br Rheumatic heart disease RHD affects over million people w

Rheumatic heart disease (RHD) affects over 32 million people worldwide; the vast majority of patients are in low-income and middle-income countries. It is a leading cause of premature mortality in children and young adults living in endemic regions. Patients with RHD often present in an advanced stage of the disease when treatment options are limited. On the other hand, patients with milder forms of the disease, for whom the benefits of treatment are proven are difficult to detect owing to lack of symptoms. These cases are best diagnosed by echocardiography, since the accuracy of clinical auscultation is low. Several studies have been published in the last decade in which schoolchildren living in endemic regions have been screened using a portable echocardiography machine. These studies have revealed a three-fold to ten-fold higher prevalence of RHD than previously reported. Most cases had a mild form of RHD.
In , Nadia Akseer and colleagues document the fairly positive maternal and child health outcomes achieved in Afghanistan over the course of a little over a decade. The publication of the Article is timely because the global health isradipine is grappling with the lessons learned from the Millennium Development Goal period and also with the outcomes of several Ebola-related reviews. A message common to many of these reviews is that, unless we find ways to build functional health systems in fragile and failed states, it will be harder to make further progress on key global goals, such as the reduction of maternal and child mortality, as well as to protect the world from new infectious disease outbreaks. It is important to understand the context that faced the new government and its partners in early 2002 in Afghanistan because success was by no means inevitable. After many decades of conflict and instability and the reign of the Taliban, which had sought to impose a very strict interpretation of Islamic laws on the country, by the end of 2001, the human and physical infrastructure of the country was in ruins. Additionally, the health system in Afghanistan was highly dysfunctional; girls and women were banned from education and the workforce and their access to health services was highly restricted. Outbreaks of cholera, measles, polio, diphtheria, and even rare micronutrient deficiency disorders such as scurvy, were common. Child and maternal health indicators were very poor; one study suggested that maternal mortality in the remote north-east of the country was one of the highest ever recorded worldwide. While there was no absolute shortage of doctors, there was a shortage of midwives and nurses. Given the volatile political and security context and the state of the health system after the Taliban rule, a reduction of mortality in children younger than 5 years of almost 30%, during the subsequent decade, and a maternal mortality reduction likely to be of a of a similar magnitude to those of child mortality, might seem surprising. In fact, the health sector outcomes described in Akseer and colleagues\' Article were the result of deliberate choices made very early on during the post-Taliban period, driven by analysis of lessons learned from other post-conflict experience, and based on some sound principles. These drivers have been reviewed in detail elsewhere but included a commitment to ensure the health priorities responded to the disease burden in the country; a focus on building confidence in the public health sector by implementing rapidly, and at scale, some major programmes (eg, national vaccination campaigns); the development of a standardised basic package of primary health-care services; the decision to focus the role of the government on stewardship and setting of standards (given the capacity gaps in the Ministry of Health and the likelihood that service delivery of the public sector would have taken many more years to reach scale); the decision to allow international and national non-government organisations to implement this basic package according to Ministry of Health guidelines (ie, contracting out); a strong commitment to monitor and evaluate and to accountability for results; sustained political commitment and leadership within the government; and a small group of strong and cohesive international partners in the UN, non-governmental organisations, and the donor community that supported this approach consistently over a decade.