Communities of practice
Expert opinion split, as study revives an old debate
21 Jan 2011
Citation: Cavalli A, Bamba SI, Traore MN, Boelaert M, Coulibaly Y, et al. (2010). Interactions between Global Health Initiatives and Country Health Systems: The Case of a Neglected Tropical Diseases Control Program in Mali. PLoS Negl Trop Dis; 4(8): e798.
A recent study has reignited a decades-old debate over the allocation of limited health resources and the organization of health-care delivery in low-income countries.
The study, a qualitative investigation of the positive and negative effects of the USAID-funded Neglected Tropical Disease (NTD) programme on Mali’s health system, was published on 17th August in the open-access journal PLoS Neglected Tropical Diseases. And though it went by largely unnoticed by the mainstream media, the study, the first to address interactions between an NTD programme and a country health system, has touched a nerve.
Indeed, while critics of so-called Global Health Initiatives (GHIs) targeting single-disease issues have long argued that such “vertical” programmes distort national policies and erode countries’ ability to provide basic care, never before has so pointed an indictment been published in the peer-reviewed literature.
To calculate the impact of the NTD campaign on the provision of basic care, the researchers, led by Anna Cavalli of the Public Health Department at the Institute of Tropical Medicine (ITM) in Antwerp, Belgium, analyzed documents, conducted interviews, and observed health workers at 16 health centres in two rural districts of Mali. They then examined the results using a conceptual framework developed by WHO based on six interrelated elements, including health service delivery, health workforce, health information system, drug procurement system, financing and governance.
Describing their findings, the researchers noted that in fragile health centres the additional campaign-related workload “severely interfered with routine care delivery,” contributing also to “operational problems affecting the quality of mass drug distribution”. The latter, the mainstay of the integrated NTD treatment campaign, is targeted at five neglected diseases endemic to Mali: lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, onchocerciasis and trachoma.
The team also found that, of the 16 health centres assessed, only the two most robust were able to maintain routine services and to use the campaign as an opportunity for quality improvement. “While the campaign increased the availability of NTD drugs at country level,” they wrote, “the parallel systems for drug supply and evaluation required extra efforts, burdening local health systems”.
And although education and training were found to improve drug distribution, the authors reported that these initiatives failed to address other NTD disease control strategies, such as curative care or sanitation. In conclusion, they wrote, “the chaotic architecture for development assistance for health remains a major obstacle for health system strengthening. Progress towards effective and inclusive health systems will not result from the sum of selective GHI interventions”.
A number of experts disagree with these conclusions and none more vehemently than David Molyneux. Long an outspoken advocate of NTD control efforts, Molyneux describes as “grossly unethical” the authors’ implication, as he sees it, that health systems should be strengthened at the expense of withdrawing medication that prevents the progression of a disease causing irreversible blindness.
“Are they suggesting that they would not, as a policy, have recommended pursuing this activity – and would therefore have allowed probably thousands of individuals to progress to irreversible blindness?” he asks. “The authors must address this question with a simple ‘yes’ or ‘no’.”
Molyneux notes that, in Mali, the 18-year use of ivermectin, which the Ministry of Health has supported, resulted in the cessation of onchocerciasis transmission last year . That study, by Diawara et al., provided the first empirical evidence that in addition to controlling onchocerciasis as a public health problem, ivermectin treatment can in fact eliminate the disease in some endemic foci. According to the study, the finding has already introduced a new paradigm for onchocerciasis control across the continent; the board of the African Programme for Onchocerciasis Control (APOC) has adopted an additional objective for APOC to “develop the evidence base on when and where ivermectin treatment can be stopped, and provide guidance to countries on how to prepare for and evaluate cessation of treatment where feasible”.
Cavalli et al. counter that, although health systems in sub-Saharan Africa have improved their short-term response to specific diseases, through the absorption of control programmes like APOC, “this has not necessarily led to long-term solutions, nor to an improvement of their overall responsiveness to people’s felt needs”.
And while the authors acknowledge that it is theoretically plausible that reductions in overall morbidity due to NTD-specific campaigns could reduce stress on already overburdened health systems, they maintain that, “demand for modern health care in sub-Saharan Africa is mainly related to serious acute problems, such as malaria, respiratory and acute diarrheal diseases, and injuries”. On the other hand, they say, demand for health care related to helminth infections is usually relatively low:
“Infected people tend to live with these chronic disabling conditions, and/or there is little medical care to offer for the disabling morbidity. Thus, a reduction in helminth diseases would undoubtedly improve wellbeing in the community, but it would not reduce stress on health care systems.”
Are the authors aware, Molyneux asks, of the global efforts to eradicate guinea worm and eliminate lymphatic filariasis? “The aims of these programmes are to reduce incidence to a level at which there will be no continued need,” he says. (It’s hard to get much more long-term than that.)
With regard to the assertion that demand for health care related to helminth infections is weak, he says, “Not true”. Molyneux points to the work of Dreyer and Addiss on hydrocoele as proof: “Hydrocoele surgery represents some 25% of surgery demand at the district level in northern Ghana. It costs $30–50 per case, and it’s preventable. So putting in place preventive measures to reduce this burden will free up hospital services for other conditions”.
Molyneux adds that improved wellbeing isn’t the only co-benefit of treating helminth infections with mass chemotherapy. Others include increased school attendance rates, improved cognitive function and reductions in anaemia.
Cavalli et al. caution readers not “to lump all NTDs together or to consider NTDs as a homogenous group, because they are not”. Sleeping sickness, Buruli ulcer, visceral leishmaniasis (kala-azar), cutaneous leishmaniasis: for these diseases there is a demand for health care, they note, and control critically depends on curative care (early case detection and treatment). “But this group of NTDs does not benefit from NTD campaigns nor from reductions in overall morbidity from specific campaigns for other NTDs, such as helminthiases.”
As Molyneux points out though, WHO clearly differentiates between “tool-ready” and “tool-deficient” NTDs. And the authors should be aware, he says, of the experience of “siloeing” control in the Democratic Republic of Congo (DRC), one of the most vertical programmes that ever existed. “When the health system collapsed, the consequences were grave, and today it’s only through disease-specific programmes that such diseases can be controlled.”
The ITM team is careful to note that while “a large part of interactions between GHI and health systems is based on HIV/AIDS-related programmes,” the NTD control programme’s focus on protection rather than responsiveness to patient demand, “distinguishes it from HIV/AIDS-related GHIs scaling up access to ARV treatment for individual patients.
Yet it’s funding for HIV/AIDS, argues Molyneux, that is primarily to blame for diverting health resources to a single disease. “In sub-Saharan Africa, 30 million people out of a total population of 780 million are infected,” he says. “That means 750 million do not have the infection. When a country with a 2% prevalence of HIV receives, for HIV alone, four times its total annual budget, that is not equity.” As for NTD programmes, he says, “at least they do not discriminate, prevent grossly disabling and incurable conditions, and can arrest transmission permanently”.
Cavalli et al. stress that although their research reveals a net negative impact of GHIs on Mali’s health system, they do not advocate halting targeted disease programmes. “Control of NTDs in communities is a necessity,” they write. “But so is health system strengthening, in order to respond adequately to other health problems and to ensure sustainable achievements, including NTD control.”
The authors refrain from speculating on how the two might be merged, but the clear implication is that mass drug distribution aimed at controlling NTDs would best be conducted through a country’s health system. Where exactly that health system begins and ends, however, is not so clear. Are vaccination campaigns part of it? School health programmes? Community-directed treatment? And who is included in the health system? Only people wearing a stethoscope? Or others too?
Assuming that Cavalli et al. do argue for mass drug distribution through the existing health system, this “passive” approach comes with its own set of complications. First, rather than searching out high-risk populations in remote areas as vertical programmes do, the health system approach would rely on patients to present for treatment at health centres, few and far between though they tend to be.
And while distribution through the health system would certainly reach a number of patients suffering from the acute symptoms of infection, those afflicted with the chronic and often silent symptoms of progressive disease caused by macroparasites (parasites that do not replicate in the final host) would surely be missed, making it even more difficult to break the cycle of disease and poverty.
When asked if a negative impact on health systems might be an acceptable cost for a control programme targeting NTDs in a population with a burden as high as Mali’s, Cavalli et al. replied that this depends on “the crucial issue of who should decide what is needed, acceptable, feasible and affordable, and based on which criteria”. Decisions on NTD campaigns are often solely based on technical evidence of burden of disease and cost-effectiveness, they said. “However, the overall health situation (including presence of other diseases, health system functioning etc.) should also be taken into consideration, and priority-setting should be participatory, based on evidence of both technical and social efficiency, and in line with national and local priorities.”
Molyneux urges the authors to reflect on the decisions countries themselves have made to control NTDs. “It is totally unacceptable for EU-based academics to criticize the endemic countries,” he says, citing the well-documented success of NTD campaigns like the Guinea Worm Eradication Programme and the Onchocerciasis Control Programme, which African ministers of health have publicly committed to supporting in recent years . Molyneux says he also wishes to remind the authors that, “the APOC programme treats 60 million people annually via 450,000 community workers in 19 countries. Of those treated, 30 million are more than 20 kilometres from the nearest health facility of any kind”.
As researchers, policymakers and government officials gear up for the First Global Symposium on Health Systems Research in mid November, international attention will be increasingly focused on how health systems can better implement interventions and deliver care to poor populations in the developing world. But given the immense burden of NTDs in sub-Saharan Africa, the question of whether strengthened health systems alone are sufficient to break the cycle of poverty and disease is sure to remain at the centre of the debate.
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1. Diawara L et al. (2009). Feasibility of onchocerciasis elimination with ivermectin treatment in endemic foci in Africa: first evidence from studies in Mali and Senegal. PLoS Negl Trop Dis; 3(7): e497. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19621091
2. Amazigo U, Boatin B (2006). The future of onchocerciasis control in Africa. Lancet; 368(9551):1946-1947. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17141687
2010 Cavalli et al.
Author’s reply to “Expert opinion split, as study revives an old debate”
The Montreux Conference on health systems showed a large consensus on at least one point: if we want to move forward in the search for positive synergies between disease control and health systems we need more evidence on what works and what not. This was exactly what our case study in Mali set out to do. We never questioned the relevance of a Neglected Tropical Diseases Control Program – on the contrary, we explicitly recognized its importance and public health benefit.
Cavalli A, Bamba SI, Traore MN, Boelaert M, Coulibaly Y, Polman K, Pirard M, Van Dormael M.
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