Will Maimaris and colleagues systematically review the evidence that national or regional health systems, including place of care and medication co-pays, influence hypertension awareness, treatment, and control.Please see later in the article for the Editors' Summary Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control.Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care.This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs.Please see later in the article for the Editors' Summary In 2008, one billion people, three-quarters of whom were living in low- and middle-income countries, had high blood pressure (hypertension). Worldwide, hypertension, which rarely has any symptoms, leads to about 7.5 million deaths annually from heart attacks, stroke, other cardiovascular diseases, and kidney disease. Hypertension, selected by the World Health Organization as the theme for World Health Day 2013, is diagnosed by measuring blood pressure, the force that blood circulating in the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is contracts to pump blood out (systolic blood pressure) and lowest when the heart relaxes and refills (diastolic blood pressure). Normal adult blood pressure is defined as a systolic blood pressure of less than 120 millimeters of mercury (mmHg) and a diastolic blood pressure of less than 80 mmHg (a blood pressure of less than 120/80 mmHg). A blood pressure reading of more than 140/90 mmHg indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat fatty or salty foods are at high risk of developing hypertension.Most individuals can achieve good hypertension control, which reduces death and disability from cardiovascular and kidney disease, by making lifestyle changes (mild hypertension) and/or by taking antihypertensive drugs. Yet, in both developed and developing countries, many people with hypertension are not aware of their condition and are not adequately treated. As with other chronic diseases, weaknesses in health care systems probably contribute to the inadequate treatment of hypertension. A health care system comprises all the organizations, institutions, and resources whose primary purpose is to improve health. Weaknesses in health care systems can exist at the national, regional, district, community, and household level. In this systematic review , the researchers investigate how national and regional health care system arrangements influence hypertension awareness, treatment, and control. Actions that might influence hypertension care at this level of health care systems include providing treatment for hypertension at no or reduced cost, the introduction of financial incentives to healthcare practitioners for the diagnosis and treatment of hypertension, and enhanced insurance coverage in countries such as the US where people pay for health care through insurance policies.The researchers identified 53 studies that analyzed whether regional or national health care systems arrangements were associated with patient awareness of hypertension, treatment of hypertension, adherence to antihypertensive medication treatment, and control of hypertension. The researchers used an established conceptual framework for health care systems and an approach called narrative synthesis to analyze the results of these studies, most of which were conducted in the US (36 studies) and other high-income countries (eight studies). Nearly all the studies evaluated the effects of health system financing on hypertension outcomes, although several looked at the effects of delivery and governance of health systems on these outcomes. The researchers' analysis revealed an association between reduced medication co-payments  and improved hypertension control and treatment adherence, mainly in US settings. In addition, in US settings, health insurance coverage was associated with improved hypertension outcomes, as was having a routine physician or place of care.These findings suggest that minimizing co-payments for health care and expansion of health insurance coverage in countries without universal free health care may improve the awareness, treatment, and control of hypertension. Although these findings are based mainly on US studies, they are likely to apply more generally but, importantly, these findings indicate that additional, high-quality studies are needed to unravel the impact of health systems arrangements on the management of hypertension. In particular, they reveal few studies in low- and middle-income countries where most of the global burden of hypertension lies and where weaknesses in health systems often result in deficiencies in the care of chronic diseases. Moreover, they highlight a need for studies that evaluate how aspects of health care systems other than financing  and interactions between health care system arrangements affect hypertension outcomes. Without the results of such studies, governments and national and international organizations will not know the best ways to deal effectively with the global public-health crisis posed by hypertension.http://dx.doi.org/10.1371/journal.pmed.1001490.Please access these Web sites via the online version of this summary at high blood pressure (in English and Spanish)The US National Heart Lung and Blood Institute has patient information about high blood pressure  and personal stories about dealing with high blood pressureThe American Heart Association provides information on hypertension and a personal story about hypertensionThe UK National Health Service (NHS) Choices website provides detailed information for patients about controlling blood pressure and on health systems ; its "A Global Brief on Hypertension" was published on World Health Day 2013The World Health Organization provides information on high blood pressure (in English and Spanish)MedlinePlus provides links to further information about  Hypertension (HT) is common worldwide, affecting an estimated billion people, nearly three-quarters of whom live in low or middle income countries (LMICs) Previous systematic reviews have examined the effects of health systems interventions delivered at the community or health facility level on HT care, such as educational interventions that target providers, organisational interventions strengthening collaboration between physicians and pharmacists, and using electronic records to improve management A protocol for this study has been published on the PROSPERO international prospective register of systematic reviews, with the record number PROSPERO 2012:CRD42012002864 We included studies that reported on the effects of national or regional health system level arrangements  on HT control and key upstream determinants of control: HT awareness, treatment, and medication adherence. Definitions of these outcomes are given in Box 1.We included studies looking at any adult population, including general populations, populations on treatment, and studies of people with specific co-morbidities, such as diabetes.The following types of studies were included: (1) Studies, such as controlled trials, cohort studies, and cross-sectional studies, which quantify the effects on HT outcomes of interventions, policies, or programmes, which are enacted at national or regional health system level, acting on one or more domains of the health-system. (2) Studies, such as qualitative studies, which report on the views and experiences of actors  on national or regional health-system level barriers to HT awareness, treatment, control, or antihypertensive medication adherence. (3) Studies reporting on the impact of national or regional HT care policies or interventions that have relevance for other disease programs or for the design of the health system more broadly, such as those that require or lead to changes in primary care provision or other general aspects of the health system.Quantitative studies were included only if they reported a measure of association between the health system arrangement under investigation and at least one of the HT outcomes of interest (Box 1).There were no date or language restrictions.Studies that evaluated interventions, policies, or programs that are enacted at the individual level  or organizational level of the health system , and do not require change at the level of the national or regional health system were excluded.(1) HT awareness. Defined as persons with clinically measured HT who have been diagnosed by a health care professional as hypertensive.(2) HT treatment. Defined as the use of at least one antihypertensive medication in an individual with known HT.(3) Antihypertensive medication adherence. Defined as consistently taking the antihypertensive medication regimen as prescribed by the health care provider.(4) HT control: defined as the achievement of BP below 140/90 mmHg (or other explicitly defined threshold) in individuals being treated for HT, or, alternatively, measured by the mean BP amongst individuals with HT.The search strategy and terms were developed collaboratively with an information specialist. Key words (MeSH terms) and free text terms were identified for each domain of our health systems framework and combined with search terms for HT outcomes to generate the search strategy for the electronic databases Medline, Embase, and Global Health . To imprTwo reviewers independently screened the search results by title and abstract for potential eligibility. Full texts of potentially suitable articles were obtained and were further screened for inclusion by two reviewers. Disagreements in the screening of full texts were resolved by a third reviewer with expertise in health systems and this was required for four of the 122 screened papers.A data extraction form was developed in Microsoft Excel. Data were extracted from each study on study design, setting, health system domains investigated, study methods, and outcomes . Where mIncluded studies were independently assessed for risk of bias by two reviewers. For observational study designs, risk of bias was assessed using a simple proforma for three domains: selection bias, information bias , and confounding . AssessmDue to the recognized importance of context and complexity to health systems research A narrative synthesis was performed, with studies categorized according to the health system domain they investigated and the setting in which the study was performed. For making causal inferences about reported associations between health systems arrangements and HT outcomes, randomized controlled trials (RCTs) were considered the strongest study design, followed by cohort studies and then case-control studies. Cross-sectional studies and ecological studies, alone, were not considered appropriate for causal inference. Meta-analysis was not conducted as we judged that the included studies were heterogeneous in important aspects, including: populations (different ages and settings), study designs , variable definitions (including different definitions of exposures and outcomes), comparisons , and analytical strategies (adjustment for different confounders).The screening process is described using an adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart  [21]. 5,One study examined the effect of health system factors relating to physical resources . This stThree studies examined the effect of health system factors relating to human resources, none of which had a low risk of bias . Two of One US cross-sectional study evaluated the effect of the treating physician's seniority on HT control One Mexican cross-sectional study evaluated the impact of being treated by a specialist on HT control Another Mexican cross-sectional study evaluated the effect of the density of health professionals and did not find an association with HT treatment or control None of the included studies evaluated the effects of health system factors relating to intellectual resources on HT outcomes.None of the included studies evaluated the effects of health system factors relating to social resources.38 quantitative studies analyzed the effects of health systems financing on HT outcomes (34 of these studies were conducted in high-income countries and four in middle-income countries). Four different health system arrangements were analyzed, with 21 studies assessing effects of health insurance coverage, 11 examining the effects of medication co-payments or costs, three analyzing co-payments for medical care, and two looking at physician remuneration models.p<0.05) Twenty of 21 studies evaluating health insurance coverage were conducted in the US and one in Mexico . Seven op<0.05), 1.02 for US$10–US$29 co-payments (p>0.05), and 1.32 for co-payments >US$30 (p<0.05)) p<0.001) Fourteen quantitative studies measured the association of medication co-payments or costs with HT control or treatment adherence, nine of which were set in the US, and one in each of Cameroon, China, Finland, Israel, and Brazil . Two of Three studies assessed co-payments or costs of medical care (not simply medications), two of which were conducted in the US (an RCT and a case-control study) and one in Hong Kong (a cohort study).  [24], “contemporary multi-ethnic urban community” “Among industrialized countries, only the United States lacks universal healthcare.” “These cities have mixed Arab-Jewish populations and are among the poorest in Israel, defined by the Israeli Social Security Agency as having an SES in the lowest 10% of the population.” [On a regional health system in Cameroon] “When the program for hypertension and diabetes started in 2007, there were 79 peripheral clinics in the area offering nurse-led primary health care. Four of these had a physician among the staff; the remaining 75 were exclusively led by Non Physician Clinicians. Most (78%) of the peripheral clinics were public where consultations are usually free of charge but diagnostics and drugs for curative services have to be paid out-of-pocket. The area also has eight district hospitals and two missionary hospitals.” Eleven of the 53 studies discussed linkages or interdependencies between health system domains Twenty-three of 53 studies considered how HT outcomes may be influenced by relationships between health systems factors and contextual factors, such as socioeconomic status, as well as individual factors, such as gender, age, or co-morbidities Despite the limited scope and variable quality of literature found, as well as the context specificity of the findings, it remains possible to make inferences about the effect of some health system arrangements on HT outcomes. This is particularly the case for the characteristics of the US health system, which while unique among high income countries has features that can be found in other parts of the world. Evidence from longitudinal studies reported here suggests a small positive impact of the presence of health insurance in the US on HT awareness and control, and adherence to antihypertensive medication Although lacking longitudinal studies, we found a large positive association between having a routine physician or place of care for HT management and treatment, awareness, control, and adherence to antihypertensive treatment, again in the US All four included studies that evaluated complex multi-component national or regional policy interventions reported some improvement in HT care. These studies had significant methodological flaws including, in some cases, a lack of an adequate control group, precluding attribution of the improvement in HT outcomes to the intervention. However, despite their limitations, these studies may be useful for policymakers seeking to understand ways to strengthen health systems for chronic disease care, particularly in LMICs Research on health systems factors influencing HT care is unequally distributed geographically. There is a lack of evidence from LMICs, which bear around three-quarters of the global HT burden A number of included studies used models to conceptualize the mechanisms by which health systems factors may interact with other key variables to influence HT outcomes. For example Moy et al. and Ahluwalia et al. (1997) used the Anderson-Aday model, which illustrates how three types of population characteristics can influence medical care for HT The majority of included quantitative studies were cross-sectional, and the few longitudinal studies we did find were restricted to either health system arrangements relating to financing or to evaluating the effects of complex multi-component interventions. Inferences about temporal and potentially causal relationships between health systems arrangements and HT outcomes, could, therefore, only be made for a limited number of factors. In addition, included quantitative studies were of variable methodological quality, with only one being randomized and a minority having a low risk of bias for all assessed methodological domains.When considering the findings of this review, the risk of publication bias cannot be ruled out, particularly for the positive findings relating to health insurance status, medication and treatment costs and co-payments, and presence of a routine setting of care, where it is possible that studies with null findings are under-published. It was not possible to produce an Egger funnel plot to formally assess the risk of publication bias, for the same reasons that meta-analysis was not performed, namely the heterogeneity in the study designs, outcome measures, analysis strategies, and populations in the included studies. Reporting bias within individual studies may also be a factor, many of which might have explored the effects of multiple factors on HT outcomes, and may have failed to report results for health system arrangements which did not show significant effects. The lack of published protocols for the included studies did not allow us to estimate the magnitude of this potential bias. A strength of the review is the addition of forward and backward searching methods to the initial database search for articles. A number of additional studies were identified using these methods, before reaching a saturation point at which the only relevant studies being identified were already included. We included only two qualitative studies, which did not contribute important data about the views of policymakers and health care workers on health systems factors affecting HT care, contrary to what we had initially hoped.The use of a conceptual health systems framework facilitated the conduct of the review, enabling systematic generation of terms for the search strategy and for classification of included studies according to the domains in the conceptual framework. However, the classification and reporting of our findings according to health system domain does not encourage the integrated view of health systems that the framework promotes. For example, classifying the effect of usual source of care into the domain of health systems governance and delivery obscures the fact that the delivery of care from a regular source is very much dependent on human and physical resources inputs to the health system. The difficulties in presenting such complexities are perhaps a reflection of the fact that few of the included studies explored inter-linkages between health system components, with the majority exploring the association between health system arrangements and HT outcomes as simple linear relationships. There were some notable exceptions, however; one study, for example, examined the interaction of insurance status and the presence of a usual source of care on HT outcomes We found an association between reduced co-payments for health care, including for medications, and improved outcomes of HT care in multiple US studies, and in single studies set in Finland, Israel, and Brazil. This is consistent with a wealth of other evidence on how co-payments reduce uptake of necessary care and has clear implications for policy makers, particularly as the balance of evidence does not suggest that reducing medication co-payments leads to an increase in overall health care expenditure This study indicates a number of possible implications for future research. Ultimately, an increase in the number of high quality, longitudinal and randomized studies identifying and analyzing the effect of health system arrangements on HT care is required, particularly in LMICs where the majority of the global burden of HT lies, and where weaknesses in health systems are thought to play a significant role in deficiencies in chronic disease care Moving forward, there is a clear need for more robust designs of studies in a much wider range of settings, especially in LMICs. This will ideally include cluster RCTs and prospective longitudinal studies with detailed data on individual and health system characteristics, complemented by qualitative studies to see inside what is often a health systems black box. Such studies also call for consistency in health systems definitions and outcome measures. A particular challenge will be to take account of the complexity of health systems and all health system domains, as well as interpreting studies by not simply as showing what works, but what works in what circumstances Table S1(DOCX)Click here for additional data file.Text S1(DOCX)Click here for additional data file.Text S2(DOCX)Click here for additional data file.Text S3(DOCX)Click here for additional data file.Text S4(DOCX)Click here for additional data file.


There is a severe healthcare workforce shortage in sub Saharan Africa, which threatens achieving the Millennium Development Goals and attaining an AIDS-free generation. The strength of a healthcare system depends on the skills, competencies, values and availability of its workforce. A well-trained and competent laboratory technologist ensures accurate and reliable results for use in prevention, diagnosis, care and treatment of diseases.An assessment of existing preservice education of five medical laboratory schools, followed by remedial intervention and monitoring was conducted. The remedial interventions included 1) standardizing curriculum and implementation; 2) training faculty staff on pedagogical methods and quality management systems; 3) providing teaching materials; and 4) procuring equipment for teaching laboratories to provide practical skills to complement didactic education.A total of 2,230 undergraduate students from the five universities benefitted from the standardized curriculum. University of Gondar accounted for 252 of 2,230 (11.3%) of the students, Addis Ababa University for 663 (29.7%), Jimma University for 649 (29.1%), Haramaya University for 429 (19.2%) and Hawassa University for 237 (10.6%) of the students. Together the universities graduated 388 and 312 laboratory technologists in 2010/2011 and 2011/2012 academic year, respectively. Practical hands-on training and experience with well-equipped laboratories enhanced and ensured skilled, confident and competent laboratory technologists upon graduation.Strengthening preservice laboratory education is feasible in resource-limited settings, and emphasizing its merits  provides a valuable source of competent laboratory technologists to relieve an overstretched healthcare system. The strength of a healthcare system, in addition to physical infrastructure, depends on the skills, competencies, values and availability of its workforce. In sub Saharan Africa, there is a severe shortage and imbalance in its workforce that poses a major threat to achieving the Millennium Development Goals. Due to The clinical laboratory workforce plays a vital role in healthcare service delivery and has been recognized as one of the six key components for healthcare systems strengthening that would impact and improve the well-being of the community. ProperlThe critical shortage of healthcare workers has been further revealed during the HIV/AIDS epidemic in sub Saharan Africa as countries tried to accelerate their response. There was already a shortage of skilled and properly trained healthcare workers, which affected the care and treatment of AIDS patients. Many of the healthcare workers themselves succumbed to AIDS,6. InnovPreservice education training has an important role in maintaining a steady supply of skilled and knowledgeable healthcare workers to ensure country ownership and sustainability. In the reauthorization of the US President’s Emergency Plan for AIDS Relief (PEPFAR) II, PEPFAR set a target, supported with funding, for training and retention of 140,000 new healthcare workers in recognition that maintaining an appropriate healthcare workforce is a critical component for country ownership, sustainability and overall healthcare system strengthening[The absence of hands-on experience is a major challenge facing preservice education because medical laboratory technology graduates only see this equipment for the first time at healthcare facilities on the first day they have been employed. This may further exacerbate equipment maintenance problems as the newly employed laboratory technologists, if not properly trained, often resort to trial and error with equipment at their new healthcare facility. There iThe goal of this research was to carry out a formative evaluation of the feasibility of strengthening preservice laboratory education in partnership with local universities to ensure a skilled and well trained laboratory workforce for overall healthcare system strengthening.The provision of ART monitoring services in laboratory facilities revealed some weaknesses in the laboratory workforce. There was a wide spectrum and knowledge gap among undergraduate laboratory technologists graduating from medical laboratory training universities and joining the workforce. There was limited or no prior exposure with hands-on practicals with ART monitoring equipment, marked differences with students of the same level but different universities, longer duration to orientate and provide practical hands-on training to ensure competency to new graduates in their new facilities with minimal disruption of services. These shortcomings prompted PEPFAR Ethiopia to contact and collaborate with the Department of Medical Laboratory Services, Addis Ababa University (AAU) to improve preservice laboratory education in Ethiopia. Following initial contacts with AAU, there was the need to involve the remaining major public universities. The formative evaluation study describes efforts toward standardization and implementation of curriculum, training of faculty, provision of equipment to complement didactic courses and the impact on preservice education strengthening. The intended outcomes were to successfully develop and implement a standardized curriculum and train faculty students to become competent by practical hands-on experience with ART equipment.In 2008, CDC Ethiopia, in collaboration with faculty staff of five universities with medical laboratory technology training schools, conducted a joint assessment of medical laboratory education. The preservice laboratory education strengthening program activity was carried out at all five public universities with medical laboratory technologist training schools throughout Ethiopia Figure . The uniASCP engaged in different consultative meetings and a scope of work was developed to address some of the training needs that were identified. ASCP then organized three different workshops, and the first workshop was held between March and April 2008 at Addis Ababa University Medical Laboratory School. ASCP was selected because of its wealth of experience in developing curricula and has tailored a curriculum for laboratory technologists training in both the United States and developing countries. In 2010, CDC Ethiopia, together with ASCP, initiated several interventions including standardizing the curriculum, modularization of courses and procurement of equipment at the different laboratory training schools following the assessment. PEPFAR funds were used for procurement of HIV-related equipment, installation reagents and other consumables to strengthen preservice education in the different universities. Faculty staff members were trained on pedagogical skills, research proposal and grant writing skills.The assessment showed that the curriculum used for teaching at the different university laboratory training schools was not standardized. There were differences in credit hour allocations, course contents and student evaluation methods. In addition, the depths of content materials in each of the subjects varied and were dependent on the instructor’s level of commitment and on the reference materials available. The curriculum did not reflect the strategic objectives of Ethiopia’s integrated national laboratory strategic plan established by MOH/Ethiopian Health and Nutrition Research Institute. The curTo resolve these gaps, ASCP consultants organized three workshops to develop and refine a standard curriculum and teaching materials. The curriculum revision mirrored the recommendations by the Ministry of Education (MOE). Participants at the workshop included ASCP consultants, senior faculty and staff, CDC staff, experts from the national reference laboratory, MOH, curriculum experts from MOE, Addis Ababa University and a senior mentor in the medical laboratory field. A total of 98 faculty staff from the five universities participated in the three workshops Table . The revIn addition, faculty staff of the different universities established a network for sharing of information. The lecturers were also trained on using the new curriculum as well as improving their skills for effective teaching using different methods and classroom lectures. Finally, the lecturers were liaised with ASCP consultants for continuous education through valuable and resourceful website materials.ASCP consultants and CDC staff offered intensive training to faculty staff on competitive grant writing/management and quality management systems. ASCP consultants provided pedagogic training to faculty staff, including preparation for lectures, instructional skills, interaction with students, upgrading of lectures to accommodate novel technology and setting and grading of examinations questions. Faculty staff trained in grant writing/management were provided with resources for competitive grants solicitation as well as for quality control and monitoring of performance of laboratory equipment. Experts from CDC trained faculty staff on quality management systems (QMS) including the 12 quality management essentials. A totalIn the 2010/2011 and 2011/2012 academic years, the standardized curriculum and modularized courses were instituted in all five universities for undergraduate students. Together the five universities have a total of 2,230 undergraduate students who benefitted directly from the standardized curriculum, 252 out of 2,230 (11.3%) students from University of Gondar, 663 (29.7%) from Addis Ababa University, 649 (29.1%) from Jimma University, 429 (19.2%) from Haramaya University and 237 (10.6%) from Hawassa University. Together, the five universities graduated 700 laboratory technologists, 388 in the 2010/2011 and 312 in the 2011/2012 academic year, respectively.While students received appropriate didactic training through electronic slide presentations, complementing these lectures with practical hands-on training was limited due to unavailability of appropriate equipment. Previously, it was difficult to assess the competency of the students on different assays without laboratory equipment. For example, prior to the assessment there were no clinical chemistry, hematology and immunophenotyping automated analyzers to complement clinical chemistry, hematology and immunophenotyping courses. Students understandably lacked confidence without practical hands-on training with equipment. The schools sought placements for their students in healthcare facilities with appropriate equipment for hands-on training to complement the courses. This approach was unsuccessful for a variety of reasons. First, the student population was usually large and healthcare facilities regularly providing clinical services were reluctant to engage in placement agreements. In some instances, the placement in healthcare facilities came with conditions. For example, only a certain number of students in the final year were eligible for placement, and the schedules were not compatible with other required courses. This meant a lack of balance and consistency in taught courses and practical hands-on training within and between the different schools. Second, most healthcare facilities simply did not agree to placement agreements. They viewed new trainees who had no prior exposure to these equipment platforms as a potential source of service disruption and equipment malfunction. AdmitteFunding from PEPFAR was used to procure curriculum-based course manuals, storage drives, computers, LCD projectors, which were donated to all the schools for the lecturers. In 2010, a pilot study was initiated at three universities  by CDC Ethiopia in which three clinical chemistry analyzers, three hematology analyzers, three BD FACScount analyzers, vortex mixers, photometers and uninterrupted power supply (UPS), installation reagents and other laboratory consumables were donated to the universities to establish a strong laboratory for practical hands-on training and experience. To maintain the sustainability of reagent supplies, the university medical laboratory schools reagent request was proposed to be integrated with the university teaching hospital comprehensive reagent procurement. Also, competitive grant solicitation proposals were written by some faculty staff, and funding from potentially awarded grants would enable maintaining reagents for use on the instruments. The consignment of equipment included installation and training at each university of the clinical chemistry, hematology and BD FACScount analyzers. The donated equipment was chosen based on platforms used regularly at healthcare facilities and in keeping with the integrated national laboratory strategic plan, which ensured that graduate students would easily integrate into the healthcare facilities that hire them.A total of 3,199 students had hands-on training with the analyzers from the three universities in the initial pilot. This number included undergraduate, postgraduate and continuing laboratory education students. In University of Gondar in 2010/2011 academic year, 150 students each had direct practical hands-on training with hematology, chemistry and BD FACScount analyzers respectively (Table Complementing theoretical lectures with practical hands-on experience on the analyzers had made it easy for students to conceptualize and apply theory. The faculty and staff feedback indicated that the students’ mastery of operating the equipment, using good clinical laboratory practices, performing manufacturer recommended preventive maintenance and analyzing and interpreting results was greatly enhanced and ensured a skilled, confident and competent laboratory workforce upon graduation. These findings are similar to other studies indicating that students’ conceptual and technical understanding of methodologies taught in class was greatly increased with practical hands-on training in the laboratory,22.To ensure sustainability and the use of the equipment, the universities were committed to providing reagents for use in training. In addition, the schools have engaged service maintenance contracts with equipment vendors or their representatives to attend to any maintenance needs. Despite the commitment undertaken by universities to maintain equipment, equipment maintenance still remains a challenge. Due to One of the major advantages of the study was the development of a standardized curriculum that was implemented in five universities that enabled and maintained consistency across the various universities. Additionally, the provision of ART monitoring equipment for practical hands on training that complemented didactic lessons.Limitations of this study include the absence of a follow-up survey of graduated technologists, their employers, to assess the performance of the technologists in their new workplace. The findings of such a survey would have provided a more accurate measure of the effectiveness of the revised curriculum and practical hands-on training by new graduates. Nevertheless, it is noteworthy that the standardized curriculum across the five universities and the introduction of practical hands-on training on equipment were used for academic evaluation and scoring of the students prior to recommendation for graduation.Preservice laboratory education strengthening is feasible with situational analysis, careful planning, involvement of appropriate stakeholders and appropriate intervention including procurement of appropriate instruments. The development of a standardized curriculum, integration of teaching modules and complementing students training with hands-on training on equipment greatly enhanced the skills, competency and confidence of the students and ensures maintaining a valuable source of quality laboratory staff. CDC Ethiopia, working directly with indigenous local universities, ensures local capacity building and sustainability. Continued advocacy and partnerships is key to implementing successful preservice laboratory education strengthening programs.ART: Antiretroviral therapy; BD: Becton Dickinson; PEPFAR: US president’s emergency plan for AIDS relief; QMS: Quality management system.The authors have no conflicts of interest to disclose. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.PNF, YK, AT and TK conceived the study and design. PNF wrote the first draft. DT, WA, KY, SK, MA, WC, HM, ET, and AT participated in implementing and monitoring the study as well as collecting data, and TK provided general oversight and guidance in implementing the study as well as critically reviewing and editing the manuscript. All authors participated in the write-up, review, feedback and approval of the manuscript.


David Stuckler and colleagues examine five large private global healthfoundations and report on the scope of relationships between these tax-exemptfoundations and for-profit corporations including major food and pharmaceuticalcompanies. Institutional relationships in global health are a growing area of study,but few if any previous analyses have examined private foundations.Tax-exempt private foundations and for-profit corporations haveincreasingly engaged in relationships that can influence globalhealth.Using a case study of five of the largest private global healthfoundations, we identify the scope of relationships between tax-exemptfoundations and for-profit corporations.Many public health foundations have associations with private food andpharmaceutical corporations. In some instances, these corporationsdirectly benefit from foundation grants, and foundations in turn areinvested in the corporations to which they award these grants.Personnel move between food and drug industries and public healthfoundations. Foundation board members and decision-makers also sit onthe boards of some for-profit corporations benefitting from theirgrants.While private foundations adopt standard disclosure protocols foremployees to mitigate potential conflicts of interests, these do notalways apply to the overall endowment investments of the foundations orto board membership appointments. The extent and range of relationshipsbetween tax-exempt foundations and for-profit corporations suggest thattransparency or grant-making recusal of employees alone may not bepreventing potential conflicts of interests between global healthprograms and their financing.The institutional relationships that exist in global health are a growing area ofinquiry. This has been most evident in work examining corporate involvement inhealth, because tensions can arise between the profit motives of corporations andthe promotion of public health. Whereas corporations make products that can improvehealth  and relationships between publichealth institutions and for-profit corporations can be seen as positiveopportunities for corporations to improve public health The relationships of concern between for-profit institutions and health-relatedorganizations can involve direct financing—such as when pharmaceuticalcompanies give gifts to physicians in a manner that has been shown to increaseprescribing of the promoted drugs In addition to examining corporate relationships in the health arena, public healthadvocates have also expressed concerns about whether potential conflicts ofinterests among state development aid programs could negatively affect healthoutcomes. Many government development agencies act explicitly in the interests oftheir own country possibly corrupt the motivation foran act in the other [italics in original]” When the agendas of institutions working in global health coincide, relationships canbring health benefits. But where agendas differ, a conflict of interest may arise.Sometimes termed “competing interests,” conflicts of interest havevarying definitions. The strict, legal meaning of “conflicts ofinterest” under US law is a situation in which there is “a real orseeming incompatibility between one's private interests and one's publicor fiduciary duties” A conflict of interest can occur when a Partner's ability to exercisejudgment in one role is impaired by his or her obligations in another role or bythe existence of competing interests. Such situations create a risk of atendency towards bias in favor of one interest over another or that theindividual would not fulfill his or her duties impartially and in the bestinterest of the RBM Partnership.A conflict of interest may exist even if no unethical or improper act resultsfrom it. It can create an appearance of impropriety that can undermineconfidence in the individual, his/her constituency or organization. Both actualand perceived conflicts of interest can undermine the reputation and work of thePartnership. While corporate involvement in and government aid for health has been extensivelyanalyzed and critiqued in the public health literature, less attention has beenpaid to the impact of private donors on public health Yet, it is intuitive that those who donate money have a set of goals andobjectives that are of interest to them in making such donations. Although thephilanthropic activities of wealthy individuals and corporations have attractedcontroversy in the past , their cIn this paper, we examine the scope of potential conflicts of interests thatexist among the private foundations that are major funders of global health. Weuse the WHO definition of potential conflicts of interest, as detailed above. Weconducted a case study using data about the networks, activities, and fundingpatterns of the Bill & Melinda Gates Foundation, Ford Foundation, W. K.Kellogg Foundation, Robert Wood Johnson Foundation, and Rockefeller Foundation,because these are the largest private global health foundations. We include anexamination of both the potential conflicts that may arise in relation to thesefoundations' overall activities and those of their individual employees,which are already typically covered by the foundations' conflict ofinterest policies. We show that, taken together, these conflicts of interest cancreate complex situations whose potential effects may be difficult to assess inisolation.Before proceeding with the findings of our analysis, we first review thegovernance and regulations of private nonprofit foundations.Nongovernmental, nonprofit organizations operate under different rules andregulations in each country. In the United States' common law system,private foundations must qualify for federal tax exemption. Unlike publiccharities, they usually do not provide services directly, but instead makegrants to other entities to fulfill the foundation's mission. Private foundations may receive most of their funds from a parent for-profitcorporation (such as PepsiCo Foundation) or wealthy individuals and families(such as the Doris Duke Foundation), sometimes in the form of investments (giftsof stock) and cash endowments. Historically some foundations have maintainedseparation between management of their endowments and grantmaking decisionsDespite the existence of policies explicitly designed to mitigate potentialconflicts of interest, the boundaries between foundations, their investments,and their parent corporations or private funders can become blurred. Often,directors of the boards of foundations also sit on the board of privatecorporations, adopting multiple roles. Thus, the Hilton Foundation has “anindependent Board of Trustees and Grants Committee comprised of independent aswell as senior Hilton personnel. The Board of Trustees includes independentmembers and Hilton members nominated by the business” To understand whether measures currently employed to prevent potential conflictsof interest among private foundations are sufficient to prevent an adverseimpact on public health, it is first necessary to evaluate the scope of thesepotential conflicts. Previous analyses of corporate boards using power structuremethods have studied corporate philanthropy and economic developmentorganizations There are more than 100,000 private nonprofit foundations operating in the US, manyof which contribute to global health activities and research (holding aboutUS$569 billion in assets). In the sociology and political science literature, aid organizations have typicallybeen studied by examining at least three sets of observable questions about powerand financial relationships, with the intent of “following the money”The Bill & Melinda Gates Foundation's endowment mainly comes from BillGates' personal fortune and stock in Berkshire Hathaway given to theFoundation as a gift from Hathaway's CEO Warren Buffett. In 2006, Buffettmade a pledge to gradually give away all of his Berkshire Hathaway stock to theBill & Melinda Gates Foundation, most recently with an additional 24.7million shares in July 2010 At the end of 2008, the Bill & Melinda Gates Foundation Trust hadUS$29.6 billion assets under its management: $13.5 billion were incorporate stock, $1.8 billion in corporate bonds, $6.1 billion inUS and state government obligations, and $8.2 billion in otherinvestments, land, and temporary holdings As shown in About half of the Bill & Melinda Gates Foundation's stock holdings arealready invested in Berkshire Hathaway, a conglomerate holding company owningseveral subsidiary companies, including banks, railroads, candy production,retail, and utilities. Thus, it is necessary to examine the holdings of theBerkshire company to analyze the Foundation's stock holdings. BerkshireHathaway's largest investment is in Coca-Cola. It owns an additional8.7% of Coca-Cola  and 6.3%of Kraft  Endowment investments in pharmaceutical and food companies were similarlyobserved among the Ford, Rockefeller, W. K. Kellogg Foundation, and Robert WoodJohnson Foundations New York Times report on the matter in the year 2000 Bill and Melinda Gates, according to their own statements, guide the managers ofthe Foundation's endowment, Cascade Investment LLC , and regularly assess the endowment's holdings. As noted by theFoundation's description of management practices, “When instructingthe investment managers, Bill and Melinda also consider other issues beyondcorporate profits, including the values that drive the foundation's work.They have defined areas in which the endowment will not invest, such ascompanies whose profit model is centrally tied to corporate activity that theyfind egregious. This is why the endowment does not invest in tobaccostocks.” The Foundation had invested in Philip Morris bonds prior to aThe Bill & Melinda Gates Foundation conflict of interest policy also sets outguidelines for employees with stockholdings The Ford Foundation has a mission statement to “reduce poverty andinjustice, strengthen democratic values, promote international cooperation, andadvance human achievement” Like the other private foundations, the Bill & Melinda Gates Foundation doesnot disclose the detailed discussions that take place among its Board whenfunding decisions are made, because of the need to ensure free comment on grantapplications. However, the Foundation's detailed policy on potentialconflicts of interest for its employees The Bill & Melinda Gates Foundation's management committee oversees allthe Foundation's efforts . Themanagement committee comprises three co-chairs ; three trustees (Bill and Melinda Gates and Warren Buffett);a CEO (Jeff Raikes); three presidents of its respective programs in GlobalDevelopment (Sylvia Mathews Burwell), United States (Allan Golston), GlobalHealth (Tachi Yamada); chief administrative (Martha Choe), financial (RichardHenriques), human resources (Franci Phelan), and communications officers (KateJames); a managing director of public policy (Geoff Lamb); and a general counseland secretary leading the legal team (Connie Collingsworth). Each program has aleadership team, such as the Global Health Leadership team, led by the presidentof the program.http://mapper.nndb.com/start/?map=12051; see also Several of the Foundation's members of the management committee, leadershipteams, affiliates, and major funders are currently or were previously members ofthe boards or executive branches of several major food and pharmaceuticalcompanies  The bulk of the Bill & Melinda Gates Foundation's financial transfers inglobal health have been to programs developing medical technologies Several grants are linked to companies that are represented on theFoundation's board among its investments. The Foundation has establishedpartnerships with the Coca-Cola Company, which, in the words of the Foundation,are intended to “create new market opportunities for local farmers whosefruit will be used for Coca-Cola's locally-produced and sold fruitjuices” In addition, many of the Foundation's pharmaceutical development grants maybenefit leading pharmaceutical companies such as Merck and GlaxoSmithKline The Foundation has also funded initiatives that are not obviously linked tocorporations, such as those for health surveillance and monitoring of diseaseburdens. It invested $105 million to create the Institute for HealthMetrics and Evaluation at the University of Washington, which is led by one ofthe leading researchers responsible for the Global Burden of Disease Study  and has now become a leadinginstitution for estimating global mortality and disability rates. The Foundationis also one of the largest donors to the WHO, giving sums that amount to about4% of WHO's overall budget (∼$150 million) Here, we have observed that five major US private nonprofit foundations havesignificant investments in food and/or pharmaceutical companies, directors whocurrently or have previously sat on the boards of those companies, and, in severalcases, enter in partnerships with those companies. Our analysis focused mainly onthe potential conflicts of interests among the largest foundation, the Bill &Melinda Gates Foundation. As one example, we found that Bill & Melinda GatesFoundation has substantial holdings in the Coca-Cola Corporation, and alsoparticipates in grants that encourage communities in developing countries to becomebusiness affiliates of Coca-Cola. It has been noted by some commentators that sugarydrinks such as those produced by Coca-Cola are correlated with the rapid increase inobesity and diabetes in developing countries Before assessing the implications of these findings, important limitations of ourstudy must be addressed. First, as with all studies into the sociology ofinstitutions A private foundation clearly has the legal right to spend money however it wisheswithin the limits of the law; yet, in an environment where private foundationsinfluence the future direction of, for example, what programs will be introducedinto a foreign community, in a manner that does not necessarily involve directorshipor voting from the community members themselves, it is reasonable to subject thedecision-making processes of these entities to public debate, especially if thesefunds were to have otherwise been collected for public redistribution throughfederal taxation.Several strategies may help mitigate the potential for conflicts of interests inprivate foundations to negatively impact global health decision-making also :Divestment: Investments should not counteract thefoundation's charitable mission statement and objectives in either areal or a perceived way. There should be separation between investmentmanagement and the foundation's board. It is also possible to create a“blind trust” so that the foundation leaders are not aware oftheir corporate investments and avoids the possibility that investmentknowledge influences program decisions.1. Transparency: Full disclosure of actual or potentialconflicts of interest is necessary in making public health decisions. Thisincludes disclosing corporate affiliations  and personal investment holdings. When board members andtheir friends and relatives stand to be directly affected by grantdecisions, they should recuse themselves from the discussion and decision.Members may also resign from corporate boards and sell stock . Independent audits can also routinelymonitor the scope and management of potential conflicts of interest withinprivate foundations. A widely shared and monitored public health code ofethics could provide guidance to mitigate conflicts of interest atfoundations from adversely influencing practice.2. Alignment of aid with community needs: Foundation investmentand program portfolios should incorporate representation from the intendedrecipients of its support.3. Private foundations have been advised to not invest in companies that stand toprofit from the tax-exempt foundation's agenda or in those that produceproducts such as tobacco, salty foods, or sugary drinks that havewell-established connections to global health epidemics Given that there is a limited pool of specialist expertise that can be drawnupon, it is possible that situations may arise where some persons who sit on theboards of, or advise, philanthropic foundations, will also have links tocorporations. It would be unreasonable to demand that foundations refuse toengage with those who have corporate links, so denying themselves the bestadvice in some fields. Many authors have stated that a solution to this issue isto adopt full disclosure, or transparency, and to ensure that all individuals onfoundation boards recuse themselves from decisions related to their affiliatecompanies It is important to align aid with community needs. However, despite numerousdeclarations to align aid with the preventable burden of disease, privatefoundations tend to operate in “silos,” focused on a core set ofissues that their founder or governing director decides is important Major funders can have a significant impact on overall financial flows;International Monetary Fund (IMF) economists are advising that countries divertaid to reserves because of concerns about its unreliable and unpredictablenature, and the desire to privatize health care services rather than perpetuatestate-run health care operations The question of whether and how financial and institutional relationships might shapefoundation decision-making has yet to be answered, and continues to be a point ofcontroversy. To draw a recent example, if a Chinese businessperson invested in theChinese auto industry were to donate to the Hurricane Katrina relief efforts in NewOrleans, such a donation would no doubt be welcomed; if the donation, however, wasconditional upon renovating New Orleans′ factories to produce products for theChinese auto industry, such a program may produce legitimate debate. Analogously,when the Gates Foundation is heavily invested in Coca-Cola and simultaneously worksto orient developing country farmers towards production for Coca-Cola instead ofalternative development strategies, such an approach has potential consequences forgrant-receiving communities and their health Potential conflicts of interest exist everywhere, but there is considerable variationin how they are managed. When such topics have been discussed in the medicalliterature in the past, they have resulted in the avoidance of disastrousoutcomes—such as the revelation that major biomedical research wasinappropriately analyzed to support drug marketing by academics influenced by thepharmaceutical industry Figure S1Sampling of major interlinkages of leading members of the Gates FoundationBoard of Directors and advisory panels. File provides access to externallyhosted information.(DOC)Click here for additional data file.Text S1Historical controversy about the politics of philanthropy.(DOC)Click here for additional data file.Text S2Rules and regulations governing US private foundations.(DOC)Click here for additional data file.Text S3Sources of data.(DOC)Click here for additional data file.Text S4Full corporate stock investment listings filed with the SEC (Form 13-HR),Bill & Melinda Gates Foundation Trust and Berkshire Hathaway Holdings,30 June 2010.(DOC)Click here for additional data file.Text S5Examples of interlocking appointments with food, pharmaceutical companies,and other private foundations.(DOC)Click here for additional data file.