ArticleLiterature Review

The Contribution of International Agencies to the Control of Communicable Diseases

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Abstract

Although inequality is often measured through three critical indicators-education, income and life expectancy-health-related differences are also essential elements for explaining levels of equality or inequality in modern societies. Investment and investigation in health also involve inequalities at the global level, and this includes insufficient North-South transfer of funds, technology and expertise in the health field, including the specific area of communicable diseases. Globally, epidemics and outbreaks in any geographic region can represent international public health emergencies, and this type of threat requires a global response. Therefore, given the need to strengthen the global capacity for dealing with threats of infectious diseases, a framework is needed for collaboration on alerting the world to epidemics and responding to public health emergencies. This is necessary to guarantee a high level of security against the dissemination of communicable diseases in an ever more globalized world. In response to these needs, international health agencies have put a number of strategies into practice in order to contribute to the control of communicable diseases in poor countries. The principle strategies include: 1) implementation of mechanisms for international epidemiologic surveillance; 2) use of international law to support the control of communicable diseases; 3) international cooperation on health matters; 4) strategies to strengthen primary care services and health systems in general; 5) promotion of the transfer of resources for research and development from the North to the South.

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... Although inequality is often measured through three critical indicators -education, income and life expectancy-health-related differences are also essential elements for explaining levels of equality or inequality in modern societies (Lazcano-Ponce et al., 2005). Investment and investigation in health also involve inequalities at the global level, and this includes insufficient North-South transfer of funds, technology and expertise in the health field, including the specific area of communicable diseases (Lazcano-Ponce et al., 2005). ...
... Although inequality is often measured through three critical indicators -education, income and life expectancy-health-related differences are also essential elements for explaining levels of equality or inequality in modern societies (Lazcano-Ponce et al., 2005). Investment and investigation in health also involve inequalities at the global level, and this includes insufficient North-South transfer of funds, technology and expertise in the health field, including the specific area of communicable diseases (Lazcano-Ponce et al., 2005). ...
... Therefore, given the need to strengthen the global capacity for dealing with threats of infectious diseases, a framework is needed for collaboration on alerting the world to epidemics and responding to public health emergencies. This is necessary to guarantee a high level of security against the dissemination of communicable diseases in an ever more globalized world (Lazcano-Ponce et al., 2005). ...
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Rabies remains the most important zoonotic disease in many countries. Public concern and fears are most focused on dogs as the source of rabies infection to humans and other domestic animals. Several bat species are reservoir hosts of rabies and therefore can be a public health hazard. The possibility of a carrier state or asymptomatic form of rabies deserves serious evaluation. Rabies in most countries was successfully controlled through mass vaccination of dogs, long before the recognition of bat and other wildlife rabies and the availability of modern vaccines. Though, the epidemiology, virology, transmission, pathology, clinical manifestations, diagnosis, treatment and control of rabies infection have been described extensively, the incidence is increasingly on the high side. However, experts have recognized for decades that rabies is wholly eradicable from all species except bats through targeted mass immunization, and the chief obstacle to eradicating rabies especially in bats is that no one has developed an aerosolized vaccine that could be sprayed into otherwise inaccessible caves and tree trunks. Inventing such a vaccine is considered difficult but possible. Forestalling this problem will require active epidemiological surveillance of wild and domestic animals with a wide range of modern molecular and ancillary epidemiological tools. This also demands government and private sector intervention, funding and collaboration of professionals in human and veterinary medicine with those in the environmental sciences. Recently, the heroic recovery of an unvaccinated teenager from clinical rabies offers hope of future specific therapy. While post-exposure vaccination is essential and should be continued with improvement to achieve consistently positive results, progress toward eliminating rabies has been markedly faster in nations that have emphasized preventive vaccination of animals.
... In the absence of official surveillance, WHO or UNHCR have led on establishing surveillance systems [35,36,39]. Such international involvement in surveillance stems from organisational mandates to protect health globally and across borders [46,47]. An example is WHO's Global Outbreak and Response Network (GOARN) that deploys technical assistance to areas of need [46,47]. ...
... Such international involvement in surveillance stems from organisational mandates to protect health globally and across borders [46,47]. An example is WHO's Global Outbreak and Response Network (GOARN) that deploys technical assistance to areas of need [46,47]. ...
Article
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Background Data on infectious disease surveillance for migrants on arrival and in destination countries are limited, despite global migration increases, and more are needed to inform national surveillance policies. Our study aimed to examine the scope of existing literature including existing infectious disease surveillance activities, surveillance methods used, surveillance policies or protocols, and potential lessons reported. Methods Using Arksey and O’Malley’s six-stage approach, we screened four scientific databases systematically and 11 websites, Google, and Google Scholar purposively using search terms related to ‘refugee’ and ‘infectious disease surveillance’ with no restrictions on time-period or country. Title/abstracts and full texts were screened against eligibility criteria and extracted data were synthesised thematically. Results We included 20 eligible sources of 728 identified. Reporting countries were primarily European and all were published between 1999 and 2019. Surveillance methods included 9 sources on syndromic surveillance, 2 on Early Warning and Response (EWAR), 1 on cross-border surveillance, and 1 on GeoSentinel clinic surveillance. Only 7 sources mentioned existing surveillance protocols and communication with reporting sites, while policies around surveillance were almost non-existent. Eleven included achievements such as improved partner collaboration, while 6 reported the lack of systematic approaches to surveillance. Conclusion This study identified minimal literature on infectious disease surveillance for migrants in transit and destination countries. We found significant gaps geographically and on surveillance policies and protocols. Countries receiving refugees could document and share disease surveillance methods and findings to fill these gaps and support other countries in improving disease surveillance.
... By its worldwide distribution, TB is classified in this category as HIV. Lazcano-Ponce, Allen and Gonzalez [99], assert that framework is essential for collaboration on alerting the world to epidemics and responding to public health emergencies. This is necessary to guarantee a high level of security against the dissemination of communicable diseases in an ever more globalized world. ...
... These data evidence one more time the inequality between developing countries and industrialized ones in our page 54 modern societies. As Lazcano-Ponce, Allen and Gonzalez[99] explained in their paper, investment and investigation in health also involve inequalities at the global level, and this includes insufficient North-South transfer of funds, technology and expertise in the health field, including the specific area of communicable diseases. Furthermore, although lower-resource countries have by far the highest burden of TB, we can regret that molecular epidemiology studies are never still performed in a high number of these countries. ...
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IntroductionGeneral Points on Mycobacterium Tuberculosis (MTB) and Pulmonary Tuberculosis (PTB)Genetics of MTB, Molecular Tools, and Population StructureUse of Molecular Epidemiology for Understanding Tuberculosis Transmission and PathogenesisUrgent Needs for TB Control, Limitations, and New Issues for Molecular EpidemiologyConclusion and PerspectivesAcknowledgmentsAbbreviationsGlossaryReferences
... By virtue of its worldwide distribution,TB, like HIV, is classified in this category. Lazcano-Ponce et al. [104], assert that the framework is essential for collaboration on alerting the world to epidemics and responding to public health emergencies. This is necessary to guarantee a high level of security against the dissemination of communicable diseases in an ever more globalized world.Thus, global molecular epidemiology studies of MTB appear as fundamental as local ones in order to develop strategy to control and fight TB. ...
... These data evidence once again the inequality between developing and industrialized countries in our modern society. As Lazcano-Ponce et al. [104] explained in their paper, investment and investigation in health also involve inequalities at the global level, and this includes insufficient north-south transfer of funds, technology, and expertise in the health field, including the specific area of communicable diseases. Furthermore, although lowerresource countries have by far the highest burden of TB, we can regret that molecular epidemiology studies have not yet been conducted in many of these countries. ...
... The health of the community and public is often affected by what an entire community understands about health and disease. Communicable diseases, like tuberculosis (TB) for instance, are still a major priority in low and middle-income countries (26,27), and are kept under surveillance globally (22,28,29). The movement of people across the globe between areas with endemic diseases to areas with lower incidence of communicable disease may result in disease migration, and even re-emergence in some places (22,23,30). ...
Thesis
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Improving health literacy can be key to improving patient health. Health literacy can be complicated by language and cultural barriers, which are often prevalent in immigrant communities. Development of targeted visual materials for health communications may address such challenges and improve health. Aims: The aim of this study was to explore perspectives of the Swedish Somali immigrant community on the use of visual media in health communication. Setting: The research was conducted in Stockholm County, Sweden. Methods: A focus group discussion guide was prepared and piloted. Six focus group discussions were completed in Somali, followed by qualitative thematic analysis of the data. Results: Our data presented the following two themes “strong connection to visuals as a communication tool,” and “future learning preferences for health.” In the first of these we identified that even with limited art training and exposure to fine art participants had clear visual preferences that could be applied in the future. Participant awareness of how visuals could be a trusted source of information was also evident and suggested a level of visual literacy. The second of the themes illuminated the importance of a combined approach in future education with both visuals and interpersonal dialogue. Additionally, the Somali language and its associated challenges for communication were revealed. Conclusion: The results establish that visual communications would be appropriate to use with this community and may facilitate an increase in health literacy, provided they are developed using this knowledge of their visual style and learning preferences.
... The health of the community and public is often affected by what an entire community understands about health and disease. Communicable diseases, like tuberculosis (TB) for instance, are still a major priority in low and middle-income countries (26,27), and are kept under surveillance globally (22,28,29). The movement of people across the globe between areas with endemic diseases to areas with lower incidence of communicable disease may result in disease migration, and even re-emergence in some places (22,23,30). ...
Thesis
Full-text available
Improving health literacy can be key to improving patient health. Health literacy can be complicated by language and cultural barriers, which are often prevalent in immigrant communities. Development of targeted visual materials for health communications may address such challenges and improve health. Aims: The aim of this study was to explore perspectives of the Swedish Somali immigrant community on the use of visual media in health communication. Setting: The research was conducted in Stockholm County, Sweden. Methods: A focus group discussion guide was prepared and piloted. Six focus group discussions were completed in Somali, followed by qualitative thematic analysis of the data. Results: Our data presented the following two themes “strong connection to visuals as a communication tool,” and “future learning preferences for health.” In the first of these we identified that even with limited art training and exposure to fine art participants had clear visual preferences that could be applied in the future. Participant awareness of how visuals could be a trusted source of information was also evident and suggested a level of visual literacy. The second of the themes illuminated the importance of a combined approach in future education with both visuals and interpersonal dialogue. Additionally, the Somali language and its associated challenges for communication were revealed. Conclusion: The results establish that visual communications would be appropriate to use with this community and may facilitate an increase in health literacy, provided they are developed using this knowledge of their visual style and learning preferences.
... The health of the community and public is often affected by what an entire community understands about health and disease. Communicable diseases, like tuberculosis (TB) for instance, are still a major priority in low and middle-income countries (26,27), and are kept under surveillance globally (22,28,29). The movement of people across the globe between areas with endemic diseases to areas with lower incidence of communicable disease may result in disease migration, and even re-emergence in some places (22,23,30). ...
Thesis
Full-text available
Improving health literacy can be key to improving patient health. Health literacy can be complicated by language and cultural barriers, which are often prevalent in immigrant communities. Development of targeted visual materials for health communications may address such challenges and improve health. Aims: The aim of this study was to explore perspectives of the Swedish Somali immigrant community on the use of visual media in health communication. Setting: The research was conducted in Stockholm County, Sweden. Methods: A focus group discussion guide was prepared and piloted. Six focus group discussions were completed in Somali, followed by qualitative thematic analysis of the data. Results: Our data presented the following two themes “strong connection to visuals as a communication tool,” and “future learning preferences for health.” In the first of these we identified that even with limited art training and exposure to fine art participants had clear visual preferences that could be applied in the future. Participant awareness of how visuals could be a trusted source of information was also evident and suggested a level of visual literacy. The second of the themes illuminated the importance of a combined approach in future education with both visuals and interpersonal dialogue. Additionally, the Somali language and its associated challenges for communication were revealed. Conclusion: The results establish that visual communications would be appropriate to use with this community and may facilitate an increase in health literacy, provided they are developed using this knowledge of their visual style and learning preferences.
... Partners include government agencies, universities, research institutes, training programmes and networks, non-governmental organisations (NGOs), international organisations and a range of related specialist networks, especially those concerned with laboratory investigations, infection prevention and control, clinical management, and WHO networks managing chemical, environmental and food safety events. As GOARN established a reputation for competency in major outbreak responses through the provision of technical, multi-disciplinary expertise and grew in recognition (Lazcano-Ponce, Allen, & González, 2005), it became increasingly important to ensure access to additional capacity in specific areas of expertise and to individuals with the requisite language skills and to incorporate a wider geographic representation of partners. There has therefore also been a concerted effort over recent years to ensure that the network's composition is as broad as possible, through engaging technical partners in more countries and regions. ...
Article
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The Global Outbreak Alert and Response Network (GOARN) was established in 2000 as a network of technical institutions, research institutes, universities, international health organisations and technical networks willing to contribute and participate in internationally coordinated responses to infectious disease outbreaks. It reflected a recognition of the need to strengthen and coordinate rapid mobilisation of experts in responding to international outbreaks and to overcome the sometimes chaotic and fragmented operations characterising previous responses. The network partners agreed that the World Health Organization would coordinate the network and provide a secretariat, which would also function as the operational support team. The network has evolved to comprise 153 institutions/technical partners and 37 additional networks, the latter encompassing a further 355 members and has been directly involved in 137 missions to 79 countries, territories or areas. Future challenges will include supporting countries to achieve the capacity to detect and respond to outbreaks of international concern, as required by the International Health Regulations (2005). GOARN's increasing regional focus and expanding geographic composition will be central to meeting these challenges. The paper summarises some of network's achievements over the past 13 years and presents some of the future challenges.
... Indeed, frustrated by developed countries' stranglehold on WHO via its policy of zero-nominal budget growth and conditional voluntary contributions, developing and emerging countries may demand a new approach to global health security governance in which they have greater influence. They may also demand greater transfers of resources, technology and expertise-all of which have recently been advocated for by international health organizations (Lazcano-Ponce et al. 2005). Alternatively, this future order could arise from recognition among policymakers in developed countries that health for all people is a global responsibility such that they have a duty to provide assistance to poorer states. ...
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Background: Attention to global health security governance is more important now than ever before. Scientists predict that a possible influenza pandemic could affect 1.5 billion people, cause up to 150 million deaths and leave US$3 trillion in economic damages. A public health emergency in one country is now only hours away from affecting many others. Methods: Using regime analysis from political science, the principles, norms, rules and decision-making procedures by which states govern health security are examined in the historical context of their punctuated evolution. This methodology illuminates the catalytic agents of change, distributional consequences and possible future orders that can help to better inform progress in this area. Findings: Four periods of global health security governance are identified. The first is characterized by unilateral quarantine regulations (1377-1851), the second by multiple sanitary conferences (1851-92), the third by several international sanitary conventions and international health organizations (1892-1946) and the fourth by the hegemonic leadership of the World Health Organization (1946-????). This final regime, like others before it, is challenged by globalization (e.g. limitations of the new International Health Regulations), changing diplomacy (e.g. proliferation of global health security organizations), new tools (e.g. global health law, human rights and health diplomacy) and shock-activated vulnerabilities (e.g. bioterrorism and avian/swine influenza). This understanding, in turn, allows us to appreciate the impact of this evolving regime on class, race and gender, as well as to consider four possible future configurations of power, including greater authority for the World Health Organization, a concert of powers, developing countries and civil society organizations. Conclusions: This regime analysis allows us to understand the evolution, etiology and eventualities of the global health security regime, which is essential for national and international health policymakers, practitioners and academics to know where and how to act effectively in preparation for tomorrow's challenges.
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Despite the increasing 'globalization' of health, the responsibility for it remains primarily national, generating a potential mismatch between global health problems and current institutions and mechanisms to deal with them. The 'Global Public Good' (GPG) concept has been suggested as a framework to address this mismatch in different areas of public policy. This paper considers the application of the GPG concept as an organizing principle for communicable disease control (CDC), considering in particular its potential to improve the health and welfare of the developing world. The paper concludes that there are significant limitations to the GPG concept's effectiveness as an organizing principle for global health priorities, with respect to CDC. More specifically, there are few areas of CDC which qualify as GPG, and even among those that can be considered GPGs, it is not necessarily appropriate to provide everything which can be considered a GPG. It is therefore suggested that it may be more useful to focus instead on the failure of 'collective action', where the GPG concept may then: (1) provide a rationale to raise funds additional to aid from developed countries' domestic budgets; (2) promote investment by developed countries in the health systems of developing countries; (3) promote strategic partnerships between developed and developing countries to tackle major global communicable diseases; and (4) guide the political process of establishing, and mechanisms for providing and financing, global CDC programmes with GPG characteristics, and GPGs which have benefits for CDC. In short, the GPG concept is not without limitations and weaknesses as an organizing principle, but does provide, at least in some areas, guidance in improving collective action at the international level for the improvement of global CDC.
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We examined recent special health initiatives to control HIV/AIDS, malaria, and tuberculosis, and make four policy recommendations for improving the sustainability of such initiatives. First, international cooperation on health should be seen as an issue of global public goods that concerns both poor and rich countries. Second, national health and other sector budgets should be tapped to ensure that global health concerns are fully and reliably funded; industrialized countries should lead the way. Third, a global research council should be established to foster more efficient health-related knowledge management. Fourth, managers for specific disease issues should be appointed, to facilitate policy partnerships. Policy changes in these areas have already begun and can provide a basis for further reform.
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Despite some improvements in the health status of the world during the last few decades, major obstacles remain. Improvements in health outcomes have not been shared equally among countries and poverty is clearly the main reason. Infectious diseases, which remain the major cause of death worldwide, are an incalculable source of human misery and economic loss. In fact, 25% of all deaths and 30% of the global burden of disease are attributed to infectious diseases. Unfortunately, more than 95% of these deaths, most of which are preventable, occur in the developing world, where poverty is widespread. The 3 major infectious disease killers in these countries are HIV/AIDS, tuberculosis, and malaria. The principles of social justice and health as a human right in the developing world have been advocated as the main justification for health assistance from rich to poor countries. Although we do not disagree with this, we argue that a strategy that emphasizes the shared benefit to rich and poor countries would facilitate this process. We propose that the accomplishment of these challenging tasks should be viewed from the perspective of game theory, where the interests of the parties (in this case rich and poor countries) overlap. As the world becomes increasingly integrated, economic development in resource-poor countries will increase the opportunities for richer countries to profit from investment in the developing world. Global health has political and international security implications for the developed world, as well. In view of the current health status of the developing world, we are not playing a game but facing a matter of life and death. "When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied" --Herophilus, 325 BCE (Physician to Alexander the Great). The purpose of this article is to address the relationship between health, poverty, and development in the context of game theory. We will focus on the link between economic inequalities and health outcomes, exclusively concentrating our analysis on the impact of infectious diseases. Subsequently, we will outline the game, the players, and the potential win-win outcomes that may potentially result.
Article
The Global Polio Eradication Initiative was launched in 1988. Assessment of the politics, production, financing, and economics of this international effort has suggested six lessons that might be pertinent to the pursuit of other global health goals. First, such goals should be based on technically sound strategies with proven operational feasibility in a large geographical area. Second, before launching an initiative, an informed collective decision must be negotiated and agreed in an appropriate international forum to keep to a minimum long-term risks in financing and implementation. Third, if substantial community engagement is envisaged, efficient deployment of sufficient resources at that level necessitates a defined, time-limited input by the community within a properly managed partnership. Fourth, although the so-called fair-share concept is arguably the best way to finance such goals, its limitations must be recognised early and alternative strategies developed for settings where it does not work. Fifth, international health goals must be designed and pursued within existing health systems if they are to secure and sustain broad support. Finally, countries, regions, or populations most likely to delay the achievement of a global health goal should be identified at the outset to ensure provision of sufficient resources and attention. The greatest threats to poliomyelitis eradication are a financing gap of US 210 million dollars and difficulties in strategy implementation in at most five countries.
Article
Child mortality continues to be a public health priority world-wide. Even though under-five mortality rates have declined from an estimated 84 per 1000 in 1985-89 to 67 per 1000 in 1999, wide geographical differences persist. During the 1990 World Summit on Children in New York, the world's policy-makers and researchers made improving children's lives by ensuring that each child receives the best care and attention possible their main goal. The strategies identified to achieve this goal have guided and benefited from the progress in child health research throughout the last decade. Indeed, research into the causes of ill-health informs and guides public health programmes to improve the burden of preventable deaths, but it requires sustained and renewed investments for the developing world. In this review paper we have aimed to describe the magnitude of current child morbidity and mortality in the developing world; to review the main advances in child health research since the 1990 World Summit on Children and evaluate the implication of different institutions involved in international child health; to measure the adequacy between priority research setting and public health needs for child health in developing countries; to identify constraints in the application of the research results; and to define key strategies and research challenges that are required in the next decade to respond to child heath needs in developing countries. This assessment is based on a ten-year literature review through Medline and a survey to key international informants in the field of child health in developing countries, using a trilingual open-ended questionnaire. The literature published from January 1990 to June 2001, covering more than 4,700 references, enabled us to review more than 130 articles. We contacted 91 institutions involved in child health, located in 27 countries from five continents, and the response rate to our survey was 49.5%. The current priority health needs of children in developing countries most frequently stated in the literature are the reduction of the burden of malnutrition, diarrhoeal diseases, respiratory diseases, perinatal health, HIV/AIDS, measles and malaria. Based on the survey results, malnutrition (78% of respondents) and perinatal health were the most frequently quoted. Less than 15% of the survey respondents provided an example of a successful application of research in the field of infectious diseases. Political support and conflict of interest are the main constraints mentioned. Malnutrition and non-communicable diseases are considered as main areas of neglect in the field of child health research. Our study shows that the perception of field actors in child health on research priorities does not always correspond to the reality of health needs of children in developing countries. Furthermore, it appears that descriptive epidemiology, evaluation and priority setting strategies are essential tools to guide adequate research activities and further improvement of child health.
Article
This week an international panel announces a list of 14 Grand Challenges in Global Health, and scientists throughout the world will be invited to submit grant proposals to pursue them with funds provided by the Bill and Melinda Gates Foundation. We describe the characteristics of these challenges and the process by which they were formulated and selected after receiving over 1000 responses to a "call for ideas" from the scientific community.
Article
A disease is controlled if, by means of a public policy, the circulation of an infectious agent is restricted below the level that would be sustained by individuals acting independently to control the disease. A disease is eliminated if it is controlled sufficiently to prevent an epidemic from occurring in a given geographical area. Control and elimination are achieved locally, but a disease can only be eradicated if it is eliminated everywhere. Eradication is plainly a more demanding goal, but it has two advantages over control. First, the economics of eradication can be very favourable when eradication not only reduces infections but also avoids the need for vaccinations in future. Indeed, when eradication is feasible, it will either pay to control it to a fairly low level or to eradicate it. This suggests that, from an economics perspective, diseases that are eliminated in high-income countries are prime candidates for future eradication efforts. Second, the incentives for countries to participate in an eradication initiative can be strong; indeed they can be even stronger than an international control programme. Moreover, high-income countries typically benefit so much that they will be willing to finance elimination in developing countries. Full financing of an eradication effort by nation-states is not always guaranteed, but it can be facilitated by a variety of means. Hence, from the perspective of economics and international relations, eradication has a number of advantages over control. The implications for smallpox and polio eradication programmes are discussed.
Article
District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a ‘second generation’ reform—to be superseded by third generation reforms with a market orientation—flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass compaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor. Copyright
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