Health systems and the implementation of disease programmes: case studies from South Africa.

This paper analyses the transfer and implementation of two internationally formulated infectious disease strategies in South Africa, namely, directly observed therapy (DOTS) for TB and syndromic management (SM) for sexually transmitted infections (STIs). Using the tools of policy analysis, this paper seeks to draw conclusions from contrasting experiences with the two strategies. DOTS and SM differ with respect to styles of engagement by World Health Organization (WHO), the international agency promoting the ideas, in the following ways: continuity and networking between policy makers, practitioners and researchers nationally; and approaches to sub-national implementation. We show how these factors may have been important to national uptake, and conclude on the need for a context sensitive approach to policy transfer and a balance between bottom-up and top-down implementation strategies. These insights may have relevance for the current global wave of treatment programmes for HIV and other infectious diseases.

Intensity-modulated, stepped frequency cw lidar for distributed aerosol and hard target measurements.

A compact frequency-modulated, continuous wave (FM-cw) lidar system for measurement of distributed aerosol plumes and hard targets is presented. The system is based on intensity modulation of a laser diode and quadrature detection of the return signals. The advantages of using laser diode amplitude modulation and quadrature detection is a large reduction in the hardware required for processing and storing return signals as well as the availability of off-the-shelf integrated electronic components from the wireless and telecommunication communities. Equations to invert the quadrature signal components and determine spatial distributions of multiple targets are derived. Spatial scattering intensities are used to extract aerosol backscatter coefficients, which can then be directly compared to microphysics aerosol models for environmental measurements. Finally, results from laboratory measurements with a monostatic FM-cw lidar system with both hard targets and aerosols are discussed.

The historical development of human resources policies in the health sector of four Caribbean territories: imitated or created?

Health systems are labour intensive, dependent on a mix of professionals to provide health care in both public and private sectors. In this paper, we explore the historical development of human resources, focusing on doctors and nurses, in four Caribbean territories-the Bahamas, Martinique, Suriname and Trinidad and Tobago. All these territories have faced issues around the out-migration of doctors and nurses and tensions between public health, hospital services and private sector policies. Early policies to increase the number of nurses and doctors were costly, because they were implemented against a tide of increasing outward migration. Both push and pull factors were evident. Human resources policies focused on ways to counter pull factors-such as introducing regional medical training-but neglected push factors. These began to be addressed from the 1980s on, although tensions between public health, hospital services and private sector policies led to resistance and conflicts in attitudes to reform among health professionals. Policy responses were the product of many influences, and it is too simple to conclude they were either imported from abroad or internally generated. However, it is clear that in all four territories the medical profession played a dominant role in human resources policy development either directly or indirectly.

Phase sensitive demodulation in multiphoton microscopy.

Multiphoton laser scanning microscopy offers advantages in depth of penetration into intact samples over other optical sectioning techniques. To achieve these advantages it is necessary to detect the emitted light without spatial filtering. In this nondescanned (nonconfocal) approach, ambient room light can easily contaminate the signal, forcing experiments to be performed in absolute darkness. For multiphoton microscope systems employing mode-locked lasers, signal processing can be used to reduce such problems by taking advantage of the pulsed characteristics of such lasers. Specifically, by recovering fluorescence generated at the mode-locked frequency, interference from stray light and other ambient noise sources can be significantly reduced. This technology can be adapted to existing microscopes by inserting demodulation circuitry between the detector and data collection system. The improvement in signal-to-noise ratio afforded by this approach yields a more robust microscope system and opens the possibility of moving multiphoton microscopy from the research lab to more demanding settings, such as the clinic.

Globalization and health.

Globalization means different things to different people; a general definition is the increasing movement of information, material and people across borders. It can be considered in terms of five conflicting but inter-relating themes, economic transformation; new patterns of trade; an increasing poverty gap associated with widening health inequalities; the revolution in electronic communication; and the growing role of non-state actors, such as non-governmental organizations and transnational corporations, in global governance. Globalization is both an opportunity and a threat, but it is not inexorable. Successful action against its undesirable aspects is possible.

A political analysis of corporate drug donations: the example of Malarone in Kenya.

This paper describes the introduction of the Malarone Donation Programme in KENYA: Using a policy analysis approach it illustrates the political nature of donation programmes and how they are affected by a large and varied group of national, regional and international stakeholders, with different levels of influence and experience. The paper shows that interaction between these different groups may affect the development and implementation of the donation programme. It ends by raising some more general questions about public/private partnerships and corporate donation programmes, and their potential impact on national drug policies.

The role of MCH and family planning services in HIV/STD control: is integration the answer?

During the mid 1990s, high HIV and sexually transmitted disease (STD) prevalence led to calls for the integration of effective services with maternal and child health and family planning (MCH/FP) programs. There are advantages and disadvantages to integration, but little evidence existed to assess the practicalities of implementing this policy. Analysis of policy development for integration was conducted in Ghana, Kenya, South Africa, and Zambia. Semi-structured interviews were conducted with policy-makers at national, provincial and district levels and a survey of facilities was undertaken to identify gaps between policy intent and implementation. Significant advances had been made at the national level to formulate policies to integrate reproductive health and primary health care. However, barriers to implementation included entrenched HIV/STD and MCH/FP vertical programs; diverse demands on district managers and providers, such as on-going institutional reform; and conflicting objectives of international donors. Policy-makers need to address conflicting objectives between the needs for vertical accountability and the reality of providing integrated services. More careful consideration of implementation is required at earlier stages of policy design. Increased consultation with those who are to implement and provide integrated services is recommended.

Global public–private partnerships: part I – a new development in health?

The latter half of the 1990s witnessed a burgeoning number of initiatives involving collaboration between the corporate and public sectors with the purpose of overcoming market and public "failures" of international public health, using global public-private partnerships for health development. One example of such a partnership is provided by the International AIDS Vaccine Initiative, incorporating a range of public and private interests which have undertaken to share the risks, costs and benefits of research into an effective vaccine against human immonudeficiency virus (HIV). While such partnerships bring major resources into the international public health arena and have the potential to benefit large populations, they also blur the traditional distinctions between the public and private sector's aims and responsibilities.This is the first of two articles in which we explore global public-private partnerships. In part I we review the concept of partnership and delineate what we mean by global public-private partnerships (GPPPs) for health development. We then turn to the context, from which these partnerships are emerging, focusing particularly on changes confronting the United Nations and the corporate community during the 1990s. Part II, which is scheduled to appear in the next issue of the bulletin, discusses a conceptual framework for understanding the different forms of global public-private partnership in the health sector, and explores the implications of GPPPs for the 21st century, looking at issues of governance and equity.

Global public-private partnerships: Part I--A new development in health?

The proliferation of public-private partnerships is rapidly reconfiguring the international health landscape. This article (part I of two on the subject) traces the changing nature of partnership, and discusses the definitional and conceptual ambiguities surrounding the term. After defining global public-private partnerships (GPPPs) for health development, we analyse the factors which have led to the convergence of public and private actors and discuss the consequences of the trend toward partnership between UN agencies (including the World Bank) and commercial entities in the health sector. Generic factors such as globalization and disillusionment with the UN, and factors specific to the health sector, such as market failure in product development for orphan diseases, are examined. Reviewed are the interests, policies, practices and concerns of the UN, the private-for-profit sector, bilateral organizations, and governments of low-income countries with respect to public-private partnership. While GPPPs bring much needed resources to problems of international health, we highlight concerns regarding this new organizational format. Part II, which will be published in the May issue of the Bulletin, presents a conceptual framework for analysing health GPPPs and explores the issues raised.

Implementing the integration of component services for reproductive health.

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.

Global public-private partnerships: Part II--What are the health issues for global governance?

This is the second of a two-part review of global public-private partnerships (GPPPs) for health development. Part I was published in the April issue of the Bulletin (Vol. 78, No. 4). The recent emergence of GPPPs is rapidly reconfiguring the international health landscape. While most multilateral and bilateral agencies are currently grappling with how to proceed, there is little information in the public domain concerning how individual partnerships work and to date very little consideration of the many implications of this trend. This paper differentiates between product-based, product development-based and issues/systems-based GPPPs and describes a number of examples of each type in the health sector. The benefits of these initiatives, not least the major resources which they harness for specific health problems, are identified. The final section of the paper explores the implications and dilemmas posed by GPPPs. It discusses whether or not shared goals can transcend conflicting values and mandates and how governance of partnership arrangements may transform and undermine certain attributes of multilateral organizations. The paper concludes that the current climate of goodwill between public and private sectors offers an opportunity that should not be missed: it can be used not only to foster new partnership but to ensure that partnership is truly in the interests of international public health.