Paul Farmer, Maureen Bisognano, Fiona Godlee, Charles Alessi - the Panel at Turning World Upside Down

The beauty of the Turning the World Upside Down idea (the brain-child of Lord Nigel Crisp – here and here), is that it challenges our perceptions of development as something provided by ‘developed’ to ‘less developed’ countries. The website launches a movement whose intent is to promote a model of co-development, in which we recognise the mutual nature of development, promoting the idea that we can and should be learning from one another. An example of the ideas presented at the meeting included work with Community Health Workers in Brazil, which is now being used as part of a research project on health service delivery in Wales. Prof Andy Haines, of the London School of Hygiene and Tropical Medicine, talks about Brazil’s experience here.

Necessity is one of the greatest drivers of creativity, and innovative ideas being developed to overcome or cope with sheer lack of resources in developing countries may provide helpful insights to different ways of working that can have benefits in rich and poor countries alike. The site is seeking to gather ideas and examples of innovation, and hopefully will lead to some robust evaluation of these approaches, helping build an evidence base for new, effective ways of working.

I was prompted to blog on this idea as I have been reading a set of country case studies on Universal Health Care, commissioned by the World Bank (here), which contain a number of important lessons, including from Brazil, which could be of value to other countries.

Taking the Brazil thread of this post a step further, Brazil’s experience, as the host of the 3^rd Global Forum of the Global Health Workforce Alliance, to be in Recife in November this year, will be one of the key inputs to what is shaping up to be an important meeting. Given the importance of building a strong and capable health workforce in support of Universal Health Coverage, the research and evidence feeding into this meeting is likely to be central to the on-going consultation on what will shape priorities after 2015, in the so called ‘post MDG’ period (and here).

An article by Professor Mala Rao in the British Medical Journal also highlights how DFID’s work in India and an innovative technical partnership established with China is already fostering a process of mutual learning. The nature of UK aid is transforming rapidly to reflect the changing nature of our country partnerships.

Co-infection Conference

The meeting was organised by the International Society for Neglected Tropical Diseases, and focused on  co-infections between neglected tropical diseases and other diseases.The Neglected Tropical Disease link above gives a list of this group of diseases, which includes things like worm infections, river blindness, and guinea worm. Many of these diseases, which are most common in tropical climates co-exist in areas where diseases such as HIV/AIDS, TB and Malaria are also major problems (there is a link to a European Commission site on the three diseases here). It has been suggested that we need to develop rapid intervention packages to treat neglected diseases as part of the response to HIV/AIDS, TB and Malaria (here). A highlight of the meeting was a video address from the Minister of Health of Rwanda, Dr Agnes Binagwaho.

An effective response to any disease requires political ownership and leadership, and it was really good to see Dr Binagwaho's presentation and then hear from Emil Ivan, on malaria and helminthic (worm) co-infection in HIV positive pregnant women. In Rwanda, there is clearly a recognition of the need for integrated services to tackle the full range of health problems, using targeted funds in ways which strengthen the overall capacity of health services.

My interventions at the meeting highlighted this important issue of strengthening the health system as part of any targeted disease response. I highlighted in my blog on the Global Fund New Funding modality (here), that resources mobilised to fight the three diseases also need to invest in human resources and the key building blocks of good health services. The same is true for interventions which aim to tackle any of the neglected tropical diseases, the final push to eradicate guinea worm will be far more cost effective if it also addresses issues of water and sanitation and strengthens the capacity of health workers more generally. Unless we build health services which can meet the most pressing health needs of the whole population, the interventions being delivered will not be sustained over the long term, which is essential if we want to improve health.

Logo of Uganda UK Health Alliance

I attended the launch of the Uganda UK Health Alliance on 12^th February, which was held near the Houses of Parliament in the very grand council chamber of One Great George Street. I had met many of the speakers at the meeting the previous evening, at a reception in the Houses of Parliament hosted by Lord Nigel Crisp, a strong advocate of international development (here). I am always impressed by how effectively the public spaces in the Houses of Parliament are used to bring people together and stimulate discussion and networks on a wide range of important issues.

The reception hosted on behalf of the Uganda UK Health Alliance provided time and space for those agencies and individuals based in the UK and committed to health improvement in Uganda to form closer links. (A link to the site of some of those organisations that are forming the Alliance is posted here). Chief Nurse, Ms. Enid Mwebaza, Assistant Commissioner for Health for Nursing, and Dr. George Mukone, Senior Medical Officer in the Ugandan Ministry of Health, pictured below, spoke of some of the challenges of improving health in Uganda and of the value they place on the partnerships that have been established with UK health institutions.

Dr. George Mukone and Ms Enid Mwebaza

Another key group at the meeting were representatives of the Ugandan diaspora. These are Ugandans or UK citizens of Ugandan decent based in the UK who have maintained strong links with Uganda. There has been an interesting on-line discussion in The Guardian on the value of the diaspora in supporting development (here) and the interest and enthusiasm of the representatives at the meeting was testament to the potential of Ugandans overseas to support the country’s development.

In my presentation to the meeting, I highlighted the support that the UK is providing to improve health in Uganda. Between 2011 and 2015, the UK is committed to improving family planning, helping prevent AIDS, increasing access to bed nets to prevent malaria and providing support to strengthen health services. However, our discussions with the Government of Uganda have also highlighted the importance that the UK attaches to establishing stronger systems of accountability, to reduce the risk of corruption and to ensure that the human rights of all Ugandans are respected. British support directly to the government of Uganda is currently suspended whilst the Government of Uganda explores how to improve its financial management. These were messages that were well understood by those present at the meeting.

One of the main benefits of the Uganda UK Health Alliance will be much better coordination of the support provided to health institutions in Uganda. Currently multiple small scale initiatives have built good relationships, but can be quite demanding on the time of Ministry of Health officials. Coordination through the Alliance will help reduce transaction costs, and help to make the support more strategic. Rather than training individuals, the Alliance could help to ensure that training inputs are strengthening national curriculum development and training trainers, so that the benefits of inputs will be felt across the country, rather than just in individual institutions.

Lord Crisp made a point of highlighting that the lesson learning is a two way process. UK health workers visiting Uganda learn a huge amount from their experience, they have grown to respect and admire the work of many of the dedicated professionals that they meet, and they bring that learning and enthusiasm back in to the NHS. He highlighted that this 'co-development' is a two way process from which we all benefit.

For those not familiar with the Global Fund, the website (here) provides a huge amount of useful information, including links which allow you to see how money has been used to good effect in the past. Since its launch, there have been 10 rounds of funding which have allowed countries to bid for resources in support of their national response. There was a high level of concern when Round 11 funding was cancelled in November 2011 (see here).

The Partners Consultation meeting was an opportunity to hear more about how the Global Fund will operate in future and to understand better the transition process from the previous funding mechanism to the new.  The NFM is intended to ensure that the poorest countries and those with the greatest burden of disease have more chance of securing crucial funds to support the fight against the three diseases.

Abigail and Mark at Partners Consultation. Picture: Neil Squires/DFID

The Board of the Global Fund has been discussing new ways of providing funding which respond to past criticisms of the funding rounds based system of grant allocation. Of particular concern with the previous mechanism of funding was the huge amount of effort and time put in to developing funding bids which, if they didn’t meet the required standard, would fail to secure needed funding. The process could be a major distraction for hard pressed health planners struggling to use limited resources to provide a wide range of health services. Another criticism was that the very high level of ambition expressed by some countries could lead to significant funding and a welcome scale up of some services, but with negative consequences for other parts of the health service. For example, if staff were drawn away from maternity and child health services in order to staff HIV services, or to attend training on malaria or TB. With many of the countries most affected by AIDS, TB and malaria having limited numbers of doctors, nurses and other health workers (see here and here),  increasing activity in one area can easily led to a decrease of activity in another key service. This opportunity cost of different programmes competing for limited human resources, was sometimes over looked. Mark Edington and Abigail Moreland (pictured above) are two of the key members of the Global Fund team working to ensure that the New Funding Model addresses those concerns. They did a great job fielding questions about the new model and noting down ideas which could help strengthen the approach.

The Partner Consultation drew together a number of individuals and agencies who are equally keen to ensure that the new model works. There was very strong representation from the communities affected by the three diseases, and the meeting opened with a statement from Civil Society groups, who had met the previous week in Amsterdam (here) and had developed a clear list of asks for Mark Dybul, the new executive director of the Global Fund. The Global Funds has significantly improved the lives of many poor and marginalised groups, and these communities want to protect the gains made and ensure further progress.

There is a very tight timeline for rolling out the new funding model, and the production line of new guidance documents is only just beginning to deliver the first papers that will guide the process. The draft documents shared at the meeting give an early indication of some of the key elements of the new approach.

I have tried to summarise my views on the New Funding Modality (as I understand it) in terms of the good news, and potential challenges, and have set these out below:

The Good News

Those countries facing funding shortfalls for their national response to the three diseases in the period 2013-2014 will be able to apply for new funds or to re-programme existing commitments. This could mean new money for up to 50-60 countries.

A maximum of 9 countries will test out the new funding modality (these countries will be known as the early applicants). These countries will be able to bid for a set level of funding, indicated at the outset, but will also be able to express what their full demand for funding would be if they were able to secure more funding than is initially on the table. This element of the approach is intended to keep levels of ambition high.

In addition, a set of 40 to 50 ‘interim applicant’ countries will be identified who will be able to apply for bridging funding to cover anticipated shortfalls in funding for current Global Fund financed programmes. Additional funding might include things like replacement insecticide treated bed nets for malaria prevention, when nets previously provided by the global fund are nearing the end of their functional life.

For other countries, not in these groups, there will be no new funding until after the next replenishment of the Global Fund, however there will be scope to negotiate reprogramming of existing funds, and they will be encouraged to develop national strategic plans to address the three diseases, in preparation for future bids.

Each country will be given an ‘Indicative Funding level’ which is the volume of funds they might reasonably expect to apply for based on their level of need (disease burden) and on the capacity they have to fund a national response. There will be more money available for poorer countries. This is really good news in terms of promoting greater equity in access to funds to fight the three diseases and will favour poorer countries with higher disease burdens.

Indicative funding will provide a guaranteed minimum level of funding for a 3 year period, which countries know should be approved subject to a sufficiently robust application. This will remove the risk of significant time wasting in grant applications which has been a problem in the past.

The move away from the round based application process should allow more time for grant applications and allow them to be synchronised with national planning cycles. Having said that however, for the ‘early applicant’  countries, tight deadlines set for the completion of the concept notes is likely to mean that the process of application will still feels highly pressured and demanding in this early phase.

The Concept note application process is intended to lead to ‘grant ready’ funding – avoiding the problem of funding being approved subject to lots of conditions, which was a fault of the previous system. If this can be achieved, that would mark significant progress.

But there will inevitably be challenges with any new funding mechanism. The ones that I identified include the following:

The concept note process still seems to encourage single disease applications, although combined applications for all three diseases will certainly be possible. The problem with lots of single disease applications, each requiring its own application process, will be the same as for the previous funding mechanism, in that the opportunity to address some of the key system challenges, such as lack of doctors, nurses and health workers and limitations of the drug purchasing and distribution systems in ways which will benefit the whole health service may be lost. This is a problem that it should be possible to resolve and the Global Fund team are working on solutions.

The requirement that the concept note include a ‘Full Expression of Demand’ in addition to the bid for the indicative funding is intended to maintain a high level of ambition in countries response to the three diseases. Whilst ambition is good if we want to develop and expand services, it is also important to plan realistically, bearing in mind the limited resources available to deliver the wider range of health services that populations need. We do not want countries to bid for so much funding that it will draw health workers away from other critical areas of healthcare. Any tendency to encourage countries to bid for more than they can realistically and effectively spend is something to guard against.

There will inevitably be teething problems with the new funding model. However, the Global Fund is consulting and listening, and this is a real opportunity to improve on what has been a hugely important funding instrument for tackling the scourges of AIDS, TB and malaria. I, like many others at the meeting, will be keen to find out which countries volunteer and are selected for the early implementer phase. I hope that these countries can demonstrate how the new model can help build stronger health services which tackle the three diseases but also strengthen capacity to deal with the many different health challenges that every country faces.

A cold start to 2013. Picture: Neil Squires

I couldn’t resist posting this picture of the snow that is currently covering the UK, marking a cold start to what promises to be an exciting year.

2013 is the year in which the UK will achieve its commitment to spend 0.7% of the UK’s Gross National Income on development aid. There has been a huge amount of work going on in DFID over the last year, identifying areas where careful use of development aid can make the biggest difference to poor people’s lives. The discipline of developing business cases, which consider different options for spending and assess the relative value for money of these options, has driven much of this work. There is a huge commitment within DFID to ensure we get maximum value from UK aid. The work on gathering the evidence for effective investment and monitoring the impact of programmes will continue this year as we track progress and demonstrate how UK aid is translating into real results for poor people.

2013 is also a year in which there will be a major focus on what should follow on from the Millennium Development Goals, the targets that are set to reduce poverty by 2015. A High Level Panel will be assessing progress and discussing what comes next. I mentioned in a previous blog, some of the inputs that will inform these discussions, and other DFID bloggers have also posted on the ongoing process.

Clearly there will still be a need to continue to invest in many of the areas that were prioritised by the Millennium Development Goals. Poverty and gender inequity remain major challenges, people the world over want better education for their children and this needs to make sure that girls have the same access to an education as boys. Whilst there has been progress in reducing maternal death and improving child health, there is still an unacceptable toll of infant, child and maternal mortality, with continuing high levels of under nutrition contributing to the burden. Poor people in many countries still need better sanitation, improved hygiene and access to water and the threat of climate change and resulting severe climate events needs to be managed.

Some of the things I am hoping to focus on this year will feed into this agenda. My first big meeting this year will be to discuss the new funding mechanism of the Global Fund to Fight HIV/AIDS, TB and Malaria. The large investments made through the Global Fund have had significant health impacts. One of the key challenges going forward will be to make sure that continued investment to combat these three diseases also helps to build more accessible health services that are better able to meet the health needs of all people, rather than just those with specific diseases. The article posted here, highlights some of the health system challenges of achieving the Millennium Development Goals around health.

I hope to be reviewing a number of UK aid programmes throughout 2013, and to be able to highlight some of the innovative work that is being supported by DFID Health Advisers around the world. I will also be meeting with a number of the researchers and research programmes that DFID has been supporting. The new knowledge being generated by this research and reviews can help make sure we invest in the right things. Systematic reviews of key areas of health policy have been helping to identify what the evidence base is for many of the investments we make, challenging existing practices as well as identifying key gaps in our knowledge and highlighting evidence which can inform new ways of working.

The snow will be gone in a few days, leaving just a memory of the additional struggles of getting into work. The Millennium Development Goals highlighted a long term challenge that will not disappear so readily. Our efforts and investment will need to be sustained to 2015 and beyond in support of some of the most hard pressed governments who are struggling in the face of limited resources and fragile or weak systems to improve the wellbeing of their populations. A key challenge that will extend beyond 2015 will be to make sure that the benefits of development and economic growth reach the poorest, and help narrow the health gap that exists in many countries between rich and poor.

My visit to Malawi (here, here, here and here) highlighted how much has been achieved in terms of increasing access to Antiretroviral Drugs (ARVs) which can suppress the virus and protect the immune system, prolonging life and protecting health for many years. With over 350,000 people now receiving these life prolonging drugs in Malawi, there have been real benefits in reducing the number of children orphaned as a result of the disease and reduced transmission of the virus, particularly from mother to child in pregnancy, childbirth and through breast feeding. But the visit to Malawi also highlighted the need to redouble our prevention efforts. The cost of sustaining high numbers of people on ARVs for years to come will only be compounded if we do not succeed in preventing new infections.

Looking across the Zambezi, from Zambia to Zimbabwe. DFID supports HIV programmes in both countries

At a global level, the latest UNAIDS report shows an unprecedented pace of progress in the global AIDS response. There are 700,000 fewer new HIV infections each year across the world than a decade ago, especially among newborn children and more than 8 million people now have access to treatment. However, significant challenges remain, with too many people still getting infected each year (there were 2.5 million new infections in 2011), and 7 million people who are in need of treatment still not receiving it.

From my Malawi blog - there has been a decrease in the number of coffins needed, thanks to HIV treatment

The International AIDS Alliance has just released the report – Don’t Stop Now! The report calls for a UK blueprint to achieve an HIV-free generation and highlights the contribution that has been made to the global fight against HIV/AIDS by the British tax payers through UK aid. The report highlights that the UK is the second largest bilateral HIV donor and currently spends 7.1% of the development budget fighting HIV. DFID is already giving considerable thought to how it can maximise the impact of its HIV spending, in order to achieve the greatest health gain. Ensuring that the interventions we support are evidence based and that impact is closely monitored will be central to on-going support.

I met Alvaro Bermejo, the Executive Director of the International HIV/AIDS Alliance that produced the report, at an All Party Parliamentary Meeting (APPG), held in the House of Commons on 21^st November. The APPG, chaired by Lord Nigel Crisp, was gathering the views of civil society and parliamentarians on what the international development priorities should be beyond the year 2015 and the time frame of the current Millennium Development Goals. Dr Richard Horton, of the Lancet, argued the importance of Universal Health Coverage; Professor Sir Andy Haines of the London School of Hygiene and Tropical Medicine highlighted the importance of the sustainable development goals and of investments outside the health sector which can impact on health. Titilola Banjoko highlighted the importance of listening to developing countries priorities before setting out any post MDG framework, to ensure that new targets address needs defined in the poorest countries. Alvaro Bermejo, commenting from the audience, spoke very effectively on behalf of a number of Non-Government Organisations, highlighting the importance of health beyond 2015, and of continued investment to combat HIV.

Other visits I made this year, which have demonstrated the impact of HIV include a visit to South Africa (here and here) which highlighted the impact of HIV/AIDS on maternal mortality, which is often used as a measure of the health of a nation. I was surprised by the continuing high rates of maternal mortality in South Africa, given its middle income status. Even with its history of inequality, I had expected to see greater progress on key indicators such as reducing the deaths of women in pregnancy. However, the high prevalence of HIV has increased maternal mortality rates - and the difference in maternal mortality between HIV positive and HIV negative women is stark.

During my visit to Zambia a couple of weeks ago (here) I was on the banks of the Zambezi (see picture above), looking across at Zimbabwe, where DFID has a significant programme of support to tackle HIV. DFID programmes in Zimbabwe will be providing 65,000 people a year with HIV treatment by 2015 and will be targeting an additional 1200 people living with HIV in marginalised communities, with specific support for sex workers and their children.

It is clear that much has been achieved, and that DFID support is helping to make a difference. It is also clear that there remains much still to do. It is for this reason that World AIDS Day represents an important opportunity each year to reflect on progress and to consider next steps. HIV has received significant attention through the Millennium Development Goal (MDG) targets, but as will all the MDGs, there remains a huge unfinished agenda. A strong sentiment expressed at the All Party Parliamentary Group last week was that a key part of the post MDG framework for development will need to be completing the unfinished business of the MDGs, and that includes improving access to more effective health services for all,  which tackle stigma and meet the needs of people living with HIV.

Find out more on how UK aid is tackling HIV and AIDS - read our World AIDS Day feature.

A village scene next to Kayola health post (left) and Nampeyo Rural Health Centre (right). Picture: DFID

The first leg of the journey was down 20 kilometres of rough, dusty, rock-strewn dirt track to reach Nampeyo rural health centre (a health promotion poster linking hygiene and health was posted outside the centre and is pictured above).

Community Health Assistants - Hilda and Susan. Picture: DFID

At Nampeyo, we picked up the nurse/midwife and Environmental Health Officer who were previously the only service providers for this large but sparsely populated area. We travelled with them a further 17 kilometres across even rougher terrain to the health post at Kayola (unfinished at present), where the two newly recruited Community Health Assistants, Susan and Hilda (pictured) are based.

 Both Susan and Hilda come from the area and they were selected by their communities to be trained as Community Health Assistants. I was incredibly impressed by their energy, interest and commitment to serve their communities. We accompanied them on visits to households. Below is a picture of Susan visiting a mother with her two children.

Susan at work. Picture: DFID

The child, by his mother’s side in the picture, is one of twins, both of whom are very small for their 5 years of age. Stunting (a failure to grow properly as a result of inadequate diet) is a significant problem in Zambia, and in many developing countries, and is the result of chronic under nutrition. The baby in the mother's arms was a year old and being breast fed as well as receiving solids, but had already had an episode of acute malnutrition. Advice on good nutritional practice, including weaning practice and when to move from breast food alone to solids is very valuable advice that Community Health Assistants can give. However, for poor households, which are often single parent households where a husband may have died or left the family, there is limited money available to buy even basic food supplies and money becomes as important as advice on good nutrition. One of the services that Susan can provide is to refer community members to cash transfer programmes, which provide a small but important cash sum that can help make the difference between household malnutrition and the ability to cope during times of food shortage. See the Department for International Development's (DFID) evidence paper on the potential benefits of cash transfer programmes.

UK aid support for the Community Health Assistant programme in Zambia includes an evaluation, which will help to make sure that the impact of the programme is measured. Gathering the evidence needed to show that this type of initiative can be a cost effective way of increasing access to basic services and improving health will be important, particularly given national plans to scale up the training of Community Health Assistants to a total of 3,100. This is a potentially important part of Zambia’s response to its health workforce shortages.

I have discussed the issue of health workforce shortages in previous blogs (here and here). This is an issue that has been championed by the Global Health Workforce Alliance, which receives British aid, as well as being discussed by the All Party Parliamentary Group on Global Health – All the Talents report.  This visit to Zambia gave me the opportunity to see first-hand how Zambia is working with its partners in order to respond to the health workforce crisis.

One of the key aspects of the programme I was looking at was the evidence base for the effectiveness of Community Health Workers. There have been  a couple of systematic reviews of the impact of Community Health Workers and WHO have produced a policy brief. A key message that emerges is that, as with any health worker training programme designed to effectively deliver a basic package of evidence based services, the challenge will be to ensure that care and support is of good quality, is adequately supervised and those trained have access to good supplies of equipment and medicines they need to do their jobs effectively.

I was impressed with the efforts being made in Zambia to make sure that those trained are able to put in to practice what they have learnt.

Difficult dirt tracks en route to visit Community Health Assistants

This cadre of health worker is a new addition to the health workforce in Zambia, and a strategically important part of its efforts to overcome critical shortages of doctors, nurses and other health personnel. Zambia’s Community Health Assistant training programme (described here) aims to give people in remote rural areas of the country access to a trained health worker who can promote health, advise communities on disease prevention, and provide a basic range of curative services for common, but potentially life threatening, illnesses such as malaria, pneumonia and diarrhoea.

Katy, Yeko, Deputy Director from MOH and Meena discuss visit

I travelled with Dr. Meena Gandhi, a DFID health adviser in Zambia, Dr Yeko Worku and Katy Bradford Vosburg of the Clinton Health Access Initiative, and a small team from the Ministry of Health to visit the CHAs. (Meena, Yeko and Katy are pictured below with the Deputy Director of Environmental Health from the Ministry of Health).

A village house

The first stop on our visit was at Siavonga District, not far from the Kariba Dam. It was extremely hot, over 40 degrees, which highlighted one of the challenges the Community Health Assistants will face as they move from house to house delivering health messages and providing basic services.

Community Health Assistants in the health post

From the district headquarters we travelled to Namoomba village (pictured above) and their health post and met with two of the Community Health Assistants (pictured right). A quick look at the patient register highlighted diarrhoea as a significant problem locally. The CHAs had established that the community’s water source was directly from the Zambezi River (pictured below) rather than from protected wells, and that more than 50% of households still lacked even a basic latrine.

With World Toilet Day having been on 19^th November, it is only right that I should highlight a key part of the Community Health Assistant’s job is to review water, sanitation and hygiene practices in the communities they serve. A significant element of the first few months of the CHAs jobs has been to map those houses which have a pit latrine and to promote sanitation and hygiene practices and new latrine construction. There were already some signs of progress, with latrine pits under construction since the CHAs took up their posts.

Zambezi river - with Zimbabwe on the far side - the water source for Namoomba village

I have posted a picture of the Zambezi River, at the point where it runs by the side of the village, and from where the villagers draw their drinking water, do their washing and bath (despite Hippos).

A key challenge in assessing the impact of the CHA will be the documentation of the services they provide and a demonstration, over time, that these services are helping to reduce the disease burden. For now though, one of the key indicators of success for the programme has been the fact that the communities from which the health assistants were recruited, and to which they have returned, have welcomed their trained health workers back with high expectations for the potential benefits that they might bring over the coming months and years as they become the ‘front line’ of health care provision for these rural communities.

In my next post I will introduce two more health assistants - to highlight some of the challenges that they face.

By the time I met the team members of the RMCH programme on a Monday afternoon after a Sunday night on a plane, I was fired up with questions that had been prompted by my meeting with Dr Khaole that morning (see my last post) and from facts gleaned from an excellent series of articles on health in South Africa published in the Lancet in 2009.

Working together

The RMCH programme is managed by a group of different agencies led by the Futures Group, and including Save the Children, the Health Systems Trust and Social Development Direct.

The RMCH Team, Pretoria, South Africa. Picture: Neil Squires/DFID

This team formed just six months ago to support the National Department of Health. It is a dynamic and committed group of individuals working effectively under the leadership of Dr Ngubane (pictured).

DFID will be providing support through this group over the next four years to help the Government of South Africa strengthen its primary health care system. Progress is already being made as a result of the government’s legislation, which has encouraged a number of senior health workers to move from the cities to district level and strengthen services where the needs are greatest.

On Tuesday 16 October I met with Dr Yogan Pillay, Deputy Director General of the Department of Health and Dr Peter Barron, Special Adviser to the Department of Health. Dr Pillay has oversight of the RMCH programme and highlighted the national commitment to strengthening maternal, newborn and child care at the district level.

Focusing on the poorest

Like the ESMOE project, the RMCH programme has prioritised those districts in South Africa with the worst health indicators. It will be focusing on the 15 districts with the highest maternal and newborn mortality in its first phase and then expanding to cover 25 of South Africa’s 52 districts as agreed by the National Health Council.

The programme will help in building District Clinical Specialist teams, which will have the skill set to improve the quality of service delivery. These teams will work with health facilities in districts to strengthen the quality of care, and ensure that those trained through programmes such as ESMOE are putting their training to good effect.

Listening to patients and improving services

The initiative will also try to strengthen systems of accountability at the district level, so that patients who are not satisfied with care can complain. It will also help ensure that communities get a better understanding of the level of services they should expect and hear about newly planned initiatives, such as schemes to expand the range of contraceptives to increase the choice of family planning methods.

This programme is still in its early stages but it has established a solid foundation and is working closely with the National Department of Health on an important issue that will help tackle the significant differences in health between rich and poor that continue to make South Africa an unequal society.

It has been a packed, tiring, but fascinating week which has opened my eyes to some of the huge challenges and persisting inequalities that face the people of South Africa and their healthcare system. South Africa, like Malawi which I recently visited, is a country where HIV is having a massive impact on health.

Dr Khaole in the National Department of Health, Pretoria. Picture: DFID

After arriving in Pretoria, red eyed and sleepless on a Monday after a night sitting on a plane, I had just 30 minutes for a shower before the first meeting of the day. However, energy levels were soon recharged by the enthusiasm and commitment of the people I met working on these issues.

One of the first people I spoke to was Dr. Nat Khaole (pictured), the Director of Maternal Child and Women’s Health in the National Department of Health. With an encyclopedic knowledge of his subject area, Dr. Khaole highlighted many of the challenges facing South Africa as it tries to deliver the commitments the Minister of Health made to the President in the Negotiated Service Delivery Agreement. The commitments are: to increase life expectancy, reduce maternal and child mortality, combat HIV/AIDS and TB and to strengthen the health system.

In this post, I will briefly profile the ‘Essential Steps in Managing Obstetric Emergencies’ (ESMOE) project, which is run jointly by the University of Pretoria with support from the Liverpool School of Tropical Medicine and Hygiene under the supervision of the National Department of Health.

The Maternal Mortality Ratio (MMR) in South Africa is incredibly high 310/100,000 – a figure similar to other countries in Sub-Saharan Africa, but surprising for South Africa given its level of development and gross domestic product level, which at about $11,000 is much higher than most other Sub-Saharan countries.

Part of the explanation for South Africa’s high maternal mortality is the historic legacy of the apartheid years, where the level of service provision for the black majority of the population was much worse than that available to the white population, and with considerable urban rural differences. An excellent series of articles in the Lancet in 2009 give a real insight to the situation.

Investment to address this historic inequality is ongoing, but providing health services, trained staff, equipment and enabling access, particularly in remote and rural areas takes time. Like much of Africa, even with its higher level or resources, South Africa has struggled to train, deploy and retain enough doctors and nurses (a problem which is being highlighted by the Global Health Workforce Alliance). Making sure that the overworked staff who are present in facilities work in teams that have the skills needed to manage a complicated delivery of women struggling in labour, and to ensure the welfare of newborn children, is a challenge. The statistics posted below show life expectancy, maternal and neonatal mortality by year, with the target set for 2014, that the Government of South Africa hopes to achieve.

Table: Life expectancy and morality trends and targets 2009 – 2014.

Training on difficult births using a mannequin. Picture: DFID

Professor Robert Pattinson, who is the Director of the Medical Research Council (MRC) Maternal and Infant Health Care Strategies Research Unit, at the University of Pretoria, and is the extremely knowledgeable and dedicated champion of the Essential Steps (ESMOE) project. I have posted a couple of pictures taken at a training session I attended whilst in South Africa, during a visit made to assess the quality of the programme. Here, doctors and nurses being trained use a mannequin to practice managing difficult births.

The project has identified the 15 districts in South Africa with the highest levels of maternal and newborn mortality. It has developed a 4 year programme with aims to train 80% of all health staff engaged in maternal health services with saturation training on obstetric and newborn care. The training materials build on knowledge gained in medical and nursing school, but use a hands on teaching method with mannequins and simulation of obstetric emergencies in order to fine tune the skills of health workers. (View a photo gallery about a similar programme in Sierra Leone).

The programme will be evaluating how effective the saturation training is compared to just having regular, in hospital simulation exercises for staff delivered by ‘Master Trainers’, also using mannequins.

It will take time to train all of the health workers, and for the full benefits of the programme to be realised. However, the 5^th Confidential Enquiry into to Maternal Deaths report for the period 2008-2010 recognised the benefits of the training and made several recommendations about the importance of scaling up this training.

Dr Mbisha preparing for a training session. Picture: DFID

The potential prize is high. We hope to see reductions in maternal and infant mortality over the coming years as a result of expanded access of South Africans to treatment for HIV/AIDS, but hemorrhage and high blood pressure and preventable causes of death in pregnancy are killing South African mothers. This project will help HIV positive and HIV negative women alike.

It was a real pleasure to meet Dr Mbisha (pictured) and other trainers at the training session in Sasolburg General Hospital. They are doing a great job that will make a real difference to the lives of South African mothers and children.