Antibiotics: avoiding a return to the dark ages of medicine

Sean Warren, iStockphoto

Listeners to BBC Radio 4’s Today programme woke up yesterday to Prime Minister David Cameron’s prediction of a return to the “dark ages of medicine” if the problem of growing antibiotic resistance is left unchecked.

This doomsday scenario is one where routine infections which we have come to think of as treatable nuisances, are once again life threatening; where modern medical procedures such as cancer treatment and surgery, threaten patient’s lives by leaving them vulnerable to untreatable infections instead of extending and improving lives. This is scary stuff. And scarier still is the fact that most agree it is not scaremongering. Indeed, it is already happening. The European Centre for Disease Prevention and Control looked at five well known antibiotic resistant bacteria and estimated that they alone caused 25,000 deaths a year in Europe.

Today Mr Cameron announced an independent review into how to tackle the global resistance problem; as penicillin was a British invention, it was fitting, he said, that Britain should now provide leadership. He defined the challenge as consisting of three elements: evolving resistance, the lack of development of new antibiotics and the over use of existing antibiotics.

The first is an unavoidable process, due to natural selection, which can be influenced but not stopped. On this, the focus on drugs should not detract from the importance of sanitation and infection control; one way to influence the development of resistance is to influence the rate of infection. Worryingly, there are currently huge gaps in what we know about the levels of resistance around the world.

The second element is tricky too. The golden age of drug production is long gone and getting effective drugs to market is expensive and uncertain. Pharmaceutical companies argue that they face limited returns on their investment as not only are antibiotics poor money-spinners (being short-course and low cost treatments), but it is likely that sales of new drugs will be restricted as governments try to regulate their use more strictly. Still, new business models for research and development are plausible and already being negotiated.

The third element, drug use, is potentially the most complex and challenging of all. Inappropriate drug use is a problem the world over and key will be finding ways to regulate the consumption of medicine. Any British leadership on this issue must consider that, in contrast to the highly regulated NHS or European health system models, people in many Low and Middle Income Countries (LMICs) access healthcare through disorganised and unregulated markets, with the poor in particular relying on informal providers.

In these markets the use of antibiotics is rife, with the World Health Organisation (WHO) reporting they account for 40- 50% of prescriptions. Stopping ‘irrational’ and ‘inappropriate’ use of antibiotics is a common refrain. Yet these labels detract from the many risks and uncertainties which people and healthcare providers weigh up when deciding on treatment, often in the absence of diagnostics. Faced with high and dangerous disease burdens, and with limited access to good quality health services and products, using these medicines presumptively is understandable, and at times beneficial. Indeed it was not long ago that the WHO was recommending presumptive treatment of malaria in endemic regions.

The crux of the issue is the access/excess balance. How can you regulate in a way which ensures essential medicines are available when needed, but are not overused so that they become ineffective? This also involves a trade off between individual and societal needs. The availability of cheap generic drugs to hard to reach populations through informal channels has undoubtedly reduced morbidity. It has been suggested that the impressive reductions in child and maternal mortality in Bangladesh can be attributed to increased access to antibiotics to fight infections. Top down responses such as tightly restricting the availability of antibiotics, to only formal providers for instance (if that was even possible), may adversely affect the poor and vulnerable who face barriers accessing such services. As such they may also work against key development goals like reducing maternal mortality or achieving universal health coverage.

Work by colleagues in the STEPS Centre has highlighted the ways in which regulation must be appropriate for local realities. The informal sector is both problematic and potentially a life line. Attempts to ensure access and also limit antibiotic resistance must take the significant role they play in health systems into account. At the Institute of Development Studies we are partnering with organisations in LMICs who have longstanding relationships with these informal health providers in order to understand the local contexts of drug use more fully.

By Annie Wilkinson, post doctorate researcher, IDS

Forests for the future? Carbon forestry and climate compatible development in Mozambique

Following the United Nations Framework Convention on Climate Change - Bonn Climate Change Conference in Germany earlier this month, an Institute of Development Studies (IDS)-led project funded by the Climate and Development Knowledge Network (CDKN) examines the recent lessons they have learnt on how ‘climate compatible development’ initiatives are unfolding in Ghana, Kenya and Mozambique. Using a political economy approach (PDF), the case studies focus on:

• the political, economic and institutional contexts in which initiatives occur
• the potential competition or conflict between different actors and their goals, and
• the consequences in terms of who wins and who loses from different aspects of climate compatible development.

This is the third and final in the series of the three blogs, by Julian Quan, Natural Resources Institute (NRI), and Lars Otto Naess, IDS. Julian and Lars Otto are lead researchers for the Mozambique case study, which explores the political economy of carbon forestry in Mozambique.

The first blog and second blog respectively came from Thomas Tanner, Overseas Development Institute (ODI) and Pete Newell, University of Sussex.

Challenges and dilemmas of REDD+
How can a developing country like Mozambique build resilience to climate risks such as floods and droughts, while at the same time seizing new economic opportunities and global climate finance? The debate around the global programme for Reducing Emissions from Deforestation and Degradation, known as REDD+, highlights many of the challenges and dilemmas countries face in trying to capture synergies between goals for adaptation, mitigation and development.

REDD+ is an international mechanism which offers incentives to developing countries to reduce carbon emissions from forested lands and increase conservation of forest carbon stocks. While originally set up as a mitigation mechanism, its goals have been expanded to account for development and adaptation goals. In principle, it can be seen as an instrument to promote climate compatible development. Things are as ever more complicated in practice, however.

The REDD+ strategy in Mozambique has been years in the making. In 2012, according to the country’s “REDD readiness proposal”, one third of Mozambique’s entire land area was subject to proposals for forest conservation and carbon forestry from private business and global conservation agencies, which aspire to exploit carbon markets for private gain, or biodiversity conservation.

What are the interests of the diverse stakeholders  in  REDD+ in Mozambique? 
Opinions of REDD+ among local actors vary. For the government and many donors, it is a way of in which Mozambique can contribute to global emissions reduction and simultaneously generate revenue, while also safeguarding forest resources against escalating threats of deforestation, and support livelihoods,. For the private sector, it is a business opportunity, although one that – at least at the moment – looks less promising than a few years ago because of a weak carbon market. NGOs and civil society organisations differ; some are sharply opposed to it, whereas others consider that it  REDD+ and carbon forestry projects offer real potential opportunities, for farmers, rural communities and the nation as a whole: Following a wave of large-scale land acquisitions for commercial food production, biofuels and forestry, REDD+ raises a spectre of “green grabbing”, whereby large areas are dedicated to forest conservation or monoculture plantations, excluding people and usurping land rights.

Is there a viable alternative to REDD+ and what is the way forward?
There are real difficulties in envisioning alternative models which could pay rural communities to help deliver critical global environmental services on the ground. One model seen as promising by many was Envirotrade’s Sofala Carbon Project, which paid farmers for tree planting and improved forest management to earn investors returns from the sale of carbon credits, and create local social benefits. Farmer carbon payments were frontloaded before the trees reached maturity, failing to guarantee long-term carbon values and undermining sustainability. The market value of carbon has fallen, so despite a potential win-win business model, there is little commercial incentive for further investment. In practice the greater share of carbon accumulation came not from tree-planting but better natural forest management activities supported not by the market but by an EU grant, and this is where carbon measurement methodologies are weakest. For REDD+ to succeed without excluding people, it will need to address these problems.

Despite the at times very polarised debate on REDD+ in Mozambique, the study found an extraordinary – and perhaps surprising – willingness amongst local private sector and civil society players to engage with each other, and with local communities and government to implement the programme. However, it is clear that there is a need to deepen and broaden government engagement with sustainable forest management and climate change adaptation, especially at lower levels. So far, the legal and institutional framework developed for REDD+ concentrates on procedures for licensing large scale projects, rather than improving existing forest management and utilisation practices which lead to forest degradation and loss. It is striking how disconnected discussions about REDD+ have become from debates about how livelihoods, agriculture, and vulnerable national regions can adapt to climate change. Resolving forest tenure challenges and broader land governance issues will be key to progress. For REDD+ to work it is also clear that new forms of capital will need to emerge, and promote community enterprise; it will not be possible to rely entirely on the market.

Ultimately, the outcomes of REDD+ for climate compatible development in Mozambique will depend on the existence of strong governance mechanisms and ‘safeguards’ in place to secure tenure rights and benefits from forest resources and carbon stocks for local communities. In order to provide incentives for rural communities to participate and protect them against land alienation as a result of land grants for large scale project investments 

Whatever the view on REDD+: The fact remains that forest management in Mozambique is crucially important for the country’s development and for adaptation strategies, and can offer large potential carbon gains. For REDD+ to work, fundamental forest governance challenges need to be addressed. Questions thus remain:  Is it conceivable that REDD+ can be modified so that these (and other) challenges can be overcome, or is it ‘dead in the water’? If the latter, what other mechanisms for forest governance could be envisaged, taking into account climate compatible development goals? And, how much can be achieved in Mozambique through implementation of current legislation, and what additional challenges does climate change bring?

For more information on the project, contact Lars Otto Naess: L.Naess@ids.ac.uk

Land administration challenges after land reform: evidence from Masvingo

After a few weeks of commentary on wider issues relating to land and agriculture, this week I return to a focus on our field data, and the lessons this tells us for pressing policy issues in Zimbabwe. In this blog, the focus is on the implications of the complex outcomes of land reform for land administration.

As readers of this blog will know, we have been tracking 400 farms since the early 2000s across Masvingo province. One of the things we have been looking at is how plots change hands over time. This is important for a number of reasons. From this data we can examine the institutional mechanisms that have evolved for land transfer; we can look at patterns of land inheritance and the gender dynamics involved; we can identify emerging informal markets in land; we can identify the role of different authority structures in land allocation; and we can assess the level of turnover and the reasons for plot ownership transfer in the new resettlements.

All of these issues are important in thinking about new land administration and management systems in the new resettlements. With the land reform, such issues were not high on the policy agenda; the imperative was to distribute land and not think too hard about its longer term administration. But 14 years on, these issues are now significant, and ones that need to be addressed, as land administration systems are established. Understanding the existing situation and building on it makes much sense, but also future policies may wish to address anomalies and inequities that have arisen.

So in 2012, we looked at all households across the 16 sites (N=389), including in A2, A1 self-contained and A1 villagised (the former 'informal' sites have since been formalised as villagised A1 schemes), and compared the household listing made in advance of our mid-2000s surveys and the list pertaining in 2012. The period then relates to the time from establishment and 'formalisation' of 'fast-track' areas, including the issuing of 'offer letters', and 2012. This does not include the initial year or two of turmoil following land invasions when there was quite a bit of movement into and out of sites, as we described in our book (pp. 72-6). In this most recent survey, we asked about the reasons for the change in plot holder, what happened to the original holder, what relationships the new holders had to the previous one, the gender of the new plot holder, whether the new ownership arrangement had been confirmed in an 'offer letter', and the mechanism through which the new holder had got the land.

Overall, 19% of plots had changed hands over this period, with A2 sites seeing the highest change (29% of plots), followed by A1 self-contained (22%) and A1 villagised (15%). Across all sites, 57% of these changes were due to the death of the original owner. Exits for other reasons were 30% of transfer cases in the A1 sites and 75% in the A2 sites. In one A2 farm there was a particularly dramatic level of turnover, with a series of politically-motivated evictions occurring around the time of the 2008 elections. Overall though only 8% of all plots in the sample had changed hands during this period for reasons other than death (5% in A1 sites and 22% in A2 sites).

In nearly a decade this level of turnover is quite small, including when compared to previous resettlement experience. In 1983, for example, Bill Kinsey commented on the implementation problems of early post-independence resettlement, with many new settlers abandoning their plots due to inadequate planning and support. By the mid-1980s resettlement area populations had settled down and began attracting people, both kin and labourers, and there was a significant growth in household sizes. But after a long period of relative stability, old resettlement areas studied by Kinsey and colleagues have seen a significant out-migration in the period of economic collapse in the 2000s. In this period, people sought alternative options when agriculture became increasingly challenging, with shortages of inputs and absence of cash markets during hyperinflation, and household sizes shrank. This has included movement to new resettlement areas under the fast-track programme, often together with assets such as cattle which showed significant declines in the old resettlement areas.

In our 'fast track' land reform sites in Masvingo, death of the original plot holder (in all cases men) was the primary reason for change in ownership in 57% of all cases. In the A1 self-contained sites, death was the reason for 78% of changes, while in A1 villagised sites it was 68% and A2 it was 25%. Of the others, 28% left for other rural areas, mostly to original rural homes, although a few got new, better land in the resettlements. The remainder left for town (8%) or were evicted (7% – the A2 cases noted above).

Overall 31% of plots were taken over by women, very often the wife of a deceased husband. This varied between 44% (A1 villagised) and 17% (A2). There has therefore been an increase in women plot holders in the A1 sites. Yet few of these have been recognised in changes in 'offer letters', with only 23% of new holders being named in a new land occupancy registration document. Overall, 63% of all new plot holders were relatives, with 41% being immediate relatives (wife, son or daughter of the former plot holder). The remaining 37% of transfers were to people with no kin relation to the former owner.

49% of transfers were described as through inheritance, mostly to close kin (wife or children). A further 12% were passed to other relatives as 'gifts'. 2% of transfers to relatives were mediated through a church or via the chief. There were a couple of cases in an A2 site where 'purchase' was identified, although no others admitted to money changing hands. However for some of those identified as 'gifts' of land, there were exchanges made for the infrastructure developed, with between one and four cattle being paid for such improvements. The remaining 34% of transfers were through other routes – 19% via the District Land Committee and 15% through Committees of Seven. However these patterns varied across sites with 'inheritance' dominating in the A1 sites (59%), while it was only the mechanism in 25% of cases in the A2 sites. Here the formal District Land Committee process was the most important at 58% of all cases. The local site based Committee of Seven was important in 29% of A1 villagised cases, but much less so in other sites.

So what are the implications of these data?

• Turnover in plot holding arrangements has been surprisingly low in the A1 areas in particular. This indicates a strong commitment to the new land, with only about 15% of all transfers involving people leaving for their former rural homes, and even fewer back to jobs in town. When a plot holder's death occurs, transfers are usually to close relatives.
• The A2 sites show a different pattern, with higher turnover. There was a pattern of evictions (in one site, due to politically-motivated grabs), and in others death followed by kin-based inheritance was not the dominant pattern. Instead there were reallocations by the District Land Committee on vacation of the plot.
• The possibilities of effective transfer of underutilised land to new settlers seems more possible in A2 areas, where some indications of incipient ‘vernacular’ land markets are evident (probably underreporting of this due to illegality). By contrast in A1 areas transfers tend to be within families, and the opportunities for government to reallocate are relatively smaller.
• Despite the fact that District Land Committees are supposed to have control over land and oversee transfers, this is less important in A1 areas, where 'traditional' inheritance (or 'gifting') arrangements generally apply on the death of plot holder.
• The 'offer letter' system of land registration is not keeping up with land transfers, partly because so many are outside the formal system. Women are gaining land through inheritance on the death of male plot holders, and through transfers to daughters and aunts (relatively few). However women's new ownership arrangements are largely not recognised in changes in 'offer letters', raising questions about the security of such tenure.
• The Committees of Seven, established soon after land invasions for local management of new resettlements, seem to be on the wane, particularly outside the A1 villagised areas where they seem to hold some land administration function for transfers outside kin-based arrangements.
• Chiefs, churches and other institutions for land administration seem to have a limited role, although 'traditional' leadership (sabhukus etc.) are often part of Committees of Seven in many sites, so there is an overlap in both people and roles.
• Outside the one A2 case where evictions occurred, conflicts over land transfer were very rare, and in most sites none were reported. This is surprising given the intensity of competition over land. We can expect such conflicts to increase over time, however.
• Across all land transfers identified no subdivisions of plots were recorded, and all were recorded as being handed over in full. This again is surprising given growing land competition and the need to inherit land by the next generation. However subdivisions are occurring in land still held by the original holder who is still present. Sons are allocated portions of a field and have their new homes within or nearby the original home compound. As described for the earlier phase of resettlement, such 'vertically extended' household arrangements are becoming increasingly common as a form of de facto subdivision.

Overall, as the Government of Zimbabwe attempts to define a new land administration system in line with the Constitution, these findings are clearly pertinent. There is a need for more effective registration of land and ownership, and also a need for a mechanism to keep this up to date. Ensuring registration of women as plot holders is essential. To encourage turnover and the making use of underutilised land is key, especially in A2 areas, transfers can potentially be facilitated through introducing some form of land market, assisted by land taxation; although again close monitoring and transparent registration (perhaps through leases) will be vital, especially to avoid the sort of evictions seen in one site.

Subdivision is always a controversial issue, as the thorny question of what is a 'viable' farm is raised. However this varies considerably and as demand for land continues to increase, there are potential subdivision options within sites, and indeed between them, including moving A2 farms to smaller A1 self-contained arrangements. In our sites, as witnessed by the lack of subdivision on transfer, and the limited amount of conflict (outside the particular site that was subjected to external grabbing), this may be a next-generation challenge, but clearly something that must be responded to.

As Marleen Dekker and Bill Kinsey argue in relation to the first round of resettlement, the direct benefits of land reform are significant in the first generation, but as things unfold, there are new challenges requiring different forms of responsive innovation. They note patterns we are already seeing in our sites, including the growth of household size through attracting labour, for example, as well as the de facto subdivision through 'vertical extension'. These result in new land uses associated with new demographic patterns and changing social relations.

Trying to plan everything and imposing a narrow 'straitjacket' of rules and regulations only undermines potentials, they argue. There are, as Thomas Sikor and Daniel Muller note, serious limits to top-down state driven land reform. While new systems for land administration in Zimbabwe are clearly needed, they must be flexible, responsive and adaptable to new circumstances.

This post was written by Ian Scoones and originally appeared on Zimbabweland

This work has been carried out together with the Masvingo field team: BZ Mavedzenge, Felix Murimbarimba and Jacob Mahenehene

Research in Gender and Ethics (RinGs): A new partnership to build stronger health systems

Gender-sensitive health policy is a feature of international commitments and consensus documents and national-level normative statements and implementation guidance in many countries. However, there are gaps in our knowledge about how gender and ethics interface with health systems. Funded by the UK Department for International Development, this exciting new initiative brings together three health systems focused Research Programme Consortia (RPC): Future Health Systems, ReBUILD and RESYST in a partnership to galvanise gender and ethics analysis in health systems.

Our approach

As the partnership is concerned with ensuring that new approaches get translated into action, we have an interest in embedded approaches; analysis that is relevant and owned by local actors. In addition, an understanding of intersectionality is central to our work. Gender intersects with other axes of inequality, such as age, ethnicity, class, poverty, geography, (dis)ability and sexuality. Finally, in addressing power relations and social exclusion we also call attention to ethics in health systems research, policy and practice. 

What are our aims?

This partnership seeks to understand, and to encourage, a gendered approach to the study of health systems care-seeking; financing and contracting; governance; and human resources for health by:

1. Synthesising the current evidence base. This will provide tools, case studies and guidelines on gender, ethics and health systems for researchers and decision makers and set the terms of a future research agenda.
2.  Stimulating new research. Through small grants aimed explicitly at RPC partners and affiliates.
3. Encouraging mutual learning and research uptake. A learning platform will support grantees, RPC members and a wider stakeholder group (policy makers, implementers and advocates) to share and support one another in defining, conducting and applying this research. Dialogue will engage with research findings and encourage its use in policy and practice.

Who is involved? Find out more

A small team is steering the direction of the project:

• Asha George, Future Health Systems/Johns Hopkins School of Public Health
• Sarah Ssali, ReBUILD/School of Women and Gender Studies, Makerere University
• Sally Theobald, ReBUILD/Liverpool School of Tropical Medicine
• Sassy Molyneux, Resyst/KEMRI-Wellcome Trust Research Programme
• Kate Hawkins, Pamoja Communications
• Rosemary Morgan, Cross RPC /Johns Hopkins School of Public Health

Our email address is rings.rpc@gmail.com

Over time a broader group of RPC researchers will also join the projects, either as the recipients of research funding from our small grants project or as part of our learning platform. Do get in touch if you would like to learn more.

UK Policy Focus on Health Systems Strengthening

This week, health systems strengthening is all the rage in the UK policy circles. Well, at least among particular UK policy circles.

The main reason for this is that the UK Parliament's International Development Committee heard oral evidence for its inquiry into DFID's approach to health systems strengthening.

If you've got two hours to spare, you can still watch the oral evidence on Parliament TV -- with the exception of one of the MPs suggesting that 'health systems strengthening is all just a bunch of waffle', it's an interesting watch.

But if you haven't got the time on your hands, Pamoja have captured a few of the key moments and lines of enquiry in a Storify (also embedded below). And we here at Future Health Systems developed a useful primer on Buzzfeed: 7 Things To Know About DFID's Approach To Health Systems Strengthening.

Written evidence submitted to the committee is now also available. As we noted before, FHS submitted evidence to the inquiry, as did a number of our sister research programme consortia (RPCs). DFID's own response is well worth a nosey.

And all of that should prove useful background reading and viewing for tomorrow's livechat on Guardian's Development Professional Network on making health systems work in developing countries. FHS CEO, Sara Bennett will be on the panel -- so be on the lookout!

by Jeff Knezovich