The last decade witnessed growing differences in abortion dynamics inBelarus, Russia, and Ukraine despite demographic, social, and historicalsimilarities of these nations. This paper investigates changes in birthcontrol practices in the three countries and searches for an explanation ofthe diverging trends in abortion.Official abortion and contraceptive use statistics, provided by nationalstatistical agencies, were analysed. Respective laws and other legaldocuments were examined and compared between the three countries. Todisclose inter-country differences in prevalence of the modern methods ofcontraception and its association with major demographic and social factors,an analysis of data from national sample surveys was performed, includingbinary logistic regression.The growing gap in abortion rate in Belarus, Russia, and Ukraine is a genuinephenomenon, not a statistical artefact. The examination of abortion andprevalence of contraception based on official statistics and three nationalsample surveys did not reveal any unambiguous factors that could explaindifferences in abortion dynamics in Belarus, Russia, and Ukraine. However,it is very likely that the cause of the inter-country discrepancies lies incontraceptive behavior itself, in adequacies of contraceptive knowledge andpractices. Additionally, large differences in government policies, which arevery important in shaping contraceptive practices of the population, weredetected.Since the end of the 1990s, the Russian government switched to archaicideology in the area of reproductive health and family planning and neglectsevidence-based arguments. Such an extreme turn in the governmental positionis not observed in Belarus or Ukraine. This is an important factorcontributing to the slowdown in the decrease of abortion rates inRussia. In the former Soviet Union, the three Slavic republics, Belarus, Russia, and Ukraine,were very much alike not only with respect to culture and economic development butalso in terms of demographic patterns. In spite of the two decades of independentdevelopment, principal demographic characteristics of the three nations are stillvery similar. In particular, all three countries experience low total fertilityrates of 1.3–1.5 and high prevalence of one-child families. Fertility in thethree countries was below the replacement level during the last forty years with anexception for a few years in the 1980s. In times of political and economic turmoilof the 1990s, Belarus, Russia, and Ukraine experienced a sharp fertility downturnwith a slight recovery in recent years Deliberate birth control has long been a mass practice in the region. During theSoviet times, one of the most extensively used means of birth control was inducedabortion; this is another feature common to all the three countries. The USSR hadthe world's highest level in induced abortions Research on birth control in Belarus, Russia, and Ukraine is scarce and is mostlyfocused on intra-country developments. Reasons for the recent divergence in abortionrates between the three sister-countries have not been addressed and remain unclear.The aim of this study is to investigate the phenomenon and to provide its possibleexplanations.The first hypothesis is that the observed cross-country differences can be attributedto some changes in regulations concerning provision of abortion services andreporting of abortion by providers that could induce changes in data collectionsystems. We try to find out whether the quality and the completeness of abortionstatistics are comparable between the three countries and thus do not permit thepossibility that the differences in abortion incidence are a simple statisticalartefact. In addition, we look at and compare the country-specific approaches incollecting official data on contraception.The outcome of pregnancy depends on the desired number and timing of births as wellas on knowledge of and accessibility to the means of effective contraception thatwould allow the realization of reproductive preferences. Abortion is a consequenceof unintended pregnancy, which results from contraceptive failure or non- use This study relies on two types of data: official statistics on abortion andcontraceptive use; and survey data that provide micro-level information aboutcontraceptive use and variety of its covariates.Abortion statistics are available from several data sources. It appears thatfigures, which ought to be the same, often are found to be somewhat different.The data sources on abortion are as follows:Publications of the national statistical agencies and the nationalministries of health (MoHs), in Russia during 2004–2011 it was theMinistry of Health and Social Development.UN data provided through the UN Demographic Yearbooks The WHO European Health for All Database (HFA-DB) Online resource “Abortion statistics and other data –Johnston's Archive”, which provides published data fromheterogeneous sources Notable discrepancies in the data coming from different sources are especiallycharacteristic of Ukraine. For example, the number of abortions in Ukraine in2000 is 345.8 thousand according to the HFA-DB, 408.9 thousand according to theCenter for Health Statistics of the Ministry of Health of Ukraine We used the national MoHs' data on the prevalence of two types ofcontraception: use of intrauterine devices (IUDs) and use of oral contraceptives. The MoHs do not collect data on using other methods ofcontraception.www.socpol.ru). The GGS is apart of the Pan-European Program “Generations and Gender” (see:http://live.unece.org/pau/ggp/Welcome.html). Two waves of theGGS – in 2004 and 2007 – were conducted in Russia by the IndependentInstitute for Social Policy. At the moment, it is the only source for nationallyrepresentative data on family planning in Russia. The GGS questionnaire includeda list of contraceptive methods, and respondents, who were younger than 50 andhad a partner at the time of the interview, were asked to indicate methods theywere currently using to prevent pregnancy. The respective question was:“Are you or your partner/spouse using or doing any of the things listed onthe card to prevent pregnancy at this time?”.For the analysis of contraceptive practices and their determinants, we employsurvey data . Inthe http://www.childinfo.org/mics3_surveys.html). In the case ofBelarus, it is the only known survey that provides information about fertilitycontrol in this country. Ukraine has other surveys that are devoted to orembrace the issues of reproductive health; the Ukrainian Reproductive HealthSurvey (1999) Starting in 1995, the UNICEF carries out the Multiple Indicator Cluster Surveys(MICS) aiming to monitor the progress in achieving the millennium goals. Thethird wave of the MICS, conducted in 2005, included also Belarus and Ukraine.The MICS is a representative sampling survey at the country level. Amulti-stage, stratified cluster sampling approach was used for the selection ofthe survey sample, details can be found on the MICS website , 1, 2, and 3+. Place of residencecomprises three categories: rural, urban, and capital city. Due to limitedinformation on education available in the Ukrainian data, we make a distinctiononly between higher and lower than higher levels of education. Marital statushas two categories: registered marriage and cohabitation. We apply afixed-effects model using a pooled dataset with a country-variable being used asa covariate.Unfortunately, none of the three surveys includes questions on abortion.Governmental policies have the potential of suppressing abortion as a birthcontrol method. To find out more about governmental policies in Belarus, Russia,and Ukraine and their role in shaping contraceptive practice in these countries,we examine national legal documents and regulations relevant to the field ofreproductive behaviour, reproductive health, and reproductive rights, includingthose promoting family planning and contraceptive use.According to official statistics in 1990, 4.1 million abortions were registered inRussia, 1 million in Ukraine, and 261 thousand in Belarus. Relative indicators ofabortion (per 1000 women of reproductive age and per 100 live births) slightlydiffered between the three countries, but were very high in all of them at thattime. The corresponding absolute numbers of abortions in 2010 were: 1.2 million, 177and 33 thousand. The three countries achieved a significant improvement inreproductive health: in twenty years numbers of abortions dropped by several times.However, the rate of decline varied by country .Over thIn November 1920, Soviet Russia became the first country in the world, whichdecriminalized and legalized abortions. In 1936, the USSR banned abortionsagain, allowing them only on ill-health and medical indications. The ban wascalled off in 1955, and no significant changes were introduced in the relevantUSSR legislation since then. Abortion on request was legally permitted up to 12weeks of gestation, and after 12 weeks it could be performed only for medicalreasons. In 1987, the USSR Ministry of Health authorized an abortion during theperiod up to 28 weeks of pregnancy under a range of non-medical conditions Abortion laws in Belarus, Russia, and Ukraine did not experience any principalchanges in the post-Soviet period. In all of the three countries, abortionprocedure and related services are included in the basic package ofstate-provided health care guarantees. This means that by law, abortion on awoman's request must be performed in a public health care facility free ofcharge.In Belarus and Russia, each woman is legally free to choose whether to give birthor not. Woman's right to this decision is defined in Article 27 of theBelarusian law “On health care” enacted in 1993 Post-Soviet Ukraine confirms woman's right to abortion in the law“Fundamentals of Legislation on Health Care”, Article 50 th week of gestation,abortion is allowed on one and the only condition – a woman'srequest, and after the 12th week it can be performed only in thepresence of medical reasons.All in all, differences in the regulations defining abortion procedure are reallyminor in the three countries. Before the 12As far as social reasons are concerned, some differences exist between thecountries. It is noteworthy, however, that induced abortions performed on thebasis of social reasons represent a very small portion of reported abortions(less than 1 per cent), and their contribution to abortion statistics isnegligible Russia used to have a similar list until 2003, when it was dramatically reducedfrom thirteen to four items There are no any special laws regulating use of contraception in the countriesunder study and thus no legal barriers exist to using it. The only contraceptivemethod, whose use is subject to some legal regulation, is sterilization. InRussia, sterilization can be performed to a Russian citizen, who is not youngerthan 35 years of age or has at least two children, upon receiving his/herwritten request. For medical indications, sterilization is performedirrespective of the person's age or number of children. According to theBelarusian law “On health care” None of the three countries has domestic production of pills. They are allimported, and therefore their prices are relatively high.Free contraception actions happen episodically during manufacturers'promotion campaigns, anti-AIDS campaigns, and similar events. According to theUkrainian DHS (2007) data, 6.4 per cent of female respondents had IUDs insertedfree of charge, and 1.6 per cent of them had access to free oral contraceptives(pills) Belstat in Belarus, Rosstat in Russia, andDerzhstat in Ukraine) collect data on reported abortions fromthe MoHs and combine them with information obtained from medical institutions ofother ministries as well as from private abortion providers. Abortion statisticsprovided by the statistical agencies are therefore more complete than the datapossessed by the MoHs.In Belarus, Russia, and Ukraine, most of abortion procedures take place in publichealth facilities that are ruled by the national MoHs. These ministries are themajor abortion-service providers. The national statistical agencies, criminal , as well as unspecified abortions. The extended definition of abortionis the legacy of the USSR data collection. In Russia, as reported by the MHSD,spontaneous abortions accounted for more than 16 per cent of the total number ofabortions (using the extended definition) registered in 2010, and unspecifiedabortions constituted 5 per cent. The respective figures for Ukraine were about 7and 19 per cent in 2007 Due to the continued use of the extended definition of abortion, abortion rates inBelarus, Russia and Ukraine are misleadingly inflated and should be used withcaution for international comparisons. A proper comparative analysis requires thatthe above mentioned extensions  are subtracted.The problem is that data on spontaneous and other types of abortions that take placewithout medical supervision are usually not published. On the other hand, one couldargue that the inclusion of these extensions into official abortion statisticscompensates possible undercount of abortions performed in the private sector.To sum up, our analysis shows that the data collection systems in Belarus, Russia andUkraine are similar. The registered levels of abortion can be considered reliable.The fact that they share similar advantages and suffer from similar deficienciessuggests that official abortion statistics of these countries are of comparablequality and completeness. Consequently, we draw a conclusion that the divergenceobserved in the post-Soviet abortion trends in these countries is a genuinephenomenon.Regarding official statistics on contraception, this information in Belarus, Russiaand Ukraine is collected via medical networks associated with the MoH only. The MoHscompile data on patients' use of two types of contraception: intrauterinedevices (IUDs) and oral contraceptives . These data can be biasedbecause a variety of pills and other means of contraception are available withoutdoctor's prescription, and there is a growing network of private institutionsproviding family planning services. Prevalence of contraceptives among patients ofpublic medical networks may therefore differ from corresponding prevalence in thegeneral population. The MoH data are useful, however, as they give an insight intohow contraceptive use was changing over time in the three countries.Official statistics on contraception collected by the MoHs shows that proportionsof women practicing hormonal contraception (pills) were steadily growing inBelarus, Russia, and Ukraine since the early 1990s .Almost As regards the prevalence of IUDs, it was among the most commonly used moderncontraceptive methods in the late USSR. Its high popularity was a result of theaggressive promotion campaign implemented by the Ministry of Heath of the USSRin the 1980s. After the collapse of the USSR, a variety of contraceptivesavailable on the market has significantly increased, and this method becamenoticeably less common. In all the three countries under study, the rise in IUDuse persisted into the early 1990s, and then went down and levelled off in the2000s. Throughout the 1990s and the 2000s, Belarus experienced the highestprevalence of IUDs. The trends in IUD use in Russia and Ukraine differed in the1990s , but in the 2000sthey converged.IUD and pills are mutually exclusive. If one combines the use of hormonalcontraceptives with use of IUDs, one finds that the total contraceptiveprevalence increased from 28 to 41 per cent in Belarus and from 18 to 32 percent in Ukraine over the observed period of 1990–2010, whereas in Russiait has changed only slightly (25 per cent in 2010 versus 19–22 per cent inthe early 1990s).The data from the national sample surveys, which were carried out atapproximately the same time in Belarus, Russia, and Ukraine, show high levels ofcontraceptive use in all the three countries . The higcoitus interruptus); both these methods are consideredineffective. The pill is the fourth in the ranking: it is used by 11 per cent ofwomen in Belarus and Ukraine and by 12.5 per cent in Russia. These results aredifferent from official statistics  . The thiatistics , becauseatistics . OthertThe world's most popular method of contraception – sterilization– has not gained high popularity in Belarus, Russia or Ukraine. Accordingto the survey data, only 2.5 per cent of female respondents reported to haveundergone sterilization procedure in Belarus, 2.3 per cent – in Russia,and 1.3 per cent – in Ukraine. Cases of male sterilization are extremelyrare. The analysis of the Russian GGS data suggests that not all femalerespondents might have correctly understood the question concerning this method.There are grounds for suspecting that the prevalence of contraceptivesterilization might actually be even lower than shown by the survey resultsAbout one fifth of any method users in the three countries reported thesimultaneous use of several contraceptive methods. Some combinations of methodsindicated by one and the same woman, such as the simultaneous use of pills andimplants or IUDs and pills, or IUDs and sterilization, make no sense. Thehighest proportion of women reporting combined use of four or more methods isfound in Russia (1.3%); this proportion in Ukraine is 0.9%, and0.5% in Belarus. The reporting of the use of multiple methods may reflectfrequent migration from one method to another that reduces method effectivenessThe proportion of couples using only traditional methods of contraception inBelarusian and Russian samples constitutes 16.5 per cent; this proportion ismuch higher than what is reported in Western European countries. In Ukraine, itis twice as low, about 8 per cent only, but in the 1990s, the proportion ofusers of traditional contraceptive methods was substantially higher in UkraineThe analysis shows that the pattern of contraceptive behaviour considerablyvaries depending on the age of women .Young wothe unmet need for familyplanning, that is, to identify the proportion of couples who werefertile, did not wish to have a child in the near future, and did not practiceany means of pregnancy prevention. In order to calculate this indicator forRussia, we used the following GGS questions: “Do you intend to havea/another child during the next three years?”, “Is it possible foryou, yourself, to have a/another baby, if you wanted it?”, and “Doyou think it would be physically possible for your current partner/spouse tohave a child of his own, if he wanted to?”. In the MICS, questionsaddressing these issues were slightly differently formulated. We focused on thequestions allowing to distinguish respondents who could not get pregnant due tohealth-related reasons and those who wanted to get a child in the near future.For a better comparability with the Russian data, we selected those respondents,who were planning to have a child in 1–2 years or “soon”. Inother words, we selected women, who were at the risk of conception andintentionally did not use any contraception. The Ukrainian MICS additionallycontained a question: “What do you think, are you physically able tobecome pregnant now?”, which helped to produce a more accurate estimatefor this country as compared with Belarus.In addition, we tried to estimate According to our estimation, the lowest unmet need for family planning,experienced by 13 per cent of couples, is in Russia. In Belarus, it isexperienced by 16 per cent of couples, and in Ukraine – by 18 per cent.After standardization by age, the corresponding proportions remain almostunchanged. Irrespective of the observed differences, the unmet need in thesecountries is rather high by the world standards.Although the wording of the questions and therefore the way of how the index ofunmet need is estimated vary between the three countries, the unmet need inRussia is not likely to be higher than in Belarus and Ukraine. This brings us toa paradox – along with the highest level of abortions, Russia does notexhibit the highest unmet need for family planning.The logistic regression shows that women in Russia are more likely to use moderncontraceptives than women in Belarus or Ukraine. As expected, the odds of moderncontraception use decrease after age 40 , outlining the actionplan for the period until 2000. Further, in 2001, a Presidential Decree  was issued, which established the national program“Reproductive Health 2001–2005”. Finally, in 2006, the Cabinet ofMinisters set the program “Reproductive Health of the Nation” for theperiod until 2015 . The implementation of theseprograms involved establishing a network of centres and clinics providingreproductive health and family planning services as well as setting upyouth-friendly health facilities. These programs were successful in promotingresponsible sexual behaviour and raising awareness and knowledge of moderncontraceptive methods Although Belarus demonstrates the best achievements in reducing abortion incidence,no special programs that would promote family planning were initiated there.Reproductive health, sexual education, and other related issues were addressed inmore general documents such as the national program “Women of the Republic ofBelarus” or “The National Plan of Action for the Advancement of Women1996–2000”. The closest to the subject of family planning is “TheNational Program of Planned Pregnancy and Prevention of Miscarriage,2008–2010”, adopted in Belarus in 2008 . This program aims at promotinguse of and improving access to a wider variety of contraceptives; providing freecontraception to women and adolescents from socially disadvantaged families and alsothose with medical contraindications to pregnancy; as well as establishingyouth-friendly health facilities, which would include pregnancy and STD preventioncounselling.Russia was changing its stance in relation to family planning over time. In the early1990s, the wave of democratic reforms taking place in Russia helped to adopt thefederal target program “Family Planning”. In 1994, this program gainedthe support of the President of Russia  and wasintegrated into the program called “Children of Russia”. The program“Family Planning” was designed to fundamentally change societalattitudes towards human reproductive rights and to create conditions for theirrealization. For the implementation of this program, the Russian Ministry of Healthestablished a large network of centres for family planning and reproduction. Manyprofessionals attended special advanced courses and received extensive training inrelated areas. A great deal of effort was expended to improve sexual culture of theRussian population; expert groups developed programs of sexual education. Theseactivities encountered a strong resistance from some groups of the society. TheRussian State Duma (formed mainly by communists at that time) supported the campaignagainst the program, and its funding was excluded from the state budget in 1998.Programs of sexual education were never introduced in schools.The official position of the Government of Russia on having the right to familyplanning and reproductive choice as well as to safe, comfortable, and joyful sexuallife has always been and remains ambiguous. Two decades ago, the segments of societyholding traditionalist and fundamentalist views were either invisible or evennon-existent. Today, they constitute an influential social force, which stirs upnegative associations with and agitates against family planning. The belief in themyth that birth control is synonymous to low fertility and that broader access tofamily planning services inevitably leads to fertility reduction has become ratherwidespread. This myth has not only become part of folk common-sense, but also hassuccessfully penetrated the level of decision makers. The resumption of a program,similar to “Family planning”, is hardly possible given the currentpronatalist course proclaimed by the Government of Russia. On the contrary, many ofthe centres for family planning and reproduction created in the 1990s are graduallybeing closed due to lack of funding. Furthermore, by spreading fake informationabout abortion and its consequences for health as well as arguing about its moralunacceptability, the Government seems to be moving towards the decision that wouldrestrict access to abortion The Orthodox Church agitates extensively against advances in reproductive health andrights, and this is typical of all the three countries under study. However, inRussia, the Orthodox Church seems to exert an especially strong influence: itsuccessfully penetrated the public health decision-making process. The following isa quotation from the address by the Minister of Health and Social Development toparticipants of the second All-Russian Congress of Russian Orthodox doctors:“One of the important moments, where the role of the Church is especiallysignificant, is the protection of family traditions and values and the prevention ofand the reduction of abortions. We need to further pursue the campaign notifyingabout the harm caused to health by abortion, to inform people, particularly theyouth, about potential complications, to talk about the psychological impact ofabortion on women, and to create a proper mental attitude to motherhood” The hypothesis that the differences in abortion observed between Russia on the onehand and Belarus and Ukraine on the other hand is a statistical artefact was notconfirmed. Belarus, Russia, and Ukraine have liberal abortion laws and inter-countrydifferences in the regulations defining performance of abortion are minor. There areno legal barriers to availability or use of modern contraceptives in all thesecountries.The data collection systems, as far as abortion statistics is concerned, are similarin Belarus, Russia, and Ukraine. They share the same or at least similar advantagesand deficiencies, and the produced data are therefore of comparable quality andcompleteness. This finding allows to conclude that the divergence observed in thepost-Soviet abortion trends in these countries is a genuine phenomenon.Official statistics on the use of pills and IUD explain to some extent why abortionincidence in Belarus and Ukraine is lower than that in Russia. This suggests thatBelarusian and Ukrainian women who are eventually visiting medical facilities aremore actively using the two modern methods compared to their Russian counterparts.It is possible that the medical systems in Belarus and Ukraine are more committed topromoting and explaining the modern contraceptive methods among women which couldlead to more consistent and qualified use of these methods.This result contradicts to our findings based on the sample surveys. After adjustmentfor covariates, the Russian sample experiences higher odds of modern contraception. This finding isunexpected given the higher level of abortion in Russia. It is also surprising thatlow fertility and rapidly declining abortion rates in Belarus and Ukraine gotogether with the inefficient structure of contraceptive methods; this factattracted attention of other researchers too The paradoxical combination of higher contraceptive prevalence and higher abortionrate in Russia than in Ukraine was also noticed in the results of the 1999 surveysThus, the survey data did not give an explanation of why Belarus and Ukraineexperience greater progress in reducing abortion than Russia.In our opinion, the main source of the inter-country discrepancies lies incontraceptive behavior itself, in adequacy of contraceptive knowledge and practices.In other words, it is important that women who use modern contraception do it in aproper way. It might be that higher contraceptive culture in Belarus and Ukraine incomparison to Russia leads to inter-country differences in rates of contraceptivefailure. This explanation agrees with possible role of medical professionals thatcould underlie the growing gap between Russia and the two other Slavic countries inthe use of pills and IUD.The proportion of couples using traditional methods of contraception in these threecountries is higher than what is reported in Western European countries. It isnoteworthy that effectiveness of traditional methods can be very high: in the caseof consistent and correct use, the failure rate is only 4–5 per cent Differences in the state-implemented family planning policies in the three countriescould also contribute to the explanation of the higher abortion rate in Russia. TheRussian official  stance on family planning has changedin the recent years to a highly traditional and pronatalist one. The myth that birthcontrol is synonymous to low fertility and that better access to family planningservices inevitably leads to fertility reduction is very strong in Russia. Such anextreme turn in the governmental position regarding family planning is not observedin Belarus or Ukraine.The way in which information about contraception is obtained plays a significant rolein efficiency of its use. The quality of information obtained from the Internet andother types of mass media, friends and acquaintances significantly differs fromprofessional advice. Lack of medical services, sexuality education, and familyplanning promotion can result in inefficient contraceptive use and increase in therisk of unwanted pregnancy.The Orthodox Church extensively campaigns against advances in reproductive health andrights. This campaign covers all the three countries. However, in Russia the churchsuccessfully penetrated the decision making process in public health, and itsoverall influence on the Russian government is particularly strong.The latest developments related to family planning in Russia, which involveintroduction of further legal restrictions in access to abortion, confirmed ourguesstimates about the direction of the Russian governmental policies. We do notanalyze these legal changes in this paper, but if our reasoning is correct, theywill bring about a further growth in the abortion gap between the countries and mayeven terminate the ongoing decrease of abortion indicators in Russia.Figure S1Rates of decline in abortion in Belarus, Russia, and Ukraine, per 1000women aged 15–49.1990 = 100%.(PNG)Click here for additional data file.Figure S2Women aged 15–49 using IUD and hormonal contraception (pills), inper cent. MoHs data.(PNG)Click here for additional data file.Figure S3Age patterns of contraceptive use of women with a partner by method, inper cent. Source: Multiple Indicator Cluster Surveys (2005) forBelarus and Ukraine and the Generations and Gender Survey (2007) forRussia.(TIFF)Click here for additional data file.


More than half a million new items of biomedical research are generated every year and added to Medline. How successful are we at applying this steady accumulation of scientific knowledge and so improving the practice of medicine in the USA?The conventional wisdom is that the US healthcare system is plagued by serious cost, access, safety and quality weaknesses. A comprehensive solution must involve the better translation of an abundance of clinical research into improved clinical practice.Yet the application of knowledge (i.e. technology) remains far less well funded and less visible than the generation, synthesis and accumulation of knowledge (i.e. science), and the two are only weakly integrated. Worse, technology is often seen merely as an adjunct to practice, e.g. electronic health records.Several key changes are in order. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations. The absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened.It bears repeating that only by applying the wealth of existing and future scientific knowledge can healthcare delivery and patient care ever show significant improvement. How successful are we at s cost,  access, s cost,  safety, s cost,  fairnesss cost,  and quals cost,  weaknesss cost, ,7.A comprehensive solution must involve the more efficient translation of an abundance of clinical research into improved clinical practice ,9. Yet t11 and a commitment of around $500 million per year for the Clinical and Translational Science Awards, [The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency sponsoring the application of health services knowledge, but has a budget of less than $400 million per year. Adding the various translational research budgets in the National Institutes of Health (NIH) comes to less than $1 billion per year, with a focus predominantly on therapeutics as opposed to health services and care delivery. Despite unprecedented support at NIH’s most senior levels for translational research,Awards, ,13 thereAwards, . Given aAwards,  the amouSeveral key changes are in order. We argue that the absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a more mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations.Science is generally considered the search for and construction of theories about cause[new processes. Technology is the application of existing knowledge; its models allow most everything to vary. Simply put, science is the ‘why’, while technology is the ‘how’ of improvement.out cause. ScienceAdvances in scientific knowledge in medicine are well-known and manifold and steady scientific progress will continue to lead to incremental improvements in accumulated knowledge. But only the appropriate and effective application of technology, through successful modification and application of existing knowledge, can realize the promised gains in cost, safety and efficacy.In the health care domain, however, technology is best known as an enabler of process standardization and communication between providers . The fedYet electronic health records and process control do not capture the full potential of what technology can offer. For example, by integrating existing knowledge from behavioral science, organization science, engineering and clinical research and applying this in simulated environments, technology can improve and redesign existing care processes as well as engineer new ones.More generally, technology allows researchers and stakeholders to overcome the inherently complex, interacting and dynamic nature of healthcare systems . It is dand the mix of patients admitted to the system).This approach of holding many factors constant, and making small, incremental changes in a small number of factors is described as local optimization. However, such local optimization may hide the much larger impact of global optimization: making a larger number of coordinated changes to multiple components at once (e.g. the configuration of a medical instrument, the training of a provider To view this conceptually, consider a system’s performance as being highly non-linearly impacted by two factors. Here non-linearity signifies that the response of a system to one factor changes both with the level of that factor and the level of the other factor, and that those responses vary in a complex way. One way to visualize this is by taking a three dimensional coordinate system. Plot the levels of the two factors in the two horizontal dimensions and let performance be measured in the vertical dimension.The non-linearity of the relationships between the two factors and overall performance leads to a rugged ‘performance landscape’ with hills, ridges and valleys representing respectively better performance, knife-edge performance and worse performance for particular combinations of the two factors . Local oin vitro experimentation.There is a trade-off between results and effort in contrasting these two different types of optimization. Local optimization is straightforward: for example, a simple regression analysis will suggest that a factor is significantly related to overall performance. However, global optimization often requires advanced simulation and modeling technology. Similar to other complex domains, these approaches are indispensable in a clinical context since the results of hypothesized changes to multiple system components cannot be predicted ahead of time and require Consider the differences between traditional research and applied research in, for example, improving the quality of intensive care for cardiovascular disease. A common clinical imperative is to measure and reduce variability and improve end outcomes through process standardization and improvement . ClassicOn the other hand, a holistic simulation approach, using real-time data, could allow for safe experiential learning and experimentation, and thus significant improvements in the quality of such intensive care . CoupledThis trade-off between the ease of approach and potential benefits may also partly underpin the well-known phenomenon of the ‘flattening of the curve’ that represents US progress on health outcomes over time. Despite continual advances in accumulated knowledge, healthcare system performance often appears to have reached a plateau in the US . This isClinical medicine is becoming increasingly comfortable with the use of technology to store patient data and guide the provision of care . A similTo redress this, we believe, requires an unavoidable change in funding priorities and a substantial increase in the level of funding for technology development and the application of existing scientific knowledge. Equally important is how such scarce funding resources are allocated. Merely raising the proportion of NIH funding for applied research or increasing AHRQ’s limited budget will not suffice, especially if funding is generally limited to projects involving the adoption of commercial off the shelf based technologies such as electronic health records.To truly reap the returns on science-based research, the increased funding for technology development must also be better integrated with science-based research. Adapting the mission orientation of the Department of Defense, basic clinical science research must also include technology transition plans. In this different paradigm, research conducted ‘upstream’ with the objective of increasing scientific knowledge must be held closer to account in terms of ‘downstream’ applications and ultimately delivering mission-critical performance.While our focus in this article is on the US health system, it is noteworthy that other large healthcare systems have wrestled with similar concerns and have implemented similar recommendations as ours. For example, in the UK, the proportion of total funded research activity accounted for by basic biomedical research was most recently estimated as approximately two thirds of which the majority was laboratory-based biomedical research . AnotherIn the Cooksey Report, Sir David Cooksey examined publicly funded healthcare research and sought to provide recommendations to optimize its potential to benefit patients, the National Health Servie and the wider healthcare economy, on behalf of the UK Treasury. This inquiry found that the UK risked failing to reap the full economic, health and social benefits of the large investments being made by taxpayers into health research .In particular, the report diagnosed an absence of an overarching strategy to translate ideas from basic and clinical research into the development of new products and approaches to treatment of disease and illness. Similarly, another key gap noted was the absence of a strategy to implement those new products and approaches into clinical practice. Both gaps are ones we argue are still present in the US healthcare system.To a more limited extent the Report’s recommendations on prioritizing projects in view of potential downstream significance are also in line with our recommendation to insist on an implementation plan for all basic research, tying them more closely to applied research . Beyond To a large extent, the degree of non-market control of research and practice by centralized decision-makers is arguably much stronger in the UK’s essentially nationalized delivery system with centralized cost and comparative effectiveness functions. We are not convinced that changes to practice in the US will occur through organizational and cultural changes alone. We believe that demand-side consumer incentives and supply-side payment reform as well as institutional innovation in the markets for insurance and provision of care will be required .We remain convinced that system performance can improve and that any real reductions of the returns to investment or innovation are still far off. This performance deficit could, we argue, be addressed by implementing and applying some of those half a million items of scientific knowledge recently accumulated. This would be a good start to improving the practice of medicine in the US. These transformational improvements in the practice of medicine could have positive impacts in other countries around the world as well, as dissemination of applied knowledge and innovations improves .The next step is making sure that the next million funded pieces of scientific research are also coupled to technology applications to the fullest extent possible. It bears repeating that only by applying the wealth of existing and future scientific knowledge can healthcare delivery and patient care ever improve.The authors declare that they have no competing interests.Both authors are equally responsible for the paper. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/12/103/prepub


Thyroid cancer is the most common malignancy of the endocrine system. The diagnosis of thyroid nodules, made by neck examination and ultrasonography, is a common event occurring in over 50% of the patient population over the age of 50. Yet, only 5% of these patients will be diagnosed with cancer. Fine needle aspiration biopsy is the gold standard for diagnosing thyroid nodules. However, 10–15% of these biopsies are inconclusive, ultimately requiring a diagnostic thyroid lobectomy. Consequently, research in thyroid biomarkers has become an area of active interest. In the 40 years since calcitonin was first described as the biomarker for medullary thyroid cancer, new biomarkers in thyroid cancer have been discovered. Advances in genomic and proteomic technologies have defined many of these novel thyroid biomarkers. The purpose of this article is to provide a comprehensive literature review of how these biomarkers have evolved from simple screening tests into a complex array of multiple markers to help predict the malignant potential and genetic signature of thyroid neoplasms. It has been over 40 years since biological markers were first introduced as a way to detect and manage thyroid cancer ,2. As thIn theory, biomarkers should tip the scales in favor of early detection. According to the most recent statistics in 2009, the incidence of thyroid cancer accounts for approximately 37,200 cases, yet causes only 0.29% of all cancer deaths . Althougen route to its transformation from a benign to a malignant state , phosphatidylinositol 3-kinase [PI3K], c-jun N-terminal kinase [JNK]) from RET-MEN2A and RET-MEN2B expressing cells. There were 41 phosphotyrosine proteins detected downstream following RET activation from two different medullary thyroid cancer cell lines and the EGFR pathway was over-expressed. It is hoped that this information might provide new targets for anti-cancer therapies. The analysis of proteomics coupled with the analysis of gene array expression and epigenetic changes is unraveling the oncogenic pathways for the development of targeted therapeutics, as seen in breast, prostate and colorectal cancer [A 2009 study reported the presence of chniques . The stul cancer .The study and identification of biomarkers in thyroid cancer has a long history. From the beginning, the goal was to find markers that can identify benign and malignant thyroid tumors and to predict the behavior of these thyroid cancers. The evolution of thyroid biomarker research reflects the standard thinking of the time and has changed in parallel with the advancement of technology. Although thyroid cancer is one of the least deadly forms of cancer, research in the field has remained on the cutting edge of science and technology, but better diagnostic tests and predictors of tumor aggressiveness are necessary. “Finding a cure” for thyroid cancer should remain a strong impetus for continued research to identify new biomarkers and therapeutics for this disease. RET point mutations are used to predict susceptibility and prognosis of a patient with familial medullary thyroid cancer. None of the other biomarkers reviewed in this study are currently in routine clinical use, but are being used as building blocks for the future to improve treatment.This review highlights the fact that even though a significant amount of progress has been made in cancer research, we are only at the beginning of fully understanding how normal cells progress to tumors. This is why many thyroid cancer biomarkers have been identified, but few have made it into routine clinical practice. Calcitonin and thyroglobulin are markers for disease recurrence after surgical resection, and the Biomarker research continues to advance. Serum-based markers are moving from proteins secreted by tumors to detecting minute amounts of genetic material being shed by the tumor into the circulation. DNA mutations are still being studied and discovered, and have progressed from single mutation discoveries to the synthesis of “mutation pathways” and panels of DNA mutations as a single “signature”. Epigenetic regulation has become a part of biomarker research, and will increase in use as a biomarker as our understanding of these processes improves. High-throughput technologies have advanced our ability to study the human genome, but much work in the field still needs to be done in the validation and quality control of the outcome data. These technologies have also greatly expanded our ability to study the proteome, going from the study of single proteins to identifying proteomic signatures of thousands of expressed proteins. We have also begun to see a crossover of the different disciplines. Proteomics is being applied to serum-based studies, genomics is helping to identify new DNA mutations, and epigenetic regulation has changed our understanding of how DNA regulation takes place. Thyroid biomarker investigations were once the realm of a single scientist working on elucidating the mechanisms and utility of a single biomarker. We are moving into an era of biomarker research that requires a multi-disciplinary team of biologists, geneticists, statisticians, oncologists, surgeons, and even engineers. This team has the task of understanding and interpreting data from new technologies and incorporating these findings into our understanding of tumor formation. It may be that a combination of serum based biomarkers, epigenetics, genomics, and proteomics will be required to produce reliable and clinically helpful biomarkers. It could also be that ideas and mechanisms that have not yet been discovered will be the key to thyroid biomarkers. New areas of study like metabolomics, the study of the end products of cellular processes, and the kinome, the full complement of human protein kinases, have not been studied in thyroid cancer. Thyroid biomarker discovery remains an exciting field of thyroid cancer research, and will remain on the cutting edge of technology.


Cipangopaludina chinensis and Unio douglasiae, both of which are currently food for humans. The shells are well preserved and have no signs of abrasion. They are all freshwater gastropods and bivalves found in pits without water-reworked deposits and have modern representatives which can be observed in rivers, reservoirs, and paddy fields in the studied region. Mollusk shells were frequently recovered in association with mammal bones, lithic artifacts, and pottery. These lines of evidence indicate that the mollusks are the remains of prehistoric meals. The mollusk shells were likely discarded into the pits by prehistoric humans after the flesh was eaten. However, these mollusk remains may not have been staple food since they are not found in large quantities. Mollusk shell tools and ornaments are also observed. Shell tools include shell knives, shell reaphooks and arrowheads, whereas shell ornaments are composed of pendants and loops. All the shell tools and ornaments are made of bivalve mollusks and do not occur in large numbers. The finding of these freshwater mollusk remains supports the view that the middle Holocene climate in the Guanzhong Basin may have been warm and moist, which was probably favorable to freshwater mollusks growing and developing in the region.Mollusk remains are abundant in archaeological sites in the Guanzhong Basin of Northwestern China, providing good opportunities for investigations into the use of mollusks by prehistoric humans. Here we report on freshwater gastropod and bivalve mollusks covering the time interval from about 5600 to 4500 cal. yrs BP from sites of Mid-Late Neolithic age. They are identified as  Mollusks are the second most common members of the animal kingdom and have played particularly important roles in geology since the 1820s, including biological evidence for the hypothesis of continental drift and strong evidence for Lyell to create the term ‘Pleistocene’. Thereafter, most of the fossil mollusk studies have been on the palaeoenvironmental information that can be obtained from studies of mollusk assemblages, rather than on their role in human subsistence As one of the edible organisms, mollusks provide a considerable amount of food consumed by humans both present and past. Two major classes of them, gastropods and bivalves, are utilized to meet this demand because they are easy to obtain and rich in nutrition The Chinese Loess Plateau (CLP), located to the northeast of the Tibetan Plateau, is a key region for studies of environmental archaeology, especially for studies of agricultural origins, since archaeological sites particularly of Neolithic age are widely distributed and excavated. Previous studies on prehistoric foods in the CLP focused mainly on large animals and dry farming plants Mollusks are the most frequent and abundant fossil remains in the loess sequences and Neolithic archaeological sites in the CLP. Most of previous studies on fossil mollusks in the CLP have focused on paleoenvironmental information recorded by mollusk assemblages The Guanzhong Basin is located in the central part of the Yellow River valley, with the main part of the CLP to the north and the Qinling Mountains to the south . It is cCannabis sativa) and canola  The Neolithic sites are extensively distributed in the Guanzhong Basin, making it an important region for studies of prehistoric human activity In the summer of 2007, we undertook investigations of environmental archaeology at six Neolithic archaeological sites in the Guanzhong Basin: Quanhu, Yangguanzhai, Huxizhuang, Anban, Wangjiazui, and Shuigou from east to west . During 2. It is located at Quanhu and Anbao villages (about 8 km east of Huaxian County and 6 km south of the Weihe River) in the second terrace of the Weihe River in the eastern Guanzhong Basin , excavated during 1958–1959, is a large prehistoric settlement of about 600 000 mng Basin . The arcng Basin . We succng Basin . In the 14C dating sample were taken from pit AB-AH2. Further treatment and identification was performed in the laboratory as we did for the samples from the Quanhu site. Mollusk identification was carried out according to descriptions and plates published by Hu et al.  and Liu et al. (1979) The Anban site  is located at Anban village, about 4 km southeast of Fufeng County in the western Guanzhong Basin . It is aALPAL was used to calibrate these dates 14C dates obtained in the Laboratory of Nuclide and 14C Chronology of the Institute of Geology and Geophysics, Chinese Academy of Sciences. CALIB REV 5.0.1 was used to calibrate the dates All the radiocarbon samples from the Quanhu and Anban archaeological sites were measured and have been published by Zhang et al. (2010) In order to further investigate exploitation of mollusk shells by prehistoric humans in this region, we made statistics of types and quantities of shell tools and ornaments in seven archaeological sites, Quanhu, Jiangzhai, Baijiacun, Huxizhuang, Anban, Beishouling, and Guantaoyuan, from east to west in the Guanzhong Basin, based on the excavation reports of these sites Mollusks are relatively abundant in pits at archaeological sites in the Guanzhong Basin. As recorded in the excavation reports, there were more than 2500 shells in three pits found in the 1958–1959 excavations at Quanhu Cipangopaludina chinensis  and Unio douglasiae  all of the shells collected are well preserved in pits with whole shells undestroyed and no obvious signs of abrasion; 2) all the mollusks were found in pits where no water-reworked deposits were observed, but all the mollusks are freshwater gastropods and bivalves, large in size, indicating that they are not in situ fossils deposited in the pits; 3) all the mollusks have modern representatives, which can be observed in rivers, reservoirs and paddy fields in the studied region and they are still delicious foods nowadays; 4) As described in the excavation reports of the Quanhu and Anban archaeological sites Since land snails are probably one of the first domesticated animals, as suggested by Fernández-Armesto (2002) Cipangopaludina chinensis should really be considered as a seasonal food resource since its activity mainly focuses on seasons during which water temperatures are higher than 10–15 °C and lower than 30 °C, Therefore, the most possible collection season should be concentrated on months from April to October in the Guanzhong Basin. Based on these observations and the information currently available, we deduce that mollusks in the archaeological sites of the Guanzhong Basin appear to represent occasional gathering and consumption events.It has been pointed out by several researchers that mollusks should be considered a secondary and non-staple resource because they are not available all year Previous studies had shown that the prehistoric populations had exploited rice, millet, wheat, barley, oats, soybean, and buckwheat as food in the Guanzhong Basin during the Mid-Neolithic Macrochlamys angigyra and Punctum orphana, were dominant during the middle Holocene, showing warm and moist climate condition prevailed Exploitation of mollusks by prehistoric human groups is not limited to foods. The appearance of ornaments such as pendants since the Paleolithic marks an important step in the evolution of human behavior. Comparatively standard ornament forms were made of shell, tooth, ivory, or stone It should be pointed out that the periods of 5600–5000 yrs and 5000–4500 yrs correspond to Late Yangshao Culture and Early Longshan Culture, respectively, which may have different shell tools or ornaments. However, we can not discuss the evolution of the shell-tool shapes and their relationship with environmental/climatic changes based on the material presented in this study because the present sample resolution and materials are not enough to address this issue. It remains to be studied by high resolution data and mollusk shells.Cipangopaludina chinensis and Unio douglasiae, are the main species excavated from the archaeological sites in the Guanzhong Basin. They were deposited in pits which had not been reworked by water, and are well preserved with no signs of abrasion, indicating that they are not in situ fossils deposited in the pits. Their modern representatives can be observed in rivers, reservoirs and paddy fields in the studied region and used as food presently. Moreover, mollusk shells are frequently recovered in association with mammal bones, lithic artifacts, or pottery. These lines of evidence indicate that the mollusks found in the archaeological sites in the Guanzhong Basin are the remains of prehistoric meals. However, these mollusk remains may not be staple food in the Guanzhong Basin since they are not in large quantities. Shell tools include many shell knives, shell reaphooks and several shell arrowheads, whereas shell ornaments are mainly composed of pendants and furthermore a few shell loops.Mollusks are abundant remains in the archaeological sites in the Guanzhong Basin. We report exploitations of mollusks by prehistoric populations in this region in Mid-Late Neolithic age, mainly as subsidiary food and furthermore as tools and ornaments. Results showed that freshwater gastropods and bivalves, It should be pointed out that there are plenty of Neolithic archaeological sites in China, which contain abundant mollusks remaining to be investigated and studied. We only investigated mollusk remains in the archaeological sites in the Guanzhong Basin. More studies are needed to focus on the mollusks in other archaeological sites, which could provide new evidence and knowledge for our understanding of mollusks and prehistoric humans. Forthcoming studies need to address other questions related to the role of mollusks in the subsistence strategies of human groups, such as the collection patterns, the forms of preparation and consumption.


Community Eye Health Journal who are responsible for managing trachoma programmes at national, regional, or district level need to be familiar with the requirements for Zithromax® donation. The generous global donation of the antibiotic Zithromax® by Pfizer Inc. through the International Trachoma Initiative (ITI) can play an important role in the successful elimination of blinding trachoma. Therefore, the procedures required to apply for and manage the product need to be understood and followed.All readers of the Countries obtain donated Zithromax® through an application to ITI. The application is a cooperative process through which ITI, governments of trachoma-endemic countries, and other partners work together towards the national goal of eliminating blindness caused by trachoma.Since 1998, ITI has managed Pfizer's donation of Zithromax® This drug is an effective broad-spectrum antibiotic that, when administered once annually for a consecutive number of years, works to reduce the reservoir of Chlamydia trachomatis infection in endemic communities. By distributing antibiotics in conjunction with surgical interventions, health education, and increased access to water and sanitation (known as the SAFE strategy), national trachoma programmes can stop disease transmission and progression to blindness.Since the International Trachoma Initiative's inception, Zithromax® has been donated to 23 countries and over two hundred million doses have been administered. Careful planning is required to ensure that national programmes receive the right quantity of drugs in a timely manner and that appropriate supply chain systems are in place to manage the product when it arrives in the country where it will be used.The Zithromax® application process starts nearly eighteen months before the drug arrives at its destination. It requires a dialogue between the relevant ministries of health, ITI, Pfizer, and international implementing partners . The complex supply chain begins with Pfizer's suppliers, who provide raw materials, bottles, and packaging. Pfizer then manufactures the drug and arranges transport to the endemic countries. On arrival, the government, represented by the ministry of health, is expected to clear the drugs, store them safely, manage their distribution through mass drug administration (MDA), and implement the other elements of the SAFE strategy.ITI works directly with national trachoma programme managers who are designated by the ministry of health. ITI sends a new application form each year in November and the ministry must submit the completed application by February the following year. The application includes district-level data on past treatments, the latest trachoma prevalence data, a long-term forecast, and a current drug inventory. Despite the difficulty of forecasting in the long term, a 3-5 year needs assessment is critical to planning. The application process allows ITI to see whether there are programme gaps, allows Pfizer to plan raw material requirements, and allows the ministry of health to review their country plans and to ensure that partners are available to assist with all aspects of the SAFE strategy.Between February and April, ITI analyses the data on drug requirements from all existing countries and new country applicants. Prior to the World Health Organization (WHO) annual trachoma alliance meeting (GET2020) in April, each country representative meets with members of ITI, Pfizer, WHO, and other implementing partners and key stakeholders in order to review the plan and produce a forecast of Zithromax requirements. This meeting also provides an opportunity to assess partner support for SAFE strategy implementation and to review baseline and impact prevalence surveys.From these meetings, Pfizer can determine the overall drug requirements. The company can then plan manufacturing capacity for the following year, taking into account other business requirements. Any missing or additional data required for the applications is followed up by ITI in May.In June, a final Zithromax® application is reviewed by the Trachoma Expert Committee (TEC), an independent body of international experts in public health, ophthalmology, blindness prevention, and the SAFE Strategy. TEC members provide guidance to ITI on strategic, technical and operational issues during two semiannual meetings. Based on the TEC recommendations, each ministry of health applying for Zithromax® is sent either a memorandum of understanding (MOU) for the following year detailing the quantity of Zithromax® and the districts approved for distribution, or a letter explaining why the country application was unsuccessful with suggestions to help the country to meet requirements in the future.Once the MOU has been signed by the ministry and returned to ITI, delivery of Zithromax® is scheduled for approximately one to two months prior to the time when MDA is to take place. For countries that are already involved and that have received Zithromax® in past years, there needs to be an updated inventory of any drugs already in the country, including those with a short shelf life and those about to expire. On the basis of this information, adjustments to the donation forecast are made.www.trachoma.org/guides-and-manualsCurrently, Zithromax® is manufactured in two formulations, pediatric powder for oral suspension for children ages six months to five years, and tablets for people over five years of age. The product is manufactured at various sites in Europe or the USA. Once manufactured, the product is stored in one of Pfizer's European warehouse locations where the goods await allocation to recipient countries. Due to the large size of each shipment , several airplane loads may be required. Upon arrival in the country, the ministry of health must ensure customs clearance and transport to central medical stores and to regional warehouses in preparation for MDA. All charges are the responsibility of the ministry of health. A detailed description of best practices for in-country supply chain can be found in “Zithromax® in the Elimination of Blinding Trachoma: A Program Manager's Guide” at The Zithromax® donation is available only to governments of poor endemic countries for the elimination of blinding trachoma. Countries that have been approved for the donation may use it for MDA, administration after trichiasis surgery, or as part of surveillance or prevalence surveys, in addition to special pre-approved uses by ITI and the TEC.National ownership and proven commitment to the elimination goal is key for a successful application and continued donation of Zithromax® The requirements for Zithromax® donation  may be demanding for under-resourced and overstretched national health programmes. However, they are necessary to manage and monitor the Zithromax® donation to aid in the elimination of this painful and blinding disease.


It has been said that women hold up half the sky. In the HIV epidemic, women carry half the burden of the epidemic, perhaps even more. The HIV burden on women is dramatically higher in some regions, certain age groups and among marginalized groups, such as female sex workers. Women's vulnerability to HIV is exacerbated by gender inequality and domestic violence.The global effort towards elimination of paediatric HIV and keeping mothers alive deserves applause. However, the needs of women go beyond their child-bearing age or potentials and/or reproductive desires and must be recognized in the global HIV agenda. In particular, more female-controlled prevention tools are urgently required to allow women to protect themselves.Journal of the International AIDS Society is pleased to launch a thematic series to highlight articles that address the different dimensions of HIV as they relate to women.It is time to turn the tide through promoting gender equality and genuinely committing to gender-responsive policies and programmes, and encouraging a more gender-aware research agenda that can generate necessary evidence. In recognition of International Women's Day, the  It has been said that women hold up half the sky . In the The HIV burden on women is dramatically higher in some regions: in sub-Saharan Africa and the Caribbean nearly 60% of people living with HIV are women. In certain age groups, women are also at greater risk of HIV infection: adolescent girls in sub-Saharan Africa constitute 71% of all youth aged 15 to 24 living with HIV . FurtherIn general, women's vulnerability to HIV acquisition is exacerbated by gender inequality and domestic violence. Addressing gender-based violence in national HIV programmes has been proven to reduce the risk of HIV transmission, encourage HIV disclosure and improve adherence to antiretroviral therapy (ART) , 6. MoreIt would be simplistic to measure the burden of the epidemic only in terms of epidemiological data. Women carry a disproportionately large burden as primary caregivers for HIV-positive family members and also shoulder most of the unpaid household work. More equitable caregiving responsibility between men and women is a fundamental, though often forgotten, aspect of the global response. As a featured theme of the on-going 57th Commission on the Status of Women, a renewed effort to urge actions for an equal sharing of responsibilities in the context of HIV caregiving between men and women is therefore welcome [The global HIV community has taken steps towards addressing the changing face and the feminization of the epidemic, with some noticeable success. Owing to an accelerated effort in line with the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, the proportion of pregnant women living with HIV and receiving antiretroviral therapy in the 21 high priority countries in sub-Saharan Africa indentified in the Global Plan jumped from 16% in 2009 to 48% in 2011 [The needs of women, however, go beyond their child-bearing age or potentials and/or reproductive desires and must be recognized in the global HIV agenda. According to the UNAIDS 2012 country progress report, of the total HIV funding allocated for women in 2009 to 2011, 71% was invested in prevention of vertical transmission, and only 5% was allocated to prevention of gender-based violence , 9.The concept of “know your epidemic” is an important mantra that has been rightfully advocated, though it has not been extended fully to women. Data on HIV prevalence and treatment coverage reported by countries do provide a general overview of the HIV status in men and women. However, details with respect to different sub-populations are frequently absent, and data are seldom disaggregated by sex or age. Structural barriers apply to women regardless of age and sexual preference, and are influenced by complex gender dynamics and intertwined with socio-economic factors that reduce women's ability to protect themselves from HIV infection. Gender dimension must be integrated into programmes and accounted for across the continuum of care.Journal of the International AIDS Society is pleased to launch a thematic series to highlight articles that address the different dimensions of HIV as they relate to women. With this launch, we are also welcoming new contributions.In recognition of International Women's Day, the et al., published in this thematic series, the authors provide insight into such factors as stigma, fear of intimate partner violence and loss of financial support in case of abandonment as barriers to HIV disclosure by HIV-positive pregnant women to their partners [et al. provide an overview of what is considered to be female-specific programmes and propose a conceptual definition of women-centred programming in the context of HIV [et al. sheds light on the complex challenges faced by LBQT women, underlining the negligence of the HIV risk for this population, translating into an absence of directed efforts [In an article by Rujumba partners . To bettt of HIV . A quali efforts .Other relevant contributions are underway, and we welcome additional submissions that can fill the outstanding gaps on issues pertaining to women living with, at risk of or affected by HIV across ages and sub-populations.More than 30 years into the epidemic, it is time to turn the tide through promoting gender equality and genuinely committing to gender-responsive policies and programmes, and encouraging a more gender-aware research agenda that can generate necessary evidence.


Transnational or cross-border higher education has rapidly expanded since the 1980s. Together with that expansion issues on quality assurance came to the forefront. This article aims to identify key issues regarding quality assurance of transnational higher education and discusses the quality assurance of the tropEd Network for International Health in Higher Education in relation to these key issues.Literature review and review of documents.From the literature the following key issues regarding transnational quality assurance were identified and explored: comparability of quality assurance frameworks, true collaboration versus erosion of national education sovereignty, accreditation agencies and transparency. The tropEd network developed a transnational quality assurance framework for the network. The network accredits modules through a rigorous process which has been accepted by major stakeholders. This process was a participatory learning process and at the same time the process worked positive for the relations between the institutions.The development of the quality assurance framework and the process provides a potential example for others. Transnational or cross-border higher education has rapidly expanded since the eighties . Since tAccording to UNESCO 2005 the definition of cross-border HE is: “includes higher education where teacher, student, program, institutions/ provider or course materials cross national jurisdictional borders”. Cross-border higher education and transnational higher education are often used interchangeably [The definition of quality assurance in HE has evolved in the last ten years. Woodhouse  referredSchüle (2006) defines a double and joint degree as follows, using as a basis the definition provided by the European Commission (latest update 2009): a “double degree: two nationally-recognised diplomas issued separately by the universities involved in the integrated study programme”, and a “Joint degree: a single diploma issued by two or more institutions offering an integrated study programme. The single diploma  is signed by the rectors of all participating universities and recognised as substitute of the national diplomas” ,18.http://www.troped.org). The tropEd General Assembly (GA) of the network meets three times a year. Full members in the network are institutions of higher education recognized by a national authority. The voting members are 1 representative of each institution who is a full member; voting results are by majority.The initiative to create a higher education network in international health came from the directors of public/tropical health institutions who collaborated in Tropmedeurop, an association centred on tropical medicine education in Europe, in 1994. A new formalized network focused on education was established in 1996, initially with 13 institutions in Europe, named TropEdEurop. Now renamed, tropEd, the network includes more than 30 institutions of higher education in international and global health in Europe, Africa, Asia, Australia and Latin America. The tropEd network includes almost all institutions in Western Europe offering a MIH and a range of institutions outside Europe offering modules, the word largest network for a Master in International Health , see Figure In addition to the degree from their home institution, graduated Masters students receive tropEd recognition if they complied with the following criteria in addition to the mobility requirement: at least two years of relevant professional experience of which at least one year in low- and middle-income countries/societies, Master degree obtained from home institution and completion of the masters program within 5 years. In 2010, there were 479 students from different home institutions registered in the tropEd network.Given the number of partners involved in the development and functioning of the educational network, the diversity of national structures, traditions and educational practices, there has been an consistent need for quality assurance to generate and maintain high quality standards of education.This article aims to identify key issues regarding quality assurance of transnational higher education and discusses the quality assurance of the tropEd Network for International Health in Higher Education in relation to these key issues.The methods used were literature review and review of documents of tropEd.For the literature review the search terms were: higher education AND  AND quality assurance or quality improvement or quality control or accreditation or quality standards or joint degrees or double degrees or “international accreditation”. The databases searched were Pubmed, Google Scholar and Scopus. The Search period was 1990 – 2011, the search date: 13 July 2011. Keywords were searched in title/abstract/keywords; the language was limited to English. This led to 94 unique titles, of which 41 were considered relevant by the first three authors. Articles discussing distance higher education, quality assurance of professions, quality improvement, total quality management or focusing on one country only were excluded. The first author reviewed all 41 articles; the second and third author read each half of the articles (ie 20 and 21 articles). The articles were discussed until four major themes emerged as mentioned below.The research team reviewed the following documents of tropEd: all GA meeting minutes, from 2005–2011, all minutes of the Quality Assurance Committee (from 2005–2011), all minutes of the troped Erasmus Mundus consortium (2005–2011), statutes, profile, strategic plan, work plan, annual plans, procedures and guidelines, for example: guidelines for core course and optional/ advanced modules, ethical guidelines, handbook for core course/ advanced module accreditation, professional profile, institutional self-evaluation form, and forms for tropEd recognition as well as thesis guidelines using a checklist and a topic list. The checklist centered on the accreditation of the advanced module and core courses ie numbers and year. The topic list included topics such as development process of criteria, institutional agenda, transparency, decision making.Almost all relevant articles found in the literature search dealt with issues of quality assurance internationally relating to when a higher education institution ventured towards other countries either through branch campuses, franchising courses or working with partners to jointly deliver educational programs. In reported cases, most featured the USA, Great Britain or Australia ,19-22. HKey themes regarding quality assurance of cross-border education which emerged from the literature review and the tropEd experience are explored below: true collaboration versus erosion of national education sovereignty, equivalence and comparability of quality assurance frameworks, accreditation agencies and transparency.1. True collaboration versus erosion of national education sovereignty1.1. LiteratureIn the literature Hodson argues that the then existing collaborative audit approaches in ‘overseas’ higher education lacked cultural sensitivity . Both Gi1.2. tropEdparticipatory learning for all members: from the beginning, the network decided not to have a separate curriculum committee, but rather to have every institution involved. The GA decided to aim for an open process, where the GA acted as the curriculum committee, so each member could read and comment on each core course and advanced module.In the tropEd network the developed quality system was created through process of developing the quality assurance often a small group of interested representatives from different institutions worked together on different topics. This process was quite informal: during a discussion in the GA an issue needing elaboration would be identified, no terms of reference were made, and every interested GA member could join the discussion. The group would come together, sometimes during the GA meeting or sometimes in small-group meetings in between the GA meetings. Results of the discussions would be brought back and re-discussed in the GA. When necessary the small group would take the comments and suggestions from the GA and further revise before returning it to the GA for consensus. Through this process the network developed a number of documents and guidelines i.e. guidelines for core course and advanced modules, ethical guidelines, a strategic plan for the network, handbook and forms for tropEd recognition as well as thesis guidelines.During the resistance to change or to proposed procedures sometimes emerged. Within the network this resistance was often addressed through informal discussions.As in any multicultural and multi-country network with different interests, institutional agendas i.e. difference in course fee or difference in institutional procedures. These agendas were clarified, often during the GA and informal discussion, and then issues were reviewed, and possible accommodation or help/ support was offered to the members on how to deal with the resistance within the institution.Sometimes resistance emerged due to To foster student mobility and with initial members being only European institutions, the network adopted the European Credit Transfer System (ECTS), given its explicit design to foster mobility within Europe. The institutions outside Europe who joined the network later kept their own credit system, while using the ECTS for tropEd students.2. Equivalence and comparability of quality assurance frameworks2.1. LiteratureAccording to literature from the nineties onwards, increasing international mobility, and therefore international comparability, became an important issue, especially in Europe and the USA ,24. Qual2.2. tropEdinstitution the GA developed a standardized procedure, thereby checking its quality: the new institution has to subscribe to the definition of International Health by tropEd, complete a self evaluation and undergo an institutional site visit. The GA which meets three times a year, decides on official admission to the network through deliberation and voting. The GA developed a guideline for the self evaluation which includes details regarding i.e. academic background, faculty, services, research and resources and the site visit, which details i.e. discussion with students, staff, management and an ocular survey of the teaching and learning facilities. During the last five years (2007–2011) 18 institutions applied to become a member, 13 institutions were visited during a site visit, 10 of those institutions became a member of the network (tropEd GA meeting minutes 2007–2011). One became a member in 2012, other institutions’ membership is still pending or they declined.In the tropEd network to admit a new To develop the Masters program at the start of the network in 1996 the GA defined standards for the core course, advanced modules and thesis. In 2004 the GA developed a professional profile of the graduate MIH, including professional competencies and overall learning objectives.For the core course and the advanced modules the GA developed quality criteria. Later the criteria for the assessment of the core course and advanced modules became more refined, including title, learning objectives, content and alignment of assessment with learning objectives. Subsequently, further criteria were developed to support more in-depth learning, i.e. aligning learning methods with learning objectives and assessment. The curriculum content was checked for appropriateness to Masters level.binding: if an institute submitted a core course or module which the GA did not accept, the core course or module would be rejected and the representative needed to go back to the institution to re-discuss the core course or module for resubmission. In the minutes of the GA the written explanation was provided as to why the core course or advanced module was rejected. The GA needs to review and accredit the core course and advanced modules every five years. According to tropEd regulations the Executive Committee approves the core course or advanced modules with minor changes upon resubmission. The GA needs to approve major changes.The guidelines for the core course and the advanced modules were From 2007–2011 the GA reviewed 8 core courses of the 8 home institutions; 2 were accepted at once, 4 had to be resubmitted with minor changes and 2 to be resubmitted with major changes, see Table From 2007–2011 the GA reviewed 269 advanced modules, of which 71 were accepted at once. Out of the 195 rejected advanced modules, 84 modules had to be resubmitted with minor changes. The other 111 modules required major changes. Three were rejected, meaning that they were not suitable for the MIH, see Table For the thesis, as guidelines per institution differed, the GA developed generic thesis requirements, including ethical guidelines, which could be adapted by each institution.In 2004 8 tropEd member institutions established a consortium to offer 5 fulltime MIH study tracks MIH financially supported through the Erasmus Mundus program by the European Commission. Initially 1 track, and later 3 tracks offered joint degree awards while institutions of the other tracks offered double degree awards. The institutions worked closely together to align the study programs, to secure proper hand-over of students from one institution to the next institution and to fulfill all the administrative requirements to offer the double or joint degrees. Discussions and decisions regarding the Erasmus Mundus program were always reported in the GA. Because of the double and joint degree programs the participating institutions developed joint selection criteria for the scholarships. Except for the administrative issues the double and joint degree programs did not have implications for the quality assurance of the network as a whole. Because the network had an elaborate quality assurance system the tropEd Erasmus Mundus consortium was easily formed with the 8 institutions that choose to join.3. Accreditation agencies3.1. LiteratureThe literature poses a range of challenges regarding recognition of higher education institutions and courses across borders. The rapid increase of HE institutions which are not accredited in their home country, nor in the country in which they offer their cross-border education, leads to questions regarding the capability and credibility of national and international accreditation agencies .Concerns about the quality, consistency and relevance of accreditation are reflected internationally. Gu argues that in China there is insufficient knowledge and experience in quality assurance of transnational education, as most existing systems of quality assurance and accreditation focus on the local higher education system . The casA range of regional and global responses and frameworks have attempted to address such challenges. In the Caribbean, the withdrawal of the British accreditation and a rapid increase of foreign providers of HE, led to the Caribbean Community and Common Market (CARICOM) establishing a regional mechanism for accreditation, to guide governments in developing national mechanisms . In Lati3.2. tropEdtropEd has developed an internal framework to act as its own ‘accrediting’ agent due to the lack of accreditation bodies for transnational higher education at international or global level. Universities, in countries where they hold degree-awarding powers, as well as national accreditation bodies, have accepted the tropEd accreditation of programmes as well as advanced modules followed by students in member institutions in other countries. The acceptance of tropEd accreditation by these national accreditation bodies can be seen as a benchmark for tropEd.4. Transparency4.1. LiteratureIn the literature Machado argues that the rapid increase of new providers demands greater clarification and transparency regarding the normative basis of transnational education . Nationa4.2. tropEdWithin the tropEd network transparency was enhanced by involving and learning from the students. By keeping in close contact with the students through involving an elected tropEd student representative in the GA meetings, the network has been able to respond to feedback on issues of importance to students. This openness meant that issues were voiced and could be taken up at a very early stage, so that the network or member institution would be able to implement improvements. Quality criteria have been revised and refined in an open process involving the full GA in decision making.When the core course or advanced modules are submitted for reaccreditation, institutions have to give a summary of the evaluations by students over recent years, this is also published on the internet. On the internet students can find when a course or module was accredited and until when the accreditation is valid.In the tropEd network the degree is issued in a specific country, meaning that each institution needs to ensure that the course followed outside the country and within the network is recognized. Up to now that has never been an issue, possibly due to the fact that individual institutions can show the rigorous quality assurance process applied by tropEd in accrediting the core course and advanced modules. Furthermore, currently there are no specific professional bodies accrediting degrees for MIH, perhaps owing to the multi-professional and multidisciplinary nature of International Health as well as the globalised context in which these graduates work.Linking the specific experience of the tropEd network with the broader issues in the literature, a deeper understanding emerges on the key themes:• True collaboration versus national education sovereigntyMember institutions have been able to collaborate in improving their quality through peer review as well as learning from each other in International Health. The network functions well although not always the same institutional representatives can attend meetings and despite the fact that members are to some extent competitors for the same potential students. Some members are only able to the Masters offer degree by including advanced modules from other institutions so there is a utilitarian aspect to some extent for these institutions. Other members can offer the entire degree on their own but want to be part of a bigger network due to the benefits for students, the organizational learning, as well as raising the profile of international health as an academic and professional field. Some members have been able to develop new advanced modules based on the learning within the network or developed modules together. Individual institutions felt that they benefitted being a member of the network; benefits cited are: the harmonization of contents, information for tutoring of students, validation of own standards and procedures, sharing global developments in international health for the content of courses, the development of new learning approaches, of quality improvement of own modules, of common understanding of quality standards in teaching and learning. Challenges mentioned are the frequency of the meetings, the timing of the meetings, complying with all the requirements for module accreditation and reaccreditation as well as agreeing within institutions to allow students to take modules at other institutions. As Gu argues that European countries complement each other , tropEd • Equivalence and comparability of quality assurance frameworksThe tropEd network started with European institutions first, and was aided by the Bologna process, which provided a structure for harmonizing practice across Europe. In more recent years membership from outside of Europe has extended and deepened the reach of its shared quality assurance. As Billing saw a ‘general’ model of quality assurance developing in Europe, tropEd becoming increasingly global, is developing towards a global quality assurance model .• Accreditation agenciesBecause no accreditation agency for a worldwide transnational higher education network exists, tropEd ‘accredits’ its own core course and advanced modules. The acceptance by national accreditation agencies of the accreditation of tropEd of modules taken outside the country by students implies that they find the quality assurance framework of tropEd credible. However the additional burden of further quality assurance measures alongside national and institutional quality assurance requirements has been mentioned  and the • TransparencyThe tropEd network has worked hard on improving its transparency towards potential students. Stakeholder engagement with regards to i.e. employers is under development. Professional bodies for MIH graduates do not exist yet. Whether achieving tropEd recognition by graduates improved the outcome has been subject of another study . BecauseFor the study review of literature and review of documents were used. Observation and key informant interviews could have been conducted, however this was compensated by the fact that three of the authors were longstanding representatives of their respective institutions in the network with an in-depth knowledge of the development of the quality assurance and have participated either one, often two or three in all the GA meetings of the network. Though being a representative of their respective institution might constitute a bias, in-depth discussions amongst the research team during the writing of this paper deepened the understanding of the process of development.Areas for further research could include the role of the student representative, the governance of the network, to define and study outcome and impact indicators, the impact of the tropEd quality assurance process on the actual improvement of quality of the education provided as well as student/ graduate performance or workplace/ employment success.The quality assurance process in the tropEd network was and still is a participatory learning process and requires time. Quality assurance within the network has been formalized but in such a way that it is fully integrated in the functioning and learning of the network. Members of the network feel ownership of the QA standards, documents and processes and have the ability to change them and develop them. However, this process requires respect, trust and sharing tasks among the different partners. Given that in transnational HE no quality assurance frameworks or accreditation exist, tropEd has constructed an evolved and shared quality assurance structure, the validity of which has been accepted by national and international agencies and could be an example for others.HE:Higher education; MIH: Master of International Health; WFME: World Federation of Medical Education; UNESCO: United Nations Educational and Scientific Organisation.PZ, BP and LD have been members of the Executive Committee and the Quality Assurance Committee of tropEd, and PZ has been the chair of the Quality Assurance Committee of tropEd.PZ initiated the article. All authors were involved in the conceptualization, PZ, BP and LD all contributed to reviewing the articles. All authors contributed to writing and review. All authors agreed with the final content.PZ, MD, MScCH is a specialist in public health, human resource development, training and HIV/AIDS. She has extensive experience in developing and organizing degree and short courses in public health, including quality assurance as well as module development for e-learning. Currently, Dr Zwanikken is the Royal Tropical Institute’s Area leader for Education and program director of the MIH.BP, nurse, MScPHDC is the Coordinator in-charge for a 3 months Diploma Course and advanced modules in health district management within the Master of International Health program and has extensive experience in international teaching/training networks and in assessment and evaluations of health systems in conflict /postconflict countries.LD is the Senior Executive Officer (Partnerships and Collaborations) at University College London. Her quality assurance expertise includes more than a decade of working in international HE partnership networks, and coordinating an Erasmus Mundus joint Masters programme. She is currently completing a PhD at the Institute of Education in London, UK.AS, MD, PhD is the dean of the Faculty of Health, Medicine and Life Sciences at Maastricht University. He is also professor of quality improvement in medical education and consultant in many international projects.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/13/43/prepub