Sustained Political Commitment Research Articles

From malaria control to elimination within a decade: lessons learned from Timor Leste, a newly independent country

BackgroundTimor Leste has made remarkable progress from malaria control to malaria elimination in a span of 10 years during which organized malaria control efforts were instituted. The good practices and possible factors that have contributed to the remarkable transition from malaria control to elimination in a newly independent country devastated by civil unrest which left the entire administrative structure including the health sector in a disrupted non-functional state are highlighted.MethodsData from the National Malaria Control Programme were reviewed. A literature search was carried out using the key words “malaria”, “Timor Leste”, “East Timor”, and “malaria control” and “malaria elimination”. All relevant manuscripts and reports that were identified in the search were reviewed. Key personnel of the NMCP, WHO and the GFATM involved in the project were interviewed.ResultsWith the setting up of the National Malaria Control Programme just after independence in 2003 with two officers, the programme expanded over the years and strategic malaria control activities in an organized manner commenced in 2009 with funding from the Global Fund to fight AIDS, Tuberculosis and Malaria. The incidence of malaria declined dramatically from 223,002 cases in 2006 with the last indigenous case being reported in June 2017. The decline in malaria was associated with strategic application of key evidence-based interventions taking into account the burden of disease, characteristics of vectors, and stratification of risk areas ensuring universal access to malaria prevention, and quality assured diagnostic tools and effective anti-malarial medicines at point of care, intensified surveillance, monitoring and evaluation, and capacity building, including training of staff, with adequate programme funding. The programme was provided with technical expertise and sustained political commitment that ensured uninterrupted implementation of interventions based on national strategic plans. The incorporation of the malaria control programme within an evolving health system helped the transition from malaria control to malaria elimination.ConclusionUniversal access to quality assured malaria diagnosis and treatment and focussed vector control, implemented throughout the country in an organized manner with adequate funding and political commitment were key to the successful interruption of malaria transmission in the country. All the practices or factors listed did not work in isolation but rather synergistically in an integrated manner. Malaria elimination is possible even in tropical areas of South and Southeast Asia.

Rethinking the economics of water: an assessment

AbstractWater is rising on the policy agenda as population growth and climate change intensify scarcity, shocks, and access inequalities. The conventional economic policy recommendations—privatization, pricing, and property rights—have struggled due to a failure to account adequately for the politics of water and the associated distributional conflicts. We identify distinctive social and physical characteristics of water supply and demand, and explore their implications for three central areas of water policy: financing infrastructure, pricing, and property rights reform. Growing dependence on groundwater and non-networked water supplies exacerbates these challenges and reinforces the need to rethink the economics of water and tackle the political challenges head on. Meeting the water sustainable development goals would require institutional and technological innovations to supply, allocate, and manage water, as well as a sustained political and financial commitment to address those who might be left behind.

Strategic approach for combating antimicrobial resistance (AMR).

During the past 70 years, there has been a continued incremental worsening of antimicrobial resistance (AMR) by a combination of abusing antimicrobials in humans and animals as well as insufficient research and investment for new antimicrobial agents. The current trend of worsening AMR is likely to result in increased mortality and morbidity, longer stays in hospitals and accelerated health care costs. It is estimated that the global mortality attributed by AMR could reach 10 million per year by 2050, which is a massive increase from the current estimated mortality of 700, 000 per year. The year 2014 was the turning point of more than a half century of AMR history, transforming it from technical issue to a political agenda. Major progress includes adoption of the Global Action Plan on AMR at the WHO World Health Assembly in May 2015, followed by completion of a National Action Plan in most parts of the world, enactment of the Global Antimicrobial Surveillance System (GLASS) in October 2015, launch of the World Antibiotic Awareness Week in November 2015, and G20 Leaderscommitment to create the AMR Global Collaboration Hub in July 2017. Moreover, a comprehensive program against AMR has been implemented in some countries, such as UK, USA, and Germany. The strategic approach through coordination led by WHO with relevant international agencies and other entities was one of the key enabling factors for sustained political commitment on AMR.

Strengthening capacity to use research evidence in health sector policy-making: experience from Kenya and Malawi

BackgroundAmong the many barriers to evidence use in decision-making, weak capacity for evidence use has attracted a lot of focus in the last decade. The study aims to inform and enrich ongoing and future efforts to strengthen capacity for evidence use by presenting and discussing the experiences and lessons of a project implemented in Kenya and Malawi to strengthen individual and institutional capacity for evidence use within the ministries of health (MoHs).MethodsThis paper draws on the internal and external evaluations of a 3-year project funded by the United Kingdom’s Department for International Development, the Strengthening Capacity to Use Research Evidence in Health Policy (SECURE Health). To strengthen individual capacity, the project implemented a training and mentorship programme for 60 mid-level policy-makers in the two MoHs. To strengthen institutional capacity, the project conducted sustained advocacy with top leaders to strengthen structures that enable evidence-informed decision-making (EIDM), supported Kenya to develop research-for-health policies and priorities, supported Malawi to review the implementation of its health research agenda, developed EIDM guidelines for both MoHs, and supported bi-annual evidence dialogues to improve interactions and raise the profile of evidence. Internal evaluation included baseline and endline surveys (93 baseline and 92 endline interviews), 60 in-depth interviews, and intervention-specific evaluations (pre–post tests for training workshops, feedback forms for policy dialogues and tracking effects of advocacy efforts). The external evaluation was implemented alongside project implementation, conducting three annual evaluations.ResultsThe results show that training and mentorship programmes in EIDM were effective in improving competencies of civil servants. However, such programmes need to train a critical mass to be effective in enhancing EIDM practice at the MoHs. On strengthening institutional capacity for EIDM, while the project achieved some success, it did not realise long-lasting effects because of its limited time of implementation and limited focus on sustained political economy analysis, which meant that the intervention was negatively affected by frequently changing interests within the MoHs.ConclusionsAlthough training and mentorship are effective in improving EIDM competencies, they need to be incorporated in existing pre-service and in-service training programmes for sustainability. Strengthening institutional capacity for evidence use is complex and needs sustained political commitment and long-term investments.

Assessment of Adolescent and Youth Friendly Health Services in Sri Lanka using WHO’s ‘4S’ Framework

Abstract Background The Adolescent and Youth Friendly Health Services (AYFHS) in Sri Lanka (SL) are provided via three service models, viz., hospital-based, field-based and centre-based. This study assessed the implementation status of AYFHS in SL. Methods A panel of experts conducted the review by adopting a participatory approach. Policies and supporting documents were collected from the relevant sectors of the Ministry of Health using electronic and manual search and by visiting institutions/resource persons. The strengths and weaknesses of the AYFHS were identified using the WHO’s ’4S’ Framework consisting strategic information (S1), supportive evidence-informed policies (S2), strengthening services for adolescents (S3) and strengthening collaboration with other sectors (S4). Results While recent development of guidelines, standards and protocols in line with WHO/UNAIDS ’Global Standards for Quality Health-care Services for Adolescents’ was the main strength on S1, gaps in timeliness, completeness and accuracy of the data; and the gaps in effective utilization of sub-national level data addressing area specific problems were the main weaknesses. On S2, SL has a strong, supportive policy environment to promote adolescent health. Lack of coherence in existing health related policies was the main gap. A comprehensive health care package was a strength on S3, while difficulty in reaching the vulnerable groups, curative service oriented service package and underutilization of the health services by adolescents were the weaknesses. On S4, lack of sustained political commitment identifying adolescent health as a priority development issue across multi-stakeholders and their silo mentality to maintain the accountability/ownership of cross-cutting programmatic activities were the weaknesses. Conclusions Despite numerous imposing challenges, with mainstreaming and constructive monitoring, the AYFHS in SL will remain as one of the best adolescent health programmes in the region. Key messages Assessment of Sri Lankan AYFHS according to the WHO’s ’4S’ Framework revealed multiple strengths such as updated guidelines, supportive policy environment and comprehensive care package. Despite numerous imposing challenges, with mainstreaming and constructive monitoring, the AYFHS in SL will remain as one of the best adolescent health programmes in the region.

Child Rights Impact Assessment as a policy improvement tool

ABSTRACTChild Rights Impact Assessment (CRIA) is used to assess systematically the impact on children of laws, policies or budgetary allocations as measured against the Articles of the UN Convention on the Rights of the Child (CRC) and domestic human rights/child wellbeing frameworks. Internationally, a small number of governments at central, regional and local level have introduced or attempted CRIA. However, where available, documentary analysis of the assessments and published evaluations of these existing models raise questions about the quality of the impact assessments being produced. This paper examines the use of CRIA with a particular focus on the UK and its devolved governments, looks at issues that can limit its effectiveness, and suggests what should be in place to support the potential of CRIA. These include: a clear mandate for CRIA with sustained political commitment, children’s rights training and access to expert advice, tools to guide and shape the process, access to relevant data sets, and a clear expectation of involving children. Many of the practice findings draw on research conducted for UNICEF UK on CRIA practice in the UK.

Accelerating reforms of primary health care towards universal health coverage in Sri Lanka.

Since the late 1920s, the Sri Lankan health system has been based on a firm foundation of primary health care, and it has been recognized internationally as a highly successful low-cost model. However, rethinking the future health-care model has been essential, owing to the country having one of the fastest ageing populations in the world, coupled with a high premature mortality from noncommunicable diseases. To sustain past gains and meet new challenges, several models centred on an expanded primary health-care system have been trialled and refined in the past decade. Primary health care was identified as a key priority in the National Health Strategic Master Plan 2016-2025, and in 2018 the Cabinet approved the Policy on healthcare delivery for universal health coverage. This policy introduces the "shared care cluster" system, whereby an apex specialist institution serves the local primary care referral institutions. The catchment population is divided into populations of approximately 5000, for which one family doctor is responsible. Strengthening and retaining human resources at these primary-level curative institutions will be essential, especially in rural locations. Also critical will be initiatives to orient the population's health-seeking behaviours. Sustained political commitment, an effective communication strategy, a tailored health workforce policy, performance monitoring and evaluation, coordination mechanisms, and changes in administrative and financial regulations are some of the future factors that will be critical to realizing the full potential of primary health care and accelerating universal health coverage in Sri Lanka.

New chapter in tackling antimicrobial resistance in Thailand

Nithima Sumpradit and colleagues describe the experience of Thailand in developing its national strategic plan on antimicrobial resistance and highlight the need for sustained political commitment and multisectoral collaboration

Linkages between health and agriculture sectors in Ethiopia: a formative research study exploring barriers, facilitators and opportunities for local level coordination to deliver nutritional programmes and services

BackgroundIn Ethiopia, poor infant and young child feeding practices and low household dietary diversity remain widespread. The Government has adopted the National Nutrition Programme that emphasizes the need for multi-sectoral collaboration to effectively deliver nutrition-sensitive and nutrition-specific interventions. The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is one such Government-led initiative that will be implemented jointly by the health and agriculture sectors across 150 districts in Ethiopia. Prior to the design of the SURE programme, this formative research study was conducted to understand how the governance structure and linkages between health and agriculture sectors at local levels can support implementation of programme activities.MethodsData were collected from eight districts in Ethiopia using 16 key informant interviews and eight focus group discussions conducted with district and community-level focal persons for nutrition including health and agriculture extension workers. A framework analysis approach was used to analyze data.ResultsFew respondents were aware of the National Nutrition Programme or of their own roles within the multi-sectoral coordination mechanism outlined by the government to deliver nutritional programmes and services. Lack of knowledge or commitment to nutrition, lack of resources and presence of competing priorities within individual sectors were identified as barriers to effective coordination between health and agriculture sectors. Strong central commitment to nutrition, increased involvement of other partners in nutrition and the presence of community development workers such as health and agriculture extension workers were identified as facilitators of effective coordination.ConclusionsFederal guidelines to implement the Ethiopian National Nutrition Programme have yet to be translated to district or community level administrative structures. Sustained political commitment and provision of resources will be necessary to achieve effective inter-sectoral collaboration to deliver nutritional services. The health and agriculture extension platforms may be used to link interventions for sustained nutrition impact.

The investment case for cervical cancer elimination.

We already know what causes cervical cancer, how to prevent it, and how to treat it, even in resource-constrained settings. Inequitable access to human papillomavirus vaccine for girls and screening and precancer treatment for women in low- and middle-income countries is unacceptable on ethical, social, and financial grounds. The burden of cervical cancer falls on the poor and extends beyond the narrow bounds of the family, affecting national economic development and community life, as family resources are drained and poverty tightens its grip. Proven solutions are available and the priorities for the next few years are clear, as shown by the papers in this Supplement. Sustained political commitment and strategic investments in cervical cancer prevention can not only save millions of lives over the next 10years, but can also pave the way for the broader fight against all cancers.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

SummaryBackgroundThe scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.MethodsWe synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).FindingsWorldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.InterpretationThe pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.FundingBill & Melinda Gates Foundation and Bloomberg Philanthropies.

Spatio-temporal analysis of malaria incidence in the Peruvian Amazon Region between 2002 and 2013

Malaria remains a major public health problem in the Peruvian Amazon where the persistence of high-risk transmission areas (hotspots) challenges the current malaria control strategies. This study aimed at identifying significant space-time clusters of malaria incidence in Loreto region 2002–2013 and to determine significant changes across years in relation to the control measures applied. Poisson regression and purely temporal, spatial, and space-time analyses were conducted. Three significantly different periods in terms of annual incidence rates (AIR) were identified, overlapping respectively with the pre-, during, and post- implementation control activities supported by PAMAFRO project. The most likely space-time clusters of malaria incidence for P. vivax and P. falciparum corresponded to the pre- and first two years of the PAMAFRO project and were situated in the northern districts of Loreto, while secondary clusters were identified in eastern and southern districts with the latest onset and the shortest duration of PAMAFRO interventions. Malaria in Loreto was highly heterogeneous at geographical level and over time. Importantly, the excellent achievements obtained during 5 years of intensified control efforts totally vanished in only 2 to 3 years after the end of the program, calling for sustained political and financial commitment for the success of malaria elimination as ultimate goal.

Building Effective Institutions—The Biggest Challenge

This article discusses the importance of institutional capital for future well-being, seeks to assess current institutional performance, and identifies drivers of change and areas for priority action. The thesis of this article is that the economic and political institutions must evolve as much over the next 35 years as they have since the breakup of the Soviet Union, if Vision 2050 is to be realized and sustained. Whether these institutions evolve to the desired level or not, and whether the necessary change comes as a swift, continuous adaptation or as disruptive breaks, depends on many things. The long time required for institutional evolution and the vested interests opposed to institutional change make sustained political commitment essential for successful change. Most important will be the foresight of Central Asia’s leaders and the deepened involvement of the people of Central Asia in the political and economic life of their countries. This article examines how institutions, and intangible capital more generally, generate growth and identify the changes required—over a 35-year horizon—in the asset composition of Central Asian countries to realize Vision 2050. It benchmarks the institutions of Central Asian countries against world averages and comparators in East Asia and Central Europe. Additionally, this article identifies drivers of change that could be leveraged to promote the desired institutional evolution. The final section discusses areas requiring concerted attention if Central Asia’s institutions are to deliver the future to which citizens of the countries aspire.

90-90-90--Charting a steady course to end the paediatric HIV epidemic.

IntroductionThe new “90-90-90” UNAIDS agenda proposes that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020. By focusing on children, the global community is in the unique position of realizing an end to the paediatric HIV epidemic.DiscussionDespite vast scientific advances in the prevention and treatment of paediatric HIV infection over the last two decades, in 2014 there were an estimated 220,000 new paediatric infections attributed to mother-to-child HIV transmission (MTCT) and 150,000 HIV-related paediatric deaths. Furthermore, adolescents remain at particularly high risk for acquisition of new HIV infections, and HIV/AIDS remains the second leading cause of death in this age group. Among the estimated 2.6 million children less than 15 years of age living with HIV infection, only 32% were receiving life-saving antiretroviral treatment. After decades of languishing, good progress is now being made to prevent MTCT. Unfortunately, efforts to scale up HIV treatment services have been less robust for children and adolescents compared with adult populations. These discrepancies reflect substantial gaps in essential services and numerous missed opportunities to prevent HIV transmission and provide effective life-saving antiretroviral treatment to children, adolescents and families. The road to an AIDS-free generation will require bridging the gaps in HIV services and addressing the particular needs of children across the developmental spectrum from infancy through adolescence. To reach the ambitious new targets, innovations and service improvements will need to be rapidly escalated at each step along the prevention-treatment cascade.ConclusionsCharting a successful course to reach the 90-90-90 targets will require sustained political and financial commitment as well as the rapid implementation of a broad set of systematic improvements in service delivery. The prospect of a world where HIV no longer threatens the lives of infants, children and adolescents may finally be within reach.

Getting to 90-90-90 in paediatric HIV: What is needed?

Introduction The new “90-90-90” UNAIDS agenda proposes that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020. By focusing on children, the global community is in the unique position of realizing an end to the paediatric HIV epidemic. Discussion Despite vast scientific advances in the prevention and treatment of paediatric HIV infection over the last two decades, in 2014 there were an estimated 220,000 new paediatric infections attributed to mother-to-child HIV transmission (MTCT) and 150,000 HIV-related paediatric deaths. Furthermore, adolescents remain at particularly high risk for acquisition of new HIV infections, and HIV/AIDS remains the second leading cause of death in this age group. Among the estimated 2.6 million children less than 15 years of age living with HIV infection, only 32% were receiving life-saving antiretroviral treatment. After decades of languishing, good progress is now being made to prevent MTCT. Unfortunately, efforts to scale up HIV treatment services have been less robust for children and adolescents compared with adult populations. These discrepancies reflect substantial gaps in essential services and numerous missed opportunities to prevent HIV transmission and provide effective life-saving antiretroviral treatment to children, adolescents and families. The road to an AIDS-free generation will require bridging the gaps in HIV services and addressing the particular needs of children across the developmental spectrum from infancy through adolescence. To reach the ambitious new targets, innovations and service improvements will need to be rapidly escalated at each step along the prevention-treatment cascade. Conclusions Charting a successful course to reach the 90-90-90 targets will require sustained political and financial commitment as well as the rapid implementation of a broad set of systematic improvements in service delivery. The prospect of a world where HIV no longer threatens the lives of infants, children and adolescents may finally be within reach. 10.7448/IAS.18.7.20296 © 2015 Abrams E J et al; licensee International AIDS Society Received 9 May 2015; Revised 25 August 2015; Accepted 2 September 2015; Published 2 December 2015 Corresponding author: Elaine J Abrams, ICAP, Mailman School of Public Health, Columbia University, 722 W168th Street, New York, NY 10032, USA. Tel: +1 212 342 0543. (eja1@cumc.columbia.edu)

Universal Health Coverage for Schizophrenia: A Global Mental Health Priority.

The growing momentum towards a global consensus on universal health coverage, alongside an acknowledgment of the urgency and importance of a comprehensive mental health action plan, offers a unique opportunity for a substantial scale-up of evidence-based interventions and packages of care for a range of mental disorders in all countries. There is a robust evidence base testifying to the effectiveness of drug and psychosocial interventions for people with schizophrenia and to the feasibility, acceptability and cost-effectiveness of the delivery of these interventions through a collaborative care model in low resource settings. While there are a number of barriers to scaling up this evidence, for eg, the finances needed to train and deploy community based workers and the lack of agency for people with schizophrenia, the experiences of some upper middle income countries show that sustained political commitment, allocation of transitional financial resources to develop community services, a commitment to an integrated approach with a strong role for community based institutions and providers, and a progressive realization of coverage are the key ingredients for scale up of services for schizophrenia.

Situación del sarampión y la rubéola en la Región Europea de la OMS

The long-standing and widespread use of vaccines against measles has resulted in a dramatic decline in cases and measles mortality worldwide compared with the pre-vaccination era.All regions of the World Health Organization (WHO) have measles elimination goals and the WHO regions of the Americas, Europe and Western Pacific also have rubella elimination goals. This article aims to report on progress toward elimination of measles and rubella in the WHO European Region based on the latest available data. We also discuss current challenges and actions needed to reach this goal in the Region. Despite substantial progress made towards controlling measles and rubella, the countries of the WHO European Region continue to face challenges in interrupting endemic transmission of these diseases. Widespread outbreaks and endemic transmission of measles and rubella persisted in some countries of the Region in 2014 and have continued in 2015. Interrupting endemic transmission in each and every country is necessary to declare elimination for the entire Region. High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. In the absence of sustained political commitment and implementation of the required strategies by all countries, the goal of eliminating these diseases in the WHO European Region is at stake.

Brazil's space program: Dreaming with its feet on the ground

Brazil's space program represents an anomaly among those of the world's 10 largest economic powers. During a time that has witnessed the rapid emergence of a variety of national space programs—even among lesser powers like Iran and South Korea–Brazil's failure to emerge as a significant space actor requires further analysis. This article traces the history of Brazil's space efforts and examines the factors that have held it back, some of which continue to influence its policies today: inadequate funding, conflicting organizations, poorly handled foreign relations, and an unclear national vision for Brazil's “place” in space. Recent efforts to overcome these hurdles through an improved domestic strategy and smarter international relations show promise. But a more sustained political commitment to space development will be needed if they are to succeed.

Closing the health and nutrition gap in Odisha, India: A case study of how transforming the health system is achieving greater equity

Health equity is high on the international agenda. This study provides evidence of how health systems can be strengthened to improve health equity in a low-income state. The paper presents a case study of how the Government of Odisha in eastern India is transforming the health system for more equitable health and nutrition outcomes. Odisha has a population of over 42 million, high levels of poverty, and poor maternal and child health concentrated in its Southern districts and among Scheduled Tribe and Scheduled Caste communities. Conducted between 2008 and 2012 with the Departments of Health and Family Welfare, and Women and Child Development, the study reviewed a wide range of literature including policy and programme documents, evaluations and studies, published and grey material, and undertook secondary analysis of state level household surveys. It identifies innovative and expanded provision of health services, reforms to the management and development of human resources for health, and the introduction of a number of cash transfer and entitlement schemes as contributing to closing the gap between maternal and child health and nutrition outcomes of Scheduled Tribes, and the Southern districts, compared to the state average. The institutional delivery rate for Scheduled Tribes has risen from 11.7% in 2005–06 to 67.3% in 2011, and from 35.6% to 79.8% for all women. The social gradient has also closed for antenatal and postnatal care and immunisation. Nutrition indicators though improving are proving slower to budge. The paper identifies how political will, committed policy makers and fiscal space energised the health system to promote equity. Sustained political commitment will be required to continue to address the more challenging human resource, health financing and gender issues.

Effective program management: a cornerstone of malaria elimination.

Effective program management is essential for successful elimination of malaria. In this perspective article, evidence surrounding malaria program management is reviewed by management science and malaria experts through a literature search of published and unpublished gray documents and key informant interviews. Program management in a malaria elimination setting differs from that in a malaria control setting in a number of ways, although knowledge and understanding of these distinctions are lacking. Several core features of successful health program management are critical to achieve elimination, including effective leadership and supervision at all levels, sustained political and financial commitment, reliable supply and control of physical resources, effective management of data and information, appropriate incentives, and consistent accountability. Adding to the complexity, the requirements of an elimination program may conflict with those of a control regimen. Thus, an additional challenge is successfully managing program transitions along the continuum from control to elimination to prevention of reintroduction. This article identifies potential solutions to these challenges by exploring managerial approaches that are flexible, relevant, and sustainable in various cultural and health system contexts.