Recently, we have indeed seen very promising developments in prevention and treatment. For instance, treating people with anti-retrovirals can reduce the risk of onward transmission to a partner by as much as 96%.

However, preventing new infections, including mother-to-child transmission, and providing HIV treatment to all those who need it is next to impossible without a well-functioning health system. Anti-retroviral treatment requires that the patient be regularly monitored and supported in adhering to the regime, which requires that he or she has access to a health facility. Similarly, where the quality and accessibility of health services is poor, many HIV positive pregnant women do not access antenatal care, resulting in unnecessary transmission of HIV from an infected mother to her baby.

In the new book I have edited together with my LSHTM colleagues Prof. Anne Mills and Prof. Martin McKee ‘Good health at low cost’ 25 years on (downloadable for free) we offer clues to help policy-makers in low and middle income countries build stronger health systems that can effectively tackle their HIV/AIDS epidemics (among other diseases).

In the book, we raise the question of why some low and middle income countries achieve good health while others fail. Five countries that have seen remarkable improvements in the health of their populations are the focus of the book: Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu and Thailand.

Thailand in particular leads the way, having achieved the health MDGs in early 2000s and now working towards the more ambitious ‘MDG Plus’. Over a period of 40 years, the country has implemented successive pro-rural, pro-poor five-year national health plans that transcended political divides. Support from government leaders and the public health sector helped consistently strengthen the health system over generations. In particular, the focus was on improving child and maternal health, with the provision of services by the public sector (primary health centres). Long-term government policies were critical to expanding district health systems. In 2002 Thailand introduced universal healthcare covering the entire population.

As a result, when the AIDS pandemic hit 30 years ago, the Thai health system was in relatively good shape to respond to the emergency. Between 1975 and 2005 life expectancy increased, with female outpacing male due to the impact of AIDS. Studies showed that HIV was the leading cause of disability-adjusted life years lost both for men and women.

Subsequently, successful prevention and treatment turned a generalised epidemic into a concentrated epidemic among specific groups and have brought the number of new infections down dramatically from a peak in 1990. Particular successes have been noted in mother-to-child transmission, which has been integrated into general antenatal care. Nurses in district hospitals are trained to provide HIV counselling in pregnancy, offering advice about prevention and mother-to child transmission.

Although each country has a different story to tell, we were able to identify some common characteristics of a well-functioning health system, able to tackle the epidemic of AIDS. These included: leadership by individuals with a commitment to health gain; capacity within the individuals and institutions necessary to design and implement health reform; continuity to provide the stability that is required for reforms to succeed; the ability to seize windows of opportunity; and the ability to take context into account in order to develop appropriate and relevant policies.

Our research has shown that piecemeal interventions, however sound by themselves, cannot improve health without long-term commitment and attention to health system building. Despite the new advances, ending the HIV/AIDS epidemic is crucially dependent on functioning health systems.

Health systems represent the cornerstone in achieving universal access targets for HIV treatment and prevention. The lessons in our book go some way in helping policy-makers understand the key pillars required in transforming health systems and with it health care.

Contributed by Dina Balabanova, Senior Lecturer in Health Systems/Policy, London School of Hygiene and Tropical Medicine

Development education emerged in the 1960s and 1970s in response to the need to secure public legitimacy and support for aid and development. Since then in many European countries and beyond governments, NGOs and educational bodies have provided funding and developed resources for educational environments, particularly schools, on development and global issues.

However, despite the 2005 creation of the EU-supported document Consensus on Development Education, development education has been subject to political controversy. In the UK, the coalition government, despite its continued commitment to the 0.7% target on aid, has questioned the value of development education.

Behind these controversies are some difficult questions that all concerned with aid and development need to consider:
- How important is that the public needs to not only be aware and supportive of aid budgets, but also understand what is meant by those terms?
-  If there is an agreement that we need to eradicate global poverty, then surely we need to understand why it exists and why there are such inequalities in the world.
- Learning and understanding about development  is likely to raise questions about the role of aid, questions around social justice and how to secure global change.

This is where development education can come in. A criticism often made about initiatives such as ‘Make Poverty History’ in 2005 was that it may have raised awareness of global poverty, but it was ‘a mile wide but only an inch deep’ (see ‘Funding Frames – New Ways to Engage the UK Public in Global Poverty’ by Darnton and Kirk, published by BOND in 2011). Development education may have many interpretations, from Oxfam’s promotion of global citizenship to CAFOD’s education for global justice or English curriculum materials around the ‘Global Dimension’. Behind them all is a recognition of the need to demonstrate the connections between people’s lives in the UK with those in the global South, that it is more than merely gathering information about the MDGs for example.

At the Development Education Research Centre within the Institute of Education (IOE) and as partners within LIDC, we are committed to raising the debates about the value and contribution of development education to broader development questions and policies. To this end we are planning a conference on this theme in January 2012 (for further information please visit our website).

One example of our work in this area has been the publication of a major research report on ‘Geography and Development, the Contribution of Development Education to the Teaching of Geography in the School Classroom’. Written by Professor David Lambert and Dr. John Morgan from the Institute of Education, this publication suggests that geography can play a major role in learning about development, but that all too often it is taught as a topic in a neutral and economic form, and not addressing ideological questions about the purpose and value of aid and viewpoints of people from the South.

To me development education should be first and foremost an approach to learning about global and development issues. This can and should have many interpretations which in themselves are likely to be value-laden and related to wider political and organisational agendas.

With support for aid and development being questioned by aspects of the right-wing media, it could be argued that now is not the time to pose difficult questions. I would argue the opposite in fact, because without deeper understanding and opportunity to engage in debates around development, it is impossible for people come to their own conclusions.

This is why the Centre is currently engaged in a range of projects covering all sectors of education on bringing learning and understanding about development and global issues into the mainstream of learning, be it in the school classroom, the further education college or the university. For example, the Centre is currently running projects on embedding the Global Dimension within the training of all teachers at the Institute, encouraging further education colleges to include development issues within courses, and working with medics, vets and pharmacists within Bloomsbury Colleges and UCL on bringing global issues into the training of these professions, as part of the Students as Global Citizens project.

Learning and understanding about development and global issues should not be just the concern of development professionals with only a superficial covering elsewhere in society via media campaigns and fundraising. It is only through an informed and engaged citizenry that the role and purpose of development can be supported within the UK society. This is where development education comes in.

Contributed by Dr. Doug Bourn, Director of Development Education Research Centre; Editor of the International Journal for Development Education and Global Learning, Institute of Education

The 1984-85 famine which affected Ethiopia most, but also affected Eritrea (which was then part of Ethiopia) and Sudan, was largely an agricultural famine. This is not to say that it was entirely caused by drought, rather that those who were worst affected were farmers. Struck by three failed rainy seasons and a civil war that placed a stranglehold on the highland countryside in Ethiopia, farmers were neither able to produce the food they needed, nor able to buy it from local markets since traders’ access to markets was curtailed by travel restrictions, the direct targeting of market towns by government forces, and lack of food to buy from larger wholesale markets. As many as 600,000 people were displaced from their homes to areas inside Ethiopia, and another 600,000 sought refuge and assistance in camps in Sudan. Assistance was complicated by aid agencies having to negotiate access with the Ethiopian government. There were then, as there are now, concerns that famine relief might fall into the ‘wrong hands’ or be used to perpetuate the conflict.

But there are important differences between the famine of 1984-85 and that of 2011-12 (for the one we are experiencing now will certainly continue at least into the beginning of next year). The most significant of these differences is that whereas the former was an agricultural famine, this is largely a pastoral and agropastoral famine. While it may seem crass to say so, once people’s immediate food needs are met, the rehabilitation of agricultural households is easier than it is with households that rely substantially on pastoralism. This is where the current famine is different and potentially more dangerous than the earlier one. To start farming again once the drought has passed, people need animals or tractors to plough with (in the highlands virtually all ploughing is done with oxen), seeds, and tools. (They also need land, but all land is nationalized in Ethiopia so people do not lose it by selling it.) These inputs can be provided relatively easily if government or donors are willing.

In pastoral areas, rehabilitation of people affected by famine is more complicated. Many people who lose their herds are never able to return to pastoralism because they cannot get the five animals that they need to start to raise a viable herd again. The herd is the bank account of the pastoralist, and once the animals have died or been sold for rock-bottom prices, there are no savings to restart their pastoral livelihoods.  No sooner do they start to build up herds than another food shortage starts and they are forced to sell them to buy food. People thus remain camped around cities and towns for years without access to an adequate income. Their vulnerability to continued food insecurity worsens.

In Somalia and pastoral parts of Ethiopia today, those who are pouring into camps in Dadaab, Dolo Ado and Mogadishu have lost the animals they once had. Many have also lost family members. The life-saving operation that is in place now is fraught with difficulties of trying to negotiate access, in Somalia with both the al-Shabaab insurgents and the Transitional Federal Government (both of whom have reportedly tried to block aid deliveries or prevent people from crossing from one side’s area to the other’s to access relief), and in Ethiopia where there has been a sporadic counterinsurgency for the past two decades. In both cases conflict actors are interested in using famine relief for political ends, to win hearts and minds to their own side.  This aspect of the famine is receiving the lion’s share of the media coverage.

But an equally vexing question is: How can rehabilitation be made meaningful in pastoral areas, where the environment dictates that pastoralists must live in dispersed arrangements, where roads are few and far between, and where herds have been decimated and families rendered chronically vulnerable to repeated famine? Local governance in pastoral areas throughout the Horn is weak, as a result of conflict but also neglect. Even while the effort is – and should be – on saving lives in the short term, governments and aid agencies must think now about the difficult question of how meaningful recovery can be promoted. This has not been tried before with any seriousness or success, but it cannot be overlooked again.

Contributed by Dr. Laura Hammond, Senior Lecturer, Department of Development Studies, School of Oriental and African Studies (SOAS)

Twenty four senior public health staff, livestock veterinarians and wildlife health researchers from 10 African countries participated in the training, learning about One Health – an integrated approach to health and disease, highlighting inextricable links between human and animal health and the health of the ecosystems they inhabit.

This was a very different workshop! It moved away from the conventional model of static lectures for a few days, political hand-clapping and turgid recommendations squeezed out of a bored and reluctant audience, to a more dynamic event. We mixed a few lectures into a lot of debate and group discussion, problem-based learning activities, with alternate days of intensive field practicals. The field days varied from looking at ecosystem health issues to small group dialogue with the very poor and stressed communities, individuals, male and female, young and old, farmers, pastoralists, shopkeepers, mostly recently settled refugees after the genocide. The workshop continued without a pause for 10 days. We were all exhausted, although it seemed short.

The health issues identified during the workshop were acute and fascinating, both with respect to animal and human health, ranging from elephantiasis, to acute undiagnosed arthritis (Borreliosis?), HIV,TB, rabies, trypanosomosis, malaria and fevers of unknown origin (only 3% of “malaria” cases were confirmed as such in one busy clinic that we visited).

The communities we visited are embedded in a rapidly changing environment, given scarce small land parcels, carved out of a 70% degazetted National Park, with still intense interfaces with livestock and wildlife, and with seasonal water and food deficiencies. It is a hard existence, but even amongst this chaos some farmers were showing remarkable skill at conservation agriculture techniques and considerable resilience in the face of challenging health and disease threats. They were less concerned about their personal ailments than the issues of rainfall, soil erosion, crop failures and wildlife conflict issues which all have a direct impact at the community level and on their nutrition. One Health to these people is about ecosystems and their services first and then human and animal health second.

The workshop participants were given a real taste of what One Health means and they were exposed to the changing ecology from within the National Park boundaries, learning about bulk grazers to decomposers, scavengers and lichens – neither plant nor animal, to the agro-ecological human landscapes with all the threats this is presenting to biodiversity loss, water cycles and quality, soil nutrition, disease emergence and ecological instability.

The main outcome of the training was strong advocacy for a One Health approach, taking into account the ecosystem, humans, domestic animals (especially livestock) and wildlife, undertaken in a comprehensive manner and through action at all levels. One Health is crucial to disease surveillance, outbreak investigation, disease control and prevention measures at the intersection of human and animal health.

As one of the participants commented during the workshop, “ We have to find a way to make this One Health work. We owe it to our people, our animals and our environment, after taking it all for granted for so many centuries!” This is easier said than done, as human health systems are better developed than other systems in most countries, followed by livestock and finally wildlife, which is often neglected.

There is a need to “sell” a One Health approach at all levels. The ideal would be to have a permanent One Health structure established at the highest levels globally and nationally, but also at a community level. The challenge with the current One Health approach is that we are still not thinking from an ecological perspective. At the global level, WHO/ OIE and FAO are challenged to agree on a definition of One Health. The UN hopes to create a policy on One Health, but this is still work in progress. Then there are the multiple challenges of implementing One Health approaches in traditional communities, in ways that respect local knowledge, but also address prevalent misconceptions about health and disease.

The path towards One Health is rocky, but the workshop in Rwanda has brought it home to the participants and to myself that it is worth the effort – a robust One Health approach can support sustainable development and the well-being of communities in Rwanda and beyond.

Contributed by Richard Kock, Professor of Wildlife Health and Emerging Diseases at the Royal Veterinary College

Improving access to vaccines in developing countries is essential for achieving the Millennium Development Goal of reducing the number of deaths among children under five. The GAVI Alliance (Global Alliance on Vaccines and Immunisation), a global partnership of governments, donors, global institutions and the private sector, plays a key role in co-ordinating these efforts. The Alliance sets global priorities in immunisation, co-ordinates efforts to raise and distribute funds, and seeks to use its influence to lower vaccine prices.

At its recent conference in London, GAVI succeeded in raising $4.3 billion to continue the expansion of its programmes up to 2015. The Alliance is currently seen as a good investment for donors. DFID’s recent review of multilateral institutions ranked it near the top based on its organisational strength, value for money and contribution to the UK’s development objectives. GAVI has also been the favourite vehicle for innovative financing mechanisms funded by donors.

However, a key challenge for GAVI over the coming five years will be to make progress towards a more sustainable global system for immunisation. That means driving vaccine prices down and ensuring that countries take greater ownership and prioritise the purchase of their own vaccines.

Reducing prices is key to sustainability. GAVI needs to do more to innovate and apply pressure in addressing this challenge. GAVI has already convinced pharmaceutical companies to sell their existing vaccines at lower prices. We are looking at how donor funds can be used to ensure cheap supply lines for newer vaccines. For example, the Meningitis Vaccine Project (MVP) channeled donor funds and provided expertise to the Serum Institute of India Ltd, who in return will produce a new low-cost Meningitis A vaccine for 10 years at an initial price of $0.40 per dose, just above the cost of manufacture. This mechanism, whereby donor funds are used to support a specific set of activities towards a goal, is known as a “push” mechanism.

In contrast, a “pull” mechanism provides an incentive to companies to invest in meeting a specified goal, however they see fit. In 2007 the governments of Italy, UK, Canada, Russia and Norway, and the Bill & Melinda Gates Foundation committed $1.5 billion to incentivise manufacturers to supply pneumococcal vaccines for developing countries at a low price. The donor funds will be used to supplement the purchase price for a limited period. This initiative is known as the advance market commitment for pneumococcal vaccines. Two major pharmaceutical companies, GSK and Pfizer, have signed contracts to supply 30 million doses of new pneumococcal vaccines for 10 years at prices much lower than those paid in wealthier nations.

Both initiatives negotiated commitments from suppliers to provide new vaccines at a low price, although there is controversy as to whether the maximum price for the new pneumococcal vaccine was as low as it could have been. Also, the deal currently only involves the two biggest pharmaceutical companies in the world. More could be done to engage low cost suppliers in the developing world who have helped to push down the prices of other routine vaccinations.

GAVI is seeking to reduce the pressure on its international donors and increase commitments from recipient countries. But progress to date has been slow. While GAVI set out in 2000 with the goal of being time-limited, there is little prospect of achieving this. A recent independent evaluation was critical of GAVI’s approach to sustainability, suggesting that its choice of vaccines and its basic funding model have had a negative impact on countries’ ability to finance vaccines in the longer term. In particular, while GAVI’s decision to include new and more expensive vaccines has driven its success in saving lives, it has also driven its failure to move towards sustainability.

GAVI’s challenges have grown with its success. To maintain its alliance between donors, recipient countries and the private sector will require a complex balancing act. Over the next five years GAVI must make progress on sustainability as well as maintain its commitment to providing cheap vaccines.

More about GAVI evaluation
LSHTM Global Health Podcats – Dr. James Hargreaves talks about GAVI

Contributed by Dr. James Hargreaves, Senior Lecturer in Epidemiology at the London School Hygiene & Tropical Medicine, and Research Fellow, Centre on Global Health Security, Chatham House.

Over recent decades, national and international agricultural policy has encouraged intensification of food production and globalization of food chains. For human diseases in the food chain, this will mean more rapid and widespread outbreaks, delays in identifying their source and greater economic impacts of consequent responses.

E. coli is a “dead end” pathogen, which will not spread between humans, but the same agricultural processes of intensification and globalization underlie the recent emergence of diseases which could spread in populations, such as influenzas from poultry and pigs. These health threats were also associated with unexpected national economic shocks.

But modern agriculture is not fundamentally a threat to health. In principle, agricultural intensification and globalization can improve public health, through greater availability of nutritious food, reduced disease incidence in well controlled, intensified systems, and the opportunity for enlightened cooperation between countries sharing the challenge of trading food safely.

When, instead, we see responses to disease outbreaks affecting agricultural economies remote from the health threat, disease outbreaks in intensified systems becoming more frequent and food safety being used as a convenient barrier to restrict free trade, we are looking at the failure of health and agricultural sectors to build policy together.

Agricultural policy has paid too little attention to health implications. At the same time, health policy is historically preoccupied with curing rather than preventing disease, and has focused too little on encouraging healthy diets and safe food. As a result, the market processes that drive agriculture have led to overproduction and overconsumption of high energy, low nutrient foods, and to rising disease threats.

It is ironic that the E. coli outbreak not only reduces public confidence in food safety in general; it has also further reduced people’s confidence in fruit and vegetables – precisely those foods that would reverse current unhealthy dietary trends.

Last month, the Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH), took a first step to breaking down the silos that have prevented integration of agriculture and health strategy by bringing together economists and policy makers from both disciplines to explore developing a common language for measuring the effects of agriculture on health and vice versa. Some common ground was found, but this will be a long process. However, only by understanding how policies affect both agricultural and health consequences, and the magnitude of these effects, can the best policies be chosen which will minimize both health and economic losses.

LIDC facilitates interdisciplinary research and training to tackle complex problems in international development. We work with social and natural scientists from across the University of London’s six Bloomsbury Colleges: Birkbeck, Institute of Education, London School of Hygiene and Tropical Medicine, Royal Veterinary College, School of Oriental and African Studies, and The School of Pharmacy.

Our work is about bringing people together to exchange ideas and solve development problems working across disciplines and across institutions, so a multi-contributor blog seemed like an obvious choice. We would like the LIDC blog to be a platform for innovative and inspiring dialogue on development, cutting across disciplines and bringing together academics, policy-makers and development practitioners.

This blog is also an invitation: we invite LIDC members (staff, students, alumni) from Bloomsbury Colleges to become LIDC bloggers, and we invite our readers from across the development community in London and beyond to join the conversation.

We hope that you join us!