Hi class. I apologize for not posting this sooner. A response is due before class on Friday. As usual, pick one of the questions below and respond in the comments section.
1. What are some of the primary challenges to better health outcomes that Garrett highlights? Why are they so bothersome?
2. How can cooperation between entities improve health outcomes?
3. What is value in health care and how can we achieve it?
Thanks for your patience with this class as it gets off the ground. I've enjoyed meeting you all and look forward to working together!
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First off, let me just say what a joy it was to read such a thorough, informative and comprehensible piece of journalism! Laurie Garrett did a marvelous job of keeping my attention.
ReplyDelete1.What are some of the primary challenges to better health outcomes that Garrett highlights? Why are they so bothersome?
Many aspects are holding current global health situation down. I chose only the biggest ones mentioned in Garrett’s paper.
•Money/donations directed at a few “high-profile” diseases, particularly HIV/AIDS, when malaria and tuberculosis kill just as many people each year. Laurie Garrett writes that resources and action should be focused less on specific diseases, rather on more general public health and the communities “well being”.
•Lack of local infrastructure, both in the government and in communication with charities and aid workers. This is also tied in to how air workers often unwittingly undermine the government or wellbeing of the people by importing supplies and workers rather than investing in the local industries and people.
•Innovative leadership in the medical field of developing countries is sadly lacking.
•Most health programs, even the best, are still need carefully planned exit strategies, which are necessary to the sustainability of the efforts, social independence of the country and to move away from government dependency.
•Interconnection of various diseases. Diseases are interlinked far beyond first glance- where there is cleaner water and living conditions, you find less malaria and cholera etc. This is also related to poor nutrition and homelessness, which detain the infected from recovering and strain the immune system.
•Dramatic inequality of health care and work in developed and developing countries, although the poorest nations are finally beginning to spend more money on health care and training. Many governments experience frustration over lack of control of how foreign agencies, however good their intentions may be, operate in their country.
•Lack of coordination from donor activities
•Laurie Garrett briefly touched on the cultural significance we heard about from Farmer. Discrimination often shown to individuals suffering from diseases like HIV/AIDS causes “public health systems (to) have been reluctant to incorporate HIV/AIDS-related programs into general care”.
•The significant lack health education, not just for the masses, but in training nurses and doctors. There are not enough medical schools, particularly in third world countries where the need is most dire. Trained nurses and doctors are often lost to emigration, to developed countries who offer higher pay.
•Need of supplies and medicines
Laurie Garrett suggests making maternal survival and life expectancy top priorities, saying that the overall situation will rise and improve as we work on those two.
1.
ReplyDelete- Aid programs are significantly hindered by the conditions that donors place on their money. These restrictions, determined by well-meaning altruists (Paul Farmer might say they're trying to feel better about their apathetic lifestyle) are caustic to the overall mission of the donation at at times even negate any positive effect the donation may have. Labeled 'stovepiping', this action funnels money to be used very specifically, in ways that are not sustainable or sensible (for example, preventing to spread of HIV from a positive mother to her infant at childbirth but neglecting to perform standard infant immunizations). Another avoidable obstacle is the huge amount of red tape that restrains health efforts and obfuscates the path of aid to recipients. In her article, Garrett cites an analysis of aid programs which estimates that 15-30% of all funds for HIV/AIDS, TB, and malaria programs are lost in bureaucratic red tape.
- Another main problem of health programs is the lack of a public health infrastructure in poor countries to support foreign aid efforts. Most organizations are non-sustainable and lack exit strategies, in countries with a dearth of facilities, equipment, and most importantly, health professionals. A tiny percentage of locally trained doctors and nurses remain in poor countries; most emigrate to wealthier nations such as the US for exponentially higher wages. Personally, I think this is the main wrench in the gears of sustainable health programs.
-Billions of dollars are being sent to benefit programs exclusively focused on treating HIV/AIDS. This segregation from the public health sector causes an estrangement of HIV/AIDS from general care, furthers the AIDS stigma, and steals many health workers who are then trained to treat HIV only and not other common and fatal infections.
- Finally, the billions of international dollars flooding into poor countries could serve to destabilize their economy by spending more external funds than is domestically invested, and could also cause inflation. Increased international influence could harm a poor country's national sovereignty.
Anna Ruth
Question 1.)
ReplyDelete• Most of the money donated to public health is being “stovepiped”, or given to a specific cause that is narrow and specific such as HIV. This creates an environment where the overall health of patients is not the main focus; instead it is just passing out ARV drugs or handing out mosquito nets. This has lead to the downfall of life expectancy rates, a tell tale sign that the overall health of the population is declining. It has pulled resources out of maternal and general health and put them into small picture programs, causing more harm than good.
• There is not enough medical staff working in these third world countries. This is caused by one, developed countries taking talented staff through emigration. Two, talented staff dying by HIV or other diseases, and three, lack of proper medical schools and funds for their development. This has left populations desolated without care, even with donated money and equipment nothing can be administered without the staff.
• There is a lack of overall organization between the thousands of NGO’s, governmental organizations, and private donors. They all have their own agenda’s that sometimes get in each other’s way or do the same work twice. The thousands of resources big and small could be put to much better use if coordinated together.
• The locals need more of a say and a part of these donations and programs. Currently most programs are being forced upon them, causing disorganization and confusion. The foreign programs need to work more with the locals, and this includes setting up local franchises. As Garrett says, the charity will run out eventually, and there needs to be local systems in place in order for the health care system to continue running. Overall the local governments should take charity but make it serve their own priorities that work for their community.
• Infrastructure and governmental systems lack the stability for aid to be effectively implemented- Infrastructures inadequate and new funding goes to improving infrastructure to an acceptable standard. The efforts of many global health care organizations can end up creating fragmented systems which compete against each other for valuable supplies and manpower. The efforts need to focus on creating a unified solution with the local governments so they can combine the efforts of stand alone charities with the efforts of the local government and maximize the impact with these healthcare systems can have. The goal needs to be using what few workers they do have most efficiently.
ReplyDelete• A fundamental change of direction is needed in the worlds efforts to prevent disease in impoverished countries. The goal needs to shift from targeted, narrow efforts which set strict requirements for appropriations of resources to the goal of improving overall life expectancy and maternal health. These need to be the new markers for success. Currently organizations involved have mandates and look for short term signs of success to make appropriation decisions and ensure their funds are being used responsibly and effectively. This focuses on only the causes for which activism is "trendy" in wealthy countries and the outcomes could be improved by focusing on the extent of a communities health related needs. The example in Kenya shows how overall health declined significantly when the president reduced per-capita healthcare spending significantly. The worlds health organizations need to focus on general spending, which may not produce the short term quotas they are used to, but which will have a long term positive impact on the communities.
• A global shortage of health workers results in a desperate shortage of workers in developing nations. The workers receive training in their home country and then a staggering number accept more lucrative positions in developed nations which are in need for workers themselves. Organizations like the WHO and the Gates Foundation can afford to pay workers many times more than what the local ministry of health is able to afford. Small scale HIV/Aids test centers and treatment centers can outcompete the general health clinic and lead to populations being treated for aid at the expense of clinics for general health care. This ultimately has a negative effect on populations health because they have no access to treatment for any ailments the HIV/AIDS effort does not treat such as maternity care and emergency services.
1. What are some of the primary challenges to better health outcomes that Garrett highlights? Why are they so bothersome?
ReplyDelete• Many of the worlds poorest countries have no say in what they want, which projects serve their need, or adopt local innovations. With out these options these countries will not be able to support the people that need help. When a country is not prepared for the things given to them they might cook in a hot dockside, or won’t be given out because there are not enough doctors to distribute them. This ends up wasting money and many people lives that could have used those drugs a lot more.
• When organizations donate money it will come with string that will reflect the donor’s own personal views rather than what could help the country. For example the bush administration had pushed abstinence, fidelity, and faith - based programs, which would result in them not believing in giving out condoms. When you don’t give out condoms or medicines because of your own opinions it sets the society up for something dangerous.
• The countries do not have a safe environment to live in. The water might be contaminated, the food does not supply them with enough vitamins to keep them healthy, and the medical supplies are not safe to use. If they were in a safe environment they would be able to live safe and healthy lives and their population would be under control
• There are not enough trained nurses and doctors to help out. Many of them dying from the diseases themselves and others don’t get paid enough for what they have to do.
• Many of the aid money cannot be found or is stolen. With out the money medicine cannot be bought, and doctors go under paid. When the government searches for cheaper medications they are sold counterfeit medications, which can lead to deadly outcomes.
Question 1.
ReplyDeleteIn “The Challenge of Global Health”, Laurie Garrett explains that interest and donations to promote global health is now at an unprecedented level. However, she says, everyone from individual donors to international organizations needs to examine the healthcare programs they are creating for not just efficiency but also for the big-picture issues of coordination, leadership, context, and sustainability. Here are some major themes in the issues she presents:
·Lack of sufficient coordination. Money, Garrett writes, is of course necessary to address health programs. But it is almost worthless without the support of states, strong healthcare systems, and local infrastructures. Efforts should focus less on particular diseases and more on general pubic health. Garrett points out that donations for combating HIV/AIDS often go to stand-alone programs rather than to help improve general health. Instead, AIDS must be treated as part of a larger health issue. There also needs to be more coordination between organizations; with more than 60,000 NGOs created to address AIDS alone, it is difficult for countries to track, organize, and avoid duplication of efforts.
·Lack of leadership. To effectively improve global health, there needs to be more built-in methods of assessing sustainability and efficacy. Plans for programs should include “exit strategies” to avoid the danger of local governments developing dependencies on outside aid. Garrett also calls for more opportunities for the people who benefit from health programs to express their opinions. With competent oversight, corruption and illegitimate diversion of foreign funds could be curbed. By simply stripping away layers of financing bureaucracy, 15-30% of donated money could be retained. All this requires strong leadership by an organization or person. Leadership alone could make the coordination of the previous point possible.
·Lack of context. Most health problems are embedded in larger issues of poverty and lack of development. In the past, it was assumed that health would improve along with general economic developments. It has only been recently that organizations such as the World Bank realized that “disease in tropical and poor countries was itself a critical impediment to development and prosperity”. (20) Garrett argues that increases in maternal health and life expectancies should used as markers of success. These markers should take the place of numbers of incidence or mortality rates of particular diseases, and no health program should be funded without considering its impact on these goals. Garrett believes that using these markers would ensure that successes reflected success in the area’s general health, not just a success in one particular aspect that might come at the cost of a failure elsewhere. For example, in Ghana, “prenatal care, maternal health programs, the treatment of guinea worm, measles vaccination efforts [have] all have declined as the country has shifted its health-care workers to the better-funded projects”. (26)
·Lack of stability and sustainability. The biggest donations, Garrett points out, are triggered by emotional responses. Aid is often “stovepiped” to programs relating to a specific disease, which reflects the interests of the donors, not the recipients. This means that “advocacy, the whims of foundations and the particular concerns of wealthy individuals and governments drive practically the entire global public health effort.” (23) Many countries do not have the resources or political will to train and retain medical professionals: only about 8% of the nurses trained in Zambia in the last forty years have stayed in the country, and even the US needs to import nurses to cover its health needs. Garrett also wrote that an influx in foreign cash into a country, if not properly managed, could “exacerbate such conditions as malnutrition and homelessness while undermining any possibility that local industries could eventually grow and support themselves through competitive exports.” (30) Instability is especially dangerous because, as Farmer also pointed out, people who don’t follow through with—for example—TB treatments wind up creating a drug-resistant form of TB.
I also agree with Emmas starting statement, Garret's persuasive text kept me on topic more than the other two.
ReplyDelete• The drugs, priced about $14,000 a year and then requiring around $5,000 a year for general tests and medical visits, were completely unaffordable for much of the worlds HIV- Positive population. Further down the road activists tried to allow the manufacturers to offer a generic brand of the medicine for it to be more affordable.
• The need for medical supplies is a dire one to say the least. Many countries which are infected with tb, HIV-AIDS, etc, don’t have the ability to pay for the meds, which in return don’t get treated.
• The World Bank took little interest in health issues in its early decades, thinking that health would improve steadily by itself with the tandem economic development, which technically is the banks mission to promote.
• All the appropriate funds are not being spent effectively.
• Billions of dollars are being sent to benefit programs exclusively focused on treating HIV/AIDS. This segregation from the public health sector causes an estrangement of HIV/AIDS from general care, furthers the AIDS stigma, and steals many health workers who are then trained to treat HIV only and not other common and fatal infections.
• Part of the problem is that most of the global HIV/AIDS related funding goes to stand-alone programs: HIV testing sites, hospices and orphanages for people who are affected multiple ailments.
• Finally, the billions of international dollars flooding into poor countries could serve to destabilize their economy by spending more external funds than is domestically invested, and could also cause inflation.
• The problem is that you need: leaders who don’t build palaces on the Riviera. You need a clear health care system with the equity that is not donor driven, for the donors in past years haven’t shown up as well as governmental evident money.
• A Survey of Ghana’s hospital was recently done in 2002, showing that they were unable to provide the adequate expected services due to lack of employees. 43% were unable to provide full child immunizations; 77% were unable to provide 24-hour emergency services and around the clock safe deliveries for woman and childbirth.
• The HIV coordinator for the Malawi Ministry of Health notes that of the country’s twelve million people, 90,000 have already died of AIDS and 930,000 now infected with HIV. Which leads to say that the prevention efforts in Malawi are next to none, or so you would think? Over the last five years, the government has lost 53% of its health administrators, 64% of its nurses, and 85% of its physicians. This bringing a high amount of hospitals without much healthcare personnel.
• Interconnection of various diseases. Diseases are interlinked far beyond first glance- where there is cleaner water and living conditions, you find less malaria and cholera etc. This is also related to poor nutrition and homelessness, which detain the infected from recovering and strain the immune system.
- A main issue personally which I see and is thoroughly talked about within the article is that the lack of, or unemployment of nurses, physicians, and doctors world wide. Without them the act is hardly anything, though with more of them on hand, the act of curing these life threatening diseases can sky rocket.
They also seem to be issues which could easily be taken care of, by means of cutting other costs which are unnecessary, and put the money towards them.
I agree with both Emma and Tyson in that this article, although it may look very dense and hard to read, somehow the way everything was phrased made all of the statements very clear.
ReplyDelete1) What are the fundamental challenges of global health that L. Garrett idnetifies?
-On fear/challenge is that, while companies and organizations may be donating multiple large sums of money, that might no continue. With the current economic crisis, who knows when a company will have to shut down. Organizations working directly in the HIV/AIDS of Malaria infected countries rely on what money they get to continue treatment on their patients. If the flow of money stops, the treatment stops.
-A problem related to the previous one is trying to direct where the money actually goes. Laurie Garrett gives this amazing fact:
"In Ghana, for example, where such corruption is particularly rampant, an amazing 80 percent of donor funds get dirverted from their intended purposes."
-Many of the drugs that were to be delivered get "siphoned off" and get sold on the black market.
-"Most funds come with strings attached and must be spent according to donors' priorities, politics, and values."
That statement was a huge shock to me. I always thought that the organization recieving the money would be under its own jurisdiction about how they used the money.
-Definitely one of the main problems is the affordabilty of the treatment drugs. In 1997, cost of drugs, tests, and other medical visits cost around $19,000. Only a very small percent of HIV-positive people could afford that huge sum. With HIV/AIDS most common in developing countries, how could companies expect the majority of patients to pay that cost?
These are unfortunately only some of the challlenges associated with the global health situation today.
Madeline Allen
1) Many factors inhibit the development of an easy solution to current global health concerns. Here are some of the major issues that Garrett addresses in her article:
ReplyDelete-A lack of organization within the deteriorating or scant health care systems of 3rd world countries renders huge portions of foreign donation towards the cause useless. Raised funds often get “trapped in bureaucracies and multilayered banks” (22), never reaching their intended target. Ghana is a profound example, where “such corruption is particularly rampant” (22); 80% of funds are taken before the final 20% reaches the purpose.
-Organizations do not coordinate their activities. Garrett makes the case that the issues of global health cannot be addressed and satisfied by a single organization or exclusive group of doctors. It will instead require a collaborative effort to which donors are currently not rising.
-There is a general lack of organization and cooperation between the agencies offering aid and the countries who need that aid. Organizations can anticipate a surface level issue while the true burden lies elsewhere. Narrowing in on the treatment of one disease does little for the general health of a country, and foreign agencies often do not see the underlying or most critical problem that local eyes could spot. Donations can only go so far when fundamental infrastructure is not in place; countries need money that can be spent in lasting ways that are too often overlooked by money providers.
-Aid is often offered towards one specific cause (for example HIV/AIDS). This idea of “stovepiping” leaves dire problems uncared for. Because epidemics are the result of a number of factors, including general health care and malnutrition, these stovepiped funds cannot have any substantial or lasting effect. ARV distribution for children and mothers, for example, may be carried out in a city where basic infant health care does not exist. The help provided by the ARV distribution would not have the same impact on such a community as it would on one where prerequisite systems are well in place.
-There is a global shorting of health professionals, this dearth most apparent in suffering countries where training is poor if existent and wages are low. Minimal personal financial support for health professionals coupled with a sense of helplessness derived from insufficient medical supplies, doctors and nurses trained in impoverished countries are flooding to those countries with more stable health systems. Again, in Ghana of the 871 medical personnel trained between 1993 and 2002, only 276 remain in the country.
-There is not enough money or resources offered to implement a sustainable system in any crumbling country. Doctors do not have the necessary means to take care of their patients. The flip side of this issue is the phenomenon of the “Dutch-disease”; infusing too much foreign money into a country instigates a different but equally detrimental chain of reactions. Inflation within the community makes standard necessities unaffordable for some, proliferating malnutrition and similar conditions. Furthermore, the country would develop a dependency on foreign aid. For example, outside funds cannot offer high wages to entice trained nurses and doctors to remain in their own country because that takes power away from the local government, which cannot provide the same offer. The remedy would be to offer an even higher wage to those working for a government agency, but this is extremely expensive, so too often the need is only met in part.