Bulletin of the World Health Organization – January 2015

Bulletin of the World Health Organization
Volume 93, Number 1, January 2015, 1-64

The Ebola epidemic: a transformative moment for global health
Stephen B Kennedy a & Richard A Nisbett b
a. Liberia Post Graduate Medical Council, Corner of 12th Street and Russell Avenue, 2nd Floor Office Complex, Monrovia, 10001, Liberia.
b. Vanderbilt Institute of Global Health, Nashville, United States of America.
Bulletin of the World Health Organization 2015;93:2.
doi: http://dx.doi.org/10.2471/BLT.14.151068
The devastating effects of the current epidemic of Ebola virus disease in western Africa have put the global health response in acute focus. The index case is believed to have been a 2-year-old child in Guéckédou, Guinea, who died in December 2013.1 By late February 2014, Guinea, Liberia and Sierra Leone were in the midst of a full-blown and complex global health emergency.2 The response by multilateral and humanitarian organizations has been laudable and – at times – heroic. Much of the worst affected region is recovering from civil conflicts. This region is characterized by weak systems of government and health-care delivery, high rates of illiteracy, poverty and distrust of the government and extreme population mobility across porous, artificial boundaries. A more coordinated, strategic and proactive response is urgently needed.

According to the World Health Organization (WHO), the outbreak had involved 17 145 probable, suspected or confirmed cases of Ebola virus disease and 6070 reported deaths, by 3 December 2014.3 The management of the outbreak has largely been taken out of the hands of the affected communities, even though such communities have cultural mechanisms and expertise to deal with various adversities. Local churches and community-based organizations, which have previously been involved in the response to health emergencies and conflicts, have been largely excluded. Although the worst-affected communities have been subject to quarantines and cordons sanitaires, the governments imposing these have often failed to provide adequate food and water to the people thus isolated. In addition, cordons sanitaires are hard to maintain when local police and military personnel are not trusted.

Although it is difficult to build trust and community support during an Ebola outbreak, the community-directed interventions developed by the WHO’s Special Programme for Training and Research in Tropical Diseases4 might usefully be implemented. The interventions are designed to prevent, treat and control infectious diseases of poverty by empowering and mobilizing communities and building effective cross-sectoral partnerships. To be effective in addressing salient transborder health issues, global health initiatives must focus on multilateral and cross-sectoral cooperation. Often, such cooperation must accommodate high levels of poverty and illiteracy and other substantive barriers to accessing formal health systems.

As we endeavour to combine biomedicine and social medicine to create a trans-disciplinary workforce for the Ebola frontline, we must ensure that our efforts are focused on the people, households and communities at risk. If we are to achieve any global health goals, we must empower the marginalized and voiceless. In the era of globalized supply chains and rapid transportation across very porous borders, it is in our self-interest to recognize our interdependence.
We also need a dose of humility and effective approaches at household, community, societal and global levels. At the household level, we need to promote family-centred interactions and interventions. Cultural practices such as embalming, burial and caregiving are family-based as well as community-based activities.

At community level, we need to re-emphasize the value of partnerships led by trusted community- and faith-based organizations. Even in the best of situations, most of the world’s resource-limited communities tend to be wary of government officials and other outsiders.

At societal level, we need approaches that engage, mobilize and energize non-state, non-political actors while coordinating the ministries involved in health, welfare, finance and education. Grassroots groups with a high reserve of trust can be successfully engaged and motivated to intervene in a manner that is culturally sensitive.

Finally, we need global approaches that will intensify the international response. The global health community should treat the Ebola outbreak as the complex humanitarian emergency that it is.

We admire, commend and thank the tireless and brave frontline workers responding to this tragic outbreak – they are genuine heroes and national treasures. However, without a more effective and robust emergency response – and years of intensive health systems strengthening –there will be many more serious epidemics of Ebola and other infectious diseases. Such epidemics threaten not just the world’s most resource-poor settings but also the entire global community.

Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, et al. Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371(15):1418-25. 10.1056/NEJMoa1404505 http://dx.doi.org/http://dx.doi.org/ pmid: 24738640
Chan M. Ebola virus disease in West Africa — no early end to the outbreak. N Engl J Med. 2014;371(13):1183-5. http://dx.doi.org/10.1056/NEJMp1409859 pmid: 25140856
Ebola response roadmap – situation report. 3 December 2014. Geneva: World Health Organization; 2014. Available from: http://www.who.int/csr/disease/ebola/situation-reports [cited 2014 Dec 9].
CDI Study Group. Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ. 2010;88(7):509-18. http://dx.doi.org/10.2471/BLT.09.069203 pmid: 20616970

Expensive medicines: ensuring objective appraisal and equitable access
Suzanne R Hill a, Lisa Bero b, Geoff McColl a & Elizabeth Roughead c
a. University of Melbourne, Parkville, Melbourne, Victoria 3010, Australia.
b. Charles Perkins Centre, University of Sydney, Sydney, Australia.
c. University of South Adelaide, Adelaide, Australia.
Bulletin of the World Health Organization 2015;93:4.
doi: http://dx.doi.org/10.2471/BLT.14.148924

Responses to donor proliferation in Ghana’s health sector: a qualitative case study
Sarah Wood Pallas, Justice Nonvignon, Moses Aikins & Jennifer Prah Ruger
To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012.
We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research.
Ghana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.
In 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.

Neonatal cause-of-death estimates for the early and late neonatal periods for 194 countries: 2000–2013
Shefali Oza, Joy E Lawn, Daniel R Hogan, Colin Mathers & Simon N Cousens
To estimate cause-of-death distributions in the early (0–6 days of age) and late (7–27 days of age) neonatal periods, for 194 countries between 2000 and 2013.
For 65 countries with high-quality vital registration, we used each country’s observed early and late neonatal proportional cause distributions. For the remaining 129 countries, we used multinomial logistic models to estimate these distributions. For countries with low child mortality we used vital registration data as inputs and for countries with high child mortality we used neonatal cause-of-death distribution data from studies in similar settings. We applied cause-specific proportions to neonatal death estimates from the United Nations Inter-agency Group for Child Mortality Estimation, by country and year, to estimate cause-specific risks and numbers of deaths.
Over time, neonatal deaths decreased for most causes. Of the 2.8 million neonatal deaths in 2013, 0.99 million deaths (uncertainty range: 0.70–1.31) were estimated to be caused by preterm birth complications, 0.64 million (uncertainty range: 0.46–0.84) by intrapartum complications and 0.43 million (uncertainty range: 0.22–0.66) by sepsis and other severe infections. Preterm birth (40.8%) and intrapartum complications (27.0%) accounted for most early neonatal deaths while infections caused nearly half of late neonatal deaths. Preterm birth complications were the leading cause of death in all regions of the world.
The neonatal cause-of-death distribution differs between the early and late periods and varies with neonatal mortality rate level. To reduce neonatal deaths, effective interventions to address these causes must be incorporated into policy decisions.

Lessons from the Field
Informing evidence-based policies for ageing and health in Ghana
Islene Araujo de Carvalho, Julie Byles, Charles Aquah, George Amofah, Richard Biritwum, Ulysses Panisset, James Goodwin & John Beard
Ghana’s population is ageing. In 2011, the Government of Ghana requested technical support from the World Health Organization (WHO) to help revise national policies on ageing and health.
We applied WHO’s knowledge translation framework on ageing and health to assist evidence based policy-making in Ghana. First, we defined priority problems and health system responses by performing a country assessment of epidemiologic data, policy review, site visits and interviews of key informants. Second, we gathered evidence on effective health systems interventions in low- middle- and high-income countries. Third, key stakeholders were engaged in a policy dialogue. Fourth, policy briefs were developed and presented to the Ghana Health Services.
Local setting
Ghana has a well-structured health system that can adapt to meet the health care needs of older people.
Relevant changes
Six problems were selected as priorities, however after the policy dialogue, only five were agreed as priorities by the stakeholders. The key stakeholders drafted evidence-based policy recommendations that were used to develop policy briefs. The briefs were presented to the Ghana Health Service in 2014.
Lessons learnt
The framework can be used to build local capacity on evidence-informed policy-making. However, knowledge translation tools need further development to be used in low-income countries and in the field of ageing. The terms and language of the tools need to be adapted to local contexts. Evidence for health system interventions on ageing populations is very limited, particularly for low- and middle-income settings.

Measuring the incidence and prevalence of obstetric fistula: approaches, needs and recommendations
Özge Tunçalp a, Vandana Tripathi b, Evelyn Landry b, Cynthia K Stanton c & Saifuddin Ahmed c
a. Department of Reproductive Health and Research, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
b. Fistula Care Plus, EngenderHealth, New York, United States of America (USA).
c. Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
(Submitted: 09 June 2014 – Revised version received: 10 October 2014 – Accepted: 13 October 2014 – Published online: 01 December 2014.)
Bulletin of the World Health Organization 2015;93:60-62.
doi: http://dx.doi.org/10.2471/BLT.14.141473