But perhaps one of the most interesting personalities to have begun to engage actively via Twitter is Agnes Binagwaho, the Minister of Health of Rwanda, who in addition to tweeting actively runs a regular #MinisterMonday discussions where she asks Tweeps to submit questions in real time and she responds to them publicly via Twitter.

This morning she used Twitter in another way: she announced that the Ministry of Health has issued a 3-month ultimatum to all hospitals in Rwanda to build sufficient toilets in their facilities or risk losing the additional financing that has come online in Rwanda through what is known as the “Performance Based Financing (PBF)” scheme. I love it: it is bold, it is unconventional, and it might even work. Toilets are not sexy but I can tell you as a pregnant woman myself, they are completely indispensable in my life and the thought of spending anytime at a facility – even a hospital – without one is unthinkable (and we wonder why women don’t like delivering in public hospitals?).

In my view, Rwanda has become a bit of an outlier in recent years in health system improvement efforts, largely due to this unconventional approach to implementing programs and their willingness to try new things. Perhaps this initiative might even catch on elsewhere?

Other donors have also recently announced significant increases to tackle these diseases, including Sight Savers, a charity that targets onchocerciasis, a leading cause of blindness globally among other vision related causes. And I’ve heard word that we should expect some big announcements, in particular from the Gates Foundation, in the next few weeks of more resources to be given to the NTDs.

So why are the NTDs doing so well at attracting funding in the current funding climate? Perhaps it has to do with the perceived and mostly demonstrated effectiveness and cost-effectiveness of the interventions being proposed. Perhaps the fact that is is by nature an extremely equity enhancing set of diseases to go after (they tend to only affect the poorest of the poor). Perhaps it is the feeling that with proper scale up donor commitments might actually lead to elimination of these diseases. Or perhaps it has just been continued advocacy efforts from those who believe in the cause.

Regardless, it is good news, and I am looking forward to more good news in the coming weeks.

Also among my New Year’s resolutions is to read more, specifically to read more books. I spend so much time reading blogs and online materials that I never seem to find the time to read real books, and I miss it. Last year I think I managed to only read a handful of books. So this year, the plan is to read at least 30 books.

How am I doing so far? Well since the start of the year I have finished Jacques Pepin’s book “The Origin of AIDS” and am mostly through Vinh-Kim Nguyen’s “The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS“.

Up next? I plan to read “The Grandest Challenge” by Abdallah Daar and Peter Singer, “Changing Planet, Changing Health” by the recently deceased Paul Epstein, and “A Heart for the Work: Journeys through an African Medical School“.

For the good ones, hopefully I’ll get some reviews up here. But in the meantime, if you have any suggestions as to what I should be reading on global health, please share….

In this comment, Wendy Graham (whose work I profoundly admire) and Beena Varghese argue that current proposed efforts to improve Maternal and Child Health via the UN Secretary-General’s new Global Strategy for Women’s and Children’s Health are nothing less than “insane”. They argue it is time to, in their words:

…seize this opportunity to address a global insanity—continuing over and over again to deliver poor-quality health services for women and children and yet expecting positive results.

What is the problem with current efforts? They argue that current efforts are too focus on expanding “coverage” and are not focused enough on exactly what is delivered and how – that is the quality of services delivered. I could not agree more.

“What you count is what you do” is a reality that helps to explain the national and international neglect of quality targets. There is a danger of presuming sustained reductions in mortality on the basis of increased coverage of services but without intelligence about the content and quality of care.

Specifically, they argue:

This repositioning requires something else to be done differently: to routinely and robustly monitor quality along the continuum of care, including users’ perspectives as well as providers’.

What?! Asking women what they actually want and what it is they value in terms of the services that are being made available to them?! That is just crazy talk! What do they know! Actually, that has been a big part of some of the new projects I have been working on this past year in Kenya and to some extent in Ghana (see excuse above to justify the lack of blogging).

A highly recommended read.

While there was lots of good stuff discussed at the Forum this week, most of it has now been overshadowed by the announcement of interim phase III trial results of a subunit vaccine for malaria, known as RTS,S. The interim results line up with what most people who have been following the saga of this vaccine over the years would have expected, a roughly 50% protective efficacy against cases of malaria and a roughly 35% reduction in cases of severe malaria in young children roughly 12 months after the vaccines were given (I prefer the intention-to-treat results, not the higher per-protocol results that many in the press have been reporting instead). This is clearly very good news…and something no doubt worth celebrating.

That said, and unlike the rest of the world which seems to have gone crazy celebrating this news, I can’t seem to get too excited about these results, at least for now. Sure from a scientific perspective this is really groundbreaking: we now have a vaccine against malaria that has shown to be somewhat effective in a phase III trial. It is also a vaccine against a parasite, which itself is a big accomplishment. Peter Hotez released a press release earlier today in which he describes this news as the equivalent to walking on the moon in terms of its scientific contribution. Wow.

But as a public health professional, I just don’t think that enough new evidence has been presented for us to think that we found a “game changer” when it comes to malaria prevention and control. The real question, at least in my mind, that is relevant in this discussion is: does this vaccine provide any real lasting immunological protection in the target populations? The interim study was not set up to address this question. The actual full study was but, and I am not entirely sure why, the interim results were published anyway years before the real results of this study are going to be known. I am not the only one who questions the merits of this approach, in the accompanying editorial in the NEJM by Nicolas Witte, a true expert in this area, said “there does not seem to be a clear scientific reason why this trial has been reported with less than half the efficacy results available”. But of course we all know it is not always just science that drives most scientific discussions.

What this study showed was that up to 12 months there was a reduction in the cumulative number of cases of clinical and severe malaria in those receiving the treatment vs. those that did not. Unlike traditional vaccines, immunization in this case does not prevent infection per se, it might just delay it or delay the clinical manifestation of the symptoms. We don’t know. Even this study showed that the efficacy of the vaccine had already started to wane before the end of the interim study. The initial study includes a booster vaccine to be given at a later date to help boost immunity – this might be key to proving the value of this vaccine. I will wait to celebrate until after I see the results of this part of the full study.

But shouldn’t we celebrate all new vaccines? I think this might be an example of where the public health community is so trained to believe in the power of vaccines that there is little questioning of whether a new vaccine is better than none. In this particular case, I am not so sure. By the way, I blame Bill Foege’s excellent book “House on Fire” for making such a skeptic when it comes to traditional public health dogma and vaccination.

I’ve seen two interesting papers in the past year that look at the use of intermittent preventive treatment of children that showed incredibly high levels of protection (you can read more about them here on the topnamen malaria blog) in areas of high disease transmission. Will this vaccine be better than that option? Those drugs are available now.

When I travel I take a prophylactic drug to prevent malaria, would this vaccine be a better option for me than what I currently do? I would likely need 3-4 shots of the vaccine, which seems like a pain compared to my one pill a day. Is this why GSK has been so quick to say it will not try to capture profits from this new product?

I have heard talk recently of using more powerful drugs like ACTs, which are also known to block transmission, in a mass drug administration type way to dramatically reduce community levels of the disease. Would this not be worth trying?

Is this the best vaccine in the pipeline or just the furthest along? If the world commits itself to this particular vaccine would there be a risk of slowing the speed of development of a better vaccine? Why was there so little discussion of this paper published last week in Science that shows promising results from a live attenuated vaccine in preventing infection.

Would a vaccine work better in areas of low of high transmission?

To be clear, this is an exciting scientific discovery. Kudos to the authors of this paper and to the countless others who have been involved with this venture for decades for their excellent scientific work. But in my mind there are still a lot of big unanswered questions before decisions can and should be made about using this vaccine in the real world.

1. The last mile in global poliomyelitis eradication: Dr. Bhutta from Pakistan, a prolific researcher and writer, shares some thoughts on why the last phase of polio eradication is so hard. These are really complicated issues and so I am impressed with how this one short piece seems to capture most, if not all, of these issues and makes them very easy to understand. I wish more technical people could write like this.

2. Global Rise in C-Sections Troubles Experts: I’ve started doing some work lately on the rise of cesarean sections in the developing world, which in a nutshell has been dramatic in some places. Many experts are alarmed by the rates. While there is no consensus on what the rates are, there is even less of an understanding of why the rates are rising so rapidly. PBS investigates these questions here.

3. A Campaign to Carry Pregnancies to Term: Back here in the US, another consequence of high rates of cesareans here are that many pregnancies are induced or scheduled for cesarean section before the baby is full term. There are health consequences of these decisions and the March of Dimes has recently launched a campaign to promote full term births called “Healthy Babies are Worth the Wait”. You can read more about this campaign in this NYTimes piece.

4. Partners in Help: Finally, Paul Farmer who is currently promoting his new book “Haiti: After the Earthquake”, reflects on Haiti, Harvard, and foreign aid in general in this piece, which was essentially his commencement address at Harvard Kennedy’s School earlier this year. While I certainly agree with a lot in this piece, I am not always convinced that the solutions are as obvious as he would make them seem. But I thought this was a thoughtful and interesting read.

I will also be teaching “Introduction to Global Health Policy and Management” which is a required course for the students enrolled in the Global Health Leadership MPH program at NYU.

As a relatively new instructor, I am always looking for ways to improve upon the course from the previous year to make the classes most useful to students. That is why I was *thrilled* to find out that the Global Health Delivery Harvard Business School case studies that I have been hearing about for the past little while are finally launched and ready to go. In total they have put together 21 global health themed courses to help with the teaching of important global health issues, ranging from manufacturing of textiles for malaria control to dealing with the aftermath of the Haiti earthquake.

The best part of all of this? The cases are free!

You can find out more about Changamka by watching this moving video, which was produced by Al Jezeera:

Seems like a great idea, right? I think so, but of course, we won’t actually know until the program is properly evaluated. There have been many great and noble attempts to reduce financial barriers to maternity services. In fact, introducing voucher programs or user fee exemptions have become extremely popular across sub-Saharan African countries to expand access to maternal and child health programs.

Despite all of the fan fare that these programs have received (including this piece in the NYTimes last week chronicling the experience of Sierra Leone) it is not clear if we really know if these programs really work and under which conditions. Most of the programs have not been evaluated. Even if we do believe that they are effective, given that they are hugely expensive programs, it would also be good to know if they generate enough impact to justify the resources expended on them. These are all things that we believe we will be able to better understand with our proposed project.

Stop for one minute and think about it: if you could do something tomorrow, what would you do to save the lives the millions of children and women who die during childbirth?

Well if you can’t decide yourself, you can share your views on what others think might work. There were over 600 applications to this program and from the initial list of applications, 77 projects have made it to the final round. Some of the projects have been submitted for smaller proof of concept grants while others have been submitted for larger integrated solutions that can be brought to scale and evaluated for impact. The organizers are asking for your opinion – which of these programs would you support? Next week in DC there will be a Development Expo where the finalists will be displaying their ideas. Projects with the most votes are eligible to win a people’s choice award.

Full disclosure: while I wanted to help get word out about this program, I also wanted to let you know about some of the work I’ve been doing the past few months. I am part of a team that was selected among the finalists for this program. Working with an amazing health microfinance organization in Kenya – called Changamka – and some economists from Georgetown, we are proposing the development of an e-voucher that can be deployed by mobile phones in rural areas of Kenya that will subsidize the costs of maternity services. In addition, we are also proposing a series of informational interventions, which we believe can be cost-effective means of increasing demand. Most innovatively, we are also proposing the development of a crowd-sourced application that allows users to share information on the quality of health services received. And we have developed a plan to rigorously evaluate it to see what really works and why. If you like our ideas, I can promise you a free subscription to my blog for life. Go vote – and vote often!