic patients and 2000 matched controls. Subjects from Côte d’Ivoire, Indonesia, Mali and Nepal will be clinically examined and interviewed using a detailed case report form. Additionally, each participant will provide a stool sample that will be examined using a suite of diagnostic methods (i.e., microscopic techniques, rapid diagnostic tests, stool culture and polymerase chain reaction) for the presence of bacterial and parasitic pathogens. Treatment will be offered to all infected participants and the clinical treatment response will be recorded. Data obtained will be utilised to develop patient-centred clinical algorithms that will be validated in primary health care centres in the four study countries in subsequent studies.

Discussion

Our research will deepen the understanding of the importance of persistent diarrhoea and related digestive disorders in the tropics. A diversity of intestinal pathogens will be assessed for potential associations with persistent diarrhoea and persistent abdominal pain. Different diagnostic methods will be compared, clinical symptoms investigated and diagnosis-treatment algorithms developed for validation in selected primary health care centres. The findings from this study will improve differential diagnosis and evidence-based clinical management of digestive syndromes in the tropics.

Trial registration

ClinicalTrials.gov; identifier: NCT02105714.

Exploring the influence of the Global Fund and the GAVI Alliance on health systems in conflict-affected countries

Background

Global Health Initiatives (GHIs) respond to high-impact communicable diseases in resource-poor countries, including health systems support, and are major actors in global health. GHIs could play an important role in countries affected by armed conflict given these countries commonly have weak health systems and a high burden of communicable disease. The aim of this study is to explore the influence of two leading GHIs, the Global Fund and the GAVI Alliance, on the health systems of conflict-affected countries.

Methods

This study used an analytical review approach to identify evidence on the role of the Global Fund and the GAVI Alliance with regards to health systems support to 19 conflict-affected countries. Primary and secondary published and grey literature were used, including country evaluations from the Global Fund and the GAVI Alliance. The WHO heath systems building blocks framework was used for the analysis.

Results

There is a limited evidence-base on the influence of GHIs on health systems of conflict-affected countries. The findings suggest that GHIs are increasingly investing in conflict-affected countries which has helped to rapidly scale up health services, strengthen human resources, improve procurement, and develop guidelines and protocols. Negative influences include distorting priorities within the health system, inequitable financing of disease-specific services over other health services, diverting staff away from more essential health care services, inadequate attention to capacity building, burdensome reporting requirements, and limited flexibility and responsiveness to the contextual challenges of conflict-affected countries.

Conclusions

There is some evidence of increasing engagement of the Global Fund and the GAVI Alliance with health systems in conflict-affected countries, but this engagement should be supported by more context-specific policies and approaches.

De-politicizing parasites: reflections on attempts to control the control of neglected tropical diseases

Large amounts of funding are being allocated to the control of neglected tropical diseases. Strategies primarily rely on the mass distribution of drugs to adults and children living in endemic areas. The approach is presented as morally appropriate, technically effective, and context-free. Drawing on research undertaken in East Africa, we discuss ways in which normative ideas about global health programs are used to set aside social and biological evidence. In particular, there is a tendency to ignore local details, including information about actual drug take up. Ferguson’s ‘anti-politics’ thesis is a useful starting point for analyzing why this happens, but is overly deterministic. Anti-politics discourse about healing the suffering poor may shape thinking and help explain cognitive dissonance. However, use of such discourse is also a means of strategically promoting vested interests and securing funding. Whatever the underlying motivations, rhetoric and realities are conflated, with potentially counterproductive consequences.

Global aspirations, local realities: the role of social science research in controlling neglected tropical diseases

Neglected Tropical Diseases (NTDs) are both drivers and manifestations of poverty and social inequality. Increased advocacy efforts since the mid-2000s have led to ambitious new control and elimination targets set for 2020 by the World Health Organisation. While these global aspirations represent significant policy momentum, there are multifaceted challenges in controlling infectious diseases in resource-poor local contexts that need to be acknowledged, understood and engaged. However a number of recent publications have emphasised the “neglected” status of applied social science research on NTDs. In light of the 2020 targets, this paper explores the social science/NTD literature and unpacks some of the ways in which social inquiry can help support effective and sustainable interventions. Five priority areas are discussed, including on policy processes, health systems capacity, compliance and resistance to interventions, education and behaviour change, and community participation. The paper shows that despite the multifaceted value of having anthropological and sociological perspectives integrated into NTD programmes, contemporary efforts underutilise this potential. This is reflective of the dominance of top-down information flows and technocratic approaches in global health. To counter this tendency, social research needs to be more than an afterthought; integrating social inquiry into the planning, monitoring and evaluating process will help ensure that flexibility and adaptability to local realities are built into interventions. More emphasis on social science perspectives can also help link NTD control to broader social determinants of health, especially important given the major social and economic inequalities that continue to underpin transmission in endemic countries.

The Impact of Nurses on Neglected Tropical Disease Management

Although Neglected Tropical Diseases (NTDs) are largely endemic in the developing nations of Africa, Asia, and South and Central America, they are reemerging with increasing frequency in developed countries. Their diagnosis, treatment, and control are an increasing public health concern that requires a different awareness by health care providers. Neglected tropical diseases (NTDs) are chronic infectious diseases which disproportionately burden poor, rural, and marginalized populations with significant mortality and high morbidity (disability, disfigurement, impaired childhood growth and cognitive development, increased vulnerability to coinfection) that reinforces their poverty. What can we learn from the nurses in developing countries already battling NTD's that could be useful in the developed world? This article provides an overview of distribution, pathophysiology, symptoms, and management of 13 NTDs, with particular attention to the role of nurses in delivering cost-effective integrated interventions. Case studies of schistosomiasis, Chagas disease, and leishmaniasis address recognition and treatment of infected individuals in developed nations where NTD infection is limited primarily to immigrants and travelers.

Evaluation of capacity-building program of district health managers in India: a contextualized theoretical framework

Performance of local health services managers at district level is crucial to ensure that health services are of good quality and cater to the health needs of the population in the area. In many low- and middle-income countries, health services managers are poorly equipped with public health management capacities needed for planning and managing their local health system. In the south Indian Tumkur district, a consortium of five non-governmental organizations partnered with the state government to organize a capacity-building program for health managers. The program consisted of a mix of periodic contact classes, mentoring and assignments and was spread over 30 months. In this paper, we develop a theoretical framework in the form of a refined program theory to understand how such a capacity-building program could bring about organizational change. A well-formulated program theory enables an understanding of how interventions could bring about improvements and an evaluation of the intervention. In the refined program theory of the intervention, we identified various factors at individual, institutional, and environmental levels that could interact with the hypothesized mechanisms of organizational change, such as staff's perceived self-efficacy and commitment to their organizations. Based on this program theory, we formulated context-mechanism-outcome configurations that can be used to evaluate the intervention and, more specifically, to understand what worked, for whom and under what conditions. We discuss the application of program theory development in conducting a realist evaluation. Realist evaluation embraces principles of systems thinking by providing a method for understanding how elements of the system interact with one another in producing a given outcome.

Meningococcal vaccine introduction in Mali through mass campaigns and its impact on the health system

OBJECTIVE

To evaluate the impact of the meningococcal A (MenA) vaccine introduction in Mali through mass campaigns on the routine immunization program and the wider health system.

METHODS

We used a mixed-methods case-study design, combining semi-structured interviews with 31 key informants, a survey among 18 health facilities, and analysis of routine health facility data on number of routine vaccinations and antenatal consultations before, during, and after the MenA vaccine campaign in December 2010. Survey and interview data were collected at the national level and in 2 regions in July and August 2011, with additional interviews in January 2012.

FINDINGS

Many health system functions were not affected-either positively or negatively-by the MenA vaccine introduction. The majority of effects were felt on the immunization program. Benefits included strengthened communication and social mobilization, surveillance, and provider skills. Drawbacks included the interruption of routine vaccination services in the majority of health facilities surveyed (67%). The average daily number of children receiving routine vaccinations was 79% to 87% lower during the 10-day campaign period than during other periods of the month. Antenatal care consultations were also reduced during the campaign period by 10% to 15%. Key informants argued that, with an average of 14 campaigns per year, mass campaigns would have a substantial cumulative negative effect on routine health services. Many also argued that the MenA campaign missed potential opportunities for health systems strengthening because integration with other health services was lacking.

CONCLUSION

The MenA vaccine introduction interrupted routine vaccination and other health services. When introducing a new vaccine through a campaign, coverage of routine health services should be monitored alongside campaign vaccine coverage to highlight where and how long services are disrupted and to mitigate risks to routine services.

Global health initiative investments and health systems strengthening: a content analysis of global fund investments

BACKGROUND

Millions of dollars are invested annually under the umbrella of national health systems strengthening. Global health initiatives provide funding for low- and middle-income countries through disease-oriented programmes while maintaining that the interventions simultaneously strengthen systems. However, it is as yet unclear which, and to what extent, system-level interventions are being funded by these initiatives, nor is it clear how much funding they allocate to disease-specific activities - through conventional 'vertical-programming' approach. Such funding can be channelled to one or more of the health system building blocks while targeting disease(s) or explicitly to system-wide activities.

METHODS

We operationalized the World Health Organization health system framework of the six building blocks to conduct a detailed assessment of Global Fund health system investments. Our application of this framework framework provides a comprehensive quantification of system-level interventions. We applied this systematically to a random subset of 52 of the 139 grants funded in Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (totalling approximately US$1 billion).

RESULTS

According to the analysis, 37% (US$ 362 million) of the Global Fund Round 8 funding was allocated to health systems strengthening. Of that, 38% (US$ 139 million) was for generic system-level interventions, rather than disease-specific system support. Around 82% of health systems strengthening funding (US$ 296 million) was allocated to service delivery, human resources, and medicines & technology, and within each of these to two to three interventions. Governance, financing, and information building blocks received relatively low funding.

CONCLUSIONS

This study shows that a substantial portion of Global Fund's Round 8 funds was devoted to health systems strengthening. Dramatic skewing among the health system building blocks suggests opportunities for more balanced investments with regard to governance, financing, and information system related interventions. There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. Effective health system strengthening depends on inter-agency collaboration and country commitment along with concerted partnership among all the stakeholders working in the health system.

The interface between the national tuberculosis control programme and district hospitals in Cameroon: missed opportunities for strengthening the local health system -a multiple case study

BACKGROUND

Tuberculosis remains a major public health problem in sub-Saharan Africa. District hospitals (DHs) play a central role in district-based health systems, and their relation with vertical programmes is very important. Studies on the impact of vertical programmes on DHs are rare. This study aims to fill this gap. Its purpose is to analyse the interaction between the National Tuberculosis Control Programme (NTCP) and DHs in Cameroon, especially its effects on the human resources, routine health information system (HIS) and technical capacity at the hospital level.

METHODS

We used a multiple case study methodology. From the Adamaoua Region, we selected two DHs, one public and one faith-based. We collected qualitative and quantitative data through document reviews, semi-structured interviews with district and regional staff, and observations in the two DHs.

RESULTS

The NTCP trained and supervised staff, designed and provided tuberculosis data collection and reporting tools, and provided anti-tuberculosis drugs, reagents and microscopes to DHs. However, these interventions were limited to the hospital units designated as Tuberculosis Diagnostic and Treatment Centres and to staff dedicated to tuberculosis control activities. The NTCP installed a parallel HIS that bypassed the District Health Services. The DH that performs well in terms of general hospital care and that is well managed was successful in tuberculosis control. Based on the available resources, the two hospitals adapt the organisation of tuberculosis control to their settings. The management teams in charge of the District Health Services are not involved in tuberculosis control. In our study, we identified several opportunities to strengthen the local health system that have been missed by the NTCP and the health system managers.

CONCLUSION

Well-managed DHs perform better in terms of tuberculosis control than DHs that are not well managed. The analysis of the effects of the NTCP on the human resources, HIS and technical capacity of DHs indicates that the NTCP supports, rather than strengthens, the local health system. Moreover, there is potential for this support to be enhanced. Positive synergies between the NTCP and district health systems can be achieved if opportunities to strengthen the district health system are seized. The question remains, however, of why managers do not take advantage of the opportunities to strengthen the health system.

Persistent digestive disorders in the tropics: causative infectious pathogens and reference diagnostic tests

BACKGROUND

Persistent digestive disorders account for considerable disease burden in the tropics. Despite advances in understanding acute gastrointestinal infections, important issues concerning epidemiology, diagnosis, treatment and control of most persistent digestive symptomatologies remain to be elucidated. Helminths and intestinal protozoa are considered to play major roles, but the full extent of the aetiologic spectrum is still unclear. We provide an overview of pathogens causing digestive disorders in the tropics and evaluate available reference tests.

METHODS

We searched the literature to identify pathogens that might give rise to persistent diarrhoea, chronic abdominal pain and/or blood in the stool. We reviewed existing laboratory diagnostic methods for each pathogen and stratified them by (i) microscopy; (ii) culture techniques; (iii) immunological tests; and (iv) molecular methods. Pathogen-specific reference tests providing highest diagnostic accuracy are described in greater detail.

RESULTS

Over 30 pathogens may cause persistent digestive disorders. Bacteria, viruses and parasites are important aetiologic agents of acute and long-lasting symptomatologies. An integrated approach, consisting of stool culture, microscopy and/or specific immunological techniques for toxin, antigen and antibody detection, is required for accurate diagnosis of bacteria and parasites. Molecular techniques are essential for sensitive diagnosis of many viruses, bacteria and intestinal protozoa, and are increasingly utilised as adjuncts for helminth identification.

CONCLUSIONS

Diagnosis of the broad spectrum of intestinal pathogens is often cumbersome. There is a need for rapid diagnostic tests that are simple and affordable for resource-constrained settings, so that the management of patients suffering from persistent digestive disorders can be improved.

Neglected tropical diseases: comparison of the costs of integrated and vertical preventive chemotherapy treatment in Niger

BACKGROUND

This study presents evidence on the cost of integrated preventive chemotherapy treatment (PCT) to control trachoma, schistosomiasis, lymphatic filariasis and soil-transmitted helminthiasis (STH) in Niger. Integrated PCT costs are compared with the costs of vertical PCT control.

METHODS

Data were analysed for the integrated PCT of 2008 and 2009 in six districts. Receipts, treatment registers, coverage forms and drug registers provided cost and treatment information. Economic costs of the time spent on campaign activities by government staff was derived from a survey of 56 staff. Integrated control costs were compared with vertical programmes undertaken in 2005 using 2009 constant prices.

RESULTS

The average economic cost of integrated PCT was US$0.19/treatment excluding drugs (US$0.38 for a district with two drug treatments). The average financial cost was US$0.09/treatment (US$0.18 for a district with two drug treatments).The average financial cost of vertical treatment was US$0.167 for trachoma, US$0.10 for schistosomiasis and STH and US$0.075 for lymphatic filariasis. The integrated programme had savings of 16% and 21% in programme costs in 2008 and 2009, respectively, compared with the vertical programmes.

CONCLUSION

Further work is needed to forecast the effectiveness of alternative long-term integrated treatment strategies for control and/or elimination of neglected tropical diseases.

Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

Background

The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.

Methods/Design

This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.

Discussion

The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.

Implementing preventive chemotherapy through an integrated National Neglected Tropical Disease Control Program in Mali

Background

Mali is endemic for all five targeted major neglected tropical diseases (NTDs). As one of the five ‘fast-track’ countries supported with the United States Agency for International Development (USAID) funds, Mali started to integrate the activities of existing disease-specific national control programs on these diseases in 2007. The ultimate objectives are to eliminate lymphatic filariasis, onchocerciasis and trachoma as public health problems and to reduce morbidity caused by schistosomiasis and soil-transmitted helminthiasis through regular treatment to eligible populations, and the specific objectives were to achieve 80% program coverage and 100% geographical coverage yearly. The paper reports on the implementation of the integrated mass drug administration and the lessons learned.

Methodology/Principal Findings

The integrated control program was led by the Ministry of Health and coordinated by the national NTD Control Program. The drug packages were designed according to the disease endemicity in each district and delivered through various platforms to eligible populations involving the primary health care system. Treatment data were recorded and reported by the community drug distributors. After a pilot implementation of integrated drug delivery in three regions in 2007, the treatment for all five targeted NTDs was steadily scaled up to 100% geographical coverage by 2009, and program coverage has since been maintained at a high level: over 85% for lymphatic filariasis, over 90% for onchocerciasis and soil-transmitted helminthiasis, around 90% in school-age children for schistosomiasis, and 76–97% for trachoma. Around 10 million people have received one or more drug packages each year since 2009. No severe cases of adverse effects were reported.

Conclusions/Significance

Mali has scaled up the drug treatment to national coverage through integrated drug delivery involving the primary health care system. The successes and lessons learned in Mali can be valuable assets to other countries starting up their own integrated national NTD control programs.

Neglected tropical diseases (NTDs) are a group of chronic infections that affect the poorest group of the populations in the world. There are currently five major NTDs targeted through mass drug treatment in the affected communities. The drug delivery can be integrated to deliver different drug packages as these NTDs often overlap in distribution. Mali is endemic with all five major NTDs. The integrated national NTD control program was implemented through the primary health care system using the community health center workers and the community drug distributors aiming at long-term sustainability. After a pilot start in three regions in 2007 without prior examples to follow on integrated mass drug administration, treatment for the five targeted NTDs was gradually scaled up and reached all endemic districts by 2009, and annual drug coverage in the targeted population has since been maintained at a high level for each of the five NTDs. Around 10 million people received one or more drug treatments each year since 2009. The country is on the way to meet the national objectives of elimination or control of these diseases. The successes and lessons learned in Mali are valuable assets to other countries looking to start similar programs.

Neglected tropical diseases and the millennium development goals: why the "other diseases" matter: reality versus rhetoric

Since 2004 there has been an increased recognition of the importance of Neglected Tropical Diseases (NTDs) as impediments to development. These diseases are caused by a variety of infectious agents - viruses, bacteria and parasites - which cause a diversity of clinical conditions throughout the tropics. The World Health Organisation (WHO) has defined seventeen of these conditions as core NTDs. The objectives for the control, elimination or eradication of these conditions have been defined in World Health Assembly resolutions whilst the strategies for the control or elimination of individual diseases have been defined in various WHO documents. Since 2005 there has been a drive for the expanded control of these diseases through an integrated approach of mass drug administration referred to as Preventive Chemotherapy via community-based distribution systems and through schools. This has been made possible by donations from major pharmaceutical companies of quality and efficacious drugs which have a proven track record of safety. As a result of the increased commitment of endemic countries, bilateral donors and non-governmental development organisations, there has been a considerable expansion of mass drug administration. In particular, programmes targeting lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil transmitted helminth infections have expanded to treat 887. 8 million people in 2009. There has been significant progress towards guinea worm eradication, and the control of leprosy and human African trypanosomiasis. This paper responds to what the authors believe are inappropriate criticisms of these programmes and counters accusations of the motives of partners made in recently published papers. We provide a detailed response and update the information on the numbers of global treatments undertaken for NTDs and list the success stories to date.The paper acknowledges that in undertaking any health programme in environments such as post-conflict countries, there are always challenges. It is also recognised that NTD control must always be undertaken within the health system context. However, it is important to emphasise that the availability of donated drugs, the multiple impact of those drugs, the willingness of countries to undertake their distribution, thereby committing their own resources to the programmes, and the proven beneficial results outweigh the problems which are faced in environments where communities are often beyond the reach of health services. Given the availability of these interventions, their cost effectiveness and the broader development impact we believe it would be unethical not to continue programmes of such long term benefit to the "bottom billion".