| A significant
strategy for combating poverty-related diseases has arisen
through the development of vaccines and drugs. However,
to ensure its efficacy it needs to be set within an integrated
delivery programme and sustained by well-defined organisational
and management strategies. Policy measures thus need to
recognise the strengths of clinical and non-clinical approaches
to the management of poverty-related diseases. While the
emphasis is on malaria, tuberculosis and HIV/AIDS on a global
scale, attention is also given to other more neglected diseases
of regional importance such as gastrointestinal, respiratory
and vector-borne diseases.
In this chapter, good practice examples
are given of EC-funded work on cross-sectoral policy research,
health care delivery systems and the development of tools
in developing countries. These projects have contributed
enormously to capacity building in each of the countries
in which the partnerships have worked.
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MAJOR CAUSES OF MORBIDITY
AND MORTALITY IN DEVELOPING COUNTRIES
HIV/AIDS:
40 million people live with HIV, while AIDS
has caused more than 22 million deaths. An additional
5 million people are infected each year; and
almost one-third are also infected with tuberculosis
(TB). TB:
causes 2 million deaths annually. Malaria: 500
million cases/year, 2 million deaths annually,
mostly children under five. Acute
respiratory and diarrhoeal diseases:
remain major causes of ill health and mortality
particularly in children. Nearly half of child
mortality in low-income countries can be linked
to malnutrition.
Reproductive health
and rights:
maternal and perinatal causes alone lead to
the loss of 600 000 women and several million
new-borns each year. 150 000 people are dying
yearly from African
trypanosomiasis and
80 000 from leishmaniasis.
18 million people are infected with Chagas’
disease, 120
million are affected by lymphatic filariasis,
and 200 million people infected with
schistosomiasis,
while 600 million are at risk. |
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1. Health policy and systems research
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Health systems are changing
everywhere; management of change is complex.
Evidence is needed of what change is effective
and how it can be achieved. The lessons learnt
in the different countries show that reform
is an ongoing and a continuous process, and
that more reliable and refined information is
necessary for decision-making. |
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The European Commission’s involvement in health policy
and system research has steadily evolved over many years.
Strong partnership and trust based on more than ten years
of collaboration has been created between EU and devel oping
country scientists working in the field of health care delivery
systems. This has expanded to encompass the socio-economic
dimension, research for policy decisions and the implementation
of intervention strategies. Equity, access and quality of
care are among the major aims.
• Socio-economic factors
There is a need to assess how people’s
health is affected by social inequalities, through the adoption
of a multidimensional approach to understanding health systems,
an approach that takes into consideration the socio-economic
and cultural dimensions of health, well-being and of ill
health. There is a growing consensus that analysis of health
systems needs to be located within a broad definition of
health, which incorporates its historical and social dimensions.
The expanding networks of EU, African, Asian and Latin
American researchers are currently taking an interest in
understanding health systems from a multi-disciplinary perspective
that includes cultural and socio-economic factors. Examples
include studies on the development of special camp-centred
health care programmes for refugees by using and strengthening
the health services of the host country; and on setting
up a network of researchers, practitioners and policy-makers
for health response for conflict and disaster affected populations
to find alternatives to better cope with these situations.
A recent EC-funded action, ‘Restructuring of Health
Services in the Context of Globalisation’, was able
to bring together scientists working in the field of health
reforms, privatisation of services and emerging global finance
mechanisms to compare and contrast experiences of the process
in different regions. The particular focus was a comparative
one, mainly between Asia and Europe, taking into account
the socio-economic, political and historical context, and
explanatory models that provide the rationale for the current
shifts in financing health care. The way in which evidence
on health, the health sector and health services is being
collected, and how this affects prioritisation in the provision
of services, in terms of equity and access to health and
social care, were critically appraised. This action will
lead to the creation of a network on global public health
policy and practice in the 21st century.
• Research for policy decisions
Shared information:
connecting scientists
Scientists for Health
and Research for Development
– SHARED –
an EC-funded concerted action provides updated and essential
information on health research for developing countries
through the Shared virtual organisation(17).
An additional project, the Shared CD-ROM, is being funded
by the EC to increase the interactivity of Southern researchers.
It enables anyone with access to a computer to exploit the
Shared technology off-line. This option allows users to
reduce dramatically the on-line time needed to find information.
Wide dissemination of this technology is being carried out
in Africa, Latin America and Asia.
Credit: WHO/TDR/CRUMP
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Pilot health centres: models for
similar situations around the world
Thailand has experimented with ‘integrated’ health
systems that consider prevention and health education to be
as important as actual health care. The study showed the potential
and feasibility of improving primary health care through the
creation of pilot health centres in an urban region. The range
of services provided to the population, as well as their quality,
has improved considerably. This experiment now forms the basis
of the national health system reform project, and research
is ongoing to test new payment systems. The Nouna Health
Research Centre in Burkina Faso is a platform for interdisciplinary
field research in West Africa. It started in the early 1990s
as a collaborative project, and the main objectives have
now been successfully achieved. They include the scientific
investigation of health conditions and health systems in
the region; the provision of data collected through intervention-based
research to health planners and policy-makers, and institutional
capacity building in health research.
Reforming health
services for equity and efficiency in urban situations
Changes that have occurred during the late transition period
to a market economy have had a profound impact on almost
every aspect of urban health services. The impact of health
sector reforms upon access to and utilisation of health
services (rural and urban) has been evaluated by two parallel
projects in China and in three Indian States.
The unique feature of the Indian study was its multidimensional
methodology which established the epidemiological profiles
of the population as well as examining socio-economic and
cultural factors in the utilisation of health care. The
results showed that, contrary to the aims of the health
policy under the reform programme, safety nets (food subsidies
in the main) were weakened further by changes in policies
on social subsidies with detrimental effects upon the overall
state of health.
Findings from the Urban Health Reform Study in China showed
that the income gap between the highest and lowest income
groups increased in real terms between 1993 and 1998 and
that there was a significant decline in the population covered
for health care by the government insurance schemes, which
was directly related to the reforms of public sector institutions.
During the same period the proportion of the population
who had to ‘pay out of their own pocket’ for
services increased from 28% in 1993 to 44% in 1998. The
project was developed in consultation with the Ministry
of Health, and results are now ready to be implemented in
China.
Strategic planning
in response to increasing health needs
Health ministries in many developing countries are developing
their own health care strategies, although no concrete guidelines
for advice on the process of strategic planning are currently
available to help them to do this. Upon a call from the
ministries for such a tool, an EC-funded project involving
EU and African scientists explored the processes underlying
strategic planning in the health sector in three African
countries: Eritrea, Mozambique and Zimbabwe. The guidelines
are not ‘how to do it’ manuals, but are designed
to help governments and, in particular health ministries,
to assess and strengthen their own strategic planning systems.
EU and Asian partners in another concerted action are
working on monitoring shifts in health sector policies in
South Asia regarding trends in health status, health policies
and concepts of public health. An important organisational
objective is to promote a regional network of South Asian
scholars and to develop links with European scholars around
the main theme of the project.
Credit: WHO/TDR/STAMMERS |
Uncovering a
counterfeit drug for schistosomiasis
The objective of this EC-funded concerted action, set up
in 1997, was to collect and analyse all available information
on the use of Praziquantel(18), the
drug of choice for the treatment of a parasitic disease,
schistosomiasis, also called bilharziasis. The initial team
of 15 expanded to involve a total of 41 scientists and health
administrators from 17 countries. The group worked on various
features of chemotherapy, focusing on instances of treatment
failure and its underlying causes, including drug resistance
in the parasite.
To assess the quality of Praziquantel, 34 samples from
19 different manufacturers were collected in 13 disease-endemic
countries, mostly at the user level. Fifteen of the 19 brands
were of satisfactory quality for all the variables assessed
(content of active substance, impurities, disintegration,
and dissolution). Three brands did not meet the standards.
One brand, labelled ‘International Ltd Co, Canada’,
and collected from two sources in Sudan, was counterfeit
and contained no active substance at all. Apart from the
commercial fraud, such an ineffective product is undoubtedly
harmful to the health of patients, and may reduce confidence
in medical intervention. This work has led to the redefinition
of quality control mechanisms for generic drugs.
Ethics high
on the global agenda
As the result of funding from the EC and other international
organisations (WHO, NIH, etc.), a very successful seminar
took place in Africa last year on Health Research Ethics
to set common ethical criteria and to establish local scientific
and ethical review boards in Africa. Different organisations
are involved in setting up local ethical review boards and
committees in developing countries.
The European Group on Ethics (EGE) has already proposed
suggestions for an Action Plan in Europe on culturally sensitive
ethical questions in science. EGE is now initiating dialogue
on ethics with other cultures.
• Health care services intervention
Better pharmacy
practice
One priority of EC health policy is the provision of affordable
medicines of good quality to entire populations, especially
the poor. The partners of an EC-funded research project
– a collaboration between EU and Asian partners –
on ‘Good Pharmacy Practice (GPP): a multi-intervention
approach to rationalise drug use through private pharmacies’,
performed a randomised, controlled trial in Thailand and
Vietnam to evaluate drug distribution practice in private
urban pharmacies. Policy-makers were provided with the scientific
basis for decisions relating to pharmacy practice and national
drug policy reform in order to improve case management of
major diseases of public health importance. This intervention
study significantly improved private pharmacy practice and
knowledge in both countries, while the monitoring instruments
developed may well be adapted to national level surveillance
systems for private pharmacy practice. The results are now
being considered by the health authorities in each country
for nation-wide implementation.
Simple interventions
to save lives
The Commission-funded study ‘Effectiveness and efficacy
of zinc for the treatment of acute diarrhoea in young children’
shows that children who receive three times the recommended
daily allowance of zinc recover from acute diarrhoea faster
than children who receive a placebo. Moreover, the treatment,
which resulted in a nearly 50% reduction in the risk of
prolonged diarrhoea, was as effective when it was given
by the mother as when given by field workers. The study,
which involved 1800 children in Nepal from all socio-economic
groups, is a good example of simple and efficient health
care services intervention to save children with acute diarrhoea
which, if not treated properly, can prove detrimental in
children.
In a parallel EC-funded field trial in India, the distribution
of daily zinc supplements to healthy children resulted in
a 25% reduction in the incidence of pneumonia and an even
greater reduction in the occurrence of severe and recurrent
diarrhoea. This shows that including zinc in the daily diet,
as a means of improving child nutrition, may have substantial
child health benefits.
The conclusion of a major international clinical trial,
the ‘Magpie Trial’, co-funded by the EC, is
that the administration of magnesium sulphate injections
to pregnant women with pre-eclampsia (pregnancy-induced
high blood pressure, commonly known as toxaemia) greatly
reduces the risk of developing eclampsia (convulsions) and
can therefore save their lives. One in ten pregnant women
world-wide suffers from pre-eclampsia, often during their
first pregnancy. Currently, the only available treatment
is to deliver the baby early. The three-year study (involving
10 000 women) was conducted in 33 countries covering much
of the developing world where eclampsia is the most common
cause of death among pregnant women.
• From research to action in
reproductive health
Credit: WHO/TDR/CRUMP |
How the EU defines and implements its policies in this
field is illustrated by its approach to sexual and reproductive
health. Industrialised and developing countries alike agreed
upon the Programme of Action set out at the International
Conference on Population and Development (ICPD) held in
Cairo in 1994. This agreement led to greater efforts on
the part of both the EU and individual nations to tackle
issues such as the increasing prevalence of STD/HIV/AIDS,
adolescent reproductive health, safe motherhood and family
planning. Funds are provided to carry out operational research
dealing with sexually transmitted diseases and related services
for people in high-risk situations, on sensitive issues
such as evaluation of major maternal risks of induced abortion
and miscarriage, violence against women, gender issues,
reproductive and sexual rights, etc.
Putting adolescent
reproductive health research high on the agenda
The impact of the EC-funded ‘Adolescent Reproductive
Health Network’ (ARHNe) between five European and
five Southern and East African countries, has been substantial.
Institutions within ARHNe comprised research and health
services, governmental agencies, as well as international
and non-governmental organisations. Information was disseminated
from the network to a wide audience including national and
local policy-makers and professionals providing day-to-day
services to young people. This network has resulted in two
new research projects on school-based HIV/AIDS intervention
in Sub-Saharan Africa, and in bridging gaps between public
and traditional health care sectors testing a model to improve
the quality of STI/HIV/AIDS care in the same region.
Better births
and improved maternity care
The ‘better births’ initiative, an EC-funded
project involving EU and African scientists, was set up
to help women in low-income countries who often endure procedures
during labour which are both unpleasant and degrading. Health
professionals, who are often overstretched, may treat their
patients with a lack of respect. The purpose of the initiative
was to improve maternity care by identifying what could
be done specifically to improve dramatically women’s
experience of labour. Methods of engendering such changes
were developed and tested, and a simple strategy was agreed
upon which is both accessible to and suitable for low-income
countries. The strategy was implemented in local spheres
of influence, while other countries were encouraged to adopt
the better births care package.
2. Research and development of tools
For most of the infectious diseases, such as malaria, HIV/AIDS,
Schistosomiasis, Chagas’ disease, hemorrhagic fevers,
tuberculosis, etc., early, sensitive, specific and discriminative
diagnostic tools are indispensable. These tools should be
affordable, usable in the field and offer great potential
for treatment in health services for monitoring and evaluation,
e.g. indicators of infection, morbidity and disease outcome.
Current research is based on the development of new drugs
and treatment strategies, including a combination therapy
necessary against these diseases. Promising candidate antigens
(which could be used as potential vaccines) have been identified
for some of these diseases; several have been selected for
further development and some are currently in clinical and
field trials. Research on the epidemiology and the development
of new control strategies, including environmental control
methods for the above-mentioned diseases, is very important.
The European Commission promotes active collaboration
on equal terms between researchers in European institutions
and those in developing countries for research and development
of tools to combat these diseases. The European and Developing
Country Clinical Trials Platform (EDCTP) initiative (see
Policy Framework)
is one of the most recent examples of such collaboration.
Hence, a range of novel weapons is evolving in the war
against disease in the poorer countries, on new rapid detection
methods, preventive measures, and medicines. At the same
time, fresh strategies are being devised to make the best
use of the many resources that are now available. Below
are some good practice examples of such research funded
by the EC and based on equal partnership between EU and
developing country scientists.
• New tools
A rapid diagnostic
test for Ebola
The Ebola virus, which causes massive internal and external
bleeding, first appeared in Africa in 1976. Since then it
has killed more than 1 000 people in outbreaks that have
spread panic across the continent, the last being in December
2001. Efforts to contain repeated outbreaks have so far
failed, mainly because the only laboratory test available
was taking too long to identify the virus. Thanks to an
EC-funded project, researchers from Europe in partnership
with research teams from developing countries have successfully
developed a new technique to diagnose infections resulting
from the Ebola virus. The test takes the form of a low-cost,
portable kit that can be used in the patient’s home.
It is based on the detection of viral genomes by PCR (polymerase
chain reaction), and requires far fewer procedural steps
than the standard PCR test previously available. This new
blood test has proved very timely since it was used successfully
during the recent Ebola outbreak in Gabon last December.
This new simplified test has allowed doctors to rapidly
identify infected individuals, isolate the victims, and
treat them before they can infect others.
ARIVAS/ARIVA
– reinforcing independent vaccination programmes in
Africa
Two support programmes recently established by the EC –
ARIVAS and ARIVA – have provided funds totalling €11
million to a large number of African countries to enable
them to run their vaccination programmes independently.
Funded by the EC’s EuropeAid Office (AIDCO), the programmes
have run interdependently among countries on the African
continent. They offer these countries the possibility to
share their vaccination strategies through a network of
locally based experts.
The regular co-ordination and communication of participants
contribute towards the cost-effective implementation of
the Expanded Programme on Immunisation (EPI), and results
in strengthening local capacity. During the implementation
of the project a good collaboration between the regions’
authorities was observed and established, and even led to
the possibility of ‘lending’ vaccines in cases
of necessity or emergency. This reinforcement will open
up new pathways for discussions with all stakeholders, including
the pharmaceutical industry.
Control starts
with prevention: the need for an effective global response
As yet there is no antimalarial vaccine. Prevention of malaria
involves mosquito control and bite prevention, mainly through
mosquito-repellent impregnated bed-nets and taking antimalarial
drugs. Resistance to drug treatment is a growing problem.
Therefore, existing cost-effective interventions such as
impregnated bed-nets remain the best prevention. However,
these remain underused and often do not reach the most needy.
Research demonstrates that targeted investments in the control
of communicable diseases improve the health of the poorest.
Intensified support to strengthen health systems is necessary
for effective delivery.
The widespread use of impregnated bed-nets could prevent
600 000 child deaths per year.
Malaria vaccine initiatives
and networks
The EC has been dealing with malaria issues for many
years. Set up in 1998, the European Malaria Vaccine Initiative
(EMVI)(19) aims to speed up the development
and testing of antimalarial vaccines. The many potential
vaccines that have already entered the different stages
of clinical evaluation and testing are the outcome of an
international cooperative effort involving 11 countries
from Latin America, Africa, Asia and the EU. The consortium
has been stimulating international collaboration with scientists
from developing countries in order to tackle this disease.
Clinical testing of the first potential EMVI-supported malaria
vaccine will soon start clinical evaluation in Africa.
The Commission is also funding the African Malaria Vaccine
Testing Network (AMVTN)(20) involving
six EU and nine African institutes. Over the past six years,
AMVTN has established itself as a leading pan-African network
building human capacity in malaria vaccine research, development
and clinical trials. The knowledge and skills gained will
ensure adherence to established international standards
of ethics, data management, monitoring and evaluation of
intervention trials. EMVI and AMVTN work closely together.
In addition, the African Malaria Network Trust (AMANET)
was created recently to carry out all activities previously
undertaken by AMVTN.
In a demonstration of the determination to fight this
terrible disease, three vaccine development donors have
recently joined forces. In June 2001, EMVI, USAID’s
Malaria Vaccine Development Programme (MVDP), and the Gates-funded
Malaria Vaccine Initiative agreed to cooperate in the development
of a malaria vaccine in order to facilitate and ensure accessibility
and affordability in developing countries. These networks
are working in close collaboration with the new EDCTP initiative.
A molecule that
blocks the malaria disease process?
Apart from supporting research into vaccines, the EC has
funded basic research into the metabolic processes by which
human malarial parasites proliferate in the bloodstream
of their host. Once again, through several EC programmes,
good scientific collaboration and partnerships were established
among North and South scientists. This has now led to the
discovery of a molecule, G25(21), which
might block the activity of malarial parasites. G25 has
demonstrated positive results in the laboratory at very
low concentrations, even against drug-resistant strains
of the parasite. Subsequent in vivo trials with G25 in monkeys
infected with the human malarial parasite, Plasmodium falciparum,
look promising. The next step is to see if it is as effective
in humans.
HIV/AIDS cluster
project
The European Commission is promoting projects in
'clusters' whereby research teams involved in HIV/AIDS co-ordinate
their efforts. A good example of such an initiative is the
HIV-Superinfection Study (HISIS) network, a joint activity
by six European and African research institutes. This network
is engaged in trying to understand the different biological
factors that lead to HIV superinfections which occur when
a primary HIV infection fails to induce sufficient immunity
to ward off a secondary HIV infection. Insights gained into
what actually offers protection against AIDS are essential
to the development of HIV vaccines. This study involves
the follow-up of a group of 600 bar workers in regions of
high HIV transmission in Africa. The HISIS team shares its
findings with other AIDS vaccine initiatives, such as the
European Vaccine effort against AIDS (Eurovac) which aims
to develop new vaccines and conduct clinical trials with
them. The network will utilise the capacity build up in
Tanzania to prepare for future vaccine trials, and will
be working in close collaboration with the EDCTP.
Tuberculosis
There are currently 15 research teams in seven countries
working in another cluster, the 'tuberculosis prevention
cluster' with the objective of finding ways to make the
most of existing treatments for TB. This is being done through
greater understanding of the mechanisms whereby the bacteria
that cause TB acquire resistance to the drugs currently
in use. The research also hopes to find potential targets
in the bacterial structure that could be used in the design
of new drugs, but is mainly aiming to use strategies to
optimise the use of existing TB drugs. When these drugs
are not taken correctly, e.g. in combination therapy or
by completing a full course, microbial resistance is encouraged.
The EC also funds projects in which research is carried
out on the daily observed treatments (DOTs).
Pneumonia
An EC-funded project now offers great promise is the search
for vaccines for a variety of serious acute respiratory
infections and related diseases in children in developing
countries. This is being done in the Philippines by looking
at the role played by a particular pneumococcal conjugate
vaccine in preventing the onset of childhood pneumonia.
Over 12 000 children are to be enrolled in a scientifically
controlled clinical study over a period of four years. The
final results – due within five years – will
immediately be made available to the large and growing number
of developing countries with rather high death rates among
newborns, at around 50 in 1 000 births.
• Improved strategies
(Credit: WHO/TDR/STAMMERS) |
Chagas’
disease vector control network
The ECLAT network, an EC-funded concerted action
between 33 EU and Latin American institutions and the USA,
has been set up to exchange research results on the biosystematics
and behaviour of triatomine bugs to define cost-effective
Chagas’ disease vector control measures throughout
Latin America. The network investigates the insects responsible
for Chagas, especially how these essentially forest-dwelling
species adapt so readily to human habitats.
Infection is directly related to poverty and is therefore
very common among the poorest populations. A control strategy
is necessary for the eventual elimination of the disease,
especially through better housing and health education.
Using phenetic and genetic markers the network was able
to characterise the different vectors involved in disease
transmission and to advise governments about the most appropriate
interventions for surveillance and control. It has been
very successful in establishing liaisons between seven countries
of the Southern Cone region (Argentina, Bolivia, Brazil,
Chile, Paraguay, Uruguay and South Peru), four countries
in the Andean Pact region (Venezuela, Colombia, Ecuador
and North Peru) and seven in Central America (Guatemala,
Honduras, El Sava, Nicara, Belize, Costa Rica and Panama).
ECLAT plays a key role in launching major national and regional
Chagas’ disease control programmes.
Identification
and characterisation of major malaria vectors
Seven research institutions have worked in close collaboration
to ascertain the species status of the three major malaria
vectors in South East Asia, namely Vietnam, Cambodia and
Laos, and have evaluated the role of the individual species
and secondary vectors in malaria transmission. A new comprehensive
key was developed for the identification of the specimens
in field conditions. Reference specimens from Thailand,
Indonesia and China were used during the validation process.
This research has led to considerable improvement of the
vector control activities by focusing the control measures
on the efficient vectors with the appropriate tools and
in relation to their behaviour. The project is seen as a
success story which resulted in substantial research capacity
strengthening of the partner institutions directly involved
in National Malaria Control Programmes within the region.
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