Blockchain Papers

Brittany Hagedorn, Jeremy Cooper, Oluwole Odutolu, Ojukwu Mark Ojukwu · 5 authors

Abstract Background The availability of essential medicines and supplies remains a serious impediment to effective primary health care (PHC) in many lower and lower middle-income countries. Most of these countries rely on centralized procurement, centralized stores, and a “push” distribution system. We describe here the impacts of a large-scale randomized trial in Nigeria, which provided modest funding directly to facilities to spend, on supply availability. Methods Districts in three states were randomly allocated to either direct facility financing (DFF) or performance-based financing (PBF) and matched to a control group. Both DFF and PBF transferred funds to facility bank accounts and allowed the facility management committee to spend on operational costs, including essential drugs. Facilities could procure medicines on the government’s essential drug list from pre-approved suppliers if they were certified by the national drug regulator. We conducted a difference-in-difference (DiD) analysis using facility survey data to assess the impact on availability of essential drugs and supplies. Results Drug availability was initially similar for the three arms of the trial (9 of 29 essential medicines). After three years, DFF and PBF facilities had significantly higher product availability than control (p<0.05). This amounted to an increase of 28/ 34 percentage points in DFF/PBF facilities (an additional 8/10 products, respectively), and only 10% in control (3 additional products). We did note that there was little difference between control and intervention arms in the availability of medicines for donor-supported vertical programs like immunization, family planning, and malaria. However, there were very large improvements for products like antibiotics, obstetrical drugs, diagnostics, and TB medications. Conclusion Providing funds directly to health facilities improved drug availability. It was superior to the typical centralized procurement and “push” distribution system that is widespread in lower-income settings. This approach is already spreading and should be adopted more widely.

Syed Masudur Rahman Dewan

Reading the letter “Transforming Health Insurance in Bangladesh: A Future-Ready Approach” that was submitted in response to “The Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspective” [1] inspired me to write this response, and I am grateful to the author(s) for their work. The author(s) makes a valid and necessary point about the need for a paradigm shift away from traditional state-led models and towards decentralized, technology-driven, behaviorally informed strategies. But while we're looking at the present situation, we must also recognize the government's current efforts and see how they could support or even lay the groundwork for a universal health insurance program that would benefit all citizens. The Health Ministry of Bangladesh has announced that the government has initiated a program to offer free medical treatment and medications to the population. The ministry has announced plans to implement 24-h health services at 500 centers and to distribute a healthcare card to each household under the “Shyastha Surokkha Karmasuchi” (SSK) package. This card enhances patient identification at hospital admission and optimizes the payment process by monitoring diagnostic information and service usage; however, it has not been fully implemented yet [2]. The government's efforts to improve healthcare access and quality are commendable, but they also bring attention to a basic problem. People with lower and medium incomes, as well as those working in the informal economy, are disproportionately impacted by the unequal distribution of resources caused by the tax-based approach that forms the basis of many of these programs. Several economic studies have pointed out that, in Bangladesh, many families continue to struggle financially since out-of-pocket costs make up around 68.5% of overall healthcare spending [3]. Despite the importance of programs like SSK that offer free services, this circumstance shows that these efforts do not solve the underlying problems with the healthcare funding system, which include structural disparities and financial instability. A shift toward a universal, all-encompassing health insurance system seems essential and advantageous in this light. A strong health insurance system might have two benefits: first, it would help those who can't pay for medical treatment get coverage, and second, it would provide a system for reliable, long-term financing. Germany, France, and Japan are only a few examples of the nations that have demonstrated that social-insurance models may achieve both universal coverage and fair allocation of resources through income-based premiums and required participation [4]. The difficulty for Bangladesh comes from trying to apply these models to our own social and economic situation. The large informal sector of the Bangladeshi economy, which has long been exempt from traditional tax and insurance systems, is a major obstacle to the widespread adoption of health insurance. We propose a multi-pronged strategy to address this. To begin, one way to guarantee affordability is through progressive premium systems, in which contributions change according to income levels. Premium payments from informal workers might be made easier with the use of innovative collecting techniques, such as community-based networks and mobile payment systems like “bKash” and “Nagad,” which would reduce administrative responsibilities [5]. Second, providing low-income groups with government subsidies is essential. The state may make sure that no one is left out because they don't have enough money by paying part of the premiums for those who are vulnerable. It is really essential for everyone to take part; to eliminate coverage gaps and deal with fluctuating participation rates, it is recommended to use a default opt-in method. This means that all citizens would be automatically registered in the health insurance program, and opting out would only be permitted under certain circumstances. Behavioral economics principles have been used successfully in other contexts to significantly boost enrollment using this method. The insurance system's risk pool and financial foundation may be further expanded if measures were to be considered that would promote the formalization of workers in the informal sector [5]. Integrating technology stands alongside these funding improvements as another pillar of a health insurance system prepared for the future. Claims processing using blockchain technology, for instance, has the potential to streamline administrative operations, make them more transparent, and cut down on fraud and settlement delays [6]. Furthermore, predictive underwriting algorithms have allowed for more precise and inexpensive premium changes in East African pilot programs using AI-driven adaptive pricing techniques [7]. Bangladesh can create a system that can handle large-scale operations while catering to people of varying income levels by adopting this state-of-the-art technology. Without the larger healthcare system, no health insurance system can possibly operate. While it is great that SSK and other government programs are working to make services more accessible, such as free prescription programs and 24/7 care centers, these efforts should be supplemented by steps to make sure healthcare resources are distributed fairly. When contrasted with metropolitan regions, rural communities still lack enough infrastructure and medical specialists. We can encourage fair allocation of resources with a single health insurance system that is built with targeted incentives and a tiered reimbursement mechanism. For instance, healthcare providers may be more motivated to offer high-quality services to rural communities if they were to get higher payment rates for institutions in underserved locations and participate in public-private partnerships. In conclusion, free healthcare programs are a huge step forward, but they also show how flawed a system that relies just on taxes to pay for healthcare may be. The solution to long-term, fair healthcare in Bangladesh lies in a universal health insurance system that is prepared for the future and can flexibly integrate public programs with creative private sector solutions. The healthcare system in Bangladesh may be revolutionized by adopting a hybrid model that incorporates digital technology, progressive premium collections, behavioral defaults, and mandated insurance. A more equitable and effective distribution of resources would be fostered by such a system, which would shield its inhabitants from ruinous medical bills. It is anticipated that these reflections will contribute to the ongoing conversation regarding the enhancement of healthcare financing in Bangladesh. An approach that is collaborative and integrates the benefits of state-driven initiatives with decentralized, technology-enabled, and socially equitable models is likely to facilitate long-term reform. S.M.R.D. conceptualized, supervised, and wrote the draft. The author has nothing to report. The author declares no conflicts of interest. The lead author SMRD affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Leith Greenslade, Samy Ahmar, Ekpedeme Inyang, Sylvia Warren · 5 authors

Pneumonia, the leading infectious killer of children under five, has been called a “forgotten killer,” “a neglected tragedy,” and a “global cause without champions.”1, 2 Despite causing 800 000 child deaths, more than HIV/AIDS, tuberculosis and malaria combined, pneumonia has never attracted the levels of support commensurate with its burden.3 Less than 5% of international Development Assistance for Health and just 3% of all infectious disease research spending, are allocated to pneumonia.4 While the Global Action Plan for Diarrhoea and Pneumonia (GAPPD)5 launched by World Health Organization and UNICEF in 2013 did set a global target of three child pneumonia deaths per 1000 live births by 2025, no government had developed a national strategy to achieve this target by 2019.a The lack of funding and planning have contributed to slow progress meeting the target and just two countries—Bangladesh and Indonesia—of the 20 with more than 10 000 annual child pneumonia deaths are on track to achieve the GAPPD pneumonia target.6 At current rates of progress, an estimated 6.3 million children will die from pneumonia by 2030 and many low- and middle-income countries (LMICs) will fail to achieve the sustainable development goal for child survival. The solution is not another vertical program channeling billions of dollars to tackle a single disease. There would be little appetite from national governments or the global health and development community for such a mechanism, which might undermine efforts to expand the reach of integrated community case management (iCCM) and integrated management of childhood illness (IMCI) and strengthen primary health care services to deliver Universal Health Coverage (UHC). Experience suggests that further reductions in child mortality in LMICs will require approaches that are sensitive to the complex patterns of comorbidity between pneumonia, diarrhea, malaria and malnutrition, and cognizant of the rising challenges of rapid urbanization, vaccine hesitancy, air pollution, and the double burden of under and overnutrition. The case for harnessing existing mechanisms such as Gavi, the Global Fund, Unitaid, and the Global Financing Facility to better integrate vaccine delivery, nutrition, and community case management is increasingly compelling, and much more work is needed to align the efforts of international agencies engaged in child survival in the high-burden countries.7 The Every Breath Counts Coalition (EBCC; https://stoppneumonia.org/) was officially launched in November 2017 to provide a platform for governments and international health agencies to work together to achieve the GAPPD target. In an acknowledgment of the progress achieved by the Global Fund and Gavi, the 40 member EBCC is a public-private partnership with representation from UN agencies, nongovernmental organizations (NGOs), private foundations, pharmaceutical and medical technology companies, and universities. Each member has made a written commitment to support government efforts to accelerate reductions in child pneumonia deaths according to their capabilities along with the prevention, protection, diagnosis, and treatment continuum. EBCC works with governments to develop data-based pneumonia control strategies, delivered as part of national primary health care strengthening and UHC efforts. The EBCC has prioritized support to four large “transnational” clusters with large populations of children at heightened risk of death from pneumonia including, (a) Chad, Nigeria, Niger, and Mali, (b) Democratic Republic of Congo and Angola, (c) Ethiopia and Somalia, and (d) Pakistan and Afghanistan, the ambition of which is to support the development of bespoke pneumonia control strategies in each country. At the global level, three EBCC teams drive progress towards specific childhood pneumonia “global public goods” including: The development of routine indicators to measure access to pneumonia diagnosis and treatment; a set of agreed research priorities; and robust advocacy and communications activities. As Nigeria has the largest population of children at greatest risk of death from pneumonia, the EBCC supported the Nigerian Federal Ministry of Health (FMoH) to develop a pneumonia control strategy between January 2019 and 2020. Coalition members including USAID, the Nigerian offices of Dalberg, Save the Children, UNICEF, and the Clinton Health Access Initiative (CHAI) joined forces to support the process. To better understand the barriers preventing faster progress on reducing child pneumonia deaths in Nigeria, the Family Health Department within the FMoH invited 75 participants to a strategy workshop in Abuja in January 2019. Following this workshop, approximately 40 interviews with national and global stakeholders, supplemented by desk research and analysis of state-level policies and data on the burden of pneumonia deaths, were conducted by the strategy firm Dalberg on behalf of the FMoH. By early March 2019, the FMoH and the EBCC had developed a draft pneumonia control strategy, and the FMoH invited 30 partners to meet in Abuja in April 2019 to review the strategy and align the contents with the RMNCAH+N Strategy. EBCC and the FMoH then worked together to develop a more detailed implementation plan and an estimation of the financial resources needed to implement the strategy. Less than 7 months after the process began, a final workshop to validate the strategy took place in Abuja in July 2019. In October 2019, the Minister of Health officially approved the strategy and the strategy was officially launched in Nigeria on January 2020. This strategy development process generated several key lessons. The pneumonia control strategy development process elevated the status of childhood pneumonia as a key public health challenge in Nigeria. Bringing together a range of public (eg, Federal and State Ministries of Health and donor government missions), private (eg, manufacturers of vaccines, medical devices, and antibiotics), faith-based organizations, and civil society actors demonstrated an appetite for a greater focus on pneumonia and drew attention to the gaps and barriers in pneumonia control that were impeding progress to Nigeria's child survival target. Despite many competing priorities in health, stakeholders involved in the process became champions for pneumonia control. Two NGOs, Save the Children and CHAI even decided to integrate parts of the pneumonia control strategy into their own newborn and child health programming. The pneumonia control strategy development process also showed that it is possible to focus on a specific cause of child death, while promoting integrated case management of childhood illnesses at community and facility levels (ie, iCCM and IMCI). By emphasizing that pneumonia should be accorded a level of attention commensurate with its disease burden, the FMoH and EBCC were able to reposition and prioritize pneumonia as a major killer, deserving of at least the same levels of investment as other leading but much better resourced killers (eg, malaria). The process to develop the pneumonia control strategy enhanced cross-sectoral and interministerial collaboration across all levels of government in Nigeria. Effective pneumonia control depends on the coordinated actions of different federal, state, and local government agencies to prevent, diagnose, and treat pneumonia at all levels of the health care system. The Nigerian FMoH had to work closely with the Agriculture, Energy, and Environment Ministries to prevent pneumonia by improving vaccination, nutrition, and clean air. In addition, the FMoH must find ways to influence State and Local Government health actors to improve the diagnosis and treatment of childhood pneumonia in primary health care and hospital services, as these are decentralized responsibilities. The FMoH and EBCC were able to bring these various government actors together for the first time to talk about pneumonia control and offer the support of private and nonprofit sector partners. Lastly, and critically, the experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first. While it is still challenging to map child pneumonia deaths at national and subnational levels, data are improving rapidly and governments have new tools to identify childhood pneumonia “hotspots” where deaths concentrate.8 In Nigeria, the subnational child pneumonia maps released by the Institute for Health Metrics and Evaluation in 2019 revealed “hotspots” in several northern states. Targeting pneumonia control efforts to these children represents the most cost-effective path to reduce pneumonia deaths and achieve the GAPPD target. The EBCC is committed to sharing these new tools with governments so that they can help direct scarce resources in ways that maximize the number of child pneumonia deaths prevented. These maps not only enable governments to prioritize the most vulnerable children but also to require their international health and development partners to do the same. Nigeria is pioneering a new approach to achieving the GAPPD target. Its pneumonia control strategy will need to be monitored and evaluated over the next 5 years to assess results, to ensure that partners are held accountable for delivering on their commitments and to capture learnings that can inform other governments. If successful, the Nigerian pneumonia control strategy could become a blueprint for other countries struggling with heavy burdens of child pneumonia deaths to achieve the GAPPD target and strengthen integrated newborn and child health policies and programs.

Kiconco Rosette

The study examined the relationship between fiscal decentralization and health service delivery in Itojo sub-county. It was guided by the objective which were; to find out the extent to which citizens’ participation in planning and budgeting influence health services delivery in Itojo sub-county in Ntungamo District, to analyse how monitoring and evaluation of health care services affect health service delivery in Itojo sub-county in Ntungamo District and to identify the factors that constrain fiscal decentralization and health service delivery in Itojo sub county. The study used a case study design which and incorporated both qualitative and quantitative approaches. The sample for this study was 136 respondents and these were selected by use of purposive sampling. The study used questionnaires, interview guide and documentary review in gathering data for the study. Data analysis was done using SPSS which were used to generate frequency and percentages. From the findings, it was revealed that all decisions regarding health care services delivery are fully decentralized for effective delivery; decentralized planning has improved equitable health service delivery. Furthermore, it was revealed that monitoring is a key aspect of resource utilization for health service delivery. Further findings also revealed that feedback on the performance of the health sector is disseminated to technical staff at the local government level and this enhances health service delivery. It was pointed out that one of the most daunting challenges facing fiscal decentralization of health services in Uganda derives from the concerns relating to accountability, transparency, auditing and institutional corruption within both central and sub-national governments. From the findings corruption causes delays in implementation of health programmes thus ineffective healthcare service delivery. It was thus concluded that citizens’ participation in planning and budgeting influences health service delivery. The findings indicated that monitoring and evaluation greatly affect health service delivery. This implied that an increase in monitoring and evaluation of health services has positively influence on health service delivery. The study thus recommended that there is need for an effective and harmonized decentralized planning and budgeting processes at all levels in Uganda. There should be an effective budget committee in place in each of the districts to over-see resource mobilization and allocation of finance. Routine monitoring, supervision and evaluation of performance should be encouraged so that errors and misappropriations are reduced or eliminated in order to enhance effective health service delivery.

Ernest Mensah, Moses Aikins, Margaret Gyapong, Francis Anto · 6 authors

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.

Dorcas Mugure Mwangi

The rationale for considering decentralization in anti-poverty programs is that it might have positive effects on the economic development. Decentralization brings the government closer to the people. Local officials are better informed on the local needs, and are thus more capable of providing the optimal mix of local policies. While the SMEs subsector constitute close to 80% of employment, it only contributes to about twenty percent (20%) of the Gross Domestic Product (GDP) in 2011 in Kenya. This implies dismal subsector performance despite its potential contribution to employment, income and equity as was asserted in the ILO report in 1972. The performance of the SMEs in Kenya is linked to several constraints among which the regulatory and institutional framework is alleged to be one of the factors. SMEs in Kenya are threatened for survival as a competitive enterprise. The purpose of the study was to establish the effect of devolution on small and medium enterprises performance in Kenya. The study adopted a descriptive survey research design. The target population of this study composed of representatives of the various industries including the matatu, dairy, supermarkets, jua kali and small manufacturing companies in Nairobi and its environs. The target population of this study was therefore 1015. The study used stratified random sampling method to select 10% of the respondents who formed a sampling frame of 102 respondents. Data was collected using questionnaires. Data was analyzed using descriptive statistics done with the help of software program SPSS version 21 and presented using frequency tables. In addition, multivariate regression model was applied to determine the relative importance of each of the two variables with respect to SME performance. The study revealed that that fees and levies, affect the performance of Small and Medium Enterprises in Kenya to a moderate extent. The study concluded that fees and levies, cess and rates by the county government affect the performance of Small and Medium Enterprises in Kenya. The study also concluded that SME financing mechanism, fair trading practices, capacity development, mechanism for value addition and increase in supply, distribution and access to goods and services affect the performance of Small and Medium Enterprises affect the performance of SMEs in Kenya. The recommends that the county government should use the finances collected from fees and levies, cess and rates in proper and controlled manner with a goal of improving the working environment for the SMEs in Kenya. The study also recommends that the county government should put in strict measures to ensure that there is no corruption in the fees and levies, cess and rates collection process to ensure that the amount collected do not go to the hands of few individuals and that a substantial amount can be received to support the plans and policies of the county government. The study suggested that a similar study should be carried out in other counties to find out whether it will yield the same results. The study focused on SMEs, another study should be carried out to find out the effect of devolution on large companies.

Ellen Einterz, Myra E. Bates

INTRODUCTION: In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. METHODS: The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. RESULTS: Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. CONCLUSIONS: To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.

Samuel Penkar, Prakash Deo

INTRODUCTION The expectation is that in the next two decades, China and India will turn into super-powers and industrialized nations. The analysis in this paper will help in understanding how each country's corporate setup works and will help in evaluating the investment potential in the buying of stocks of firms of each country in their various industry sectors. This study contains a literature review followed by the results of the study. The study utilizes a three step top to bottom analysis; macroeconomic analysis followed by industry analysis and lastly with company analysis. The various tables and figures are attached to the end of the article. LITERATURE REVIEW Hu and Honghua (2002) compare key measures of strengths between China and India. These measures include GDP, ratio of long-term economic growth expectation in the world's total, average years of education, and the ratio of exported goods and services in the world's total. The authors conclude that China is far ahead of India. Husain and Harris (2009) compare and contrast broader aspects of the political, economic, and sociocultural climates within the two countries. Kalish (2007) and Zhao (2007) draw similar conclusions based on detailed comparisons and the risks and opportunities of doing business in each country. Wu (2007) compares the service sector growth in China and India and analyzes the determinants of growth in services with an econometric model. He finds that role of services in both China and India has been rising, with China starting from a lower base. Srinivasan's (2004) exhaustive study on comparison of economic performance between China and India identifies key differences and similarities, the underlying causes of success and failures and concludes that China and India have a lot to gain, both from trading with each other and cooperating in the WTO. Maddison (2002) reveals that although India forged ahead of China until the outbreak of the First World War, since 1980, China has forged much farther ahead. Rwaski (2001), Srinivasan and Bardhan (1974), Deato and Kozel (2003), Park and Wang (2001) discuss the sources of estimates of economic performance in China and India, and their frailties. Bahl and Martinez-Vazquez (2003) argue that China's governance is much decentralized than indicated by the government and therefore, it is hard to predict the effect of greater decentralization on China's future fiscal health. Battacharya and Patel (2002) note that the Indian economy suffers from a large and increasing role of the government. Bosworth and Collins (2007) point out the weak and strong performances of India and China in various sectors and conclude that both economies should be able to sustain their growth. While a wealth of literature exists on evaluation of these two countries from a macroeconomic perspective, there exists a gap in the finance literature, specifically, a perspective for potential investors in trying to determine where to place their investment funds. In this article, we examine the valuation issues that an investor needs to consider when investing in china and India. By and large the finance literature advocates a three-step (also known as top-down) valuation process. The first step includes evaluation of general macro-economic factors which influence a country's economy. These factors include fiscal and monetary policy of countries, political conditions. The second step involves identification and assessments of an industry environment in a country's economy. It includes labor skills and relations, capital-labor and business cycle-industry inter-relationships, demographics, scope of the industry and its competitive environment to gauge business risk. The final steps comprise of individual firm analysis in an industry. We use this three-step framework to evaluate and compare the valuation environment in China and India. THE ECONOMIES We deploy Goldman Sachs version of the three-step process, which includes examination of GDP as the key component of a country's economy. …

Dermot Maher

The global financial crisis poses a threat to global health, and may exacerbate diseases of poverty, e.g. HIV, malaria and tuberculosis. Exploring the implications of the global financial crisis for the health sector response to tuberculosis is useful to illustrate the practical problems and propose possible solutions. The response to tuberculosis is considered in the context of health sector development. Problems and solutions are considered in five key areas: financing, prioritization, government regulation, integration and decentralization. Securing health gains in global tuberculosis control depends on protecting expenditure by governments of countries badly affected by tuberculosis and by donors, taking measures to increase efficiencies, prioritizing health expenditures and strengthening government regulation. Lessons learned will be valuable for stakeholders involved in the health sector response to tuberculosis and other diseases of poverty.

John Grundy, Valentine Healy, L Gorgolon, E Sandig

INTRODUCTION: In 1991 the Philippines Government introduced a major devolution of national government services, which included the first wave of health sector reform, through the introduction of the Local Government Code of 1991. The Code devolved basic services for agriculture extension, forest management, health services, barangay (township) roads and social welfare to Local Government Units. In 1992, the Philippines Government devolved the management and delivery of health services from the National Department of Health to locally elected provincial, city and municipal governments. AIM: The aim of this review is to (i) Provide a background to the introduction of devolution to the health system in the Philippines and to (ii) describe the impact of devolution on the structure and functioning of the health system in defined locations. METHOD: International literature was reviewed on the subjects of decentralization. Rapid appraisals of health management systems were conducted in both provinces. Additional data were accessed from the rural health information system and previous consultant reports. RESULTS: Subsequent to the introduction of devolution, quality and coverage of health services declined in some locations, particularly in rural and remote areas. It was found that in 1992-1997, system effects included a breakdown in management systems between levels of government, declining utilization particularly in the hospital sector, poor staff morale, a decline in maintenance of infrastructure and under financing of operational costs of services. CONCLUSION: The aim of decentralization is to widen decision-making space of middle level managers, enhance resource allocations from central to peripheral areas and to improve the efficiency and effectiveness of health services management. The findings of the historical review of devolution in the Philippines reveals some consistencies with the international literature, which describe some negative effects of decentralization, and provide a rationale for the Philippines in undertaking a second wave of reform in order to 'make devolution work'.

Imrana Qadeer, Kasturi Sen, Kesavan Rajasekharan Nayar

Introduction PART ONE: THE POLITICAL ECONOMY OF HEALTH AND DEVELOPMENT Landmarks in the Development of Health Services in India - Debabar Banerji Structural Adjustment and the Poor in Pakistan - Jennifer Bennett Donor-Driven Family Planning Services in Bangladesh - Farida Akhter Impact on Women's Health Changes in Health Care Systems in Europe - Meri Koivusalo Focus on Finland Structural Adjustment Policies and Health in the Plantation Sector in Sri Lanka - Indira Hettiarachchi Dilemmas for Research in Primary Health Care in the Era of Reforms - Marc De Bruycker PART TWO: CONCEPTS AND EVIDENCE Impact of Structural Adjustements Programs on Concepts in Public Health - Imrana Qadeer Health Reforms and Developing Countries - Kasturi Sen A Critique Disability Adjusted Life Years as a Tool for Public Health Policy - Ritu Priya A Critical Assessment Re-Thinking Public Health - Sheila Zurbrigg Food, Hunger and Mortality Decline in South Asian History Biological Stress and History from Below - Lalita Chakravarty The Millet Zone of India, 1970-92 PART THREE: SHIFTS IN HEALTH SERVICES AND HEALTH FINANCING Health Sector Reforms and Structural Adjustment - Rama V Baru A State-Level Analysis Reforms and Their Relevance - V Raman Kutty The Kerala Experience Health Sector and Economic Reforms - K Seeta Prabhu A Study of Maharashtra and Tamil Nadu Structural Adjustment and Economic Slowdown - S Akbar Zaidi Likely Impact on Health Outcomes in Pakistan Health Services in Bangladesh - A Q Khan Development and Structural Reforms Structural Adjustment Programs and Health Care Services in Sri Lanka - Dulitha N Fernando An Overview Evolution of India's Leprosy Program from Control to Elimination - B R Chatterjee Tuberculosis Program in India - A K Chakraborty Current Operational Issues PART FOUR: DECENTRALIZATION IN HEALTH CARE Politics of Decentralization - K R Nayar Lessons from Kerala Promises and Problems of Panchayati Raj - Anwar Jafri Experiences from Madhya Pradesh An Assessment of the Effectiveness of Decentralization of Health Services in Sri Lanka - Nimal Attanayake People's Health Care Initiative in Chhattisgarh District, Madhya Pradesh - Binayak Sen PART FIVE: PERSPECTIVES OF CLINICIANS Prescribing Practices - Anant R Phadke A Comparison of Public and Private Sectors Revisiting the Community Health Worker - Shyam Ashtekar Disturbing Trends in the Treatment of Malaria - Yogesh Jain Public Health in Vellore - Anand Zachariah Experiences with Malaria and Cholera The Revised National Tuberculosis Control Program - Anurag Bhargava A Critical Perspective PART SIX: EXPERIENCES AT THE MICRO-LEVEL The Plague, the Poor and the Health Services - Ghanshyam Shah Public Health Issues of Small Towns - K S Sebastian The Case of Alleppey The Labor Process and Its Impact on the Lives of Women Workers - Meena Gopal The Reproductive Health Package - Alpana Sagar A Chimera for Women's Health The Rhetoric of Reproductive Rights - Mohan Rao Quinacrine Sterilization in India

Tore Godal

In international development, paradigms shift about once every 10 years. An important shift that is now taking place is from economic development to poverty reduction. The link between health and poverty has been recognized for a long time. The traditional way of looking at this is in terms of ‘wealthier means healthier’ ( Figure 1). While nobody disputes this link, the poverty reduction focus raises the question whether investment in health is important for poverty reduction. Quantitative evidence to answer this question is now emerging and producing astonishing findings. Health and income (a) the traditional view and (b) a new paradigm. In an analysis of geography, health and other factors in relation to poverty, Gallup et al. (1998) found one of the strongest correlations between poverty and malaria. In a longitudinal analysis of health, health policy and economic performance, Jamison et al. (1998) detected important time-frame relations between investments in health, the nature of these investments and economic performance. Bloom et al. (1998) found evidence that a change between dependent and the productive part of a population, i.e. reduction in fertility and increased child survival, can lead to a spurt in economic development. This demographic gift may be one of the reasons for the economic miracle in Asia. This effect is temporary and will turn negative when the cohorts grow old. At the microeconomic level there is also strong evidence for a link. For example, the programme fighting river blindness has given a 20% return on investment ( World Bank 1993). Moreover, families with river blindness spend twice as much on health as others, and their children are twice as likely to drop out of school, girls more often than boys. In a related chronic disease, lymphatic filariasis, patients produced 30% less material per hour than healthy cotton weaver coworkers ( TDR 1996a). Thus diseases and their underlying causes can affect the economies of families in a number of ways: Reduced productivity, impediment of education or retained high dependency ratios. The emerging conclusion is that the right investment in health is at least as important as education. While further quantitative research is needed to substantiate findings, leading decision-makers are are already convinced, as illustrated by the G8 resolutions at Cologne relating to debt relief for for highly indebted poor countries (HIPC). As the communique said, ‘The central objective of this initiative is to provide a greater focus on poverty reduction by releasing resources for investment in health, education and social needs’. The resources that could be available through the new debt relief initiative if not drained away in other directions are significant. According to estimates provided by Jeffrey Sachs (1999), the amounts are about 5 billion dollars annually for over 40 countries with a population of about 750 million. Thus we are considering about $7 per capita or $120 million per country. If health were allocated half of this, health spending could amount to $60 million per country. This has come at just the right time to accelerate our development of concepts and policies. In May a meeting between WHO and international development agencies dealt with the role of specific strategies in health to achieve poverty reduction ( WHO 1999a). In education the simple notion is that poor people are illiterate, so to secure basic schooling for the poor is paramount, and indeed much evidence supports that view. Similarly, the basic assumption in health is that the first priority in is to fight diseases from which the poor suffer most, i.e. their excess burden. Further analyses of what these conditions are, their quantitative relation to poverty country by country and relative importance as targets for investment to reduce poverty have been initiated. This has now become a priority for WHO (1999b). The major conditions linked to excess burden among the poor and their global importance in terms of mortality are set out in Table 1. According to ongoing work by Gakidou and Jamison (personal communication), they all show a strong excess in poor populations. Tuberculosis is 10 times more prevalent in people earning < $1 a day; maternal mortality about eight times, and childhood mortality (< 5 years) four to five times more common in children of poor families. One effect of this poverty reduction perspective is prioritizing and focusing. Thus we are faced with a limited set of predominantly infectious diseases. The question is, then, how to address them most effectively. What are the relative merits of the available tools in addressing disease burden? How cost-effective are they and what is their potential for reaching the populations in need? Clearly we need modules of different sets of interventions and need to look for synergies. From an immunization perspective we believe that with the pneumococcal vaccine soon becoming available, about 3.5 million deaths can potentially be prevented by immunization ( Table 2). Three and a half of 12.7 million (and let us add 2.3 million equivalents for family planning) would suggest that immunization could justify use of more than 20% of the resources on this basis alone, without taking into account cost effectiveness or capacity to reach the poor. In both these parameters immunization would, of course, score very high ( Miller & Hinman 1999). Based on the HIPC calculations with about $60 million per country where on average one million children are born every year, $12 would be available per child for immunization services. One of the advantages of investing in excess burden for poor people is that the investments become self-targeting, i.e. one does not need to consider specialized services for the poor, as they are notorious for becoming ‘poor’ services. While this does not exclude the possiblity of using vouchers and other mechanisms where payments are required for systems reasons, services for those conditions could be free or almost free in a poverty reduction programme. Moreover, if one focuses on outcomes, one does not necessarily have to target investments at specific disease categories. A very good example of this comes from Ghana ( Adjei 1999). Ghana has undertaken profound health sector reforms by adopting and implementing a sector-wide approach. The government agreed with international agencies and bilateral donors that resources would be pooled and and used towards an agreed strategic framework. During 1997, &, 1998, immunization coverage has increased by about 20% (from approximately 50%–70% for measles). What are the reasons? There appear to be several: Vaccine procurement was protected in a general procurement mechanism. There was a shift in resources from tertiary care to district care. District support increased from 22% in 1996 to 39% in 1998 in national health budgets. Private healthworkers including midwives have become involved in immunization activities. This has dramatically increased the number of sites at which immunizations take place. Outreach points have increased from 7 to 11 per health facility. Immunization coverage has become an outcome measure used in the negotiation between central government and districts regarding resource allocation. The impact of health reforms on immunization in other countries appears to be mixed, but hard data is difficult to come by. Decentralization appears to have had a negative effect in many countries because central functions such as procurement suffered. In Latin America at least these effects were temporary (Ciro de Quadros, personal communication). In Uganda the reform process apparently led to the cutting of all resources of outreach services, which had a dramatic effect on coverage ( Ngoma 1999). A detailed review of the impact of sector-wide reforms is in preparation by the WHO. It is important in this context to conclude that reforms do not necessarily have a negative impact. The issue is therefore not whether the investments go into one pot or not – this will depend on the stage of reform in each country. Strategies for investments in health in relation to poverty reduction may with appropriate know-how be used to promote reforms to achieve better services rather than inhibit them. We should be able to overcome vertical in favour of horizontal entrenchment. To reach out to poor populations represents a great challenge. This is where the biggest gains of poverty reduction are likely to be achieved, as illustrated by the striking differences in coverage between routine polio 3 immunization and national vaccination days ( Table 3). Similarly high coverage has been achieved with ivermectin distribution in Africa, where quantitative randomized trials showed that a community-driven approach resulted in better coverage than health centre-driven ones ( TDR 1996b). Thus it would appear that we now have several successful models: Polio national immunization days with community mobilization; Ivermectin distribution directed by communities; Health sector reforms shifting resources from tertiary to primary care; Contracting of privately practicing midwives and other health personnel; Securing resources for mobile services including transport. The optimal mix of these would of course depend on geography and other local factors. The costing of outreach services is a priority in this perspective. They may bring up the cost of services severalfold, depending on the circumstances. Over the last 1½ years, kick-started by a meeting in the World Bank, an analysis of immunization services has taken place. The analysis showed: stagnation of immunization services globally with a decline of EPI coverage for certain countries as well as marked regional discrepancies ( WHO 1999c); newly developed, efficacious vaccines against major killers are not being introduced into poorer countries, the gap between the number of vaccines used in the ‘North’vs. the ‘South’ is widening; limited investment into vaccine research for diseases that predominate in the poorest developing countries. As a result of this analysis the major partners in the field decided to strengthen their global effort in this field, leading to the formation of the Global Alliance for Vaccines and Immunization (GAVI) in July 1999 ( GAVI 1999a). GAVI has the following strategic objectives: Improve access to sustainable immunization services; Expand use of all existing, safe and cost-effective vaccines where they address a public health problem; Accelerate development and introduction of new vaccines and technologies; Accelerate R & D efforts for vaccines needed primarily in developing countries; Make immunization coverage a centrepiece of international development efforts. The main instruments created for GAVI to advance these objectives ( GAVI 1999a) are; A Global Fund for Children's Vaccines (GFCV) with the aims of purchasing vaccines and safe injection materials, financing access, infrastructure and R & D. The fund's first priority is to secure availability of newer vaccines (Hepatitis B, Haemophilus influenza b, yellow fever) ( Figure 2); A Governing Board comprising 11 members from partner constituencies. Dr Gro Harlem Brundtland, Director General of WHO, will chair for the first two years followed by Ms Carol Belamy, Executive Director of UNICEF, for the following two years; A small secretariat to implement the directions of the Board and ensure the involvement and representation of the broader immunization community; A Partners' Working Group to ensure Board decisions are translated into operational actions appropriate to each lead agency; Task forces of limited duration to address specific issues; A biannual meeting to bring together the broader immunization community. Structure of the Global Fund for Children's Vaccines. The intention of GAVI's modus operandi is to ensure that the partners do the work and that the secretariat remains small to avoid duplication of efforts. The working group with its weekly teleconferences appears to be an important mechanism for coordination with strongly dedicated people of the main partners. The Fund became reality before the end of the year 1999 with a contribution of $150 million per year for five years from the Bill and Melinda Gates Foundation. This needs to be matched by a 30% contribution from other sources to become a charity with tax-free status. The UNICEF national committee of the US has taken on that challenge. Initially the Fund will be used to supply HEP B, HIB and yellow fever vaccines to the poorest countries with a per capita GNP < $1000. China, Indonesia and India are considered special cases because of their purchasing power and vaccine production capacity. Thus GAVI will discuss with these countries how best to support them through mechanisms other than external purchase. Countries are invited to submit proposals which will be reviewed on the basis of clearly defined eligibility criteria ( Unicef 1999b), giving considerable scope for synergy with HIPC-based investments. With an estimated $1 billion potentially available over the next five years, Figure 3 illustrates the possible disbursement of funds to sets of countries in $50 million increments. These countries would receive fully funded vaccines for three years; support would then be tapered off by 25% per year with the last 25% continuing for three years, giving a total support period of eight years. $1 Billion distributed in 4 separate $250 million trunches each starting with $50 million for 3 years. Different shaded areas relate to different cohorts of countries with different implementation rates. The cost of vaccines and safe injection material for a fully immunized child is approximtely $10. Thus $200 million will cover 20 million children, i.e. about half of the total child cohort in eligible countries. Assuming that many countries would need to strengthen their immunization services first, both in terms of infrastructure and access to qualify, the programme is being phased in to reach maximum capacity in the third year. With the Fund, GAVI has extraordinary new opportunities in relation to immunization, but if they are to materialize fully, some problems need to be resolved. Many countries targeted for this programme have low coverage of DPT3, often < 60%. Their infrastructure was eroded in the 1990s and coverage capability is limited. A substantial proportion of children may not receive a full immunization schedule. However, the polio eradication initiative greatly strengthened infrastructure in recent years. As outlined above, clear successes have been achieved in sector and community-based research. Strengthening current services is a challenge to GAVI partners already involved in supporting health and immunization services, notably the countries themselves, UNICEF, WHO, bilateral agencies and the development banks. We do not consider it likely that the GFCV will play an instrumental role here initially. GAVI will support the strengthening of existing mechanisms. HEP B and HIB vaccines will be required for newborns every year in the poorest countries. Thus their continued financing must be secured. While the costs of the vaccines is likely to continue to fall, substantial investments will be required on a continuing basis, necessitating collaboration of all parties concerned. The governments of eligible countries have a particularly important role to play: Only if it is a priority to them can bilateral agencies provide assistance and development banks concessionary loans. New vaccines, such as one agains pneumococcal pneumonia, are in the pipeline. This vaccine alone could save more than a million children from dying of acute respiratory infection. Unless we can secure the funding of currently available vaccines, we cannot ensure funding of new ones. On the other hand, if we are successful with the former, we will have a good chance to raise the resources required to introduce new vaccines. This is illustrated in Figure 4. The need to secure sustainable financing to secure funding for new vaccines. Since the last biotechnological revolution, we have seen a continuos trend towards a sharper distinction between public and private sector, which has accelerated after the collapse of the communist system. Within R & D the roles have also become more distinct: The public sector plays a key role in supporting basic, clinical, epidemiological and operational research while the private sector tends to be responsible for product development. Product development is, in part due to rules and regulations imposed by the public sector, a complex operation spanning intellectual rights related to discovery, preclinical and clinical development, production, marketing and post marketing surveillance. The driving force for the private sector is profit. Through a century of competitive development, the R & D industry has become the most effective actor in this field, and continues to undergo change to retain that competitive edge especially in a globalized market. A problem arises for unprofitable products; so far, the public sector has had to take a responsibility for these. Most who have been involved in public sector product development realize that it is difficult to match the range of expertise and competence required. Thus, if the public sector could guarantee a market that would engage the private sector, many obstacles would be overcome. This is what is called the ‘pull’ mechanism. For some products, such as the pneumoccocal vaccine which has a market in the industrialized countries, the pull mechanism does not need to be very substantial. Potential availability of $100–200 million for the poorest countries is expected to be sufficient. On the other hand, vaccines that are of greater use to poor populations and countries, such as vaccines against malaria, HIV/AIDS or tuberculosis, would require a stronger pull, on the order of magnitude of a billion dollars or more per year for at least five years. We are awaiting private sector assessments. There is considerable interest in pursuing this mechanism by the World Bank, by Jeffrey Sachs and colleagues at Harvard, and the US government. If the GFCV were to become a vehicle for such a pull mechanism, it would need to be substantially strengthened. If increased investments in vaccine R & D can be achieved, many resent discoveries and tools provided by basic science would become part of a development effort. These include identification of protective antigens selectively synthesized in vivo where tissue damage occurs; functional and structural characterization of antigens derived from genomics efforts; rationalization of the immunization process itself through improved methods for introduction and expression of vaccine DNA and selective targeting to the presentation mechanisms of the immune system ( Hoffman & Liu 1999); and simpler The most important challenge for GAVI is to that all whether in the or in the field, will as part of this effort to and health, through the use of safe

Andrea Steinert, Hans Jürgen Rösner

In May 1993 the Grameen Bank in Bangladesh ‐ one of the most successful and internationally best‐known self‐help projects ‐ launched a programme to provide poor people in rural areas with basic health care. The first four medical centres were followed by six more by July 1995. The organization and methods of operation of the Grameen Health Programme are based on the tried and tested self‐help principles underlying the loan programme which has been in operation since 1976. The services offered include medical care at reduced fees and free counselling. Target groups are primarily poor women, to whom the programme's women field workers initially give information on simple preventive measures plus advice on avoidance of unwanted pregnancies. This article presents a provisional evaluation based on two primary inquiries conducted in 1994 and 1995. The overall conclusion was that the health programme has still far to go in order to attain the longer‐term objective of becoming self‐financing. Nevertheless, it demonstrates that decentralized access to health services, and preventive healthcare counselling in particular, can be of real assistance to poor people in rural areas.

Allison Greenspan

Bangladesh has a population of 115 million people, and the economic growth rate of 3.7% during the 1980s was undermined by rapid population growth. The annual population growth rate was 3% in the 1960s and early 1970s, 2.5% between 1981-91 decreasing to 2.3% in 1991. The average of number of children is 4.6/woman compared with 7 in the 1960s. Infant mortality dropped from 150/1000 births in 1976 to 118/1000 in 1991. Life expectancy rose from 47 to 54 years. The 1991 Contraceptive Prevalence Survey showed that 39.9% of married women under 50 use contraceptives in 1991 vs. 18.6% in 1981. The use of modern methods increased from 10.9% in 1981 to 31.2% in 1991, while traditional methods rose from 7.7% to 8.7%. Sterilization was most prevalent in 1981. 29,000 female family planning (FP) workers were aggressively engaged in dispensing FP services in 1990. The Social Marketing Company sells pills, condoms, and oral rehydration salts through 130,000 retail outlets. The 1989 Contraceptive Prevalence Survey showed that 40% of pill and condom users obtained them from this network, and 95.4% of women knew about 4 methods of contraception. In 1990 there were 120 private organizations providing contraceptive services. Some of the components of the government FP program include field worker distribution door-to-door of injectable contraceptives (50% injectable usage rate in the Matlab project); recordkeeping activities; a satellite clinic network with access to contraceptive services; and decentralization through the Upazila (subdistrict) approach. The logistics system of FP has improved the warehousing, transportation, and management information system. Foreign aid (mainly USAID) financing of contraceptives helped avert 14.4 million births between 1974-90. The increase of contraceptive prevalence to 50% by 1997 would avert another 21.9 million births during 1991-96 (replacement fertility requires 70% prevalence.