Between Donor Interest, Global Models and Local Conditions: Treatment and Decision-Making in the Somalia-Finland Tuberculosis Control Project, 1981–3

Despite numerous global health initiatives after World War II, tuberculosis still poses a major threat in sub-Saharan Africa. This article examines one attempt to tackle this problem: the Somalia-Finland Tuberculosis Control Project. Conducted in the 1980s as a bilateral development aid project between the two countries, it became the most extensive – and expensive – tuberculosis initiative in Somalia in that decade. An interesting feature of the project is that, despite a lack of previous experience in tuberculosis work in developing countries, the Finnish partner decided not to follow the WHO global guidelines designed to standardise tuberculosis activities across the developing world. Instead, Finns established their own treatment programme based on X-ray and short-course chemotherapy – otherwise rarely used in clinical practice in Africa. Through a close reading and comparison of the correspondence, project plans, memos and minutes, the article analyses the formation of this strategy. Focusing on ground-level decision-making, it argues that the decisions were based not only on a belief in the superior clinical effectiveness of these methods, but also on the fact that they better suited Finnish ambitions and project logic. Thus, the article supports the notion that donor perspectives on resources and project objectives determined what was seen as feasible treatment in a developing country. By shedding light on the debate between the supporters of short-course chemotherapy and the WHO standard treatment strategy, it also contributes to the early history of DOTS (directly observed treatment, short course).

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Evaluating the impact of tuberculosis control: number of deaths prevented by short-course chemotherapy in China

International Journal of Epidemiology ◽

10.1093/ije/29.3.558 ◽

2000 ◽

Vol 29 (3) ◽

pp. 558-564 ◽

Cited By ~ 27

Author(s):

C. Dye

Keyword(s):

Tuberculosis Control ◽

Short Course ◽

Short Course Chemotherapy ◽

The Impact

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Evaluating the impact of tuberculosis control: number of deaths prevented by short-course chemotherapy in China

International Journal of Epidemiology ◽

10.1093/intjepid/29.3.558 ◽

2000 ◽

Vol 29 (3) ◽

pp. 558-564 ◽

Cited By ~ 7

Author(s):

Christopher Dye ◽

Zhao Fengzeng ◽

Suzanne Scheele ◽

Brian Williams

Keyword(s):

Tuberculosis Control ◽

Short Course ◽

Short Course Chemotherapy ◽

The Impact

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What climate change means for farmers in Africa: A triptych review Left panel: Increasing climate variability and a response approach for African farmers

African Journal of Food, Agriculture, Nutrition and Development ◽

10.18697/ajfand.61.13240b ◽

2014 ◽

Vol 14 (61) ◽

pp. 8445-8458

Author(s):

CJ Stigter ◽

◽

E Ofori ◽

Keyword(s):

Climate Change ◽

Decision Making ◽

Climate Variability ◽

Climate Models ◽

Southern Oscillation ◽

Climate Science ◽

Direct Consequence ◽

Sub Saharan Africa ◽

Local Conditions ◽

Weather And Climate

In this paper in three parts, climate change is approached by dealing with the three sides from which the danger comes: (i) global warming, (ii) increasing climate variability, (iii) more (and possibly more severe) meteorological and climatological extreme events. These are the three panels of this triptych review and this left panel is about (ii). This second panel starts with a compelling review of the present situation of food security, referring to African examples to improve the situation. Then the influence is discussed that the El Niño Southern Oscillation (ENSO) has on increasing climate variability as a consequence of climate change. It is indicated that, to date, climate models have been developed with little knowledge of agricultural systems dynamics. On the other hand one can illustrate that agricultural policy analysis has been conducted with little knowledge of climate dynamics. As a direct consequence of capricious behaviour of particularly rainfall in West Africa, the adaptation of its farmers has lagged behind enormously. This statement is valid for most farmers in sub-Saharan Africa. Within the climate science community there is an emerging effort to make findings more suitable for decision making, but as yet there is little consensus as to how data may be relied upon for decision making. Then a lot of attention is paid to how response farming, that is thoroughly defined, can play an important role in coping with the consequences of climate variability. Response farming is often limited envisaging rainfall events, but coping with weather and climate (and often soil) disasters as well as using windows of weather and climate (and often soil) opportunities are other forms of responding to weather and climate (and often soil) realities. Services such as in advice on design rules on above and below ground microclimate management or manipulation, with respect to any appreciable microclimatic improvement: shading, wind protection, mulching, other surface modification, drying, storage, frost protection and so on belong to such “response farming” agrometeorological services. Ideally, to get optimal preparations, farmers get advisories/services through extension intermediaries, backed by scientists, to properly understand decision options through discussions supported by economic analyses. Throughout the paper text boxes are used that illustrate local conditions that must be taken into account if one wants to understand the impacts/consequences of climate change for African farmers and how they may cope with them.

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Feasibility study of a district tuberculosis control programme with an 8-month short-course chemotherapy regimen utilizing the integrated health service network under field conditions in Nepal

Tubercle and Lung Disease ◽

10.1016/0962-8479(95)90582-0 ◽

1995 ◽

Vol 76 (1) ◽

pp. 65-71 ◽

Cited By ~ 4

Author(s):

I. Onozaki ◽

T.M. Shakya

Keyword(s):

Health Service ◽

Feasibility Study ◽

Chemotherapy Regimen ◽

Control Programme ◽

Field Conditions ◽

Tuberculosis Control ◽

Service Network ◽

Tuberculosis Control Programme ◽

Short Course ◽

Short Course Chemotherapy

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Health technology assessment in sub-Saharan Africa: a descriptive analysis and narrative synthesis

Cost Effectiveness and Resource Allocation ◽

10.1186/s12962-021-00293-5 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Samantha Hollingworth ◽

Ama Pokuaa Fenny ◽

Su-Yeon Yu ◽

Francis Ruiz ◽

Kalipso Chalkidou

Keyword(s):

Decision Making ◽

Health Technology Assessment ◽

Technology Assessment ◽

Technical Assistance ◽

Health Technology ◽

Sub Saharan Africa ◽

Main Theme ◽

Narrative Synthesis ◽

Policy Makers ◽

Sub Saharan

Abstract Background Countries in Sub-Saharan Africa (SSA) are moving towards universal health coverage. The process of Health Technology Assessment (HTA) can support decisions relating to benefit package design and service coverage. HTA involves institutional cooperation with agreed methods and procedural standards. We systematically reviewed the literature on policies and capacity building to support HTA institutionalisation in SSA. Methods We systematically reviewed the literature by searching major databases (PubMed, Embase, etc.) until June 2019 using terms considering three aspects: HTA; health policy, decision making; and SSA. We quantitatively extracted and descriptively analysed content and conducted a narrative synthesis eliciting themes from the selected literature, which varied in study type and apporach. Results Half of the 49 papers identified were primary research studies and mostly qualitative. Five countries were represented in six of ten studies; South Africa, Ghana, Uganda, Cameroon, and Ethiopia. Half of first authors were from SSA. Most informants were policy makers. Five themes emerged: (1) use of HTA; (2) decision-making in HTA; (3) values and criteria for setting priority areas in HTA; (4) involving stakeholders in HTA; and (5) specific examples of progress in HTA in SSA. The first one was the main theme where there was little use of evidence and research in making policy. The awareness of HTA and economic evaluation was low, with inadequate expertise and a lack of local data and tools. Conclusions Despite growing interest in HTA in SSA countries, awareness remains low and HTA-related activities are uncoordinated and often disconnected from policy. Further training and skills development are needed, firmly linked to a strategy focusing on strengthening within-country partnerships, particularly among researchers and policy makers. The international community has an important role here by supporting policy- relevant technical assistance, highlighting that sustainable financing demands evidence-based processes for effective resource allocation, and catalysing knowledge-sharing opportunities among countries facing similar challenges.

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Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries

Health Policy and Planning ◽

10.1093/heapol/czaa166 ◽

2020 ◽

Author(s):

Justin Parkhurst ◽

Ludovica Ghilardi ◽

Jayne Webster ◽

Robert W Snow ◽

Caroline A Lynch

Keyword(s):

Decision Making ◽

Malaria Control ◽

Qualitative Interviews ◽

Sub Saharan Africa ◽

African Countries ◽

Health Community ◽

Control Programmes ◽

Control Decision ◽

Sub Saharan ◽

Economic Considerations

Abstract This article explores how malaria control in sub-Saharan Africa is shaped in important ways by political and economic considerations within the contexts of aid-recipient nations and the global health community. Malaria control is often assumed to be a technically driven exercise: the remit of public health experts and epidemiologists who utilize available data to select the most effective package of activities given available resources. Yet research conducted with national and international stakeholders shows how the realities of malaria control decision-making are often more nuanced. Hegemonic ideas and interests of global actors, as well as the national and global institutional arrangements through which malaria control is funded and implemented, can all influence how national actors respond to malaria. Results from qualitative interviews in seven malaria-endemic countries indicate that malaria decision-making is constrained or directed by multiple competing objectives, including a need to balance overarching global goals with local realities, as well as a need for National Malaria Control Programmes to manage and coordinate a range of non-state stakeholders who may divide up regions and tasks within countries. Finally, beyond the influence that political and economic concerns have over programmatic decisions and action, our analysis further finds that malaria control efforts have institutionalized systems, structures and processes that may have implications for local capacity development.

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OP179 Quantitative Evidence Synthesis Methods For Assessing The Effectiveness Of Treatment Sequences For Clinical And Economic Decision-Making: Methodology Review

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462321000738 ◽

2021 ◽

Vol 37 (S1) ◽

pp. 4-4

Author(s):

Ruth Lewis ◽

Dyfrig Hughes ◽

Alex Sutton ◽

Clare Wilkinson

Keyword(s):

Decision Making ◽

Chronic Conditions ◽

Evidence Synthesis ◽

Policy Decision ◽

Clinical Effectiveness ◽

Synthesis Methods ◽

Economic Decision Making ◽

Treatment Sequencing ◽

Policy Decision Making ◽

Treatment Sequences

IntroductionThe sequential use of alternative treatments for chronic conditions represents a complex, dynamic intervention pathway; previous treatment and patient characteristics affect both choice and effectiveness of subsequent treatments. Evidence synthesis methods that produce the least biased estimates of treatment-sequencing effects are required to inform reliable clinical and policy decision-making. A comprehensive review was conducted to establish what existing methods are available, outline the assumptions they make, and identify their shortcomings.MethodsThe review encompassed both meta-analytic techniques and decision-analytic modelling, any disease condition, and any type of treatment sequence, but not diagnostic tests, screening, or treatment monitoring. It focused on the estimation of clinical effectiveness and did not consider the impact of treatment sequencing on the estimation of costs or utility values.ResultsThe review included ninety-one studies. Treatment-sequencing is usually dealt with at the decision-modelling stage and is rarely addressed using evidence synthesis methodology for clinical effectiveness. Most meta-analyses are of discrete treatments, sometimes stratified by line of therapy. Prospective sequencing trials are scarce. In their absence, there is no single best way to evaluate treatment sequences, rather there is a range of approaches, each of which has advantages and disadvantages and is influenced by the evidence available and the decision problem. Due to the scarcity of data on sequential treatments, modelling studies generally apply simplifying assumptions to data on discrete treatments. A taxonomy for all possible assumptions was developed, providing a unique resource to aid the critique of decision-analytic models.ConclusionsThe evolution of network meta-analysis in HTA demonstrates that clinical and policy decision-making should account for the multiple treatments available for many chronic conditions. However, treatment-sequencing has yet to be accounted for within clinical evaluations. Economic modelling is often based on the simplifying assumption of treatment independence. This can lead to misrepresentation of the true level of uncertainty, potential bias in estimating the effectiveness and cost effectiveness of treatments and, eventually, the wrong decision.

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