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by Dr Vijayashree HY 

This session was chaired by Mr.Sunil Nandraj (Faculty, Public Health Foundation of India, Delhi) and co-chaired by Dr.Werner Soors (Institute of Tropical medicine, Antwerp).

Prof Fran Baum (Flinders University, Adelaide, Australia), in her presentation entitled ‘ The Tip of the Iceberg: neglected diseases and social determinants of health and health inequities’  spoke about approaches in reducing health inequities through action on social determinants of health (SDH). Click here to listen to her presentataion

Another panelist Dr Devaki Nambiar (Research Scientist, Public Health Foundation of India, New Delhi), by narrating a story of snake bite from the field, highlighted the health system failures at various levels in managing snake bite cases. She illustrated how larger cultural and social factors but also environmental factors shapes situations where snakebites cases becomes common in India. She emphasized the urgent need of health system preparedness to tackle such situations. It was debated that snake bite is indeed a neglected tropical disease and deserves more attention.

Dr. Upendra Bhojani (Faculty, Institute of Public Health, Bangalore) emphasized what Prof. Fran Baum described as Health in All policies concept. By highlighting how policies in different sectors like, transport, food, trade, taxation, agriculture as well as larger political economy affect whether tobacco use gets promoted or reduced in India. Subsequently he made other point that, it is not that health sector has no role in addressing SDH but there is an unique challenge to health professional to go beyond health care sector and become advocate for healthy policies in other sectors. He demonstrated how the practice of advocacy for health in all policies might look like, by briefing his experience along with his team members: Dr. Vishal, cancer surgeon who does political and administrative advocacy, Mr. Mohanraj, cancer patient spearheading voice of tobacco victim movement, and Mr. Amit doing media advocacy.

Some more discussions surrounding panelists’ presentations:

• What is the role of global community in reducing deaths by snake bites. How the global community could help in improving the situation in tropical countries?
• Social determinants of health for tobacco use: Is it critical to engage with upstream determinants like tobacco production units?
• Why despite having supporting evidences in health policies, why we fail on social determinants of health. Is it we have not really figured out how to do this?
• There is a consensus on the need to focus more on SDH. However, in the same vein we should also focus on quality health services. Changing SDH is difficult as there is power associated with it. If there is lack of political will and lack of resource allocation, can we expect a change in the system?
• Deaths caused road traffic accidents and suicides have been neglected. How SDH will determine this?
• SDH is all about power.  It depends on how much control the system has on the community. It will take long time to change the SDH. It needs a strong leadership. But this leadership should come from within health services or from the society?

by David Hendrickx 

The NTD (neglected tropical diseases) debate continued this morning at the ITM-IPH colloquium with a closer look at a few key challenges the research community is being faced with in terms of informing NTD control initiatives.  Although the session focused predominantly on the case of visceral leishmaniasis and its control in the Indian subcontinent, the questions discussed throughout the presentations and discussions were just as relevant to other NTDs.  What is the precise role of vector control in reducing disease incidence?  What is the best vector control strategy, considering factors such as (cost-)effectiveness, acceptability and risk of insecticide resistance?  What is the role of asymptomatic carriers of infection in disease transmission?  How can we effectively and safely treat patients for these conditions, without running the risk of losing the few drugs we currently have at our disposal to drug resistance?

These were just a few of the questions that were raised.  It was sobering (yet fitting, for a neglected problem?) to observe that many of the presented studies put forward more questions and ‘known unknowns’ than they provided answers and clear ways forward.  It feels like we are slowly piecing together a huge and complex puzzle, with the added challenge of not knowing how many pieces we will need, nor what the picture on the box looks like.  So where should our research priorities lie in terms of NTD control?  And should we focus on implementing what we think we know?  Or would we be wise to invest more time and resources in exploring alternate control strategies and possible ‘unknown unknowns’?  As we continue to piece together the puzzle of NTD control, it remains clear that our continued research efforts are much needed, whatever our discipline or expertise.

Fran Baum: “The Tip of the Iceberg: neglected diseases and social determinants of health and health inequities”

Watch the video and post your questions to Prof Baum either as comment below this post or on the Colloquium Facebook group.

by Dr Vijayashree HY

This session started with Prof. Freddie Ssengooba’s (Makerere University School of Public Health, Uganda) presentation. He talked about the health system evidence to guide disease control. He emphasized that public health interventions are often implemented without much pre-trial development research and invariably there will be program adaptations during implementation. Thus, the evaluation methods need to take into account the complexity and evolutionary adaptions. He also stressed the importance of using randomization methods for evaluating public health innovations in such situations where contextual and implementation learning are not vital.

Some discussions surrounding this presentation:

• Before any innovations, it is essential to assess the readiness of system, whether it is stable/mature to absorb the innovation  and thus the innovation is sustainable. There is a need to have a feedback loops through communication and learning from downstream to upstream.
• Evaluation results based on Randomised Control Trials are not a good strategy to initiate a good dialogue with policy makers. They do not really understand the term ‘control’. We need to deliberate on how  we can be more clear and be more effective in communicating  the issues of in complex health system with policy makers.
• What drives performance in the health system: sometimes Performance Based Financing (PBF) can pose a problem to the system. International donors need to understand the local priorities and social ingredients well before the implementation. In the majority of the cases, it affects the  generation of quality data which can be used for surveillance.
• Role of administrators is crucial in disseminating the policy to grass root level workers in a way that; they understand the message which eventually gets absorbed into their daily routine. There should be a feedback loop in the system, to enable grass root level workers to flag constraints to higher authority
• How does one measure motivation and contextual factors affecting health system functioning? Measuring these environmental factors add scientific credibility. There are some things which need to be understood and some need to be quantified. Health system research using quantitative and qualitative methodology is ideal to measure a health system holistically.

1. What are alternative explanations that may account for changes – plausible explanations in addition to statistical reduction? How does a broader context help build explanations?
2. How can one use multiple methods for observation and measurements to rule out (or support) alternative explanations?
3. How can one become sufficiently familiar with the relevant contexts to understand and capitalize on contextual drivers and barriers?

The second key note speaker, Prof. Venkat Raman (Faculty of management studies  university of Delhi), talked about public private interface in disease control strategies. By providing some examples of Public Private partnerships (PPP) in health care, he discussed the advantages of working with the private sector but stressed the challenges in partnering with private sector health providers. Some issues which deserves further discussion are:

1. Most PPPs in health sector are ‘partnerships of good faith’, not based on policy or institutional guarantee, thus lack continuity. How do we improve this?
2. Senior bureaucrats are enthusiastic, but lower officials are suspicious of PPP.How do we ensure all the players are on the same page ?
3. Will a Professional Contracts and Intermediary management agency between the private sector and the government will reduce the tension between public and private sector? 

The third key note speaker, Prof. Guy Kegels (Institute of Tropical Medicine, Antwerp), talked about Vertical analysis. He discussed ‘operational analysis’ following Piot’s model, the ‘learning cycle’ for Action Research. He stressed the need to  involve generalist program implementers in program design, whenever possible.

The fourth speaker, Dr Melissa Parker (Centre for Research in International Medical Anthropology, Brunel University) spoke about her experiences of working in Uganda and Tanzania on the uptake of drugs for neglected tropical diseases. She stressed the need to understand how social, political, economic and historical issues influence the uptake of drugs, and pointed out that anthropologists can fill in the gaps in understanding the contextual issues in the health system for certain outcomes.

Editor’s note: If the above quoted six questions are not thought-provoking enough, here are some additional questions you may want to elaborate on in the comments:

• Things should be made as simple as possible, but not simpler’: agree or not agree?
• Funders, program designers, program managers and generalist implementers (the ‘systems people’) often have quite different systems of reasoning, each of them tending to apply ‘single-metric’ systems of logic. These ‘single-metric’ systems* can be so internally coherent (and intellectually elegant) that it becomes almost impossible to  listen to people using a different one. How to deal with this, if we want to optimise the interface programs-systems?? *eg Funders:  ‘single-metric’ cost-effectiveness. Program managers: effectiveness (‘does it work?’). System-people: logic of equity, or feasibility. Others: ‘performance-based financing’. Others: regulation, discipline, bureaucratic model. Others: internalised deontology of the medical professional.
• MDA for NTDs is driven by normative assumptions, and the quest for funding. Evidence is a distraction. Is this a fair assessment of current strategies?
• Why are so few public health professionals interested in grappling with the social and political issues affecting MDA?

by David Hendrickx 

The colloquium got off to an energetic start this morning with a session on the state of the art of neglected tropical diseases (NTDs) control in Asia.  In the opening plenary presentation Professor Jacob John (Christian Medical College, Vellore, India) defined this group of diseases as those for which no health system based intention of control exists.  He argued that if certain infectious diseases are currently not under control or no initiatives are in place to move towards control, it is because of a lack of interest and determination on a political level.  Professor John therefore urged the colloquium delegates to consider their role in demanding their country’s political actors to address the issue of health and accept the principle that people’s health should be an intrinsic responsibility of the state, especially in the case of the poorest of the poor.

The session’s second keynote speaker, Professor Suman Rijal (BP Koirala Institute for Health Sciences, Dharan, Nepal) illustrated some of the opportunities and key challenges regarding the control of NTDs in Southern Asia.  His presentation highlighted the tremendous burden this group of diseases represents for the region, amounting to estimates as high as 14.8 million DALYs.  The need for integrated efforts towards NTD control was discussed, stressing that effective interventions need to be multifaceted.  This was illustrated by the case of Kala Azar (or visceral leishmaniasis) and the elimination initiative that has been put into place in the Indian subcontinent. This program adopted a two-pronged strategy consisting of early diagnosis and treatment, and integrated vector control.

Throughout the various presentations and discussions the session also put forward a call for moving beyond the vertical programme-based approach to NTD control in Southern Asia.  This strategy was considered unrealistic, uneconomical, and potentially damaging to the health system.  Instead, it was argued that the health system’s own capacity to monitor and control NTDs should be strengthened.  A well-established disease surveillance system is essential for developing such an integrated strategy for the control of NTDs, although it was argued that the value of such a system is wholly dependent on the ability to effectively translate the generated information into interventions.  Or how concerted action speaks louder than numbers and histograms.

Other challenges and knowledge gaps for NTD control were highlighted throughout the session, including our limited understanding of the role of animal reservoirs in disease transmission and the need for improved clinical guidelines for the hands-on management of NTDs.  Nevertheless, there was reason for optimism, as several NTDs are coming close to elimination in Southern Asia.  However, given the current resurgence of malaria in India after it was previously considered to be under control, we should learn from past lessons. Vigilance is in order.  With the few NTD elimination goals that are currently within our reach in Southern Asia, complacency is a luxury we clearly cannot afford.

So are we close to NTD elimination in Southern Asia? What is your take?

The Strategic Network of Neglected Diseases and Zoonoses held a satellite workshop before the Colloquium 2013.
The presentations and other resources have been posted on their website, so interested parties can have a look here:
http://www.snndz.net/snndz-events/itm-colloquia/bangalore-2013/

The other reporter of the Colloquium will be Dr Vijayashree, summarizing the main points of discussion for session 3 (planning and evaluation in disease control) and 6 (panel on social determinants). David and Shree will work together on session 7.

Dr.Vijayashree is a medical graduate, currently working as faculty at the Institute of Public Health, Bangalore. She is pursuing PhD from the Institute of tropical medicine, Antwerp, Belgium. Her study focuses on public private partnerships in health care, with particular emphasis on National Tuberculosis programme in India. She is also involved in a World Bank project where she is evaluating the  Results-Based Financing strategies for Tuberculosis Control in the Private Sector in India.

Previously Dr.Vijayashree has worked in a multi country project which investigated the health system regulation and governance in three Asian countries (2010-2012). She worked as WHO-Consultant in India’s National TB programme, providing technical assistance to the Government  in implementing the programme (2006-2009). She served as medical officer in the Ministry of health and family welfare, Karnataka Government, where she provided primary care and implemented national health programmes (2000-2005)

As highlighted in a previous post, there will be two young researchers reporting from the sessions. Their report will be posted online here on a day of the session.

One of them will be David Hendrickx, he will be your reporter for sessions 2 and 4, on the state of the art of control of neglected diseases.

David is an early career researcher with a particular interest in social determinants of health and the control of neglected infectious diseases.  He is currently based at the Telethon Institute for Child Health Research in Perth (Australia), where he is pursuing a PhD on the topic of Aboriginal health and wellbeing.  Through the work he is doing as part of his PhD, he hopes to identify sustainable and culturally appropriate ways of improving the control of skin infections in Western Australia’s remote Aboriginal communities.  David previously worked as a research assistant at the Institute of Tropical Medicine in Antwerp before starting his PhD in 2012.  During his time at the ITM he coordinated two of the institute’s international networks (LeishRisk and the FA3 Strategic Network on Neglected Diseases) and was involved in several studies related to the control of neglected infectious diseases.  He loves travelling, listening to people’s life stories and eating chocolate.

Press Release:

International meet on neglected diseases in Bengaluru

Over 200 delegates from 30 countries to deliberate health systems and neglected diseases 

Bengaluru, November 18, 2013: Come November 20^th and Bengaluru will host an international scientific event to deliberate one of the important but often-neglected public health challenges of our times. The city-based Institute of Public Health (IPH) in collaboration with the Institute of Tropical Medicine, Antwerp, Belgium (ITM) will be organizing the Colloquium 2013 with the theme “Health systems and control of neglected diseases in Asia” from Nov 20 to Nov 23 at the Hotel Park Plaza. Over 200 delegates from 30 countries – from Uganda to China and Belgium to India – representing governments, academic institutions and NGOs will participate. The term ‘neglected diseases’ is a political one to highlight a wide array of diseases that are not given due attention and that in fact have become drivers of poverty. These include the so-called ‘big three’ (HIV, TB and malaria) but also 23 neglected tropical diseases that still impoverish and kill people but hardly get attention from health services and policymakers. As per the World Health Organization these “diseases are a proxy for poverty and disadvantage, affect populations with low visibility and little political voice, cause stigma and discrimination…are low on many research funders’ agenda…”

Shri U.T. Khader – Hon’ble Minister of Health & Family Welfare (Government of Karnataka) will be inaugurating the event in the august presence of Dr. L S Chauhan, Director of the National Centre for Disease Control (New Delhi, Government of India), Prof. Marleen Boelaert, Head of Department of Public Health at the ITM (Belgium) and Dr. N. Devadasan, Director of the IPH (Bangalore).

Dr. Werner Soors, a public health researcher at the ITM, Belgium said, “the long-standing collaboration between ITM and IPH Bangalore is known for its shared expertise and important advances in health systems research. We have robust evidence today that stronger health systems can enhance effectiveness of disease control programmes and vice versa. I am confident that the Colloquium, with its deliberations and experience sharing by delegates from across the world would optimize the interface between disease control programmes and national health systems, in India and elsewhere”.

Dr. Devadasan, Director at IPH, Bangalore opined that “with sessions on the state of the art of neglected diseases in Asia, design and evaluation of disease control programmes, disease control and health systems strengthening, and disease control and social determinants of health, the Colloquium is a firm step towards effective disease control, strengthened health systems and – hopefully – health for all in a better world.” Shri U T Khader (Honourable Minister of Health and Family Welfare, Government of Karnataka), Dr. L S Chauhan (Director of the National Centre for Disease Control, Government of India) along with other eminent leaders have kindly consented to inaugurate the Colloquium on evening of Nov 20.

All documents related to the Colloquium will be freely available at the dedicated website

For further information, please contact Dr. Upendra Bhojani of IPH @ 9342349121, upendra@iphindia.org

Find below some images from the Press Meet on November 18 at the Press Club of Bangalore.

Participants of the Colloquium 2013 and interested parties who cannot attend this time will be happy to hear that everyone will be able to follow the fruitful discussions of the event online. What’s more, they can even contribute to them and participate virtually!

First of all, there will be some discussing-stimulating “provocative questions” raised is each session. Participants will be invited to discuss these still in the sessions and then carry the discussion further, online.

There will be a short summary posted on this very blog after each session. Participants are invited to go online and comment on these summaries and provocative questions. Our Colloquium “bloggers” will be David Hendrickx and Dr. Vijayashree H.Y. You will be able to read more about them on the blog in the coming days. This platform is open to the general public an is an excellent source for updates on the event.

Facebook will also be used as an online platform, however, our group will only be open to participants of the Colloquium. They need to become member of the Facebook group to be able to post. They are welcome to post their comments there on the provocative questions and/or on the sessions! Easy access (also during a session) for short contributions, also from smartphones/tablets. This is also an ideal platform to share photos that are taken during the event. (Editor’s note: the general public will also find photos on this website later on.)

Finally, there is a chance to follow the Colloquium on Twitter, by keeping an eye on the hashtag #colloq13. The accounts of both institutions are also worth to check out: @ITMantwerp, @iphindia.