National health accounts data from 1996 to 2010: a systematic review.

OBJECTIVE: To collect, compile and evaluate publicly available national health accounts (NHA) reports produced worldwide between 1996 and 2010. METHODS: We downloaded country-generated NHA reports from the World Health Organization global health expenditure database and the Organisation for Economic Co-operation and Development (OECD) StatExtract website. We also obtained reports from Abt Associates, through contacts in individual countries and through an online search. We compiled data in the four main types used in these reports: (i) financing source; (ii) financing agent; (iii) health function; and (iv) health provider. We combined and adjusted data to conform with OECD's first edition of A system of health accounts manual, (2000). FINDINGS: We identified 872 NHA reports from 117 countries containing a total of 2936 matrices for the four data types. Most countries did not provide complete health expenditure data: only 252 of the 872 reports contained data in all four types. Thirty-eight countries reported an average not-specified-by-kind value greater than 20% for all data types and years. Some countries reported substantial year-on-year changes in both the level and composition of health expenditure that were probably produced by data-generation processes. All study data are publicly available at http://vizhub.healthdata.org/nha/. CONCLUSION: Data from NHA reports on health expenditure are often incomplete and, in some cases, of questionable quality. Better data would help finance ministries allocate resources to health systems, assist health ministries in allocating capital within the health sector and enable researchers to make accurate comparisons between health systems.

Tracking development assistance for health to fragile states: 2005-2011.

BACKGROUND: Development assistance for health (DAH) has grown substantially, totaling more than $31.3 billion in 2013. However, the degree that countries with high concentrations of armed conflict, ethnic violence, inequality, debt, and corruption have received this health aid and how that assistance might be different from the funding provided to other countries has not been assessed. METHODS: We combine DAH estimates and a multidimensional fragile states index for 2005 through 2011. We disaggregate and compare total DAH disbursed for fragile states versus stable states. RESULTS: Between 2005 and 2011, DAH per person in fragile countries increased at an annualized rate of 5.4%. In 2011 DAH to fragile countries totaled $6.2 billion, which is $5.05 per person. This is 43% of total DAH that is traced to a country. Comparing low-income countries, funding channeled to fragile countries was $7.22 per person while stable countries received $11.15 per person. Relative to stable countries, donors preferred to provide more funding to low-income fragile countries that have refugees or ongoing external intervention but tended to avoid providing funding to countries with political gridlock, flawed elections, or economic decline. In 2011, Ethiopia received the most health aid of all fragile countries, while the United States provided the most funds to fragile countries. CONCLUSIONS: In 2011, 1.2 billion people lived in fragile countries. DAH can bolster health systems and might be especially valuable in providing long-term stability in fragile environments. While external health funding to these countries has increased since 2005, it is, in per person terms, almost half as much as the DAH provided to stable countries of comparable income levels.

Sources and Focus of Health Development Assistance, 1990-2014.

IMPORTANCE: The governments of high-income countries and private organizations provide billions of dollars to developing countries for health. This type of development assistance can have a critical role in ensuring that life-saving health interventions reach populations in need. OBJECTIVES: To identify the amount of development assistance that countries and organizations provided for health and to determine the health areas that received these funds. EVIDENCE REVIEW: Budget, revenue, and expenditure data on the primary agencies and organizations (n = 38) that provided resources to developing countries (n = 146-183, depending on the year) for health from 1990 through 2014 were collected. For each channel (the international agency or organization that directed the resources toward the implementing institution or government), the source and recipient of the development assistance were determined and redundant accounting of the same dollar, which occurs when channels transfer funds among each other, was removed. This research derived the flow of resources from source to intermediary channel to recipient. Development assistance for health (DAH) was divided into 11 mutually exclusive health focus areas, such that every dollar of development assistance was assigned only 1 health focus area. FINDINGS: Since 1990, $458.0 billion of development assistance has been provided to maintain or improve health in developing countries. The largest source of funding was the US government, which provided $143.1 billion between 1990 and 2014, including $12.4 billion in 2014. Of resources that originated with the US government, 70.6% were provided through US government agencies, and 41.0% were allocated for human immunodeficiency virus (HIV)/AIDS. The second largest source of development assistance for health was private philanthropic donors, including the Bill and Melinda Gates Foundation and other private foundations, which provided $69.9 billion between 1990 and 2014, including $6.2 billion in 2014. These resources were provided primarily through private foundations and nongovernmental organizations and were allocated for a diverse set of health focus areas. Since 1990, 28.0% of all DAH was allocated for maternal health and newborn and child health; 23.2% for HIV/AIDS, 4.3% for malaria, 2.8% for tuberculosis, and 1.5% for noncommunicable diseases. Between 2000 and 2010, DAH increased 11.3% annually. However, since 2010, total DAH has not increased as substantially. CONCLUSIONS AND RELEVANCE: Funding for health in developing countries has increased substantially since 1990, with a focus on HIV/AIDS, maternal health, and newborn and child health. Funding from the US government has played a substantial role in this expansion. Funding for noncommunicable diseases has been limited. Understanding how funding patterns have changed across time and the priorities of sources of international funding across distinct channels, recipients, and health focus areas may help identify where funding gaps persist and where cost-effective interventions could save lives.

Regional variation in the allocation of development assistance for health.

BACKGROUND: The Global Burden of Disease (GBD) 2010 Study has published disability-adjusted life year (DALY) data at both regional and country levels from 1990 to 2010. Concurrently, the Institute for Health Metrics and Evaluation (IHME) has published estimates of development assistance for health (DAH) at the country-disease level for this same period of time. FINDINGS: We use disease burden data from the GBD 2010 study and financing data from IHME to calculate ratios of DAH to DALYs across regions and diseases. We examine the magnitude of these ratios and how they have varied over time. We hypothesize that the variation in this ratio across regions would be relatively small. However, from 2006 to 2010, we find there was considerable variation in the levels of DAH per DALY across regions. For total funding, the relative standard deviation (standard deviation as a percentage of the mean) across regions was 50%. For DAH specific to HIV/AIDS, malaria and tuberculosis, the relative standard deviations were 50%, 200% and 60%, respectively. While these deviations are high, with the exception of malaria, they have decreased since the 1990s. CONCLUSIONS: There are no evident explanations for so much variation in funding across regions, especially holding the purpose of the funding constant. This suggests donors' allocation processes have not been particularly sensitive to disease burdens. To maximize health gains, donors should explicitly incorporate new disease burden data along with the relative costs and efficacy of interventions into their allocation process.

Vaccine resource tracking systems.

BACKGROUND: From 1999 to 2010, annual disbursements of development assistance for health for vaccinations increased from $0.5 billion to $2.0 billion (all financial values USD 2010). In its 2012 Global Vaccine Action Plan (GVAP), the World Health Assembly recommended establishing a comprehensive vaccination resource tracking system to better understand the source and recipients of these funds, and ultimately their impact on outcomes. This systematic review aims to respond to the GVAP recommendation in reviewing and assessing the state of the data and literature on vaccination resource tracking. METHODS: We scrutinized all relevant vaccination resource tracking systems identified in the literature and by practitioners in the field. We examined schemes used elsewhere in the health sector and by other sectors. Informant interviews were also conducted to determine what data exists and how it might be utilized. With this information, we completed a qualitative assessment of existing approaches to vaccination resources tracking. RESULTS: Tracking systems provide information about some vaccine-related activity in the majority of low- and middle-income countries. Data are generally available for the period of 2006-2010. Levels of granularity vary. Interviewees were concerned about the degree of rigor used to validate the data and the lack of verification. Data are often presented in tabular form, which may be unwieldy for non-technical audiences. CONCLUSIONS: The schemes currently in place to track the resources available for vaccinations were fairly advanced relative to other mechanisms in the health sector. Nonetheless, the coverage, validity, and accessibility of vaccination resource tracking data could be ameliorated. Establishing improved feedback loops and verification mechanisms that connect country-level administrators and the international organizations that support reporting efforts would enhance data quality.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report.

INTRODUCTION: Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment. CASE REPORT: We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation. CONCLUSION: The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

Comparison of Outcomes in Medical Therapy vs Surgical Intervention of Esophageal Foreign Bodies.

Objectives (1) Compare efficacy of primary medical therapy vs primary surgical intervention in patients with esophageal foreign bodies (EFBs). (2) Investigate variables that may predict successful outcomes in patients treated for EFBs. Study Design Case series with chart review. Setting Single-institution academic tertiary care medical center. Subjects and Methods Adult patients (older than 18 years) seen at the University of Michigan Emergency Department (ED) over an 8-year period with the diagnosis of EFBs (January 1, 2003, to December 31, 2011; N = 250). Decision was made by ED physicians whether to treat patients with first-line medical therapy vs surgical intervention. Pertinent clinical and demographic data were extracted from medical records and summarized by descriptive statistics. Results First-line treatment with surgical intervention (flexible or rigid esophagoscopy with foreign body removal) was much more likely to lead to resolution of symptoms than medical therapy (glucagon alone or in combination with other medical therapy) (98% vs 28%, P < .0001). When delivered within 12 hours of symptom onset, medical therapy was more likely to be successful (34% resolution vs 12% resolution, P < .01). There was no difference in complication rates for primary medical therapy vs surgical intervention (8% vs 8%). Conclusions Patients with EFBs are a commonly encountered consultation for both otolaryngologists and gastroenterologists. In these patients, first-line surgical intervention is superior to medical therapy and should not be avoided for a trial of medical therapy or concern for higher morbidity. Implementation of these findings has the ability to positively affect treatment patterns, outcomes, and patient quality of life.

Estimating the development assistance for health provided to faith-based organizations, 1990-2013.

BACKGROUND: Faith-based organizations (FBOs) have been active in the health sector for decades. Recently, the role of FBOs in global health has been of increased interest. However, little is known about the magnitude and trends in development assistance for health (DAH) channeled through these organizations. MATERIAL AND METHODS: Data were collected from the 21 most recent editions of the Report of Voluntary Agencies. These reports provide information on the revenue and expenditure of organizations. Project-level data were also collected and reviewed from the Bill & Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria. More than 1,900 non-governmental organizations received funds from at least one of these three organizations. Background information on these organizations was examined by two independent reviewers to identify the amount of funding channeled through FBOs. RESULTS: In 2013, total spending by the FBOs identified in the VolAg amounted to US$1.53 billion. In 1990, FB0s spent 34.1% of total DAH provided by private voluntary organizations reported in the VolAg. In 2013, FBOs expended 31.0%. Funds provided by the Global Fund to FBOs have grown since 2002, amounting to $80.9 million in 2011, or 16.7% of the Global Fund's contributions to NGOs. In 2011, the Gates Foundation's contributions to FBOs amounted to $7.1 million, or 1.1% of the total provided to NGOs. CONCLUSION: Development assistance partners exhibit a range of preferences with respect to the amount of funds provided to FBOs. Overall, estimates show that FBOS have maintained a substantial and consistent share over time, in line with overall spending in global health on NGOs. These estimates provide the foundation for further research on the spending trends and effectiveness of FBOs in global health.

Low level chlorpyrifos exposure increases anandamide accumulation in juvenile rat brain in the absence of brain cholinesterase inhibition.

The prevailing dogma is that chlorpyrifos (CPF) mediates its toxicity through inhibition of cholinesterase (ChE). However, in recent years, the toxicological effects of developmental CPF exposure have been attributed to an unknown non-cholinergic mechanism of action. We hypothesize that the endocannabinoid system may be an important target because of its vital role in nervous system development. We have previously reported that repeated exposure to CPF results in greater inhibition of fatty acid amide hydrolase (FAAH), the enzyme that metabolizes the endocannabinoid anandamide (AEA), than inhibition of either forebrain ChE or monoacylglycerol lipase (MAGL), the enzyme that metabolizes the endocannabinoid 2-arachidonylglycerol (2-AG). This exposure resulted in the accumulation of 2-AG and AEA in the forebrain of juvenile rats; however, even at the lowest dosage level used (1.0mg/kg), forebrain ChE inhibition was still present. Thus, it is not clear if FAAH activity would be inhibited at dosage levels that do not inhibit ChE. To determine this, 10 day old rat pups were exposed daily for 7 days to either corn oil or 0.5mg/kg CPF by oral gavage. At 4 and 12h post-exposure on the last day of administration, the activities of serum ChE and carboxylesterase (CES) and forebrain ChE, MAGL, and FAAH were determined as well as the forebrain AEA and 2-AG levels. Significant inhibition of serum ChE and CES was present at both 4 and 12h. There was no significant inhibition of the activities of forebrain ChE or MAGL and no significant change in the amount of 2-AG at either time point. On the other hand, while no statistically significant effects were observed at 4h, FAAH activity was significantly inhibited at 12h resulting in a significant accumulation of AEA. Although it is not clear if this level of accumulation impacts brain maturation, this study demonstrates that developmental CPF exposure at a level that does not inhibit brain ChE can alter components of endocannabinoid signaling.

Global health development assistance remained steady in 2013 but did not align with recipients' disease burden.

Tracking development assistance for health for low- and middle-income countries gives policy makers information about spending patterns and potential improvements in resource allocation. We tracked the flows of development assistance and explored the relationship between national income, disease burden, and assistance. We estimated that development assistance for health reached US$31.3 billion in 2013. Increased assistance from the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the GAVI Alliance; and bilateral agencies in the United Kingdom helped raise funding to the highest level to date. The largest portion of health assistance targeted HIV/AIDS (25 percent); 20 percent targeted maternal, newborn, and child health. Disease burden and economic development were significantly associated with development assistance for health, but many countries received considerably more or less aid than these indicators predicted. Five countries received more than five times their expected amount of health aid, and seven others received less than one-fifth their expected funding. The lack of alignment between disease burden, income, and funding reveals the potential for improvement in resource allocation.