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						   The Swiss Centre for International Health (SCIH)
                                                  	                                                                                             69

    The Swiss Centre for International                               The client portfolio is large: Swiss government agencies




                                                                                                                                              SECTION 12
                                                                     (SDC,	 SECO	 and	 the	 Swiss	 Federal	 Office	 for	 Health),	
    Health: improving health systems                                 GTZ	(Deutsche	Gesellschaft	für	Technische	Zusammen-
    worldwide                                                        arbeit), the KfW development bank, the Financial Mecha-
                                                                     nism Office of the European Economic Area and Lux-
    The Swiss Centre for International Health (SCIH) is an           Development	are	important	clients.	Global	Initiatives	like	
    operational department of the STI.                               the	 Global	 Fund	 to	 Fight	 HIV/AIDS,	 Tuberculosis	 and	
                                                                     Malaria,	the	Drugs	for	Neglected	Diseases	initiative,	the	
    We provide services worldwide in developing health sys-          Medicines	 for	 Malaria	 Venture	 and	 other	 international	
    tems and pharmaceutical medicine. We are engaged                 agencies now constitute more than 50% of the portfolio.
    in short- and long-term projects globally, with a special
    focus on Africa, Asia, Central and Eastern Europe, and           The relationship of the SCIH with partners and clients is
    Switzerland. Since early 2008 SCIH has become a WHO              governed by a spirit of collaboration and mutual respect.
    collaborating centre for health systems development.             The projects the SCIH supports are developed in line
                                                                     with policies, guidelines and priorities of partner coun-
                                                                     tries,	 in	 keeping	 with	 the	 principles	 of	 the	 2005	 Paris	
                                                                     Declaration	of	alignment	and	coordination	for	aid	effec-
                                                                     tiveness.

                                                                     The number of SCIH support staff in Basel has been in-
                                                                     creased from three to six, and they are all familiar with
                                                                     international procurement procedures, management of
                                                                     short-term staffing and the organisation of training pro-
                                                                     grammes. The SCIH’s capacity and range of competen-
                                                                     cies is further enhanced through collaboration with other
                                                                     professionals in the STI. To cover specific and short-term
                                                                     capacity gaps, we have a wide network of external pro-
                                                                     fessional collaborators.

                                                                     The SCIH staff in Basel travel frequently on assignments,
    The focus of the SCIH on the dual streams of health sys-         and have first-hand experience of the countries with
    tems support and pharmaceutical medicine is uncom-               which they work. Furthermore, some staff members are
    mon, but has in fact led to cross-fertilisation of ideas         based	 in	 other	 countries:	 Chad,	 Burkina	 Faso,	 Djibouti,	
    and practices. Health systems support benefits from the          the	Democratic	Republic	of	the	Congo,	Niger,	Senegal,	
    rigorous standards applied by staff working in contract          Rwanda,	 Tanzania,	 Romania,	 Ukraine	 and	 Tajikistan.	 In	
    research in pharmaceutical medicine, while the pharma-           six of these countries the SCIH has created offices with
    ceutical medicine expertise is enriched by the systems
    view of the more public health orientation of the health
    systems support units of the SCIH.                                Mission statement of the SCIH

    The SCIH has a matrix structure, which centres on five            The Swiss Centre for International Health (SCIH) contributes to im-
    areas of expertise:                                               proving health systems and population access to effective health
                                                                      services and medicines worldwide. It combines scientific knowl-
                                                                      edge and practical expertise to reduce inequalities in health.
    Health systems support
    •	Health	systems	and	economics	                                   In strengthening health systems and developing vaccines and drugs
    •	Reproductive	health	and	HIV/AIDS                                for neglected diseases, our approach is to offer comprehensive,
    •	Health	technology	and	telemedicine                              interdisciplinary and multi-sectoral services, covering project and
    •	Systems	performance	monitoring	and	evaluation	                  programme identification, planning, implementation, and monitor-
                                                                      ing and evaluation. Our services are based on evidence developed
    Drug	and	vaccine	development                                      by the Swiss Tropical Institute (STI) and its wider network of col-
    •	Pharmaceutical	medicine	                                        laborators. The experiences of our collaborators feed into the teach-
                                                                      ing provided by the STI.
    For internal management purposes, each of the areas of            Our guiding principle is to work with partners to respond to local
    expertise has been translated into a management unit.             needs, thus tailoring our services to the contexts and countries we
    The five units cluster competences and further develop            work in. The SCIH combines the state-of-the-art knowledge of a
    them. To facilitate a transdisciplinary working style, each       multidisciplinary academic institution with the industry standards of
    unit also manages and contributes to the projects of the          a consulting and contract research organisation.
    other	 units,	 with	 the	 exception	 of	 the	 Pharmaceutical	
    Medicine	 unit	 (PMU),	 which,	 due	 to	 the	 nature	 of	 con-    The SCIH is a department of the STI in Basel, Switzerland, and
                                                                      works on a non-profit basis. Any benefits generated are reinvested
    tract research, independently manages the design, organ-
                                                                      in creating knowledge and providing training in the field of interna-
    isation, conduct, monitoring and auditing of clinical trials      tional health.
    according to international guidelines.
 70          The Swiss Centre for International Health (SCIH)
             an	 NGO	 status,	 which	 are	 independent	 of	 a	 specific	    papers in peer-reviewed journals. The SCIH organises an
SECTION 12


             project.                                                       annual symposium on topical international health issues.
                                                                            In 2007, the theme was the human resource crisis and
             The professional staff of the SCIH, numbering around 70        innovative ways to deal with it, and in 2008 information
             at present, have a broad background covering the follow-       and communication technology in health. Both attracted
             ing disciplines: public health, epidemiology, reproductive     a high level of international and national speakers.
             health, health economics, informational and biomedical
             technology, sociology, social geography, public adminis-       During	the	reporting	period,	the	SCIH	further	consolidat-
             tration, medical anthropology, education, financial audit-     ed its leading position as a consulting agency in interna-
             ing, social and cultural management, pharmaceutical            tional health in Switzerland and continues to expand into
             medicine and pharmacology.                                     international markets. To sustain this growth, the SCIH
                                                                            has developed a strategy up to the year 2015 that will
             The SCIH team is multicultural and multilingual. Overall,      enable it to maintain its reputation for providing services
             more than 23 nationalities are now represented among           in international health based on institutional, technical
             SCIH staff in Basel and worldwide.                             and scientific expertise. Human resource development,
                                                                            regional and decentralised collaboration are key elements
             Senior SCIH staff are also involved in teaching in various     of the strategy, as is a performing quality management
             training	programmes	at	the	STI,	the	University	of	Basel,	      system to ensure efficient processes which comply with
             and other Swiss, African and European universities. A          highest ethical standards. In addition, SCIH’s internal
             number	of	students	at	the	University	of	Basel	as	well	as	      knowledge management system will be further strength-
             students of other universities have successfully carried       ened.
             out research projects or are in the process of doing so
             with the support and supervision of collaborators of the       The following sections will present our areas of exper-
             SCIH. SCIH staff contribute actively to the international      tise in more detail, together with a sampling of our
             discussion on health development and regularly publish         projects and programmes.

             Many, but not all SCIH
             collaborators.
             (Photo	X.	Bosch-Capblanch)




             Health systems and economics
             Efficient health systems are fundamental for providing         STI health economists are actively involved in teaching
             effective, equitable and sustainable health care to popu-      and training in health economics. Apart from courses at
             lations. Furthermore, economic analysis provides an im-        the	University	of	Basel	and	the	STI,	in	2007	for	example	
             portant basis for designing, implementing and evaluating       the SCIH organised an introductory course on health
             the impact of health systems and health policies, not          economics for senior GTZ staff and collaborators of Ger-
             only on health outcomes but also on society more gener-        man consultant agencies. Health financing and aid mo-
             ally.                                                          dalities	are	addressed	within	the	context	of	PhD	super-
                                                                            vision, regular STI taught courses, SCIH projects and
             Three thematic areas are covered by the health econom-         courses outside the institute.
             ics projects of the STI: (i) sustainable health systems de-
             velopment, (ii) aid modality and (iii) economic analysis.      Health systems and health economics projects enjoy
             Cutting across these themes are pro-poor and equitable         partnerships and receive funding from a range of part-
             health policies, a focus on priority diseases and intersec-    ners	 and	 clients.	 The	 Swiss	 Agency	 for	 Development	
             toral issues in health. Focus health topics include malaria,   and	Cooperation	(SDC)	finances	implementation	projects	
             HIV/AIDS,	 vaccine-preventable	 diseases	 and	 environ-        in	the	Great	Lakes	Region	(Rwanda,	Burundi	and	South	
             mental health.                                                 Kivu in the near future) and in Tajikistan, where health
                                                                                                               	                                 71

                                                                       human resources and poor motivation of existing per-
                                                                       sonnel, lack of coordination between the activities of
                                                                       governmental and non-governmental health actors, inad-
                                                                       equate roads and transport and an overreliance of health
                                                                       facilities on the finances of the project in the absence of
                                                                       decentralised	 government	 funds.	 Demand	 from	 poten-
                                                                       tial clients is weak due to poor physical access (difficult
                                                                       terrain and long distances) and their inability to pay for
                                                                       fee-for-service health services or to afford the subscrip-
                                                                       tion for community health insurance schemes. These
                                                                       constraints notwithstanding, there is a need for contin-
                                                                       ued systemic and comprehensive support to the health
                                                                       system from the community up to the district level.

                                                                       Technical staff: M. Zahorka, T.	Vogel	(up	to	January	2008), B. Sava-
“…	first	grandmother,	who	has	a	toothache	…”.	(Photo	T.	Schuppisser)                    dogo,	J.	Schwarz
                                                                       Collaboration:	 Ministry	of	Health,	Government	of	Rwanda;	School	
                                                                                        of	Public	Health,	Butare,	Rwanda
economics and financing expertise are essential inputs                 Funding:	        SDC
for the selection and implementation of project activities.
Furthermore, health economics expertise is drawn on by
                                                                       Burundi health systems support
the	 SDC’s	 backstopping	 mandate	 with	 the	 SCIH	 (see	
above) and the long-standing expertise of the SCIH in the              Following the success of the public health project in
sector-wide approach.                                                  Rwanda	and	positive	political	developments	in	the	Great	
                                                                       Lakes	Region,	the	Swiss	government	is	preparing	long-
An important funding partner is the Bill & Melinda Gates               term development support to neighbouring Burundi. The
Foundation (BMGF), which supports the malaria-model-                   SDC’s	 current	 humanitarian	 support	 will	 gradually	 give	
ling project and the cost-effectiveness analysis of inter-             way	to	an	SDC	development	programme,	spearheaded	
mittent preventive treatment for malaria and anaemia                   by a health programme. The SCIH led a feasibility study
control	in	infants	(IPTi).                                             for	the	SDC	during	2005,	which	concluded	that	there	is	
                                                                       considerable potential for the development of systemic,
                                                                       comprehensive and decentralised support to the health
Kibuye Public Health Project, Rwanda: sustainable health
                                                                       system	 in	 Burundi.	 The	 SDC	 and	 the	 Government	 of	
systems development                                                    Burundi	 have	 subsequently	 selected	 Ngozi	 province	
Since	2002	the	STI	has	been	mandated	by	the	SDC	to	                    (which	borders	on	Rwanda	in	northern	Burundi,	popula-
implement	the	Kibuye	Public	Health	Project	in	Rwanda,	                 tion 700,000) for a project intervention. An initial project
at an annual budget of CHF 1.2 million. Kibuye province                phase	began	in	July	2006.
is	 located	 in	 western	 Rwanda,	 and	 until	 2005	 covered	
four health districts and six administrative districts                 Technical staff: M. Zahorka,	T.	Vogel	(up	to	January	2008),	J.	Cowley,	
(480,000 population). Following a local government re-                                  J.	Schwarz	
form in 2005, the project now supports two newly de-                   Collaboration: Ministry of Health, Government of Burundi
fined	districts	(Rutsiro	and	Karongi),	which	cover	a	slight-           Funding:	        SDC
ly	larger	area	and	population	(560,000	population).	During	
2006 the project underwent a 1-year “reorientation”
phase to assist with the reform process and to define a
new 3-year project phase for 2007–2009.
The aim of the project is to address priority health tar-
gets,	in	particular	the	health-related	Millennium	Develop-
ment	Goals	(MDGs),	within	an	overall	goal	of	improving	
health and reducing poverty. To achieve this aim, the
project works through the government health system
and supports the health policies of the Government of
Rwanda,	 using	 both	 technical	 and	 financial	 support.	 Fi-
nancial support is provided directly to all tiers of the
health system – district offices, community health insur-
ance schemes, 27 primary health facilities and 4 hospi-
tals. Technical support is provided both through STI staff
based	in	Rwanda	and	Basel,	and	national	experts.

Based on the experience it has gained in the years since               “…a health referral system needs transport: it must not be an air-
it started in 2002, the project recognises the challenges              conditioned,	four-wheeled	ambulance;	a	‘slightly	modified’	bike	can	
of resource-constrained settings, such as the lack of                  do	as	well	in	a	Burundi	setting”.	(Photo	J.	Cowley)
 72          The Swiss Centre for International Health (SCIH)
             Support to health reform and family medicine in Tajikistan
SECTION 12


             The	Tajik-Swiss	Health	Reform	and	Family	Medicine	Sup-
             port	 Project	 (Sino)	 supports	 and	 complements	 ongoing	
             reform initiatives in Tajikistan. In response to health re-
             form plans of the government, project Sino started in
             April	2003	with	the	support	of	the	SDC.	The	first	phase	
             of the project ended in 2006 and has been followed by a
             second phase which will come to an end in March 2009.
             Both	phases	have	a	budget	in	the	range	of	USD	4	million.

             The goal of project Sino is to improve access to basic
             health care in four pilot districts. The main components
             for achieving this goal have focused on supporting the
             development of family medicine, relating community and                    “… and then the granddaughter – both take advantage of the visit of the
             social development to primary care services and trans-                    community	nurse	at	their	home”.	(Photo	T.	Schuppisser)
             ferring and disseminating experiences to health policy
             planning and decision making. As a consequence, the                       In	2007	the	SCIH	supported	SDC	in	capitalising	its	vast	
             project has been involved in policy dialogue and imple-                   experience	in	a	comprehensive	workshop.	Proceedings	
             mentation support to health financing reforms, especially                 are available. SCIH staff have also undertaken short-term
             with regard to the introduction of allocation of funds on a               assignments for various agencies and attended interna-
             per capita basis to decentralised entities and of the basic               tional meetings on aid modality, such as the International
             benefit package at the primary care level. Gender main-                   Conference	 on	 Programme-based	 Approaches	 in	 the	
             streaming has been integral to the project concept.                       Health	Sector	in	Antananarivo/Madagascar	in	October	2007.

             The project has focused activities on both the supply and                 Technical staff: N.	Lorenz,	C.	Kessler,	H.	Prytherch,	S.	Weiss
             demand side of health services. For example, the project                  Collaboration: Ministries of Health, international partners
             has supported a range of short-term courses provided by                   Funding:	        SDC	and	STI	own	resources	
             local specialists. While the project continues to provide
             continuing medical education, including support to the
                                                                                       Health care financing
             uptake of clinical guidelines, there is a need to address
             the financial and non-financial incentives offered to fam-                In the field of health care financing, the SCIH is involved
             ily doctors and nurses.                                                   at various levels. Within the health system support
                                                                                       projects	implemented	by	the	STI,	such	as	those	in	Rwan-
             Project	 Sino	 is	 playing	 a	 key	 role	 in	 testing	 and	 imple-        da and Tajikistan, staff members have been involved in
             menting a range of health reforms in Tajikistan. The in-                  the ongoing development, implementation and evalua-
             creasing number of agencies currently working there re-                   tion of national and sub-national health sector financing
             quires coordination to improve effectiveness of inputs                    policies. For example, in Tajikistan through the project
             and avoid duplication.                                                    Sino (see above), the national basic benefit package has
                                                                                       been costed in terms of resource requirements and im-
             Technical staff: N.	Bottone	(project	manager,	Tajikistan),	X.	Bosch-      plementation.	Project	staff	have	also	contributed	to	the	
                              Capblanch,	 D.	 Burkhard	 (external),	 B.	 Clary,	 R.	   design and planned implementation of a simple resource
                              Galeazzi (external), K. Goschler, C. Kristiansson,       allocation formula from national to district level in
                              B. Matthys, F. Tediosi, K. Wyss                          Tajikistan, and in the drug revolving-fund setup in project
             Student:	        R.	Aye                                                   Sino’s	intervention	districts.	In	Rwanda,	project	staff	sup-
             Collaboration:	 Ministry	of	Health	of	the	Republic	of	Tajikistan
                                                                                       ported the implementation, monitoring and evaluation of
             Funding:		       SDC
                                                                                       the national policy on universal coverage of health insur-
                                                                                       ance.
             Aid modalities
                                                                                       Economic assessment and cost effectiveness analysis
             Since 2002 the SCIH has provided technical support on
             the sector-wide approach (SWAp), which is a form of aid                   of IPTi
             delivery that increases the coordination of development                   IPTi	 is	 designed	 to	 provide	 infants	 up	 to	 12	 months	 of	
             aid and also mandates recipient governments to take the                   age	with	antimalarial	drugs	when	receiving	EPI	(Expand-
             leadership in strategy formulation and policy implemen-                   ed	Programme	on	Immunisation)	vaccines	to	reduce	ma-
             tation. In many developing countries worldwide, the                       laria	and	anaemia	morbidity	and	mortality.	IPTi	has	already	
             SWAp in the health sector has proven important in sup-                    been shown to be a highly efficacious intervention in
             porting home-grown strategic thinking and leadership,                     separate, randomised controlled trials in Ifakara and
             reducing health service duplication, encouraging donor                    Muheza, Tanzania. In addition to evidence on efficacy
             harmonisation, and rationalising the flow and allocation                  and effectiveness, it is important to understand the cost
             of funds.                                                                 implications	of	introducing	and	delivering	IPTi	and	avert-
                                                                                       ing malaria episodes, at both the household and health
                                                                                                               	                                     73

facility	level.		The	IPTi	Consortium	was	formed	in	2003	to	              efficiency and impact on vaccination programmes. The
provide a comprehensive research and implementation                      study	compared	a	single	fully	liquid	DTP-HepB-Hib	vac-
agenda and is made up of a number of working groups.                     cine with a lyophilised vaccine with two vials requiring
The	SCIH	is	leading	the	IPTi	Cost-Effectiveness	Working	                 reconstitution. Study results indicated significant time
Group. Economic studies are being conducted alongside                    savings for vaccine preparation and total vaccine consul-
clinical and implementation trials in six sub-Saharan sites              tation for the fully liquid vaccine of 52 and 23%. Extrapo-
and	one	in	Papua	New	Guinea	and	will	provide	key	infor-                  lated to India, delivery time savings could be around
mation on the economic and financial costs and cost-                     100,000 working days per year, and savings could be up
effectiveness	of	delivering	the	IPTi	intervention.	Informa-              to	USD	50	million	per	year.
tion generated by the studies will be used at both the
national and international level to add to the evidence                  Based on these results, we developed an economic
base and help inform the debate on policy changes, pri-                  model to assess potential financial and economic impli-
ority setting, resource allocation and budgeting. The                    cations	 of	 replacing	 the	 currently	 used	 DTP-Hib	 plus	
project	 is	 linked	 to	 two	 PhD	 projects,	 one	 of	 which	 is	        HepB	vaccines	with	a	fully	liquid	DTP-HepB-Hib	vaccine	
being conducted in Tanzania (2003–2008) and is a large                   in the national immunisation programme of South Africa.
collaborative research project.                                          Results	 indicated	 that	 total	 potential	 financial	 savings	
                                                                         would	be	around	USD	2.5	million	per	year.	These	savings	
Technical staff: L. Conteh, G. Hutton, M. Tanner, F. Tediosi             hide more important economic benefits such as the re-
Students:        F. Manzi, B. Obonyo                                     duction of over 7,000 health worker working days yearly
Collaboration:	 Centre	de	Recerca	en	Salut	Internacional	de	Barce-       in a country with a critical shortage of health workers.
                 lona;	Ifakara	Health	Institute,	Tanzania;	Papua	New	
                 Guinea	Institute	of	Medical	Research;	CDC/KEMRI	        We also carried out an economic appraisal for introduc-
                 Research	Station,	Kisumu,	Kenya;	Medical	Research	
                                                                         ing	Hib	antigen	into	the	national	EPI	of	Egypt	as	the	fully	
                 Unit,	 Albert	 Schweitzer	 Hospital,	 Lambaréné,	
                 Gabon;	 National	 Institute	 for	 Medical	 Research,	
                                                                         liquid	pentavalent	DTP-HepB-Hib	vaccine.	Introduction	of	
                 Tanga, Tanzania                                         a new vaccine must be based on solid evidence of cost-
Funding:         BMGF                                                    effectiveness in a country with limited resources. Based
                                                                         on available data, we calculated the potential cost of a
                                                                         new vaccine, benefits and savings related to reduced
                                                                         burden of disease and resource implications.
Fully liquid pentavalent DTP-HepB-Hib paediatric combi-
nation vaccine: a time-motion study and economic models                  We presented the results of these studies at the Interna-
Immunisations against childhood communicable diseas-                     tional	Congress	of	Infectious	Disease,	the	World	Society	
es are among the most cost-effective public health inter-                of	Pediatric	Infectious	Disease	and	the	Egyptian	Society	
ventions and are essential to achieve the Millennium                     for	Pediatric	Allergy	and	Immunology.	
Development	 Goal	 (MDG)	 of	 reducing	 child	 mortality.	
Fully liquid combination vaccines have been developed
                                                                         Technical	staff:		C.	 Chattopadhyay,	 S.	 Chattopadhyay,	 D.	 Farouk,	
to rationalise vaccine delivery and to simplify supply and
                                                                                           R.	 Ghosh,	 M.	 Hetzel,	 Z.	 Heddaya,	 E.	 Hossny,	 R.	
administration	 of	 vaccines.	 A	 fully	 liquid	 DTP-HepB-Hib	
                                                                                           Kundu,	A.	Kumar	Mukherjee,	C.	Napierala,	F.	Tedi-
vaccine offers advantages, and including it in national                                    osi, S. Weiss, K. Wiedenmayer
immunisation programmes might prove to be an optimal                     Students:	        R.	Ayé,	R.	Merkle
use of resources.                                                        Collaboration:	 Institute	 of	 Child	 Health,	 Calcutta,	 India;	 SBDevi	
                                                                                           Charity	 Home,	 Calcutta;	 Ministry	 of	 Health	 and	
A time-motion study was conducted in Calcutta, India, to                                   Population,	 Cairo,	 Egypt;	 Ain	 Shams	 University,	
understand	implications	of	a	fully	liquid	pentavalent	DTP-                                 Cairo
HepB-Hib vaccine in terms of resource requirements,                      Funding:		        Novartis	Vaccines




Sexual and reproductive health and HIV/AIDS
Today the promotion of sexual and reproductive health                    Global	Fund	to	Fight	AIDS,	Tuberculosis	and	Malaria	and	
(SRH)	 has	 gained	 new	 momentum.	 Recognition	 of	 the	                President	Bush’s	Emergency	Programme	for	AIDS	Relief	
domain’s importance for global demographics, sustain-                    (PEPFAR).	The	US	government’s	influence	attempted	to	
able development, poverty reduction and enhanced man-                    reduce	HIV	prevention	and	the	SRH	agenda	to	a	highly	
agement of the world’s fragile environmental resources                   restricted, value-laden set of strategies. This was coun-
opens the door to an era of unprecedented opportunity.                   teracted by the progressive European position rooted in
                                                                         the	1994	International	Conference	on	Population	and	De-
This follows a period of neglect during which attention                  velopment Agenda. At the level of health systems, the
focused	primarily	on	tackling	HIV/AIDS	and	other	“major	                 limitations and distorting effects of disease-focused, ver-
killer diseases”. Global initiatives and private foundations             tical approaches became increasingly apparent. The ad-
have	 mushroomed,	 and	 a	 staggering	 increase	 in	 HIV	                dition of a new target for universal access to reproduc-
funding has been achieved – most notably thanks to the                   tive	health	by	2015	to	the	Millennium	Development	Goal	
 74          The Swiss Centre for International Health (SCIH)
             of “Improving maternal health” has given renewed prior-                  tained response, and the need to address quality aspects
SECTION 12


             ity to addressing the health services related to the health              is becoming paramount. The multisectoral nature of the
             outcomes	of	MDG	4	and	MDG	5.	                                            global	 response	 to	 HIV/AIDS	 is	 increasingly	 seeing	 re-
                                                                                      quests for technical assistance from beyond the health
             Existing evidence shows that poorer segments of soci-                    sector.
             ety have the highest unmet need for family planning. The
             area of population dynamics is currently receiving greatly               Policy	 advice	 and	 technical	 support	 provided	 by	 mem-
             increased attention, also in view of the crucial link be-                bers of the SCIH follow a rights-based approach. We re-
             tween population growth and emerging priority prob-                      spond to the increasing demand for quality services by
             lems, such as climate change and food security. The                      offering expertise in prevention campaigns and health
             challenge lies in positively repositioning family planning,              promotion, gender equity and social development. At the
             without falling back into the old population control de-                 same time we contribute within the broader context of
             bate that was associated with coercive practices back                    health sector reform, strengthening health systems and
             in the 1970s and 1980s. Health systems need to be                        efforts to improve the quality of overall service delivery
             strengthened so they can be accessed by women and                        (quality assurance and management). Capacity building
             men of all age groups for comprehensive advice and                       and efficient resource management along with auditing,
             services. An integrated continuum of reproductive care                   monitoring and evaluation are strengths of the multidis-
             covers the pre-conception phase, the course of a preg-                   ciplinary team approach within the department. Through
             nancy and delivery well into the post-natal period.                      our consultancy and advisory services at the policy
                                                                                      and implementation levels and the teaching we provide,
             The lack of progress towards a reduction in maternal                     we	 address	 all	 thematic	 fields	 of	 SRH.	 Currently,	 our	
             mortality should be addressed as an absolute priority.                   long-term projects in this area mainly cover the fields
             Effective family planning to prevent unintended pregnan-                 of	 HIV/AIDS	 (multisectoral	 response,	 mainstreaming,	
             cies, preventing and managing the consequences of un-                    youth-centred approaches, prevention and social mar-
             safe abortion, providing safe abortion where legal and                   keting, scaling up antiretroviral treatment services and
             ensuring access to emergency delivery services are key                   so on), perinatal and maternal health, health sector
             strategies with high potential for impact on maternal                    reform and strategic policy development. The following
             mortality.                                                               section presents examples of major mandates in more
                                                                                      detail.	For	the	full	list	of	projects,	see	our	website:	http://
                                                                                      www.sti.ch/en/health-systems-support.html	 under	 “ex-
                                                                                      perience” as well as the comprehensive list of long- and
                                                                                      short-term projects.

                                                                                      Romanian Swiss Neonatology project
                                                                                      The	 Swiss	 Agency	 for	 Development	 and	 Cooperation	
                                                                                      (SDC)	supported	the	Romanian	Ministry	of	Health	in	its	
                                                                                      efforts to modernise its perinatal services through the
                                                                                      Romanian	 Swiss	 Neonatology	 project	 (RoNeonat)	 from	
                                                                                      2002 to 2007. Started as a pilot project in two health re-
                                                                                      gions in 2002, the project scaled up its experience na-
                                                                                      tionwide from 2006 onwards in collaboration with the
                                                                                      National	Health	Sector	Reform	Programme	(HSRP)	fund-
                                                                                      ed	by	the	Romanian	Government	through	loans	from	the	
                                                                                      World Bank and the European Investment Bank. The main
             Creating access to factually correct and youth-friendly information on   objective is to increase access to specialised, high-quality
             sexual	and	reproductive	health.	(Photo	T.	Schuppisser)                   neonatal care within a continuum of perinatal health.

                                                                                      Objectives and project approach
             In	the	field	of	HIV/AIDS	impressive	achievements	have	
             been made over the past few years with regard to scal-                   Targeting	the	“modernisation	of	the	Romanian	neonatol-
             ing up access to antiretroviral treatment. An emphasis                   ogy system” the project strengthened the regional health
             on prevention has been re-embedded in a comprehen-                       systems approach, which regulates the level and spe-
             sive promotion of sexual and reproductive knowledge,                     cialisation of care available at each level and the referral
             rights	and	services.	Reaching	young	people	in	particular	                system between these structures. After an initial infra-
             is	critical	to	reversing	global	incidence.	Remaining	major	              structure improvement (rehabilitation of buildings, pro-
             challenges	are	the	weak	roll-out	of	Prevention	of	Mother	                curement of technical equipment) and introducing a con-
             to	 Child	 Transmission	 (PMTCT)	 services	 and	 paediatric	             tinuous training programme, the project complemented
             treatment as well as the extreme demands that weak                       the services offered (post-neonatology intensive care
             health systems face when attempting to meet treatment                    unit follow-up, neonatal transport services) and devel-
             and care needs. Strategies for health system strengthen-                 oped a comprehensive management approach based on
             ing are now seen to be pivotal in the quest for a sus-                   a quality management (QM) framework. Elements sup-
                                                                                                       	                                    75

ported were EBM (Evidence-based Medicine)-based                  The seven “centres of excellence” created during the
clinical	practice	guidelines	(CPGs),	management	of	mod-          project combining up-to-date skills with the capacity of
ern health technology, hospital budget reform and the            training centres continue their activities at university level.
introduction of QM principles with a client-centred ap-          The activities include the training packages developed
proach.	Further,	RoNeonat	conducted	annual	community	            within a continuing medical education (CME) scheme
information campaigns targeting pregnant women and               which is nationally accredited.
their families to promote healthy pregnancies and pro-
vide information about available health services.
                                                                 Complementary services developed by the project
                                                                 Services for postnatal follow-up of premature babies
Lessons learned
                                                                 have been integrated into the package paid by the
The transparent and participatory nature of all the project      National	 Health	 Insurance	 House,	 and	 hospitals	 with	
phases as well as the publicity generated during them            respective capacity can contract these. Audiometry was
clearly contributed to the project’s capacity for policy dia-    recently added to the portfolio of services, and training
logue. The dynamic of the project and its communica-             activities are ongoing. The collaboration of neonatolo-
tion of achievements using available opportunities and           gists with expert teams for the prevention and care of
channels created a “snowball effect” that increased the          neurophysiologic and cognitive impairments continues
number of participating perinatology centres and facili-         to improve.
tated incorporation of regulatory innovations [e.g. QM
and health technology management (HTM) in hospitals,             Provision	of	specially	equipped	neonatal	transport	vehi-
complementary services, quality assessment tools, and            cles, and development of specific criteria and guidelines
benchmarking in hospitals and facilities].                       reduce the risk of trauma during transport of premature
                                                                 neonates. Following the example generated by the pro-
Setting	up	a	Romanian	legal	institution	as	the	local	imple-      ject,	more	Romanian	centres	will	be	equipped	with	these	
menter	of	the	RoNeonat	project	–	the	CRED	Foundation	            ambulances. Additionally, some centres experience a
– has had a number of benefits, including local capacity         visible increase of in utero transport.
building for managing complex projects, neutrality to-
wards the partners, continuous partner contacts and              Although functioning in only a few centres due to the
familiarity	with	local	conditions.	Particularly	in	the	highly	   limited availability of bioengineers, HTM has contributed
volatile policy environment, the consistency of purpose          to better management and use of modern medical equip-
and	 the	 institutional	 memory	 provided	 by	 CRED	 are	 at	    ment. The positive example provided has encouraged
least partly responsible for the success of the project.         the	Romanian	Health	Sector	Reform	Programme	to	seek	
                                                                 larger implementation. There is considerable interest in
                                                                 regional collaboration with neighbouring countries.
Way forward
With	the	accession	of	Romania	to	the	European	Union,	            Management reform
funding from the Swiss government ceased for all such
projects at the end of 2007. Given the substantial institu-      The	project	developed	CPGs	for	neonatology	and	obstet-
tional knowledge now acquired and commanded by the               rics, which continue to be used and will further be devel-
CRED	Foundation	and	the	fact	that	the	project’s	activities	      oped. The experience stimulated the discussion about
were	always	carried	out	in	partnership	with	the	Romani-          CPG	development	in	other	medical	disciplines.	The	intro-
an Ministry of Health, the process of further modernising        duction of QM schemes in neonatology wards continues
the	Romanian	neonatology	system	continues.                       in	a	fruitful	way.	ISO	9001/2000	certification	was	award-
                                                                 ed to the Iasi neonatology department and approaches
                                                                 completion in Targu Mures (together with the obstetrics
                                                                 department). The interest in participating is high in the
                                                                 other five centres of excellence.

                                                                 Through its work on guidelines and the implementation
                                                                 of QM schemes, the project encouraged the provision
                                                                 of services at adequate levels of care. Transfer rates to
                                                                 specialised centres for neonates both in utero and after
                                                                 delivery increase continuously, thus reducing the risk of
                                                                 care at non-appropriate levels.
                                                                 Technical staff: N.	 Fota	 (project	 coordinator	 in	 Romania),	 A.	 Ne-
                                                                                  graru	(Romania),	M.	Blunier,	R.	Werlein,	J.	Schwarz,	
                                                                                  M. Zahorka
                                                                 Collaboration:		 CRED	 Foundation	 Romania;	 various	 obstetric	 and	
                                                                                  neonatal health departments at Swiss university
                                                                                  hospitals in Geneva, Basel, Bern, Zurich and
                                                                                  Lausanne;	 the	 child	 surgery	 department	 of	 the	
Cuza-Voda	neonatology	ward,	Iasi,	2005.	(Photo	N.	Fota)                           Inselspital	Bern;	Iasi	University,	Department	of	Bio-
 76          The Swiss Centre for International Health (SCIH)
                           engineering,	Romania;	various	other	organisations	   young people. Close collaboration has been established
SECTION 12


                           in Switzerland and Germany on QM in health           with	networks	of	people	living	with	HIV/AIDS.	They	are	
             Funding:		    Swiss	 Agency	 for	 Development	 and	 Cooperation	   supported in their daily life, and substantial effort is being
                           (SDC)                                                exerted to reduce stigma.
             Web:          www.sti.ch/scih-cd/roneonat
                           www.deza.admin.ch/de/Dossiers/Swiss_support_
                           to_Romania_s_health_sector_reform	
                                                                                PPSAC	 is	 implemented	 in	 close	 collaboration	 not	 only	
                           www.cred.ro                                          with the social marketing associations of Cameroon,
                                                                                Central	African	Republic	and	Chad	but	also	the	national	
                                                                                governmental	HIV/AIDS	control	programmes,	and	bi-	and	
                                                                                multilateral	agencies	such	as	the	United	Nations	Popula-
             A regional approach to HIV/AIDS prevention in
                                                                                tion	Fund	(UNFPA)	and	UNAIDS.	This	allows	good	shar-
             Central Africa                                                     ing of experience and dissemination of knowledge.
             Both social marketing of condoms and information and
             communication measures for behavioural change are                  The	 experience	 of	 PPSAC	 indicates	 that	 a	 regional	 ap-
             well-tested	 and	 effective	 strategies	 for	 reducing	 HIV/       proach	embedded	within	national	HIV/AIDS	control	strat-
             AIDS	transmission.	Typically,	related	activities	are	organ-        egies offers various opportunities, including economies
             ised at the national or subnational level and have limited         of scale in commodity procurement that can result in an
             influence over wider geographical issues.                          increase in condom sales. A regional approach to knowl-
                                                                                edge sharing also facilitates collaboration and partnership
             Since 2005 German financial cooperation through the                between	 NGOs,	 national	 HIV/AIDS	 programme	 and	 re-
             KfW development bank (KfW) has been providing sup-                 gional institutions and donors, leading to improved efficien-
             port	 for	 a	 regional	 programme	 titled	 “Programme	 Pré-        cy	and	effectiveness	of	HIV/AIDS	prevention	activities.
             vention	VIH/SIDA	en	Afrique	Central	(PPSAC)”	covering	
             Cameroon,	 the	 Central	 African	 Republic	 and	 Chad.	 It	        Technical staff: E. Gbaguidi (project coordinator in Cameroon),
             aims	 to	 ensure	 sustainable	 HIV/AIDS	 prevention	 in	 an	                        C.	 Kwagheu,	 S.	 Lindou,	 U.	 Shura	 (Cameroon),	
             area	 where	 HIV/AIDS	 prevalence	 rates	 range	 between	                           M. Blunier, K. Goschler, C. Kessler, K. Wyss
             3.3%	(Chad)	and	around	6.2%	(Central	African	Republic)	            Collaboration:		 Association	 Centrafricaine	 de	 Marketing	 Social;	
             among the general population. More specifically, activi-                            Association	 Camerounaise	 de	 Marketing	 Social;	
                                                                                                 Association	de	Marketing	Social	du	Tchad;	Organi-
             ties aim to improve coverage with quality condoms at
                                                                                                 sation	de	Coordination	de	la	Lutte	contre	les	Endé-
             subsidised prices, to increase knowledge among the                                  mies	en	Afrique	Centrale;	UNFPA;	UNAIDS
             population – with particular emphasis on groups with               Funding:         KfW Entwicklungsbank
             high-risk behaviour – as well as to reduce the stigma of
             people	living	with	or	affected	by	HIV	or	AIDS.	The	coor-
             dination of activities is assured by the SCIH and embed-
                                                                                Technical assistance to the World Food
             ded within the regional organisation for control of dis-
             ease	 (OCEAC),	 which	 is	 physically	 located	 in	 Yaoundé.	      Programme’s HIV and AIDS response
             KfW	provides	funding	of	roughly	EUR	3	million	per	year	            The	United	Nations’	World	Food	Programme	(WFP)	is	ac-
             to	 social	 marketing	 associations	 (NGOs),	 governmental	        tive in over 80 countries throughout the world. Since
             entities and other partners of the project.                        2000	WFP	has	directly	engaged	in	the	HIV	and	AIDS	re-
                                                                                sponse, and since 2003 within the framework of the
             In 2007, the national social marketing associations sold           policy	 paper	 “Programming	 in	 the	 Era	 of	 AIDS:	 WFP’s	
             1.6 condoms per inhabitant in Cameroon (around 26 mil-             Response	to	HIV/AIDS”.	WFP	has	specific	HIV	and	AIDS	
             lion	 condoms),	 1.0	 in	 the	 Central	 African	 Republic	 and	    activities in over 40 countries and undertakes advocacy
             0.3 in Chad, corresponding to 33.5 million condoms in              activities, including internal mainstreaming through its
             the whole region. These numbers reflect a substantial              HIV/AIDS	in	the	Workplace	Programme.	The	goal	of	WFP’s	
             increase in both condom utilisation rates and sales over           HIV	and	AIDS	initiatives	is	to	provide	food	and	nutritional	
             the last years. To meet the increased demand, the pro-             support to food-insecure individuals and families who are
             gramme was tasked with pooling procurement of con-                 infected	with	the	virus	and	affected	by	AIDS.	The	main	
             doms. This facilitated a drop in the unit costs of condoms         activities are provision of nutritional support to treatment
             up to 21% and allowed for harmonisation of condom                  and care programmes, support to orphans and children
             prices across the three countries, thus substantially re-          affected	by	AIDS,	school	feeding	programmes,	food	for	
             ducing cross-boarder selling, for example between Cam-             work and assets, and linking prevention education with
             eroon and Chad.                                                    relief operations activities. Establishing effective partner-
                                                                                ships and gender mainstreaming are important elements
             Regionally	harmonised	approaches	towards	information	              in	all	WFP’s	HIV	and	AIDS	activities.
             and communication measures targeting adolescents and
             other high-risk groups gained substantially in momentum            As	set	out	in	the	SDC	AIDS	Policy	2002–2007,	HIV	and	
             and led amongst other benefits to an increase in condom            AIDS	is	an	institutional	priority	of	SDC.	SDC	is	commit-
             utilisation. In addition, the programme supports the               ted to integrative and cross-sectoral responses to the
             monthly publication of a youth magazine about facts and            global epidemic in collaboration with its partner countries
             figures	concerning	HIV/AIDS.	Schools	conduct	informa-              and international organisations. In order to optimise
             tion campaigns that involve condom demonstrations for              learning about approaches to food security and nutrition-
                                                                                                                       	                                  77

                                                                               bwe, which are among the countries with the highest
                                                                               incidence	of	HIV	and	AIDS	in	the	world.	

                                                                               Outcomes of the evaluation highlighted the important
                                                                               role of food in the regional and national responses to the
                                                                               HIV	epidemic	in	southern	Africa.	There,	the	generalised	
                                                                               epidemic is driven by and in turn exacerbates a complex
                                                                               of dynamics that perpetuate food insecurity and social
                                                                               inequalities that threaten the future recovery of nations
                                                                               most heavily affected. As the highest prevalence of the
                                                                               virus is among the most productive members of society,
                                                                               food production has become inadequate, and the result-
                                                                               ing food insecurity increases negative short-term coping
                                                                               strategies that include the sale of production assets
                                                                               (such as cattle, seed and land) and high-risk transactional
                                                                               sex to meet basic food needs.

WFP	food	for	distribution	to	HIV-infected	and	AIDS-affected	people	in	rural	   On the basis of the findings on the role of food assist-
Zimbabwe,	2006.	(Photo	K.	Molesworth)                                          ance	in	the	global	response	to	HIV	and	AIDS,	SDC	made	
                                                                               the	decision	to	support	WFP	in	its	broader	and	in-depth	
al support in response to the epidemic in food-insecure                        thematic	 evaluation	 of	 HIV	 and	 AIDS	 responses	 to	 fur-
countries,	in	November	2006	SDC	supported	WFP	in	its	                          ther inform on the impact of innovative approaches to
Mid-Term	 Evaluation	 of	 the	 Southern	 Africa	 Protracted	                   nutritional	support	in	WFP	working	contexts	beyond	the	
Relief	and	Recovery	Operation	(PRRO).	SDC’s	Humani-                            Southern	Africa	PRRO.	The	SCIH	is	leading	the	Thematic	
tarian	Aid	Division	mandated	an	HIV	and	AIDS	specialist	                       Evaluation team. The evaluation is intended to inform on
from	 the	 Reproductive	 Health	 Unit	 of	 the	 SCIH/STI	 to	                  the importance and practical issues surrounding the im-
ensure that aspects of food security and nutrition relat-                      plementation	of	HIV	and	AIDS	approaches.	
ing	 to	 HIV	 and	 AIDS	 were	 addressed	 in	 the	 evaluation	
and recommendations. Fieldwork for the evaluation was                          Technical staff: K. Molesworth
conducted in Malawi, Mozambique, Lesotho and Zimba-                            Funding:		       Humanitarian	Aid	Division,	SDC




Technology for Health
The delivery of health services is increasingly driven by
technologies. The steady inflow of new methods, mate-
rials and clinical devices into health services shapes the
way	in	which	health	care	is	provided.	Unprecedented	op-
portunities arise, but health systems are also confronted
with an array of new challenges. Service quality and ef-
ficiency are directly related to the proper use and mana-
gement of technologies. Furthermore, the availability
and the maintenance of a supportive facility infrastruc-
ture must be ensured.

The ever increasing numbers of new technologies and
the lack of preparedness of decision makers to deal with
them often have serious consequences. They also make
it difficult to set priorities, to allocate resources and to
identify the most effective technologies. In low-income
countries, the use of inappropriate technologies frequent-
ly leads to a waste of resources and even a weakening of
system performance due to drainage of funds from more
essential interventions.

In international health, the acute shortage of health work-
ers is recognised as one of the main constraints to
improved health services. As evidence shows, the avai-
lability of technologies and appropriate infrastructure                        Appropriate technology enables staff to perform essential interventions.
are important factors in counterbalancing the shortage.                        (Photo	M.	Blunier)
 78          The Swiss Centre for International Health (SCIH)
             Technologies increase the effectiveness of the work-           identified to transfer knowledge and to enhance service
SECTION 12


             force and are important in motivating staff. In the past       delivery. Telemedicine and eHealth initiatives are current-
             decade, Information and Communication Technologies             ly being realised and evaluated in the health programmes
             (ICTs) have finally found their way into the health sector,    in	the	Ukraine,	Romania	and	Moldova.	
             creating virtually unlimited possibilities to support and
             develop	health	services.	Due	to	falling	costs	of	hardware,	
             mobile phone services and Internet connections, ICTs
             are now also within reach for countries with limited re-
             sources.
                                                                            Presentation of projects and initiatives
             The new opportunities come along with the increasingly
             difficult task of making the right investment decisions.
             Systematic evaluation of the effects of a new technology       Egypt: Modernising diagnostic imaging services
             on health systems performance and on benefits for the          Rapid	population	growth,	changing	disease	patterns	and	
             population is required. Methods have been developed to         rising public expectations are putting pressure on Egypt’s
             retrieve, analyse and synthesise the available evidence        public	 health	 system	 for	 reforms.	 Primary	 health	 care	
             in a way that supports decision making for investments         has been restructured in the past decade in the frame-
             and policy setting. The term “health technology assess-        work of a large health care reform programme. A severe
             ment” (HTA) has been coined for this concept.                  challenge is still posed by the substandard primary and
                                                                            secondary referral care, where the population is often
             HTA and training in technology evaluation are an integral      deprived of valuable, life-saving health services.
             part of many of the projects managed by the SCIH, such
             as	the	Perinatal	Health	Project	in	the	Ukraine,	the	hospi-     Essential diagnostic services are the backbone of hospi-
             tal-upgrading	project	in	Jordan,	the	Neonatology	Project	      tal care. Beside laboratory services, conventional radiol-
             in	Romania	and	the	Radiology	Project	in	Egypt.	                ogy is the most important essential diagnostic service.
                                                                            The problem is that radiological diagnostic services have
             There are various reasons for the increasing accumula-         been neglected throughout the country, resulting in in-
             tion of medical devices and equipment in health facilities     correct diagnoses and thus inappropriate patient therapy.
             around the globe: actual and perceived needs to perform        People	have	lost	confidence	in	government	services	and	
             medical interventions, professional ambition, commercial       have been forced to seek radiology services in private
             interest and increasing demand from the public. Techno-        centres at high prices.
             logies are undoubtedly crucial enablers for preventive
             and curative medical services, but in low-income coun-         To confront this problem, an agreement on a large-scale
             tries especially, the requirements for these new tech-         initiative has been concluded between the Egyptian
             nologies in terms of recurrent costs, infrastructure needs     Ministry	 of	 Health	 and	 Population	 and	 the	 Swiss	 State	
             and knowledge for application and maintenance have             Secretariat for Economic Affairs (SECO), through a mixed-
             been grossly underestimated. As a result, much medical         credit	financing	scheme.	The	SCIH/STI	has	been	mandat-
             equipment is defective, out of order or cannot be oper-        ed to provide managerial and technical support for the
             ated because consumable items, replacement and spare           project,	called	the	Egypt-Swiss	Radiology	Project	(ESRP).	
             parts are missing. Comprehensive technology manage-            During	its	first	phase,	2004–2006,	the	project	aimed	at	
             ment capacity is needed to counterbalance these short-         improving first-line diagnostic radiography services across
             comings and support a long-lasting benefit of the capital      Egypt in 80 hospitals by supporting the modernisation
             investment.                                                    of radiology services close to the population. The second
                                                                            phase of the project, 2007–2010, pursues the same ob-
             The development and implementation of clinical equip-          jectives with an emphasis on quality assurance as well
             ment maintenance systems, the building up of clinical          as pilot activities in providing a wider array of imaging
             engineering skills and the overall enhancement of tech-        equipment and more particularly of digital radiology equip-
             nology management capacity are essential for the per-          ment in some selected facilities
             formance of any health system. Further challenges lie in
             the rapid spread of ICTs and their innovative application      The proposed concept involves the rehabilitation of 90
             in telemedicine, e-health, knowledge management, and           existing facilities, improvement of radiation safety and
             in	teaching	and	training.	Various	UN	organisations	advo-       quality assurance at x-ray departments. More than 100
             cate the availability of ICT services to developing coun-      sites will be equipped with imaging equipment. Human
             tries in order to “bridge the digital divide”, to enable ac-   resources will still be strengthened through training pro-
             cess to knowledge and to improve the efficiency and            grammes and the implementation of a series of guide-
             quality of health services. Their slogan is: “Knowledge is     lines for conventional radiology developed during the
             the foundation upon which healthier communities are            first phase of the project.
             built”.
                                                                            Technical staff: M.	Raab,	C.	Nogier,	A.	Ragaey
             The SCIH draws on conceptual and practical implemen-           Collaboration:	 Ministry	of	Health	and	Population,	Government	of	
             tation know-how in establishing ICT solutions in health                         Egypt
             care. Across various disciplines, opportunities can be         Funding:         SECO and MoH Egypt
                                                                                                        	                                  79

Malawi: Physical Assets Management Project for public                At the level of the MoH this signifies a role change away
health services                                                      from direct technical service provision to management
                                                                     of outsourced services. For a successful change of con-
Health care delivery in Malawi is constrained by the poor            cept, new expertise for MoH staff in terms of health
condition of its health facilities. Buildings and equipment          technology policy development, contracts management,
are deteriorating rapidly, and there is a widespread short-          regulation and supervision has to be built up.
age	 of	 water	 and	 energy	 supply.	 Reasons	 for	 the	 dire	
condition of facilities and equipment are weak manage-               The SCIH in cooperation with the Malaysia-based partner
ment capacities at all levels, the shortage of skilled main-         Mediconsult has for many years supported the MoH in
tenance personnel, poorly equipped clinical engineering              improving hospital equipment maintenance and will now
workshops and inadequate budgets for assets mainte-                  concentrate on supporting the development of adequate
nance.                                                               managerial structures and implementing an effective
                                                                     monitoring and evaluation system for outsourced main-
The general neglect of maintenance can be observed                   tenance services.
everywhere in Malawi, and reveals the lack of a “mainte-
nance culture”. Maintenance is not only a technical prob-            Technical	staff:	D.	Horneber	(in	Malawi),	R.	Werlein
lem, it is much more a managerial issue, and reflects the            Collaboration:	 Malawi	district	administrations;	Malawi	MoH,	PAM	
attitude of all stakeholders within the health system.                                division
                                                                     Funding:         BMZ Germany (Federal Ministry for Economic Co-
The	 Physical	 Assets	 Management	 Project	 (PAM)	 with	                              operation	and	Development)
the support of SCIH expertise addresses not only the
organisational and policy problems at all levels, but also
                                                                     Jordan: Public Hospitals Upgrading Project
provides concrete activities to establish effective decen-
tralised maintenance services. At the district level the             Following the successful project to upgrade intensive
project has established maintenance workshops in dis-                care units, neonatal services and operation theatres, this
trict hospitals and continues to assist the maintenance              project focuses on improving central sterile supply de-
management with guidelines, adequate procedure man-                  partments	(CSSDs),	laboratory	services	and	ophthalmol-
uals and training for technical, medical and administra-             ogy.	 Though	 medical	 services	 in	 Jordan	 are	 generally	
tive staff. This approach will allow district health services        quite well developed, effective care in public hospitals is
to improve the maintenance of their health facilities and            compromised by outdated equipment. Specialised equip-
to cover the maintenance of essential clinical equipment.            ment is often not available, forcing patients to search for
                                                                     services at higher costs in private hospitals. Even though
Providing	maintenance	for	more	complex	medical	equip-                the project focuses primarily on upgrading medical equip-
ment	remains	a	challenge.	Due	to	the	severe	shortage	of	             ment, additional aspects are also considered. A complete
trained personnel and the difficulty in effectively provid-          rehabilitation	of	the	CSSDs	–	financed	by	the	Jordanian	
ing spare parts and consumables, the existing regional               authorities – and a systematic improvement of sterilisa-
maintenance workshops cannot respond to the mainte-                  tion processes will accompany the delivery and installa-
nance requirements for medium and high technologies.                 tion of modern sterilising equipment in 16 out of the 28
To counterbalance the problem, an innovative public pri-             MoH hospitals. Effective use of new laboratory and oph-
vate	 partnership	 (PPP)	 approach	 has	 been	 developed.	           thalmic equipment will be supported with intensive ex-
The approach foresees service agreements with a pri-                 pert exchange and training. The STI supports the MoH in
vate maintenance provider, formed as joint venture be-               technology planning and the selection of adequate equip-
tween local and international maintenance companies.                 ment, and organises expert exchange and training.

                                                                     Technical staff: R.	Werlein, M. Blunier
                                                                     Collaboration:	 Jordanian	 MoH,	 Directorate	 of	 Biomedical	 Engi-
                                                                                      neering	and	Jordanian	hospitals
                                                                     Funding:	        SECO	and	MoH	Jordan


                                                                     Health care waste management in northern Jordan
                                                                     Infectious health care waste (HCW) is still a source of
                                                                     health risk for patients, hospital personnel and the gen-
                                                                     eral public in many countries. This project focuses on
                                                                     improved	 management	 of	 HCW	 in	 northern	 Jordan,	 in-
                                                                     cluding the handling, storage and proper disposal of waste.
                                                                     The core of the project will be the delivery and installa-
                                                                     tion of a modern, up-to-date incinerator to replace one of
                                                                     the old and outdated incinerators presently available. In
                                                                     addition, the project will support the development of an
Clinical equipment requires attention from skilled technicians and   adequate business plan for sustainable operation of the
engineers.	(Photo	D.	Horneber)                                       incinerator in the future. General support to establish ef-
 80          The Swiss Centre for International Health (SCIH)
             fective HCW management at the health facility level –                   Liberia: essential health equipment planning for a district
SECTION 12


             including segregation, internal transport, storage and col-             hospital
             lection of waste – will complete the measures and assure
             effective handling of waste from the source in hospitals                Following the devastating effects of two civil wars, Liberia
             to the final disposal of the ashes after incineration.                  is gradually rebuilding its health care infrastructure with
                                                                                     the assistance of several international donors. Specific
             Technical staff: R.	Werlein, M. Blunier                                 planning expertise for hospitals is still very limited in Li-
             Collaboration:	 Jordanian	MoH,	Directorate	of	Environmental	Health,	    beria. Therefore, the SCIH was mandated to provide
                              Hospitals;	 Jordanian	 University	 of	 Science	 and	   technical expertise to assure professional planning for
                              Technology	(Just)                                      rehabilitation work and adequate equipment procure-
             Funding:	        SECO	and	MoH	Jordan                                    ment for the Tellewoyan county hospital in the county of
                                                                                     Lofa. Equipping the newly rehabilitated hospital requires
                                                                                     comprehensive planning in accordance with the environ-
                                                                                     ment of the facility. An important technical aspect con-
                                                                                     cerns the planning and installation of the required supply
                                                                                     infrastructure (electricity and water supply). In addition,
                                                                                     staff need to be identified and trained on the proper use
                                                                                     and maintenance of the infrastructure and the new equip-
                                                                                     ment. On the managerial side, plans need to be estab-
                                                                                     lished with the MoHSW (Ministry of Health and Social
                                                                                     Welfare) to ensure the availability of recurrent funds for
                                                                                     the long-term sustainability of the new hospital.

                                                                                     In addition to the advisory and planning services, support
                                                                                     in the procurement of medical equipment was provided
                                                                                     by SCIH experts through the elaboration of essential lists
                                                                                     of clinical equipment and of technical specifications, and
                                                                                     participation in selecting suppliers. Moreover, installation
                                                                                     of equipment was supported and training courses for
             Instructions and infrastructure for good health care waste disposal.
             (Photo	M.	Blunier)
                                                                                     equipment users were conducted before the opening of
                                                                                     the new hospital in May 2008.
             Indonesia: health technology training for community
                                                                                     In general, the MoHSW faces difficulties in procuring
             health services                                                         medical equipment due to a lack of available technical
             Poor	or	non-existing	maintenance	systems	for	buildings	                 and managerial capacity. This led to a further request to
             and medical equipment at the health centre level lead to                strengthen the procurement capacity of the MoHSW by
             poor	sustainability	of	the	investment.	Rapid	deterioration	             developing norms and standards applicable in Liberia.
             of physical assets, defective medical equipment and                     The norms reflect the various levels of health care deliv-
             health workers insufficiently trained to operate equip-                 ery (health centres, clinics and district hospitals). Techni-
             ment are among key factors that ultimately lead to the                  cal specifications were elaborated for each type of equip-
             delivery of poor-quality health services.                               ment. Standard procurement contracts were developed
                                                                                     to ensure the supply of appropriate equipment and to
             To create ownership of medical equipment and develop                    ascertain that suppliers fulfilled their obligations.
             an in-house maintenance culture within the health cen-
             tres at the provincial level, the SCIH was mandated to                  Technical	staff:	C.	Nogier,	T.	Vogel	(up	to	January	2008),	N.	Lorenz,
             elaborate a maintenance strategy directed to health cen-                                 external consultant
             tre staff. A concept for a comprehensive training pro-                  Collaboration:	 MoH,	Republic	of	Liberia
             gramme comprising the proper application of equipment                   Funding:	        SDC	humanitarian	aid	programme
             and the regular conduct of preventive maintenance ac-
             tivities was developed. A training course for 15 district
                                                                                     Moldova: modernising health technology management
             trainers from the MoH was conducted in two provinces
             with the objective to further replicate the training for the            Moldova has been facing rapid changes in its economic,
             staff of more than 100 health centres. The initiative on                political and social environment since its independence.
             the improved and sustainable use of clinical devices is                 Health sector reform programmes are ongoing, and the
             part of a community health services programme financed                  MoH in particular is undertaking efforts to modernise its
             by the European Commission and implemented by Sani-                     health facilities. Hospitals and clinics have received large
             plan-Eductrade.                                                         amounts of medical equipment through donations and
                                                                                     loan programmes. Equipment from the Soviet era is also
             Technical staff: C.	Nogier                                              still in operation. Meanwhile it has become obvious that
             Collaboration:	 MoH,	 Government	 of	 Indonesia;	 Saniplan-Educ-        modern medical equipment requires attention from pro-
                              trade                                                  fessional engineering staff within an effectively managed
             Funding:         European Commission                                    maintenance system.
                                                                                                         	                                  81

To make investments in physical assets long-lasting and
safe requires developing a sound system for health tech-
nology management. In the frame of the Moldavian-Swiss
perinatology project, the SCIH had been mandated to
contribute to building a comprehensive health technolo-
gy management system that includes the development
of relevant policies, the introduction of computerised in-
ventory systems, a needs-based procurement strategy
and medical engineering services.

Technical staff: M. Blunier, C. Nogier, M. Zahorka
Collaboration: MoH, Republic of Moldova
Funding:         SDC


Ukraine: telemedicine and eLearning initiatives
In the frame of the Ukraine-Swiss Perinatology Programme,
one component is developing models for the application
of ICTs that support health systems development. Creat-
ing a technical and personal network enabling health
professionals to communicate and exchange experience
and expertise via a telemedicine platform contributes to
continuing medical education and improves professional            Ukraine – eLearning CD promoting good clinical practice for the “Normal
skills. A CD-based eLearning tool has been developed to           Delivery	Process”.	(Graphic	V.	Krasnov)
reach health professionals working in the periphery and
to stimulate their continuing medical education in addi-
tion to the official classroom-based centralised continu-
ing medical education programs.                                   experts from the institute addressed the following topics
                                                                  in the thematic field of ICT and health:
Technical staff: M. Blunier, J. Pelikan
Collaboration: MoH, Ukraine; National Medical Academy for Post-   •	Telemedicine	and	eHealth
                 graduate Education                               •	Health	management	information	systems
Funding:         SDC                                              •	Knowledge	management	and	eLearning

                                                                  At the STI, various projects and initiatives develop, im-
11th STI Symposium: the role of ICT in supporting health
                                                                  plement and evaluate applications in these fields. The
systems development                                               symposium was also an opportunity to present achieve-
This international event had the participation of WHO’s           ments and to discuss the potential of ICTs to improve
coordinator for eHealth and aimed at providing a platform         health systems.
for the exchange of experiences and lessons learned
in terms of ICT applications in health systems. Invited           Summaries and presentations given at the 11th STI Sym-
speakers from the North and the South, from multilateral          posium are available at:
and bilateral agencies, from large and small NGOs, and            http://www.sti.ch/en/about-us/sti-symposium.html



Systems Performance and Monitoring
Introduction
                                                                  nor funds to improve the health of the world’s poor,
Policy makers in the North and the South confront many            thereby assembling the technical and financial efforts of
challenges in their efforts to improve health systems.            a variety of stakeholders. Consequently, performance
Performance monitoring and auditing helps to oversee              monitoring is seen as a key aspect of GHIs. One main
the functioning of health systems, programmes and part-           line of activity within the SCIH precisely addresses the
nerships, with a primary goal of increasing their quality,        methodological and practical aspects related to measur-
effectiveness and accountability. This approach focuses           ing and monitoring health systems and programme per-
on the production process, scrutinising not only results          formance, thereby working closely together with the
(i.e. checking the consistency of inputs, processes, out-         health systems and intervention group located within
puts,	 outcomes	 and	 impact)	 but	 also	 the	 way	 planned	      GWE.
activities have been carried out.
                                                                  Collaborations cover a wide range of actors and include
In	 recent	 years	 Global	 Health	 Initiatives	 (GHIs)	 have	     the Global Fund to Fight HIV/AIDS, Tuberculosis and
emerged as important mechanisms for channelling do-               Malaria, the Financial Mechanism Office of the European
 82          The Swiss Centre for International Health (SCIH)
             Economic	Area	(EEA	FMO),	the	GAVI	Alliance	(GAVI),	the	           its mandate to follow up 29 Global Fund-supported
SECTION 12


             Global	Drug	Facility	of	the	Stop	TB	partnership	(GDF)	and	        programmes in 12 countries. The financial volume of
             the	 Presidential	 Malaria	 Initiative	 (PMI)	 funded	 by	 the	   these	5-year	programmes	ranges	from	EUR	3	million	up	
             Government	of	the	United	States.	Just	as	important	are	           to	EUR	50	million.	Progress	reports	were	reviewed	by	a	
             the institutions which benefit from these initiatives, such       team consisting of finance professionals and program-
             as	national	HIV/AIDS,	malaria	or	tuberculosis	control	pro-        matic experts and included spot-checks of the financial
             grammes.                                                          and programmatic documentation at the level of the prin-
                                                                               cipal recipient and subrecipients of funds. Quarterly
             It is readily acknowledged that the way health systems            financial controls included an analysis of transactions on
             are governed and organised, and how they collect infor-           bank statements, book entries of actual expenditures, as
             mation and manage resources and transform them into               well as follow-up of accounts receivable and accounts
             services for the population, greatly determines health            payable. Expenditures were verified on a spot-check
             outcomes. While many indications support clinical deci-           basis with a particular focus on significant amounts, con-
             sion making, the body of evidence related to policy op-           spicuous book entries and posting texts. In so doing, the
             tions for health systems organisation and management              SCIH follows the principles of performance-based fund-
             is much weaker. Hence, the SCIH aims at capitalising              ing in making financing decisions such as outlined by
             and disseminating relevant experience on performance              Global Fund principles. The aim is to ensure that invest-
             improvements of health systems and programmes. This               ments are made only where grant funding is managed
             is done through regular policy briefs, articles in peer-          and spent effectively on programmes that have an
             reviewed international journals as well as teaching, and          impact	in	the	fight	against	HIV/AIDS,	malaria	and	tuber-
             addressing all thematic fields of performance monitoring          culosis.
             and issues related to GHIs.
                                                                               The SCIH has also conducted around 30 on-site data
             The SCIH’s contribution to optimising health service de-          verifications using the standard tools available from the
             livery and priority interventions is based on a broad range       Global Fund with a view to assessing data quality and
             of skills and competencies and requires teamwork across           reliability. The field visits lasted around 3–4 days and
             various domains, including public health, monitoring and          were conducted by the national evaluation expert some-
             evaluation (M&E), and financial controlling and resource          times in combination with an international programmatic
             management, such as drug supply and human resources.              expert. The SCIH has further gained know-how on how
                                                                               best to feed back observations emerging from the on-
                                                                               site data verification so that they can effectively be taken
             Local Fund Agent for the Global Fund
                                                                               up by programme implementers and contribute to im-
             Since 2004, the SCIH has gradually increased its man-             proving the M&E system of a given programme.
             date as Local Fund Agent (LFA) for the Global Fund to
             Fight	AIDS,	Tuberculosis	and	Malaria.	Starting	with	one	          Technical	staff:	S.	Ablefoni,	I.E.	Awale,	H.	Blowers,	H.P.	Bollinger,	
             country, by 2008 it was acting as LFA for 12 countries in                          I.S. Bouh, M. Braun (up to April 2007), B. Clary,
             various regions of the world (Burkina Faso, Chad, Costa                            J.	Correa,	D.D.	Moto,	C.	Kristiansson,	K.	Goschler,	
             Rica,	 Djibouti,	 Equatorial	 Guinea,	 Maldives,	 Nicaragua,	                      D.	 Guinot,	 N.	 Lorenz,	 K.	 Martin	 (up	 to	 December	
             Niger,	 São	 Tomé	 and	 Príncipe,	 Senegal,	 Syria,	 and	 the	                     2007),	 A.K.	 Nassirou,	 A.	 Perera,	 A.	 Sanchez,	 Y.	
                                                                                                Sanchez, K. Wiedenmayer, K. Wyss
             West Bank and Gaza).
                                                                               Collaboration:	 Principal	 recipients,	 national	 control	 programmes	
                                                                                                and Country Coordination Mechanisms in 12 coun-
             According to its mandate, the role of the SCIH is to as-                           tries, secretariat of the Global Fund
             sess principal recipients’ capacity to implement grants,          Funding:		       Global	Fund	to	Fight	AIDS,	Tuberculosis	and	Malaria
             and to review proposed budgets and work plans, and the
             performance framework. So far the SCIH has established
                                                                               Appraisal and monitoring of health sector projects in the
             more than 30 initial assessments of principal recipients
             such as national disease control programmes, interna-             European Union
             tional	 non-governmental	 organisations	 (NGOs)	 and	 the	        By signing the EEA Enlargement Agreement, the EEA
             United	Nations	Development	Programme	with	regard	to	              EFTA	 States	 –	 Iceland,	 Liechtenstein	 and	 Norway	 –	
             institutional and organisational capacities, financial man-       agreed to continue their efforts to enhance cohesion
             agement systems, procurement and supply manage-                   within	the	EEA	and	to	focus	their	efforts	on	the	new	EU	
             ment,	 and	 (M&E).	 Programme-related	 documents	 lead-           accession	countries	(Bulgaria,	Cyprus,	the	Czech	Repub-
             ing to the grant signature were reviewed and assessed             lic,	 Estonia,	 Hungary,	 Latvia,	 Lithuania,	 Malta,	 Poland,	
             by the respective experts. The SCIH also assisted the             Romania,	 Slovakia	 and	 Slovenia).	 More	 than	 EUR	 1.14	
             monitoring and evaluation assessment required for grant           billion is available in the period 2005–2009 for selected
             signature between the Global Fund and principal recipi-           priority	areas	in	the	new	EU	member	states	as	well	as	
             ent and has actively participated through the SCIH                Greece,	 Portugal	 and	 Spain,	 comprising	 among	 others,	
             experts in several national M&E self-assessments.                 academic research, cultural heritage, human resources,
                                                                               sustainable development, and health and child care.
             In recent years the SCIH has gained substantial experi-
             ence in reviewing and verifying progress reports, dis-            The SCIH has been appointed as appraisal and monitor-
             bursement requests and external audit reports through             ing agent in charge of reviewing proposals submitted to
                                                                                                                	                                  83

                                                                            ing	amount	of	EUR	114	million	in	the	field	of	health	and	
                                                                            child care [prevention and promotion (e.g. drug abuse,
                                                                            obesity), country-relevant selected communicable (e.g.
                                                                            HIV/AIDS,	 TB)	 and	 non-communicable	 diseases	 (e.g.	
                                                                            cancer, respiratory diseases), and related infrastructure
                                                                            development (e.g. modernisation of equipment, facilities
                                                                            and buildings).

                                                                            To manage the appraisal and monitoring assignments ef-
                                                                            ficiently, the SCIH has been working with a network of
                                                                            STI and international experts based in the beneficiary
                                                                            countries with oversight by the SCIH in Basel. A detailed
                                                                            review of project documentation combined with site vis-
                                                                            its allows the SCIH to give the FMO qualitative recom-
                                                                            mendations on the project proposals.

                                                                            Technical	staff:	 V.	Kurkiewicz,	C.	Napierala,	S.	Oumov	(external),	
                                                                                              S.	Rosenthaler,	S.	Weiss,	K. Wyss
                                                                            Collaboration:		 Financial	Mechanism	Office,	Applicants	from	EU	
                                                                                              countries
                                                                            Funding	Agency:	 FMO	of	Norway,	Iceland	and	Lichtenstein	of	the	
                                                                                              EEA


                                                                            Data quality: measuring, explaining and improving data
                                                                            inaccuracy
                                                                            In the recent past, international health problems, espe-
                                                                            cially those affecting low- and middle-income countries
                                                                            (LMICs), have increasingly gained a relevant place in the
                                                                            international health arena. GHIs have been created under
Pulmonary	disease	department	in	a	Polish	hospital.	(Photo	S.	Weiss)         the assumption that strong partnerships between do-
                                                                            nors, governments, researchers, policy makers and in-
the EEA FMO. The focus of the work is on verifying, ex-                     dustry could tackle these issues globally and more effi-
amining and assessing the proposals and related infor-                      ciently.
mation (technical and financial concepts, methods and
risks) provided by applicants and on monitoring individual                  GHIs often take an approach similar to the classic vertical
projects during the implementation phase to verify over-                    disease control programmes by tackling specific diseas-
all project development according to the grant agree-                       es. More recently, though, GHIs have realised that pro-
ment and respective payment claims.                                         grammes cannot operate in the context of weak systems
                                                                            and have incorporated in their support strategies for
Since 2006, the SCIH has appraised more than 170 indi-                      health system strengthening, including health informa-
vidual projects (see table below) with an applied-for-fund-                 tion systems (HISs). Furthermore, GHIs adopt perform-



 Appraisal and monitoring mandate in the EU
 Beneficiary country                   Priority area                                                       No. of assignments
 Bulgaria	                             Health	and	Child	Care	                                              •	 1	baseline	study
 Czech	Republic	                       Health	and	Child	Care,	Cultural	Heritage,	Environment	              •	 25	individual	project	appraisals
 	                                     	                                                                   •	 4	monitoring	assignments
 	                                     	                                                                   •	 1	baseline	study
 Estonia	                              Health	and	Child	Care	                                              •	 7	individual	project	appraisals
 Latvia	                               Health	and	Child	Care,	Cultural	Heritage,	Environment	              •	 10	individual	project	appraisals
 	                                     	                                                                   •	 1	monitoring	assignment
 Lithuania	                            Health	and	Child	Care,	Cultural	Heritage,	Environment	              •	 21	individual	project	appraisals
 Hungary	                              Health	and	Child	Care	                                              •	 11	individual	project	appraisals
 Poland	                               Health	and	Child	Care,	Cultural	Heritage,	Environment	              •	 74	individual	project	appraisals
 	                                     	                                                                   •	 4	monitoring	assignments
 	                                     	                                                                   •	 1	baseline	study
 Portugal	                             Health	and	Child	Care	and	Sustainable	Development	                  •	 4	individual	project	appraisals
 Romania	                              Health	and	Child	Care	                                              •	 1	baseline	study
 Slovakia	                             Health	and	Child	Care	                                              •	 1	individual	project	appraisal
 Slovenia	                             Health	and	Child	Care,	Cultural	Heritage,	Environment	              •	 11	individual	project	appraisals
 84          The Swiss Centre for International Health (SCIH)
             ance-based funding mechanisms by which some of the                             Explaining data inaccuracy
SECTION 12


             funding provided is contingent on achieving programme
             objectives. Hence, more than ever, there is a need to                          Although	DQAs	provide	an	objective	measure	of	data	ac-
             monitor progress and to evaluate the impact of pro-                            curacy and help to highlight flaws in the information sys-
             grammes and interventions. In addition, and especially,                        tem,	 they	 cannot	 explain	 inaccuracies.	 GAVI	 and	 other	
             results must be timely and accurately monitored, since                         immunisation stakeholders are often dealing with differ-
             they are meant to inform decision making and, ultimate-                        ent immunisation coverage figures for the same country
             ly, may have financial consequences.                                           and time period, depending on the data source and
                                                                                            method of estimating coverage (e.g. administrative re-
             At the same time, there is growing evidence and con-                           porting,	 surveys,	 and	 country	 and	 WHO/UNICEF	 esti-
             cern about the quality of data generated within the health                     mates). Which data source to believe?
             system.	Routine,	administrative	information	systems	in	
             LMICs are often regarded as incomplete and inaccurate.                         To	answer	this	question,	GAVI	awarded	the	SCIH	a	study	
             Yet they are the backbone of the decision-making proc-                         to evaluate methods of estimating immunisation cover-
             esses at the subnational and national level and are meant                      age. This study had four components: (i) statistical analy-
             to provide information to monitor health- and poverty-                         ses of secondary immunisation data to check for discrep-
             related interventions.                                                         ancies;	 (ii)	 a	 literature	 review	 of	 documents	 reporting	
                                                                                            immunisation	 coverage	 figures	 and	 methods;	 (iii)	 inter-
                                                                                            views	 with	 producers	 and	 users	 of	 immunisation	 data;	
                                                                                            and (iv) country studies to document best recording and
                                                                                            reporting practices. The statistical components showed
                                                                                            to which extent administrative data overestimate survey
                                                                                            data, and in what coverage ranges. The overestimation
                                                                                            was partially reflected in the literature, where often cov-
                                                                                            erage was reported without sufficiently detailing the
                                                                                            methods used to estimate it. Finally, country studies
                                                                                            highlighted key elements in the production of accurate
                                                                                            information, such as clear procedures and guidelines,
                                                                                            feedback to data producers and effective use of informa-
                                                                                            tion for decision making. The final main outcome of this
                                                                                            study provided a base for reaching consensus on which
                                                                                            data and methods should be taken into account based on
             Verification	factor	(accuracy)	of	national	immunisation	coverage	figures	in	   the intended use of immunisation coverage data.
             46	Data	Quality	Audits	(DQAs).	(Source:	Adapted	from	X.	Bosch-Capblanch,	
             Report	on	the	GAVI	DQAs	conducted	in	41	countries	between	2002	and	
             2005, WHO, 2006).                                                              Improving data inaccuracy
                                                                                            Finally, once data inaccuracies have been described and
                                                                                            the reasons for them documented, the main question
                                                                                            still remains unanswered: How can data quality be im-
             Measuring data inaccuracy
                                                                                            proved? The SCIH is investigating ways of addressing
             In	 the	 year	 2000,	 the	 GAVI	 Alliance	 launched	 the	 Data	                this question by undertaking a Cochrane systematic
             Quality	Audits	(DQAs),	a	WHO-validated,	standard	meth-                         review of the literature on the effects of interventions
             od of comparing health unit records of immunisation ad-                        aimed at improving the quality of routine, administrative
             ministered against reports that aggregate immunisation                         HISs.
             data	 at	 the	 district	 and	 national	 level.	 The	 Verification	
             Factor	(VF),	the	percentage	rate	between	immunisations	                        Technical staff: X.	 Bosch-Capblanch,	 M.	 Braun	 (DQA,	 until	 March	
             recorded and reported, is used to assess the quality of                                         2007),	 D.	 Guinot,	 B.	 Matthys,	 A.	 Nassirou	 (DQA),	
             countries’	data	(ideally,	the	VF	should	be	equal	to	100%);	                                     S. Weiss
             however,	DQAs	conducted	so	far	in	around	50	countries	                         Collaboration: Liverpool Associates in Tropical Health (Liverpool,
             show that only a few countries reached 100% accuracy,                                           UK);	 Liverpool	 School	 of	 Tropical	 Medicine;	 Euro-
                                                                                                             Health	Group	(Copenhagen,	Denmark)
             and	half	of	them	are	below	80%,	a	threshold	set	by	GAVI	
                                                                                            Funding:		       The	GAVI	Alliance;	Global	Fund	to	Fight	HIV/AIDS,	
             for approving additional funding. The SCIH has imple-
                                                                                                             Tuberculosis and Malaria
             mented	 DQAs	 in	 Chad,	 Côte	 d’Ivoire	 and	 Madagascar,	
             with two more coming up in Angola and Mozambique. In
             2007, the SCIH played a key role in assisting the Global
                                                                                            Improving malaria diagnostics
             Fund	 in	 developing	 and	 piloting	 DQAs	 (similar	 to	 the	
             approach	for	GAVI	DQAs)	in	Madagascar	to	assess	the	                           Prompt	and	accurate	diagnosis	is	essential	for	effective	
             accuracy of social marketing programme indicators. The                         case management of malaria patients. Clinical diagnosis
             piloting contributed significantly to fine tuning some                         based on symptoms is widespread in large parts of Africa
             aspects of the approach. The SCIH is and has also been                         due to poor equipment, and budgetary, human resources
             under contract with the Global Fund to implement                               and training constraints. But because malaria symptoms
             DQAs.                                                                          are often unspecific, diagnoses are unreliable. In addi-
                                                                                                           	                                   85

                                                                       of	 the	 overall	 programme	 is	 USD	 20	 million	 (STI:	
                                                                       USD	680,000)	for	a	project	duration	of	5	years	between	
                                                                       November	 2007	 and	 2012.	 The	 SCIH	 is	 one	 of	 four	
                                                                       project	partners	in	the	IMaD	consortium,	which	is	led	by	
                                                                       Medical	 Care	 Development	 International	 (MCDI).	 The	
                                                                       main activity areas of the SCIH are procurement and
                                                                       M&E.

                                                                       Core	 activities	 of	 IMaD	 included	 designing	 a	 laboratory	
                                                                       assessment tool for appraisals at health facilities, with
                                                                       laboratory and pre-assessment checklists for country-
                                                                       specific health system-related information. Curricula and
                                                                       supplementary materials were developed for training
                                                                       clinicians and laboratory supervisors in laboratory man-
                                                                       agement, on-site teaching and in particular ensuring that
                                                                       malaria microscopy and quality assurance meet WHO
Classroom in a college for medical laboratory technician training in   guidelines. Checklists were adapted for supervisory staff
Monrovia,	Liberia.	(Photo	B.	Matthys)                                  for mentoring and monitoring visits. A programme matrix
                                                                       and	indicators	applicable	to	all	PMI	countries	were	elabo-
                                                                       rated.
tion, misdiagnosis and inappropriate treatment may ex-
pose patients to the risk of potentially unidentified other            A comprehensive baseline laboratory survey of 40 health
dangerous conditions and increase the danger of drug                   facilities with laboratories was carried out in Ghana. The
resistance. Finally, the launch of new and costly artemisi-            NMCPs	 of	 Ethiopia,	 Ghana	 and	 Mali	 were	 assisted	 in	
nin-based malaria medicines onto the market has made                   drafting a national malaria diagnostic policy including
treatment more expensive. Both microscopy and rapid                    training, supervision, quality assurance and control, pro-
diagnostic	 tests	 (RDTs)	 represent	 efficient	 and	 safe	            curement	assistance	and	monitoring	of	indicators.	Rapid	
means of diagnosing malaria that are adapted to various                laboratory assessments to determine laboratory capacity
levels of health care services.                                        were carried out in 8–10 health facilities at different
                                                                       health care levels in urban and rural locations in Angola,
The	Improving	Malaria	Diagnostics	(IMaD)	project	is	part	              Ethiopia, Liberia, Madagascar and Zambia. A protocol for
of a GHI that aims to develop sustainable systems for                  RDT	 evaluation	 of	 the	 performance	 of	 health	 workers	
diagnosis and subsequent treatment of the disease, in                  was drafted for Madagascar. Agreements were made in
keeping	 with	 Millenium	 Development	 Goals	 4	 and	 6	               Angola	and	Benin	with	PMI	partners	to	handle	procure-
(reduce child and maternal mortality and combat malaria).              ment needs.
Special emphasis is placed on improving microscopy-
based	malaria	diagnosis	and	appropriate	use	of	RDTs,	as-
                                                                       Technical staff (STI): B. Clary, B. Matthys
suring the quality of laboratories and supporting malaria
                                                                       Collaboration:		       National	 Malaria	 Control	 Programmes	 of	
diagnostics policy development. Based on the 2008 Ma-                                         15	PMI	countries,	MCDI;	African	Medical	and	
laria	 Operational	 Plans	 (MOPs)	 set	 forth	 by	 the	 PMI,	                                 Research	Foundation;	Hydas	World	Health
IMaD	 collaborates	 closely	 with	 the	 National	 Malaria	             Funding:		             PMI,	a	collaborative	US	government	effort	led	
Control	 Programmes	 (NMCPs)	 of	 15	 African	 countries	                                     by	the	US	Agency	for	International	Develop-
(Angola, Benin, Ethiopia, Ghana, Kenya, Liberia, Mada-                                        ment	 in	 conjunction	 with	 the	 Department	
gascar,	 Malawi,	 Mali,	 Mozambique,	 Rwanda,	 Senegal,	                                      of Health and Human Services (Centers for
Tanzania,	 Uganda	 and	 Zambia).	 The	 financial	 volume	                                     Disease	Control	and	Prevention)	and	others




Pharmaceutical Medicine
                                                                       of the burden of tropical diseases has increased, and ef-
Overview
                                                                       forts have been undertaken to find innovative ways to
Pharmaceutical	medicine	is	a	medical	scientific	discipline	            develop new and safe drugs and vaccines for the most
concerned with the discovery, development, registra-                   vulnerable and resource-poor populations. In this area
tion, monitoring and medical aspects of marketing of                   private	sector	investments	in	R&D	are	not	triggered	by	
medicines for the benefit of patients and the public                   commercial incentives. Instead, a system that shares
health. The landscape of neglected disease research and                not only the risk but also the cost of this highly expensive
development	 (R&D)	 has	 significantly	 changed	 over	 the	            undertaking has recently been invented and is now
past 5 years. On the one hand, international standards                 known	 as	 the	 public	 private	 partnership	 (PPP).	 PPPs	
for the conduct of clinical research were advanced from                mostly function like virtual pharmaceutical companies.
guidelines	to	laws;	on	the	other	hand,	global	awareness	               Today, over 90 such organisations are operational. The
 86          The Swiss Centre for International Health (SCIH)
             funding is mainly provided by key philanthropic organisa-          als. Consequently, a strong presence of technical advi-
SECTION 12


             tions, often with support by governments or (in-kind)              sors, supervisors and specialised monitors familiar with
             contributions by corporate companies.                              the disease, the local situation and the language, and
                                                                                intensive external support in site management must be
             However, the pharmaceutical industry has also renewed              guaranteed.	Very	often,	such	an	endeavour	is	only	pos-
             its interest and engagement in tropical diseases, and              sible through a joint venture of the implementing organi-
             several industry-sponsored research institutions were              sation with the responsible national or district authori-
             founded in the past few years. In addition, over the past          ties.
             2 decades, numerous research centres have been devel-
             oped in sub-Saharan Africa where high-quality clinical re-         Within	 the	 STI	 since	 the	 year	 2000	 the	 Pharmaceutical	
             search is now being conducted. Many of the centres are             Medicine	Unit	(PMU)	has	been	responsible	for	conduct-
             linked to patient cohorts or even demographic surveil-             ing clinical trials with a regulatory background. It offers
             lance systems. Such a setting makes it possible to con-            services in coordinating and administrating, and in assist-
             duct epidemiological studies and to create good baseline           ing	in	the	design,	organisation,	conduct	and/or	monitor-
             data. It also accelerates trial preparation and increases          ing of projects in this field in accordance with the relevant
             follow-up participation. However, there is a substantial           guidelines. The focus is drug product and vaccine devel-
             regional imbalance as the majority of the centres are              opment in scientific fields or geographic regions where
             located in South and East Africa and a few in West Africa.         such services are not offered by competitors on a regular
             Most of these centres are involved in studies and trials           basis or where a specialised background is required to
             on	HIV/AIDS,	malaria	and	tuberculosis,	rarely	on	chronic	          adapt projects to particular situations. Where necessary,
             diseases and almost never on neglected diseases. Teams             the	core	team	of	the	PMU	is	reinforced	by	experts	from	
             working in rural areas face challenges that do not exist in        the STI or external specialists. The experts may take a
             other settings. These challenges include a lack of well-           leading role in the trial, such as principal investigator or
             educated health personnel, high staff turnover, poor in-           medical director, or may provide support in special fields,
             frastructure, lack of standard operating procedures and            for example statistics, diagnostics or pathogen charac-
             difficult accessibility. Often the situation is complicated        terisation.
             by instability and political conflict. Importantly, traditional
             beliefs and stigma strongly influence the behaviour of             The	headcount	of	the	PMU	increased	at	a	lower	pace	in	
             the population and staff, and may also affect research             the reporting period than during the 2 years before, but
             activities. For the conduct of clinical trials in such situa-      we were able to significantly consolidate our activities.
             tions, centre assessment and site selection are of para-           One factor for this was the successful expansion from
             mount importance.                                                  our traditional focus on human African sleeping sickness
                                                                                into the field of malaria, which now constitutes more
             Still, very often capacity and infrastructure must be con-         than half of our portfolio. Another major step was to
             tinually built up and strengthened. Educating physicians           add dedicated quality assurance staff to the team. This
             in taking patient anamnesis, proper recording of data, es-         allowed us to improve the quality of services provided to
             tablishing appropriate laboratories with energy supply,            clients, to refine internal documentation and also to
             laboratory staff training, communication tools and an ap-          streamline our processes.
             propriate filing system may all be necessary to facilitate
             clinical trials that conform to the minimal requirements           In the past 2 years, our largest single project remained
             of	good	clinical	practice	(GCP).	To	control	certain	diseas-        our participation in the development programme of
             es, for example human African trypanosomiasis (HAT)                pafuramidine	maleate	(DB289)	against	first	stage	sleep-
             and onchocerciasis, specialised mobile teams visiting              ing	 sickness.	 Unfortunately,	 this	 promising	 effort	 was	
             the population at risk are necessary, and they must be             halted in March 2008 following a report of toxicity. How-
             integrated in the work flow of the respective clinical tri-        ever, we continue to be involved with HAT through the
                                                                                Drugs	for	Neglected	Diseases	initiative	(DNDi)-sponsored
                                                                                Phase	 II/III	 NECT	 (nifurtimox-eflornithine	 combination	
                                                                                therapy)	 (for	 details	 on	 both	 DB289	 and	 NECT,	 see	 be-
                                                                                low).

                                                                                In addition to providing services, we also continued our
                                                                                own research on sleeping sickness. Enrolment of pa-
                                                                                tients	into	two	Phase	II	trials	(proof-of-concept	and	drug	
                                                                                utilisation) assessing the short course for treatment of
                                                                                late-stage sleeping sickness with melarsoprol was re-
                                                                                cently	 successfully	 completed	 in	 Uganda	 and	 Tanzania.	
                                                                                In	addition,	two	MPharm	theses	yielded	very	interesting	
                                                                                results concerning the expectations of the local popula-
                                                                                tion on the nature of future sleeping sickness treatment
                                                                                and the risk of sleeping sickness treatment in pregnancy.
             DB289	Phase	IIIb	trial:	investigators	meeting	in	Kinshasa,	DRC.	   These results will be valuable in planning of future deve-
             (Photo	S.	Bernhard)                                                lopment programmes and clinical trials on HAT.
                                                                                                                 	                                   87

                                                                          field of tuberculosis and at least one more neglected dis-
                                                                          ease is envisaged. This development goes hand in hand
                                                                          with the increase in activities at the institutional level.

                                                                          PMAL03: Phase Ib trial on a potential
                                                                          malaria vaccine
                                                                          Pevion	 Biotech	 and	 the	 Molecular	 Immunology	 unit	 of	
                                                                          the STI have jointly developed a virosome-based malaria
                                                                          vaccine candidate comprising a reconstituted empty in-
                                                                          fluenza virus envelope presenting Plasmodium falciparum-
                                                                          derived synthetic peptides on its outer surface.
Announcement	of	inauguration	of	ARCEAU-RDC.	(Photo	C.	Schmid)
                                                                          Facing the demanding task of developing a malaria vac-
Our involvement in malaria projects has grown steadily.                   cine and encouraged by promising data from pre-clinical
The	starting	point	was	the	RBx11160	programme	for	a	                      profiling,	the	PMU	coordinated	a	Phase	Ia	safety	trial	at	
new antimalarial drug sponsored by the Medicines for                      the	University	Hospital	in	Basel	in	2004.	This	trial	aimed	
Malaria	 Venture	 (MMV)	 and	 the	 Indian	 drug	 company	                 at evaluating the malaria vaccine candidate to produce
Ranbaxy	Laboratories.	In	2006	the	PMU	was	contracted	                     an appropriate immune response and to determine its
to contribute to the study management and assure mon-                     safety and tolerability in healthy adult volunteers without
itoring	 for	 a	 Phase	 II	 dose-ranging,	 safety	 and	 efficacy	         pre-exposure to malaria.
trial to identify the best dose for future investigations
in	 India,	 Thailand,	 Tanzania	 and	 Zanzibar	 on	 RBx11160.	            Promising	results	led	to	a	second	clinical	trial	in	the	main	
After reviewing the preliminary data and owing to other                   target population: children living in African countries
portfolio	priorities,	MMV	decided	to	halt	funding	of	the	                 where	the	disease	is	highly	prevalent.	This	Phase	Ib	trial	
RBx11160	 project,	 which	 was	 later	 continued	 by	 Ran-                deploys a lyophilised form of the malaria vaccine candi-
baxy but without participation of the STI. Since then, the                date.	 Coordinated	 by	 the	 PMU,	 the	 trial	 was	 started	 in	
PMU	 has	 undertaken	 monitoring	 services	 for	 several	                 January	2008	at	the	Ifakara	Health	Institute,	Bagamoyo	
other	MMV-sponsored	Phase	III	trials	in	the	development	                  Branch, Tanzania. Ten adults and 40 children were en-
programme for the fixed-dose formulation of oral pyro-                    rolled	in	the	joint	“PMAL03”	project	and	already	received	
naridine	artesunate,	and	for	a	Phase	II	trial	on	intravenous	             the	second	of	two	vaccine	doses	in	June	2008.	The	trial	
artesunate in children with severe malaria co-sponsored                   aims to better understand the humoral and cellular im-
by	the	MMV	and	EDCTP.	In	addition,	we	resumed	activity	                   mune response as well as to investigate the vaccine’s
related to a virosome-formulated antimalarial vaccine.                    safety within the malaria-exposed target population. Fol-
Currently,	 a	 Phase	 Ib	 trial	 assessing	 two	 mimotopes	 is	           low-up of patients is expected to last until mid-2009.
ongoing at the Ifakara Health Institute, Bagamoyo Branch,
                                                                          Scientists:        T. Aebi (Ifakara Health Institute, Bagamoyo
in	 Tanzania.	 The	 PMU	 is	 the	 main	 coordinator	 of	 the	
                                                                                             Branch),	C.	Burri,	P.	Cech,	C.	Daubenberger	(MPI),	
PMAL03	trial	and	provides	monitoring.	The	clinical	spon-                                     H. Garden,	B.	Genton	(GWE),	B.	Ley,	G.	Pluschke	
sor	is	Pevion	Biotech,	and	the	largest	share	of	the	fund-                                    (MPI),	M.	Tanner	
ing is provided by the STI.                                               Support staff:     F. Morier
                                                                          Students:          –
The increased capacity and stability of the unit allowed                                     I
                                                                          Network	partners:	 	fakara	 Health	 Institute,	 Bagamoyo	 Branch,	
us to intensify our efforts in capacity-strengthening                                        Tanzania
projects.	The	partnership	with	the	DNDi in the capacity-                  Funding:	      	   STI;	Pevion	Biotech
building platform for clinical trials in HAT continued, and
a series of special trainings was organised. In 2007 we
also received funding from the Bill & Melinda Gates
Foundation (BMGF) to create a centre for clinical research
in	 Kinshasa	 (Democratic	 Republic	 of	 the	 Congo,	 DRC).	
After a long and complicated preparation period, we were
proud to inaugurate the tripartite Alliance for Clinical
Research	 and	 Clinical	 Epidemiology	 (ARCEAU-RDC)	 to-
gether with the new partner organisations, the School of
Public	Health,	Kinshasa,	and	the	Biamba	Marie	Mutombo	
Hospital.	In	the	framework	of	the	clinical	trials	in	the	DRC	
and the new alliance, the STI office in Kinshasa contin-
ues to provide very valuable services.

The newest strategic development in the services of-
fered	 by	 the	 PMU	 is	 clinical	 trial	 and	 site	 audits.	 A	 first	
series of audits was conducted in 2008 through a con-                     Ifakara Health Institute, Bagamoyo Branch: signature of informed consent
tract	with	the	MMV.	In	the	near	future,	expansion	into	the	               for	PMAL03	trial.	(Photo	H.	Garden)
 88          The Swiss Centre for International Health (SCIH)
             Intravenous artesunate in children with                                 NECT: nifurtimox-eflornithine combination trial
SECTION 12


             severe malaria                                                          for HAT
             Children in sub-Saharan Africa typically have not devel-                The currently available medicines for late-stage human
             oped adequate immunity against malaria. Consequently,                   HAT are very toxic, difficult to administer under field con-
             there is a high prevalence of severe malaria cases in this              ditions and show decreasing efficacy against the para-
             vulnerable patient group with consequences such as                      sites. Because there will be no alternative solutions in
             neurological disorders, organ failure and even death if                 the short- and mid-term, clinical studies are under way to
             not treated. To date, most patients with severe malaria                 explore therapeutic combinations of existing drugs. Of
             are treated intravenously with quinine, which is known                  the possible combinations, nifurtimox-eflornithine has
             to have significant adverse effects and a delicate applica-             shown the least treatment-associated toxicity and mor-
             tion procedure. Artesunate is an active, water-soluble                  tality, and adequate efficacy.

                                                                                     On	behalf	of	the	DNDi,	the	PMU	is	contributing	to	a	Phase	
                                                                                     II/III	multicentre,	randomised,	open-label,	clinical	non-infe-
                                                                                     riority study comparing the therapeutic efficacy and clini-
                                                                                     cal safety of an abridged regimen of iv eflornithine plus
                                                                                     oral nifurtimox to the standard iv eflornithine regimen. If
                                                                                     therapeutic non-inferiority can be shown, the combination
                                                                                     regimen will become an alternative therapy with simpler
                                                                                     administration, shorter hospitalisation, lower cost and pro-
                                                                                     tection against the emergence of resistance.

                                                                                     DNDi sponsored the study and Epicentre was responsi-
                                                                                     ble for the protocol, data management and overall medi-
                                                                                     cal	 coordination;	 Médecins	 sans	 Frontières	 (MSF),	 the	
                                                                                     PMU	 and	 the	 national	 sleeping	 sickness	 control	 pro-
                                                                                     grammes managed, implemented and monitored the
                                                                                     study	in	selected	HAT	treatment	centres	in	the	Republic	
             Severe malaria patient at Queen Elizabeth Central Hospital, Blantyre,
                                                                                     of	the	Congo	(RoC)	(Nkayi)	and	the	DRC	(Isangi,	Dipumba	
             Malawi.	(Photo	H.	Garden)                                               and	Katanda).	In	collaboration	with	the	DRC	HAT	control	
                                                                                     programme	 (PNLTHA),	 two	 study	 sites,	 Dipumba	 and	
             derivative of artemisinin, which has been part of tradi-                Katanda in Kasaï Oriental province, were set up by the
             tional Chinese herbal medicine for centuries and was                    PMU.	Both	sites	were	substantially	refurbished	by	DNDi,
             first isolated in 1972. Intravenous (iv) artesunate is now              and	PMU	installed	trial-related	equipment	and	provided	
             recommended by the World Health Organization (WHO)                      relevant training and support. Logistic support was pro-
             for the treatment of severe malaria in adults in low ma-                vided	by	the	STI	and	DNDi local offices in Kinshasa, and
             laria transmission areas. However, there is little infor-               the	different	subsections	of	MSF	in	the	DRC.
             mation on its efficacy in children in high-transmission
             regions, such as Africa.                                                Enrolment in the nifurtimox-eflornithine combination
                                                                                     therapy	(NECT)	trial	was	successfully	concluded	by	late	
             Under	the	direction	of	the	Eberhard	Karls	University	Tü-                2006. A total of 287 patients were enrolled, and post-
             bingen,	a	multi-country	Phase	II	clinical	trial	with	200	chil-          treatment	follow-up	was	concluded	by	mid-2008.	Patient	
             dren was initiated to simplify the dosing regimen of iv                 and	staff	compliance	was	excellent;	moreover,	the	com-
             artesunate, to evaluate its pharmacokinetic profile and to
             gain experience for its use in African paediatric patients.
             The	trial	is	funded	by	the	EDCTP	(European	and	Develop-
             ing	 Countries	 Clinical	 Trials	 Partnership)	 and	 MMV.	 The	
             PMU	was	approached	by	MMV	to	coordinate	and	moni-
             tor the trial in Gabon (Albert Schweitzer Hospital, Lam-
             baréné;	Université	de	Médecine	et	Science	de	la	Santé,	
             Libreville) and in Malawi (Queen Elizabeth Central Hospi-
             tal, Blantyre).
             Scientists:	   	   P.	Cech,	E.	Huber,	H. Garden, B. Ley
             Support staff:     F. Morier
             Students:          –
                                E
             Network	partners:	 	 berhard	 Karls	 University	 Tübingen;	 MMV;	
                                Albert	Schweitzer	Hospital,	Lambaréné,	Gabon;	
                                Université	de	Médecine	et	Science	de	la	Santé,	
                                Libreville,	Gabon;	Queen	Elizabeth	Central	Hos-
                                pital, Blantyre, Malawi                              NECT	team	at	the	end	of	patient	enrolment	in	Katanda,	DRC,	December	
             Funding:	      	   EDCTP;	MMV                                           2006.	(Photo	A.	Ngo-On)
                                                                                                                	                                     89

                                                                       conduct	the	clinical	trials	needed	to	register	DB289	for	
                                                                       first	stage	sleeping	sickness	with	the	FDA.	To	complete	
                                                                       the	development	programme,	the	CPDD	received	a	sec-
                                                                       ond	grant	from	the	BMGF	in	2006,	and	the	PMU	became	
                                                                       a full member of the consortium.

                                                                       The	Phase	II	trials	were	mostly	carried	out	in	the	DRC,	
                                                                       but	 also	 in	 Angola.	 The	 protocol	 for	 a	 pivotal	 Phase	 III	
                                                                       confirmatory trial was developed in close collaboration
                                                                       with	the	FDA.	This	study	was	initiated	in	summer	2005	
                                                                       in	four	centres	in	the	DRC,	and	one	centre	each	in	An-
                                                                       gola and South Sudan, and was scheduled to continue
                                                                       through mid-2009. 273 patients including pregnant and
                                                                       lactating women as well as adolescents were randomised
Community	information	procedure	for	NECT	in	Kakenge,	DRC,	February	    in	an	open-label	design	to	treatment	with	DB289	or	the	
2008.	(Photo	C.	Schmid)                                                comparator drug pentamidine. All patients completed
                                                                       the	assigned	drug	regimen	–	DB289	100	mg	twice	daily	
bination regimen is favoured as it is simpler to apply and             by	the	oral	route	for	10	days	or	pentamidine	4	mg/kg	in-
hospitalisation	 time	 is	 much	 reduced.	 Positive	 prelimi-          tramuscularly for 7 days – by March 2007 and are being
nary results were recently published, and the final results            followed up for 24 months to identify possible relapses.
and study report will be available by the second half of
2008.                                                                  An	analysis	by	the	Data	Safety	Monitoring	Board	(DSMB)	
                                                                       in August 2007, after half of the recruited subjects had
Currently,	DNDi is committed to apply for the addition of              undergone a 12-month follow-up examination, recom-
nifurtimox to the Essential Medicines List (EML) of WHO                mended that the study continue as planned. Approval
for HAT to be used in association with eflornithine, which             was	also	given	for	a	large-scale,	multinational	Phase	IIIb	
should	 enable	 WHO/NTD	 to	 recommend	 the	 combi-                    drug	utilisation	study	to	address	the	application	of	DB289	
nation treatment to the countries. Our contribution to the             under African field conditions during the registration
trial will continue throughout the reporting and appli-                process.
cation	process	Phases.	Beyond	this,	with	DNDi we are
planning a pragmatic trial to further document and                     Preparations	 for	 the	 Phase	 IIIb	 study	 began	 in	 January	
strengthen the evidence base for the combination regi-                 2007.	Sites	were	assessed	in	the	DRC	and	RoC,	an	in-
men in real-life field conditions. At the same time, a trial           vestigators’ meeting was held in Kinshasa in April 2007,
of the combination regimen for children is being planned               and a local Congolese training team was identified and
by	PMU	on	behalf	of	DNDi.                                              trained (including an intensive workshop in Basel). The
                                                                       sites comprised reference hospitals, specialised sleep-
Scientists:	    	 	 .	Bernhard,	C.	Burri,	D.	Kalemwa,	A.	Kuemmerle,	
                  S                                                    ing sickness centres, as well as very rural and simple
                  G.	Pohlig,	C. Schmid                                 health centres, and health posts. Eventually, it was de-
Support	staff:	 	 J.B.	Inyamwenyi,	M.	Vogel                            cided to implement the study first in 20 centres in the
Students:         –                                                    DRC.	 Material	 and	 equipment	 selected	 locally	 was	 or-
                  D
Collaboration:	 	 	 NDi	Kinshasa,	DRC;	Epicentre,	Paris;	MSF	Bel-      dered	and	shipped	by	mid-December	2007.	Parts	of	the	
                  gium,	 Kinshasa,	 DRC;	 Programme	 Nationale	 de	
                                                                       STI office in Kinshasa were reorganised to serve as a
                  Lutte contre la Trypanosomiase Humaine Afri-
                                                                       local logistics centre with a specially outfitted storage
                  caine	(PNLTHA),	Kinshasa,	DRC;	CARITAS	Mbuji	
                  Mayi,	DRC
                                                                       room.
Funding:	       	 DNDi


DB289: a novel, orally applicable drug for treatment of
first stage sleeping sickness
Only a very limited number of drugs are available to treat
human African trypanosomiasis, and none can be deliv-
ered	 orally.	 The	 international	 Consortium	 for	 Parasitic	
Drug	Development	(CPDD)	led	by	the	University	of	North	
Carolina, Chapel Hill, received funding by the BMGF to
discover and bring selected molecules to registration.
DB289	(pafuramidine	maleate),	an	orally	active	pro-drug	
with considerable trypanocidal activity and low toxicity,
was chosen for further development in the year 2000.
The	compound	underwent	extensive	preclinical,	Phase	I	
(healthy	 volunteers)	 and	 Phase	 II	 testing	 (proof	 of	 con-
cept	in	patients).	In	2001	the	PMU	was	subcontracted	by	               The	training	team	for	the	DB289	Phase	IIIb	trial	during	a	preparatory	visit	
the	US	company	Immtech	Pharmaceuticals	to	plan	and	                    to	Basel.	(Photo	D.	Kalemwa)
 90          The Swiss Centre for International Health (SCIH)
             At	the	end	of	December	2007,	however,	the	DB289	de-                                             al,	Cologne,	Germany;	PNLTHA,	Kinshasa,	DRC;	
SECTION 12


             velopment programme was placed on “clinical hold” by                                            Vanga	Missionary	Hospital,	DRC
             the	 FDA	 when	 liver	 toxicity	 was	 observed	 after	 treat-              Funding:	        	   	 niversity	 of	 North	 Carolina	 through	 a	 grant	
                                                                                                             U
             ment	in	a	healthy	volunteer	Phase	I	study	conducted	in	                                         from the BMGF
             South Africa. This study was designed to provide sup-
             portive	 safety	 data	 for	 the	 registration	 of	 DB289	 for	
             sleeping sickness and Pneumocystis carinii.	The	 Phase	
             III sleeping sickness trial data was unblinded at that time
             and reviewed by study sponsors and advisors. Liver tox-
             icity	was	significantly	less	for	the	DB289	group	than	the	
             pentamidine group.

             In February 2008, five subjects in the healthy volunteer
             study developed renal insufficiency approximately 8 weeks
             post-treatment	 that	 required	 medical	 intervention.	 Re-
             view	 of	 the	 Phase	 III	 sleeping	 sickness	 data	 revealed	
             three	 subjects	 who	 had	 developed	 glomerulonephritis/
             nephropathy	post-DB289	treatment.	Two	of	these	events	
             may	now	be	considered	possibly	related	to	DB289.	No	                       Validation	of	the	new	Reflotron	photometers	in	Vanga.	(Photo	G.	Pohlig)




                                                                                        ARCEAU-RDC: Alliance for Clinical Research and
                                                                                        Clinical Epidemiology in the DRC
                                                                                        Development	 of	 drugs	 against	 most	 tropical	 diseases	
                                                                                        was long neglected, but has recently gained significant
                                                                                        momentum. Assessment of new drugs and vaccines is
                                                                                        a very complex enterprise. Increased capacity is needed
                                                                                        in disease endemic countries, and a number of clinical
                                                                                        research excellence centres have been established in
                                                                                        Africa. However, so far none exists in Central Africa, par-
                                                                                        ticularly	in	the	DRC.	

                                                                                        The STI has longstanding expertise in international part-
             Crossing	the	Wamba	River,	DRC,	during	a	site	assessment	mission	for	the	
                                                                                        nership at many levels from basic research to health sys-
             DB289	Phase	IIIb	trial.	(Photo	E.	Huber)
                                                                                        tems	 support.	 In	 the	 DRC,	 the	 STI	 has	 been	 active	 in	
                                                                                        clinical trials in HAT for the past 8 years. The STI received
             patient in the pentamidine group was reported to have                      funding from the BMGF to help create a clinical research
             renal disease. The clinical development programme for
             DB289	was	discontinued	at	this	time,	completely	halting	
             all	preparatory	activities	for	the	planned	Phase	IIIb	trial	in	
             the	DRC.
             The	 Data	 and	 Safety	 Monitoring	 Board	 expressed	 its	
             concern about the lack of post-treatment biochemistry
             data	of	the	participants	of	the	Phase	III	study.	The	2-year	
             follow-up	of	the	Phase	III	sleeping	sickness	study	is	con-
             tinuing, and the primary efficacy endpoint, i.e. the 12-month
             follow-up examination of the study participants, was
             reached in March 2008. About 40% of the study patients
             were still due for at least one follow-up at the beginning
             of April 2008, and so far the attendance had been very
             good. Hence, a safety follow-up was implemented in
             selected	centres	by	the	PMU	in	April	2008.
             Scientists:	    	  	 .	Bernhard,	C.	Burri,	R.	Buxtorf,	P.	Cech,	E.	Hu-
                                S
                                ber,	D.	Kalemwa,	G.	Pohlig
             Support	staff:	 	  J.B.	Inyamwenyi,	M.	Vogel
             Students:          –
                                C
             Network	partners:	 	 PDD;	University	of	North	Carolina,	Chapel	Hill,	
                                USA;	 Instituto	 de	 Combate	 e	 de	 Controlo	 das	
                                Tripanossomíases,	 Luanda,	 Angola;	 Immtech	
                                Pharmaceuticals,	 Vernon	 Hills,	 USA;	 Kikongo	
                                Missionary	Hospital,	DRC;	Malteser	Internation-         School	of	Public	Health	(ESP),	Kinshasa.	(Photo	C.	Lengeler)
                                                                                                                       	                                                   91




                                                                 Publications
                                                                 Bernhard SC,	 Nerima	 B,	 Mäser	 P	 &	 Brun R (2007) Melarsoprol- and pentamidine-resistant
                                                                 Trypanosoma brucei rhodesiense populations and their cross-resistance. Int J Parasitol 37,
                                                                 1443 –1448.

                                                                 Blunier M,	Zahorulko	T,	Dobryanskyy	D	&	Brauchli	K	(2006)	Information	computer	technologies	
                                                                 for	distant	medical	collaboration	in	the	Ukraine	Swiss.	Ukraine J Telemed Med Telematics 4,
Biamba	Marie	Mutombo	Hospital,	Kinshasa.	(Photo	C.	Burri)        21– 29.

                                                                 Eperon G, Schmid C, Chappuis F & Loutan, L (2007) Clinical presentation and treatment out-
                                                                 come of sleeping sickness in Sudanese pre-school children. Acta Tropica, 101: 31– 39.
centre in Kinshasa. A tripartite agreement was signed on
                                                                 Gehler Mariacher G,	Mtasiwa	D,	Wiedenmayer K,	Bruppacher	R,	Tanner M & Hersberger KE
21	April	2008	between	the	School	of	Public	Health,	Kin-          (2007)	Optimizing	in-kind	drug	donations	for	Tanzania-a	case	study.	Int	J	Health	Plann	Manage,	
shasa	 (ESP	 Kin),	 the	 Biamba	 Marie	 Mutombo	 Hospital	       dx.doi.org/10.1002/hpm.901.
(BMMH), Kinshasa, and the STI under the name “Alliance           Gehler Mariacher G,	Mtasiwa	D,	Wiedenmayer K,	Bruppacher	R,	Tanner M, Hersberger KE
for	 Clinical	 Research	 and	 Clinical	 Epidemiology	 in	 the	   (2007) In-kind drug donations for Tanzania stakeholders view’s – a questionnaire survey. World
                                                                 Health	and	Population.	http://www.longwoods.com/product.php?productid=18771&cat=469
DRC”	(ARCEAU-RDC).	
                                                                 Koivusola M, Wyss K,	 Santana	 P	 (2007)	 Effects	 of	 decentralisation	 and	 recentralization	 on	
                                                                 equity	 dimension	 of	 health	 systems.	 In:	 Decentralisation	 in	 Health	 Care	 (Eds.	 Saltman	 R,	
Once established the partner institutions are expected to        Bankauskaite	V,	Vrangbaek	K.).	European	Observatory	on	Health	Systems	and	Policies	&	Open	
                                                                 University	Press,	New	York.
contribute to the development of new drugs and vac-
cines through participation in clinical trials and research      Kurowksi C, Wyss K, Abdullah S & Mills A (2007). Scaling up priority health interventions in
                                                                 Tanzania – the human resources challenge. Health Policy and Planning 22: 113 –127.
in	the	area	of	clinical	epidemiology.	Whereas	the	ESP	Kin	
                                                                 Lorenz N, Wyss K (2007) Global Fund: harmonisation and good governance vital. The Lancet,
will	mainly	focus	on	malaria,	tuberculosis	and	HIV/AIDS,	        Volume	370,	Issue	9593,	Pages	1127–1127.
the BMMH will concentrate research on chronic diseas-            Lorenz N	 (2007)	 Effectiveness	 of	 Global	 Health	 Partnerships:	 Will	 the	 past	 repeat	 itself?	
es such as hypertension, diabetes and cancer. To secure          Bulletin of the World Health Organization,	Volume	85,	Number	7,	July	2007,	501– 568.
continuous research on sleeping sickness, a link will be         Prytherch H & Kessler Bodiang C (2007) Challenges and opportunities around positive moth-
made to the national sleeping sickness control pro-              erhood – Closing the gap in a globalised world. Bull Medicus Mundi 105, 6 –11.

gramme.                                                          Prytherch H,	Massawe	S,	Kuelker	R,	Hunger	C,	Mtatifikolo	F,	&	Jahn	A	(2007)	The	unmet	need	
                                                                 for	emergency	obstetric	care	in	Tanga	Region,	Tanzania.	BMC Pregnancy Childbirth 7.

                                                                 Prytherch H & Merkle R	(2007)	Initiatives	addressing	human	resource	for	health	in	the	United	
The main activities during the grant period will include         Republic	of	Tanzania	–	complexity	can’t	be	allowed	to	stand	in	the	way	of	action.	Bull Medicus
staff training, laboratory and facility improvement, and         Mundi 104, 16 –18.
establishment of quality assurance systems.                      Tediosi F, Aye R, Ibodova S, Thompson R & Wyss K (2008) Access to medicines and out of
                                                                 pocket payments for primary care: evidence from family medicine users in rural Tajikistan.
                                                                 BMC Health Services Research	 8:109	 [available	 at	 http://www.biomedcentral.com/1472-
Scientists:        C. Burri,	C.	Schmid,	D.	Kalemwa               6963/8/109].
Support	staff:	 	  J.B.	Inyamwenyi,	M.	Vogel                     Thierfelder	C,	Makowiecka	K,	Vinichenko	T,	Ayé R,	Edwards	P	&	Wyss K (2008) Management
Students:          –                                             of	 Pulmonary	 Tuberculosis	 in	 Tajikistan:	 Which	 factors	 determine	 hospitalisation?	 Tropical
Network	partners:	 School	of	Public	Health,	Kinshasa;	BMMH       Medicine and International Health, in press.
Funding:           BMGF                                          Wiedenmayer K (2007) The pharmacist – a neglected workforce? Bull Medicus Mundi 104,
                                                                 67–71.

                                                                 Wyss K & Prytherch H (2007) Shortage of health staff – what is being done? The contribution
                                                                 of	the	German	Development	Cooperation	to	solving	the	Human	Resources	for	Health	Crisis	in	
                                                                 developing	countries.	Bulletin	Medicus	Mundi	Schweiz	104:	1	Available	from	http://www.medi-
                                                                 cusmundi.ch/mms/services/bulletin/bulletin104_2007.

                                                                 Wyss K & Prytherch H	(2007)	The	contribution	of	the	German	Development	Cooperation	to	
                                                                 solving the human resources for health crisis in developing countries Shortage of health staff
                                                                 – what is being done? Bull Medicus Mundi 104, 30 – 36.

                                                                 Wyss K	 (2006)	 Santé	 et	 vulnérabilité	 des	 groupes	 pauvres	 en	 milieu	 urbain	 de	 l’Afrique	 de	
                                                                 l’Ouest.	Etudes	de	cas	en	Côte	d’Ivoire,	Mauritanie	et	au	Tchad.	VertigO	Hors	Série	3	[available	
                                                                 at:	http://www.vertigo.uqam.ca].

                                                                 Wyss K	(2007)	Introduction	–	Human	Resources	for	Health	–	Beyond	the	Declarations.	Bulletin	
                                                                 Medicus	 Mundi	 Schweiz	 104:	 1	 Available	 from	 http://www.medicusmundi.ch/mms/services/
                                                                 bulletin/bulletin104_2007.

                                                                 Wyss K, Schwarz J, Prytherch H,	Bovier	P,	Hersperger	M	&	Zahorka M (2008) Gestion de la
                                                                 qualité	dans	les	soins	ambulatories:	rôles	possibles	pour	la	FMH.	Schweiz Aerztezeitung 89,
                                                                 708 –712.

                                                                 Wyss K, Schwarz J, Prytherch H,	Bovier	P,	Hersperger	M	&	Zahorka M	(2008)	Qualitätsmana-
                                                                 gement	in	der	ambulanten	Versorgung:	mögliche	Rollen	der	FMH.	Schweiz Aerztezeitung 89,
STI	office,	Kinshasa.	(Photo	C.	Lengeler)                        708 –712.

				
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