User:FrancessO/sandbox

Practice Experience Research Brainstorm: Selecting Possible Articles
Area: Sub-Saharan Africa

Topics of Interest: Historical context of relationships between ethnic groups History of foreign aid/interventions: Successes Failures Sustainability Cultural context of health initiatives: Public health Policies Interventions Healthcare systems Health practices Alternative medicine Traditional vs. Western approaches

Potential Articles: “Sub-Saharan Africa” (with subheading: “Health care” https://en.wikipedia.org/wiki/Sub-Saharan_Africa#Health_care) Notes: Gives a brief summary of most influential healthcare reforms, policies, and health system interventions and points to specific examples within countries (i.e.: Mali, Ghana, etc.); also mentions some of the most critical health challenges faced in the region (i.e.: maternal mortality, HIV/AIDS, malaria, female genital mutilation, etc.). Could be extrapolated as a separate article rather than as sub-content so as to include more detailed information about healthcare in this region; information provided is too concise to cover a region comprising 46 countries.

“Western Influence on Africa (with subheading: “Health and Wellness” https://en.wikipedia.org/wiki/Western_influence_on_Africa#Health_and_Wellness) Notes: Article has potential-- the topic is very relevant and would be useful for exploration of my research, especially as it pertains to how Western thought may (or may not) have influenced health practices, reform, and interventions in the Sub-Saharan region of Africa. However, the submission is written as an opinion essay/personal reflection and is not linked to other reference articles, which begs the question of its credibility.

Sector: Healthcare & Medicine

Topics of Interest: Existing socio-cultural taboos/stigmatized areas of health (i.e.: mental health, sexual & reproductive health) Health systems Coexistence Differences Barriers to healthcare access Unmet need Prevalence of existing health conditions/ Concentrations of highest rates

Potential Articles: “Health Equity” (https://en.wikipedia.org/wiki/Health_equity) Notes: This article is extremely applicable to my research as it details the significance of multiple factors that impact health equity in society (i.e.: socioeconomic status, education, sex & gender, race & ethnicity, sexual orientation, culture, etc.). This article will provide a solid foundation for understanding the importance of equitable access to healthcare as it relates to my practice experience.

“Global Health Initiatives” (https://en.wikipedia.org/wiki/Global_Health_Initiatives) Notes: This article is also very relevant to my research as it includes information about how global health initiatives (GHIs) function to fundraise for disease management and control as well as improve health systems in developing countries. Though detailed in content, this article could benefit from including subheadings per continent/ region to reference specific examples of how GHIs have historically and currently impacted health systems around the world.

Evaluating Two Articles:
 Article 1 (Area): “Sub-Saharan Africa” (with subheading: “Health care”) https://en.wikipedia.org/wiki/Sub-Saharan_Africa#Health_care Article content is relevant but much too limited to cover the entire Sub-Saharan region. The article references a couple of examples of health issues that are affecting the region, and cites a few countries as case examples. However, the article would be more useful if the "Health care" section was separated as an individual article rather than included as a subheading topic. This would allow for detailed information to be provided for each country within the region of Sub-Saharan Africa. The article briefly mentions initiatives implemented by the World Health Organization to reshape healthcare reform in the region. Expansion of this information could supplement my understanding of how such reforms play/have played a role in the actions that my PE organization takes to actively participate in the health sciences field in the region. The article provides neutral content. The article is pretty well cited with working citation links and reliable reference sources. The article has been listed as a Vital Article and is currently part of a number of WikiProjects, including WikiProject Africa. As such, it is an article of much use and importance.
 * Is everything in the article relevant to the article topic? Is there anything that distracted you?
 * What avenues do you find here for further learning that is relevant to your PE preparation?
 * Is the article neutral? Are there any claims, or frames, that appear heavily biased toward a particular position?
 * Check a few citations. Do the links work? Does the source support the claims in the article?
 * How is the article rated? Is it a part of any WikiProjects?

Contribution Plans: Expand the "Health care" section to include relevant information that could be applicable to the entire Sub-Saharan African region as well as pointed references to systems/cases in specific countries within the geographic area. Consider extracting this section as an entirely new, separate, individual article and link to the original "Sub-Saharan Africa" article.

 Article 2 (Sector): “Global Health Initiatives” https://en.wikipedia.org/wiki/Global_Health_Initiatives Article content is relevant but could provide much more information on the impact of global health initiatives on various national health systems. Using this article as a foundation to understand the global context of healthcare initiatives implemented around the world would be especially useful as I embark on my experience with my PE and learn the ways in which my particular organization navigates that sphere. The neutrality of this article is a bit debatable. The article needs to increase the number of citations included, and should check the reliability of sources referenced. The article is currently part of a number of WikiProjects including WikiProject Africa, WikiProject Medicine, and WikiProject Health & Fitness.
 * Is everything in the article relevant to the article topic? Is there anything that distracted you?
 * What avenues do you find here for further learning that is relevant to your PE preparation?
 * Is the article neutral? Are there any claims, or frames, that appear heavily biased toward a particular position?
 * Check a few citations. Do the links work? Does the source support the claims in the article?
 * How is the article rated? Is it a part of any WikiProjects?

More editing plans:

- Grammar & punctuation clean-up

- Organization (i.e.: hyperlinks, order of content presented)

- Improvement of word choice ("Encyclopedic" tone)

- Attach a functioning "OECD CRS" link

Contribution Plans:

Expand article to include subheadings for each continent and provide information on examples of global health initiatives that impacted countries within each continent (i.e: what exactly these initiatives were, how these such initiatives were implemented, costs and benefits to the stakeholders involved in the intervention, etc.).

Bibliography:
Article 1 (Area) Article 2 (Sector)
 * This article provides information about how the development of community-based delivery of healthcare as well as local research institutes in the Sub-Saharan African region could improve access to health facilities and resources for individuals within the region. This article would be useful for including pertinent information in my article about the means and interventions used to meet health needs in this target area.
 * This article details information regarding current access (and lack thereof) to healthcare resources and adequate funding to healthcare initiatives affecting the Sub-Saharan African region, with pointed references to specific cases in countries like Nigeria. This article would provide examples to include in my article regarding the history of healthcare funding in this region with information on limitations and improvements.
 * This article explains the historical approaches as well as suggests new practical approaches to improving healthcare systems in the Sub-Saharan African region. Including a section about targeted approaches that may benefit the region after detailing the history Sub-Saharan African healthcare systems and programs could potentially prove useful for stakeholders interested in reading my article.
 * This article is interestingly unique as it provides information regarding the perspectives of stakeholders within the Sub-Saharan African region in relation to their views on current healthcare systems and approaches. Including such information as a section within my article would be useful in the grand scheme of providing a broad range of multiple perspectives on the issue of health in Sub-Saharan Africa.
 * This article provides historical context of the Global Health Initiative (GHI) policy instituted by the United States under the Obama Administration. This article is a necessary reference for my article as it provides relevant historical information regarding US involvement in global health approaches, and can be used to set a foundation for understanding relations between the United States and other countries in the context of global health.
 * This article highlights the case study of HIV/AIDS control in identified resource-poor countries to demonstrate the effects of global health initiatives on country health systems. I intend to use this article to provide a more tangible example to the effects (both positive and negative) of the work of global health initiatives when implemented in other countries.
 * This article details information regarding exactly who (which organizations, which government authorities, etc.) hold the power to create, administer, and implement global health initiatives around the world. This article will be useful in providing a framework and foundation of the politics surrounding global health initiatives.

Summarizing and Synthesizing:
Article 1 (Area), Citation 2:

Points to Include: Article 2 (Sector), Citation 5:
 * Very few African countries have implemented their objective of allocating 15% of their GDP (the Abuja declaration, 2001) to the health sector.
 * When salary and personnel expenditures take up between 60 and 70% of hospital resources, there is little left for other hospital expenditures.[2]
 * To make matters worse, sub-Saharan governments have had to implement the structural adjustment policies recommended by the World Bank and International Monetary Fund (IMF).
 * Its as if the entire system globally functioned on the line that, the poorer the country, the more its inhabitants and people are required to pay for health care out of their individual pockets; the most in need are consequently ignored.
 * The social and economic tasks confronting African countries are gigantic on several fronts, e.g., infrastructure, health, education, security, etc., and the resources to fund them miserably small.
 * In 2015, the USA's GDP stood at $17.9 trillion; Nigeria's GDP in the same period was $568.51 billion.[10]
 * In wealthy countries, health expenditure per capita is estimated at $3100 on average. In sub-Saharan Africa, average per capita expenditure is $37.[12]
 * The government health budget of a country with a population of 10 million is equivalent to the budget of a regional health center serving 100000 people in a developed country.
 * a large number of African countries have begun to work at setting up various types of universal medical insurance coverage, such as Senegal, Ghana, Gabon, Cote d’Ivoire, Kenya, and Benin, in an effort to reduce social inequalities.
 * In addition, international solidarity (Globalfund, Gates Foundation, etc.) and pressures from civil society have made possible a number of successes against diseases such as onchocerciasis (river blindness), polio, human immunodeficiency virus, and tuberculosis.
 * Here mention must be made of the 300 or so medical doctors trained at the School of Medicine in Dakar (Senegal) by French professionals between 1918 and 1950,[7] who made a major contribution to the almost complete eradication of the epidemic and endemic diseases that took a heavy toll on West African peoples, such as trypanosomiasis (sleeping sickness), plague, yellow fever, smallpox. Today, health care services have the opportunity of benefiting from technological (e-Health) and managerial innovations.[2,3,6]

Points to Include: From cluster-randomized implementation of universal health insurance in Mexico7 to the estimation of health and educational benefits of treating Kenyan schoolchildren for intestinal parasites,8randomized trials studying the health consequences of aid and policy programs are increasingly common.
 * In May, 2009, the Obama Administration unveiled a 6-year $63 billion Global Health Initiative,1 increasing its commitment to supporting health care in the world’s poorest countries during tight budgetary times.
 * The Initiative aims to consolidate many of the existing programs in an effort to improve coordination of the current structure that uses multiple government agencies and programs.
 * include implementing new women- and girl-centered approaches; strengthening health systems; increasing support to multilateral organizations such as the GAVI Alliance (formerly The Global Alliance for Vaccines and Immunisation) and the Global Fund; and encouraging country ownership of health care plans.2
 * The Initiative’s funding priorities have shifted towards greater funding for programs that target primary health care delivery and less funding for providing antiretroviral therapy.
 * These represent a major change in direction from the past decade’s focused investment on disease-specific  programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative in an ambitious approach to tackle broader structural challenges in service delivery.
 * The focus on primary health care for women and children, health system strengthening, and country ownership is a necessary step in building a future where local health systems are capable of providing sustainable health care services.
 * Now that HIV prevalence rates are stabilizing across much of the continent, PEPFAR is evolving to reflect the values of the new Initiative: away from an emergency response and towards strengthening partner government capacity to provide HIV care and integration of HIV programs with broader global health objectives.4
 * Large investments in global health are a relatively new phenomenon in the world of foreign assistance, rising to prominence in the past decade. However, economic development assistance has a history that spans decades, and its lessons suggest a cautionary tale for the Initiative’s revised approach.
 * Numerous studies have failed to link foreign assistance with comprehensive economic development; in fact, in some accounts, countries that received the most aid have seen the least growth.5
 * This history highlights the need to evaluate aid programs more rigorously, especially in a political climate that stresses accountability for an effect with taxpayers’ dollars.
 * The Global Health Initiative (GHI), while still vague in scope, shares characteristics with transformational aid by targeting large, structural changes in recipient countries.
 * There is little doubt that aid can work, but there is considerable uncertainty about how to make it work. The challenge is how to transform dollars into effective programs.
 * This challenge for the GHI is also an unusual opportunity to generate new knowledge on the effectiveness of foreign aid generally and for health improvement in particular.
 * New approaches to delivering aid, such as results-based financing hold promise as potentially effective tools that circumvent perennial pitfalls such as misunderstanding local incentives and failure to encourage local innovation in service delivery.
 * New methods for evaluating aid programs using randomized experiments are gaining momentum.

Article 2 (Sector): '''*contribution: Direct article editing
> revising article for punctuation, grammar, and diction errors; improving "encyclopedic" tone of content''' ===

= Global Health Initiatives[edit] = From Wikipedia, the free encyclopedia

Global Health Initiatives (GHIs) are humanitarian initiatives that raise and disburse additional funds for infectious diseases (such as AIDS, tuberculosis, and malaria), immunization, and strengthening health systems in developing countries.

Examples of GHIs include the President’s Emergency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and the World Bank's Multi-Country AIDS Program (MAP)– all of which focus on HIV/AIDS. The Gavi (formerly the GAVI Alliance) focuses on immunization, particularly with respect to child survival.

GHI Functions[edit]
In terms of their institutional structure, GHIs have little in common with each other. In terms of their function – specifically their ability to raise and disburse funds, provide resources and coordinate and/or implement disease control in multiple countries – GHIs share some common ground, even if the mechanisms through which each of these functions is performed are different.

PEPFAR - an initiative established in 2003 by the Bush Administration - and PEPFAR II (PEPFAR’s successor in 2009 under the Obama Administration) are bilateral agreements between the United States and a recipient of its development aid for HIV/AIDS – typically an international non-government organisation INGO or a recipient country’s government. The Global Fund, established in 2002, and the GAVI Alliance, launched in 2000, are public-private partnerships that raise and disburse funds to treat AIDS, Tuberculosis and Malaria, and for immunization and vaccines. The World Bank is an International financial institution. It is the largest funder of HIV/AIDS within the United Nations system and has a portfolio of HIV/AIDS programmes dating back to 1989. In 1999, the Bank launched the first phase of its response to HIV/AIDS in Sub-Saharan Africa – the MAP. This came to an end in 2006 when a second phase – Agenda for Action 2007-11 – came into effect

GHI Funding[edit]
Figure 1: Donor commitments to GHIs Tracking funding from GHIs is not easy. However, it is possible to determine the amounts of funding GHIs commit and disburse from sources such as the OECD CRS online database, as well as data provided by individual GHIs (Figure 1).

Since 1989, the World Bank has committed approximately US$4.2bn in loans and credits for programs, and has disbursed US$3.1bn. Of this total, the Bank's MAP has committed US$1.9bn since 2000. Through bilateral contributions to HIV/AIDS and Tuberculosis programmes and donations to the Global Fund, PEPFAR has donated approximately US$25.6bn since 2003. In July 2008, the U.S Senate re-authorised a further US$48 bn over five years for PEPFAR II, of which US$6.7bn has been requested for FY 2010. During the period 2001-2010, donors have pledged US$21.1bn to the Global Fund, of which US$15.8bn has been paid by donors to the Fund. Gavi has approved US$3.7bn for the period 2000-2015

Impact of GHIs on Country Health Systems[edit]
There is much discussion about the extent to which the volume of these additional funds creates multiple effects that impact – positively and negatively – on health outcomes for specific diseases and also on health systems themselves. Assessing the impact of GHIs on specific diseases and health systems is also notoriously difficult, not least because of the problem of attributing particular effects to individual GHIs. A common response in evaluations of GHIs, therefore, is to acknowledge the inherent limitations of establishing causal chains in what is a highly complex public health environment, and to base conclusions on adequacy statements resulting from trends that demonstrate substantial growth in process and impact indicators.

However, it is with this very approach towards evaluating Global Health Initiatives that the social determinants of a disease are simply overlooked, as implementers and evaluators are not willing to tackle the complexity of a disease within the larger social, political, cultural, and environmental system. Even if an effective evaluation of the impacts of the GHI is carried out, perhaps showing a decrease in prevalence of the disease, we can not truly understand the long-term impacts of the GIH or expect the positive results to last if we have not addressed the root social, political, or environmental causes of the disease. In this respect, GHI should be less concerned about eradicating specific diseases, instead focusing first on basic living conditions, such as sanitation and access to nutritious food, that are essential in delivering a sustainable heath program.

Research on the effects of GHIs[edit]
A small number of institutions have shaped, and continue to shape, research on GHIs. In 2003, researchers at Abt Associates devised an influential framework for understanding the system-wide effects of the Global fund which has informed much subsequent research, including their own studies of system-wide effects of the Global Fund in Benin, Ethiopia, Georgia and Malawi - often referred to as the 'SWEF' studies.

Abt continues to support ongoing research on the effects of GHIs in multiple countries. The Washington-based Center for Global Development has also been very active in its analysis of GHIs, particularly PEPFAR financing. The Center's HIV/AIDS Monitor is essential reading for researchers of GHIs. With hubs in London and Dublin, the Global Health Initiatives Network (GHIN) has been coordinating and supporting research in 22 countries on the effects of GHIs on existing health systems.

Knowledge of the effects of GHIs on specific diseases and on health systems comes from multiple sources.Longitudinal studies enable researchers to establish baseline data and then track and compare GHI effects on disease control or country health systems over time. In addition to Abt Associates' SWEF studies, additional early examples of this type of analysis were three-year, multi-country studies of the Global Fund in Mozambique, Tanzania, Uganda and Zambia. In 2009, research findings were published from tracking studies in Kyrgyzstan, Peru and Ukraine that sought to identify the health effects of the Global Fund at national and sub-national levels.

In contrast to longitudinal studies, multi-country analyses of GHIs can provide a ‘snapshot’ of GHI effects but are often constrained by “aggressive timelines”. The Maximising Positive Synergies Academic Consortium, for example, reported in 2009 on the effects of the Global Fund and PEPFAR on disease control and health systems, drawing on data from 20 countries. Most GHI evaluations – both internally and externally commissioned – rely on this type of short-term analysis and, inevitably, there is often a trade-off between depth and breadth of reporting.

Synthesis of data from multiple sources is an invaluable resource for making sense of the effects of GHIs. Early synthesis studies include a 2004 synthesis of findings on the effects of the Global Fund in four countries by researchers at the London School of Hygiene and Tropical Medicine (LSHTM), a 2005 study by McKinsey & Company and an assessment of the comparative advantages of the Global Fund and World Bank AIDS programs.

Two wide-ranging studies were published in 2009: a study of interactions between GHIs and country health systems commissioned by the World Health Organisation and a study by researchers from LSHTM and the Royal College of Surgeons in Ireland. The latter study - The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control – reviewed the literature on the effects of the Global fund, the World Bank MAP and PEPFAR on country health systems with respect to: 1) national policy; 2) coordination and planning; 3) stakeholder involvement; 4) disbursement, absorptive capacity and management; 5) monitoring & evaluation; and 6) human resources (Table 2).

Evaluations of GHIs[edit]
Each of the four GHIs summarized has been evaluated at least once since 2005 and all four produce their own annual reports.

World Bank MAP[edit]
A comprehensive study of MAP programs published in 2007 reviewed whether MAP was implemented as designed, but did not evaluate MAP or assess its impact. In addition, there have been two evaluations that provide important additional insight into the effectiveness of the Bank's HIV/AIDS programmes (though not specifically MAP focused). In 2005, the Bank conducted an internal evaluation - Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance - which found that National AIDS strategies were not always prioritised or costed.

Supervision, and monitoring and evaluation (M&E), were weak; civil society had not been engaged; political commitment and capacity had been overestimated, and mechanisms for political mobilisation were weak; and bank research and analysis, whilst perceived to be useful, was not reaching policy makers in Africa. In 2009, a hard-hitting evaluation of the Bank’s Health, Nutrition and Population support – Improving Effectiveness of Outcomes for the Poor in Health, Nutrition and Population – found that a third of the Bank’s HNP lending had not performed well, and that while the performance of the Bank’s International Finance Corporation investments had improved, accountability was weak.

Global Fund[edit]
A five-year, comprehensive evaluation of the Global Fund published a synthesis report in 2009 of findings from three Study areas. The Fund’s Technical Evaluation Research Group (TERG) Five Year Evaluation (5YE) of the Global Fund drew on data from 24 countries to evaluate the Fund’s organisational effectiveness and efficiency, partnership environment and impact on AIDS, TB and Malaria. The Evaluation highlighted the possible decline in HIV incidence rate in some countries, and rapid scale up of funding for HIV/AIDS, access and coverage, but also identified major gaps in support for national health information systems, and poor drug availability.

GAVI Alliance[edit]
In 2008, an evaluation of GAVI’s vaccine and immunization support - Evaluation of the GAVI Phase 1 performance - reported increased coverage of HepB3, Hib3 and DTP3 and increased coverage in rural areas but also a lack of cost data disaggregated by vaccine that prevented GAVI from accurately evaluating the cost effectiveness of its programs and vaccines, and an “unrealistic” reliance by GAVI on the market to reduce the cost of vaccines. The same year, a study of the financial sustainability of GAVI vaccine support - Introducing New Vaccines in the Poorest Countries: What did we learn from the GAVI Experience with - found that although GAVI funding equated to $5 per infant in developing countries per year for the period 2005-10, resource need was accelerating faster than growth in financing.

Findings from two evaluations of GAVI’s support for health systems strengthening (HSS) were published in 2009. An external evaluation by HLSP found insufficient technical support provided to countries applying for GAVI grants, an under-performing Independent Review Committee (IRC), and weaknesses in GAVI’s monitoring of grant activities. The study also found that countries were using GAVI grants for ‘downstream’ short-term HSS fixes rather than ‘upstream’ and long-term structural reform. A study by John Snow, Inc praised the multi-year, flexible and country-driven characteristics of GAVI HSS grant funding and encouraged GAVI to continue this support. But also found weak M&E of grant activity, low Civil Society involvement in the HSS proposal development process, unclear proposal writing guidelines, and over-reliance by countries on established development partners for assistance in implementing health system reform.

PEPFAR[edit]
A quantitative study by Stanford University in 2009 – The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes – calculated a 10.5% reduction in the death rate in PEPFAR’s 12 focus countries, equating to 1.2 million lives saved at a cost of $2450 per death averted. In 2007, an evaluation of PEPFAR by the Institute of Medicine found that PEPFAR had made significant progress in reaching its targets for prevention, treatment and care but also reported that budget allocations "limit the Country Teams ability to harmonize PEPFARs activities with those of the partner government and other donors", and PEPFARs ABC (Abstinence, Be faithful, and correct and consistent Condom use) priorities "fragment the natural continuum of needs and services, often in ways that do not correspond with global standards."

History of Healthcare Development in Sub-Saharan Africa
In 1987, the Bamako Initiative conference organized by the World Health Organization was held in Bamako, the capital of Mali, and helped reshape the health policy of Sub-Saharan Africa. The new strategy dramatically increased accessibility through community-based healthcare reform, resulting in more efficient and equitable provision of services. A comprehensive approach strategy was extended to all areas of health care, with subsequent improvement in the health care indicators and improvement in health care efficiency and cost. (*EXPAND*)

**include info pertaining to the Abuja Declaration, 2001**

National Healthcare Systems and Expenditures
National health systems vary between countries. In Ghana, most health care is provided by the government and largely administered by the Ministry of Health and Ghana Health Services. The healthcare system has five levels of providers: health posts which are first level primary care for rural areas, health centers and clinics, district hospitals, regional hospitals and tertiary hospitals. These programs are funded by the government of Ghana, financial credits, Internally Generated Fund (IGF), and Donors-pooled Health Fund.

Very few African countries have implemented their objective of allocating 15% of their GDP (the Abuja declaration, 2001) to the health sector. Salary and personnel expenditures take up between 60 and 70% of hospital resources for many national health systems within the region. [2] Many Sub-Saharan governments have had to implement the structural adjustment policies recommended by the World Bank and International Monetary Fund (IMF). The social and economic tasks confronting African countries are gigantic on several fronts, e.g., infrastructure, health, education, security, etc., and the resources to fund them miserably small. In 2015, the USA's GDP stood at $17.9 trillion; Nigeria's GDP in the same period was $568.51 billion.[10] In wealthy countries, health expenditure per capita is estimated at $3100 on average. In sub-Saharan Africa, average per capita expenditure is $37.[12] The government health budget of a country with a population of 10 million is equivalent to the budget of a regional health center serving 100000 people in a developed country. A large number of African countries have begun to work at setting up various types of universal medical insurance coverage, such as Senegal, Ghana, Gabon, Cote d’Ivoire, Kenya, and Benin, in an effort to reduce social inequalities.

Major Health Challenges & Infectious Diseases
In 2011, Sub-Saharan Africa was home to 69% of all people living with HIV/AIDS worldwide. In response, a number of initiatives have been launched to educate the public on HIV/AIDS. Among these are combination prevention programmes, considered to be the most effective initiative, the abstinence, be faithful, use a condom campaign, and the Desmond Tutu HIV Foundation's outreach programs. According to a 2013 special report issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the number of HIV positive people in Africa receiving anti-retroviral treatment in 2012 was over seven times the number receiving treatment in 2005, with an almost 1 million added in the last year alone. The number of AIDS-related deaths in Sub-Saharan Africa in 2011 was 33 percent less than the number in 2005. The number of new HIV infections in Sub-Saharan Africa in 2011 was 25 percent less than the number in 2001. Estimated prevalence in % of HIV among young adults (15–49) per country as of 2011.

Malaria is an endemic illness in Sub-Saharan Africa, where the majority of malaria cases and deaths worldwide occur. Routine immunization has been introduced in order to prevent measles. Onchocerciasis ("river blindness"), a common cause of blindness, is also endemic to parts of the region. More than 99% of people affected by the illness worldwide live in 31 countries therein. In response, the African Programme for Onchocerciasis Control (APOC) was launched in 1995 with the aim of controlling the disease. Maternal mortality is another challenge, with more than half of maternal deaths in the world occurring in Sub-Saharan Africa. However, there has generally been progress here as well, as a number of countries in the region have halved their levels of maternal mortality since 1990. Additionally, the African Union in July 2003 ratified the Maputo Protocol, which pledges to prohibit female genital mutilation (FGM).

In addition, international solidarity (Globalfund, Gates Foundation, etc.) and pressures from civil society have made possible a number of successes against diseases such as onchocerciasis (river blindness), polio, human immunodeficiency virus, and tuberculosis. Additionally, about 300 medical doctors trained at the School of Medicine in Dakar (Senegal) by French professionals between 1918 and 1950,[7] made a major contribution to the almost complete eradication of the epidemic and endemic diseases that took a heavy toll on West African peoples, such as trypanosomiasis (sleeping sickness), plague, yellow fever, smallpox. Today, health care services have the opportunity of benefiting from technological (e-Health) and managerial innovations.[2,3,6]

History of Health Care Development in Sub-Saharan Africa

 * In September of 1987, UNICEF and the World Health Organization (WHO) Regional Committee announced the launching of the Bamako Initiative—  chartered in response to financial issues occurring in the region during the 1980s, and with the aim of increasing access to vital medications through community involvement in revolving drug funds.
 * The meeting was attended by African Ministers of Health who advocated for improvement of healthcare access through the revitalization of primary healthcare.
 * The public health community within the region raised issues in response to the initiative, of which included: equity, access, affordability, integration issues, relative importance given to medications, management, dependency, logistics, and sustainability.
 * As a result of these critiques, the Initiative later transformed to address the increase of accessibility of health services, the enhancement of quality of health services, and the overall improvement of health system management.

Major Health Challenges

 * The Sub-Saharan African region experiences disproportionate rates of infectious and chronic diseases in comparison to other global regions. Results of Global Burden of Disease studies reveals that the age-standardized death rates of non-communicable diseases in at least four Sub-Saharan countries including South Africa, Democratic Republic of Congo, Nigeria, and Ethiopia supersede that of identified high-income countries.
 * Maternal and infant mortality
 * Studies show that about half of the world’s maternal deaths occur in Sub-Saharan Africa.
 * The Sub-Saharan African region alone accounts for about 45% of global infant and child mortalities. Studies have shown a relationship between infant survival and the education of mothers, as years of education positively correlate with infant survival rates. Geographic location is also a factor, as child mortality rates are higher in rural areas in comparison to urban regions.
 * TB
 * Tuberculosis is a leading cause of morbidity and mortality on a global scale, especially in high HIV-prevalence populations in the Sub-Saharan African region, with a high case fatality rate.
 * Diabetes
 * Type 2 diabetes persists as an epidemic in the region posing a public health and socioeconomic crisis for Sub-Saharan Africa. Scarcity of data for pathogenesis and subtypes for diabetes in Sub-Saharan African communities has led to gaps in documenting epidemiology for the disease. High rates of undiagnosed diabetes in many countries leaves individuals at a high risk of chronic health complications, thus, posing a high risk of diabetes-related morbidity and mortality in the region.
 * Improvement in statistics systems and increase in epidemiological studies with in-depth analysis of disease risk factors could improve the understanding of non-communicable diseases (i.e.: diabetes, hypertension, cancer, cardiovascular disease, obesity, etc.) in Sub-Saharan Africa as well as better inform decisions surrounding healthcare policy in the region.
 * Neglected tropical diseases such as hookworm infection encompass some of the most common health conditions which affect an estimated 500 million individuals in the Sub-Saharan African region.

National Healthcare Systems

 * A shortage of health professionals compounded by migration of health workers from Sub-Saharan Africa to other parts of the world (namely English-speaking nations such as the United States and the United Kingdom) has negatively impacted the region’s health systems.
 * More than 85% of individuals in Africa use traditional medicine as an alternative to often expensive allopathic medical health care and costly pharmaceutical products. The Organization of African Unity (OAU) Heads of State and Government declared the 2000s decade as the African Decade on African Traditional Medicine in an effort to promote The WHO African Region’s adopted resolution for institutionalizing traditional medicine in health care systems across the continent. Public policy makers in the region are challenged with consideration of the importance of traditional/indigenous health systems and whether their coexistence with the modern medical and health sub-sector would improve the equitability and accessibility of health care distribution, the health status of populations, and the social-economic development of nations within Sub-Saharan Africa.

ARTICLE 1: FINAL CONTRIBUTIONS
Section: Demographics of Africa

History of Health Care Development in Sub-Saharan Africa
In September of 1987, UNICEF and the World Health Organization (WHO) Regional Committee announced the launching of the Bamako Initiative—  chartered in response to financial issues occurring in the region during the 1980s, and with the aim of increasing access to vital medications through community involvement in revolving drug funds. The 1987 Bamako Initiative conference, organized by the WHO was held in Bamako, the capital of Mali, and helped reshape the health policy of Sub-Saharan Africa. The meeting was attended by African Ministers of Health who advocated for improvement of healthcare access through the revitalization of primary healthcare. The new strategy substantially increased accessibility through community-based healthcare reform, resulting in more efficient and equitable provision of services. The public health community within the region raised issues in response to the initiative, of which included: equity, access, affordability, integration issues, relative importance given to medications, management, dependency, logistics, and sustainability. As a result of these critiques, the Initiative later transformed to address the increase of accessibility of health services, the enhancement of quality of health services, and the overall improvement of health system management. A comprehensive approach strategy was extended to all areas of health care, with subsequent improvement in the health care indicators and improvement in health care efficiency and cost.

Major Health Challenges
The Sub-Saharan African region experiences disproportionate rates of infectious and chronic diseases in comparison to other global regions.

Non-communicable Diseases
Results of Global Burden of Disease studies reveal that the age-standardized death rates of non-communicable diseases in at least four Sub-Saharan countries including South Africa, Democratic Republic of Congo, Nigeria, and Ethiopia supersede that of identified high-income countries. Improvement in statistics systems and increase in epidemiological studies with in-depth analysis of disease risk factors could improve the understanding of non-communicable diseases (i.e.: diabetes, hypertension, cancer, cardiovascular disease, obesity, etc.) in Sub-Saharan Africa as well as better inform decisions surrounding healthcare policy in the region.

Maternal and Infant Mortality
Studies show that more than half of the world’s maternal deaths occur in Sub-Saharan Africa. However, progress has been made in this area, as maternal mortality rates have decreased for multiple countries in the region by about half since 1990. Additionally, the African Union in July 2003 ratified the Maputo Protocol, which pledges to prohibit female genital mutilation(FGM).

The Sub-Saharan African region alone accounts for about 45% of global infant and child mortalities. Studies have shown a relationship between infant survival and the education of mothers, as years of education positively correlate with infant survival rates. Geographic location is also a factor, as child mortality rates are higher in rural areas in comparison to urban regions.

HIV/AIDS
In 2011, Sub-Saharan Africa was home to 69% of all people living with HIV/AIDS worldwide. In response, a number of initiatives have been launched to educate the public on HIV/AIDS. Among these are combination prevention programmes, considered to be the most effective initiative, the abstinence, be faithful, use a condom campaign, and the Desmond Tutu HIV Foundation's outreach programs. According to a 2013 special report issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the number of HIV positive people in Africa receiving anti-retroviral treatment in 2012 was over seven times the number receiving treatment in 2005, with an almost 1 million added in the last year alone. The number of AIDS-related deaths in Sub-Saharan Africa in 2011 was 33 percent less than the number in 2005. The number of new HIV infections in Sub-Saharan Africa in 2011 was 25 percent less than the number in 2001.

Diabetes
Type 2 diabetes persists as an epidemic in the region posing a public health and socioeconomic crisis for Sub-Saharan Africa. Scarcity of data for pathogenesis and subtypes for diabetes in Sub-Saharan African communities has led to gaps in documenting epidemiology for the disease. High rates of undiagnosed diabetes in many countries leaves individuals at a high risk of chronic health complications, thus, posing a high risk of diabetes-related morbidity and mortality in the region.

Onchocerciasis
Onchocerciasis ("river blindness"), a common cause of blindness, is also endemic to parts of the region. More than 99% of people affected by the illness worldwide live in 31 countries therein. In response, the African Programme for Onchocerciasis Control (APOC) was launched in 1995 with the aim of controlling the disease.

Malaria
Malaria is an endemic illness in Sub-Saharan Africa, where the majority of malaria cases and deaths worldwide occur.

Tuberculosis
Tuberculosis is a leading cause of morbidity and mortality on a global scale, especially in high HIV-prevalence populations in the Sub-Saharan African region, with a high case fatality rate.

Neglected Tropical Diseases
Neglected tropical diseases such as hookworm infection encompass some of the most common health conditions which affect an estimated 500 million individuals in the Sub-Saharan African region.

Measles
Routine immunization has been introduced to countries within Sub-Saharan Africa in order to prevent measles outbreaks within the region.

National Healthcare Systems
National health systems vary between countries. In Ghana, most health care is provided by the government and largely administered by the Ministry of Health and Ghana Health Services. The healthcare system has five levels of providers: health posts which are first level primary care for rural areas, health centers and clinics, district hospitals, regional hospitals and tertiary hospitals. These programs are funded by the government of Ghana, financial credits, Internally Generated Fund (IGF), and Donors-pooled Health Fund.

A shortage of health professionals compounded by migration of health workers from Sub-Saharan Africa to other parts of the world (namely English-speaking nations such as the United States and the United Kingdom) has negatively impacted productivity and efficacy of the region’s health systems.

More than 85% of individuals in Africa use traditional medicine as an alternative to often expensive allopathic medical health care and costly pharmaceutical products. The Organization of African Unity (OAU) Heads of State and Government declared the 2000s decade as the African Decade on African Traditional Medicine in an effort to promote The WHO African Region’s adopted resolution for institutionalizing traditional medicine in health care systems across the continent. Public policy makers in the region are challenged with consideration of the importance of traditional/indigenous health systems and whether their coexistence with the modern medical and health sub-sector would improve the equitability and accessibility of health care distribution, the health status of populations, and the social-economic development of nations within Sub-Saharan Africa.

ARTICLE 2: FINAL CONTRIBUTIONS
A global initiative is defined as an organized effort which integrates the involvement of organizations, individuals, and stakeholders around the world to address a global issue (i.e.: climate change, human rights, etc.).

Political Economy of GHIs
The amount of political priority given to Global Health Initiatives varies between national and international governing powers. Though evidence shows that there exists an inequity between resource allocation for initiatives concerning issues such as child immunization, HIV/AIDS, and family planning in comparison to initiatives for high-burden disorders such as malnutrition and pneumonia, the source of this variance is unknown due to lack of systematic research pertaining to this subject. Global political priority is defined as the extent to which national and international political leaders address an issue of international concern through support in the forms of human capital, technology, and/or finances in order to aid efforts to resolve the problem. Global political priority is demonstrated through national and international leaders expressing sustained concern both privately and publicly, political systems and organizations enacting policies to help alleviate the issue, and national and international agencies providing resource levels that reflect the severity of the given crisis.

The amount of attention a given global initiative receives is considerably dependent on the power and authority of actors connected to the issue, the power and impact of ideas defining and describing the issue, the power of political contexts framing the environments in which the actors operate to address the issue, as well as the weight and power of issue characteristics indicating the severity of the issue (i.e.: statistical indicators, severity metrics, efficacy of proposed interventions, etc.). Factors including objective measurability, scalability of the issue and proposed interventions, ability to track and monitor progress, risk of perceived harm, as well as simplicity and affordability of proposed solutions all contribute to the degree to which a given global initiative is likely to receive political attention.

However, case studies have shown that the likelihood of global initiatives garnering public and political attention is not limited to the aforementioned factors. For example, initiatives concerning polio eradication continue to receive substantial resources in spite of the relatively small global burden of disease as compared to chronic diseases such as cancer, cardiovascular disorders, diabetes, and some communicable diseases such as pneumonia which comparatively attract fewer worldwide resources irrespective of the high morbidity and mortality rates associated with such diseases. These cases highlight the need for extensive research methods and evaluative measures to assess the relative causal weights of factors used to determine how global political priority is attributed to global health initiatives. Existing debates also attribute factors such as the increasing influences of economic globalization, international organizations, and economic actors with little to no previous health remit as each contributing to the evolution of global health governance.

Impact of GHIs on Country Health Systems
There is much discussion about the extent to which the volume of these additional funds creates multiple effects that positively and/or negatively impact both health systems and health outcomes for specific diseases. Assessing the direct impact of GHIs on specific diseases and health systems poses challenges pertaining to the issue of attributing particular effects to individual GHIs. As such, a common response in evaluations of GHIs is to acknowledge the inherent limitations of establishing causal chains in what is a highly complex public health environment, and to base conclusions on adequacy statements resulting from trends that demonstrate substantial growth in process and impact indicators.

However, existing literature argues that this approach towards evaluating GHIs can inadvertently result in overlooking the impact of social determinants on a disease, as implementers and evaluators are less likely to tackle the complexity of a disease within the larger social, political, cultural, and environmental system. Even if a GHI is effectively evaluated– perhaps showing a decrease in disease prevalence– the challenge remains of comprehensively analyzing the long-term impacts of the GHI by addressing the root social, political, or environmental causes of the disease. Accordingly, existing debates suggest that GHIs should be less concerned with the eradication of specific diseases, and should instead focus primarily on factors– such as basic living conditions, sanitation, and access to nutritious food– that are essential to delivering a sustainable heath program.

Evaluations of GHIs
In a comparison between the three largest donors in sponsoring efforts to win the fight against AIDS in Africa, a research study found that PEPFAR performs best in money transfer and data collection; the Global Fund outperforms in tailoring programmatic initiatives and sharing data; and MAP performs highest in collaborating with government systems, strengthening health systems, and helping to build the capacity of local recipients.

World Bank MAP
The primary purpose of the MAP initiative was to introduce a major upscaling of multi-sectoral approach to responding to the HIV/AIDS crisis in Sub-Saharan Africa by involving a multitude of stakeholders including community-based organizations (CBOs), non-governmental organizations (NGOs), line ministries, and state governments at the highest levels.

Global Fund
Unlike many implementing agencies, the Global Fund has no presence in the countries it supports; rather it is a financial mechanism which provides funding to countries in the form of grants through a Secretariat in Geneva on the competitive basis of country proposals. Special emphasis is placed on proposals demonstrating country ownership as well as those that meet other evidence-based, performance-based, and inclusivity-based criteria.

GAVI Alliance
Though GHIs have been instrumental in bringing national and international attention to crucial global health issues, existing debates suggest that they can also negatively impact country health systems. As such, disease-specific GHIs such as GAVI have worked to integrate health system strengthening (HSS) measures into programmatic implementation. However, the existing global debate questions the efficacy of HSS programs aimed at targeting technical solutions with clear measurable outcomes versus those more broadly focused on supporting holistic health systems.

PEPFAR
The PEPFAR program has brought about substantial impact in its recipient countries. The level of urgency and scale of initiatives led through the PEPFAR program were commensurate with that of the HIV/AIDS epidemic at the time of implementation. Existing debates suggest that the next phase of the program consider placing emphasis on the development of knowledge surrounding HIV/AIDS programming.