The SADC Health Protocol came into force at the 2004 SADC Mauritius Summit and now applies across the region. It outlines the priorities and mechanisms for regional co-operation in health. We look forward to the protocol being raised and discussed within the parliaments of the region to see how far we are making progress in the regional priorities and approaches signed on to by the heads of state in Mauritius.
Why should parliaments be important to struggles for equity in health? Parliaments are a watchdog of public policy and consolidate this policy in law. In their legislative role they are able to transform social norms and values into binding legal entitlements. Their oversight role on the budget and on the actions of the executive provides an important opportunity to ensure that these legal entitlements are realized in practice. For example parliaments are an important watchdog of the government Abuja summit commitment that at least 15% of government budgets are invested in the public health sector. They can give voice through various processes of debate, inquiry, public hearings and consultation to public views, including the views of those areas and groups where such voice may be weaker or less articulate.
In an EQUINET, GEGA and SADC Parliamentary Forum regional meeting in South Africa in August 2003, it was recognized that parliaments are uniquely placed to build alliances with the Executive branch of government, across political parties, between different portfolio committees and with civil society, health sector and other agencies at national and regional level in support of health equity. (The report of this meeting is found at www.equinetafrica.org) The parliamentary reforms taking place in the region provide an enabling environment for this. At the August 2003 regional conference, delegates agreed that the establishment of parliamentary committees on health provided a forum for deeper review, policy monitoring and analysis, and noted that a range of health related activities were already taking place. These committees have held public hearings on laws and policies, visited and investigated conditions in the health system, held systematic hearings on the national budget and its consistency with national health policies and promoted public awareness on key areas of social norms and action in health, such as HIV and AIDS. In Zambia, South Africa and Zimbabwe, for example, with support from institutions in EQUINET and GEGA, parliamentary committees on health have analysed and made input on equity issues in the health budget and have visited districts to follow up on the equity issues raised. In Tanzania the parliament has established a parliamentary forum on AIDS at which key issues such as equity in access to Antiretroviral treatment have been debated. In Malawi parliaments have raised and promoted debate on issues of migration of health personnel and on the quality of health services at the district level.
In June 2004, during the EQUINET regional conference on equity in health, parliamentary committees and organisations working on health equity agreed that these critical areas of work needed more consistent regional exchange of information and good practice, support and activity. They would also benefit from longer term co-operation with state, academic and civil society institutions working on health equity. How can this be achieved? Is a more regular forum of health committees needed, within the SADC framework? How can the current work and institutional partnerships with parliaments be better networked and more consistently supported to ensure greater exchange of information, learning and good practice? These issues were raised as matters of concern to organisations like EQUINET working with parliaments and we invite readers and institutions working with parliaments to give feedback to these queries. What experiences exist in the region of work with parliamentarians on equity in health? How can we better strengthen and support such parliamentary roles, particularly if we are to achieve our goals of equity and social justice in health, and the policy commitments expressed in the SADC Health Protocol?
This briefing is produced by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org
1. Editorial
A new report on the funding by nine African and Latin American countries on HIV/AIDS has found that countries must do more to ensure a comprehensive response to the epidemic—incorporating prevention, treatment, care and support. The study, undertaken by NGO research institutes in each country, was jointly coordinated by Idasa in South Africa and Fundar in Mexico.
The study, entitled Funding the Fight: Budgeting for HIV/AIDS in Developing Countries will be discussed by researchers during a one-day meeting taking place in Johannesburg this week. This research project makes a remarkable contribution to the field of HIV/AIDS resource-tracking, in that comparable budget analysis studies were undertaken by civil society organisations.
The study found that while many countries have developed national strategic plans and programmes, these were poorly costed and budgeted. It also found that the tracking of resources allocated towards HIV/AIDS in national budgets was hindered by weak or absent links between allocations and their intended objectives and outputs. Governments have inadequate systems in place to track the allocation of resources for HIV/AIDS.
Yet the research yielded a number of important findings. In Africa most countries, until recently, have focused on prevention more than treatment. This despite the fact that WHO/UNAIDS estimates that 3.8 million Africans are in need of treatment, while only 150 000 people are currently receiving the life-prolonging drugs. The study notes the boost to HIV/AIDS spending following the recent announcement and launch of ARV treatment programmes in South Africa, Mozambique, Kenya and Namibia. However the researchers caution that even though governments may increase their allocations to provide treatment, this programme may be undermined if more money is not made available to strengthen the health system overall.
In the Latin American countries, where HIV/AIDS prevalence is below 1%, the bulk of government spending on HIV/AIDS is earmarked for providing antiretroviral treatment. In Argentina 90%, in Chile 80%, Ecuador 74% and Nicaragua 54% of the national AIDS budget is committed to providing treatment and care and support, with less resources available for prevention. The researchers warn that treatment alone may not be enough to curb the epidemic and that the governments of Latin America need to increase their allocations and commitment to prevention.
The Report points out that all the African countries are falling below the 15% target agreed upon by Governments at an OAU Summit in Abuja in 2001. Amongst the African countries, the health allocations as a share of total government expenditure range from 6% in Kenya to approximately 15% in Mozambique. South Africa’s allocation is estimated to be just under 12%. Health budgets in the Latin American countries, with the exception of Nicaragua, were primarily financed through state revenue, whereas in the African countries, except South Africa, they tend to rely primarily on donor funds.
While it is difficult to isolate specific HIV/AIDS allocations from the overall health budget, the report finds HIV/AIDS earmarked funds consume less then 4% of health budgets in the Latin American countries included in the study, ranging in 2002, from under 1% in Chile to 3.5% in Argentina. In Africa, the priority accorded to HIV/AIDS programmes in health budgets varied significantly—from 1.6% in Mozambique, to 11.4% in Kenya in 2002. In South Africa the HIV/AIDS allocations have climbed steadily from 0.67% of the consolidated national and provincial health budget in 2000/1, to 3.86% in 2004/5. HIV/AIDS-specific allocations made up 0.49% of South Africa’s overall national budget in 2004/5.
An important finding from the Report is that the increasing allocations being made to HIV/AIDS may be squeezing out other health priorities. In all countries the researchers observed that while HIV/AIDS allocations have been increasing, this has not been matched by a commensurate increase in allocations to the health sector overall. Without adequate attention to strengthen and support overall health infrastructure, facilities and medical personnel, HIV/AIDS programmes will be undermined, and simultaneously the health care delivery will strain under the burden of HIV/AIDS.
The report urges African countries to increase their own financial commitments to HIV/AIDS interventions. It points out that with the exception of South Africa, most African countries rely to a great extent on donor funding. Greater commitment of state funds is essential to the longevity of scaled-up programmes, particularly treatment.
The report has been able to yield very valuable findings, and the researchers are calling for budget reforms and greater transparency of government allocations for, and actual spending on, HIV/AIDS. This information will enable civil society and citizens to better understand and monitor how much is being spent on HIV/AIDS, for what programmes, and in what regions and provinces. Effective government responses to AIDS require us to know where the money is coming from, where it is going, and how well it is being spent.
For more information contact: Alison Hickey, Manager, AIDS Budget Unit, Idasa. Cell: 083 280 2759; Teresa Guthrie, Project Co-ordinator, AIDS Budget Unit, Idasa. Cell: 082 872 4694. To order a hard copy of the report, contact: nomzi@idasact.org.za A full electronic version will be available October 2004: www.idasa.org.za
EQUINET is currently carrying out work in line with the SADC Business Plan on HIV and AIDS on monitoring, protomting good practice, supporting research and sharing information on health systems and equity issues in treatment access. More information on this programme is available from the EQUINET secretariat at TARSC, email admin@equinetafrica.org.
2. Latest Equinet Updates
The Regional meeting on Health systems strengthening for treatment access produced a set of guiding principles to inform approaches to treatment access. These are posted on the Equinet site as a discussion document for your comments.
Since 2003, EQUINET and the Health Systems Trust (HST) have implemented a longer term programme of work that has carried out a wider review of the literature on the distribution and migration of health personnel in the region and a regional research programme aimed at building analytic capacity, evidence and policy engagement around the issue.
The meeting was focused on ensuring universal treatment access through sustainable public health systems. The goal of the meeting was to develop resolutions on the principles for strengthening health systems for treatment access, and to develop potential areas for work for EQUINET related to EQUINET’s programme of work areas.
3. Equity in Health
This Lancet article calls on the WHO to take the lead in championing the goal of “Universal access to essential health-care information by 2015” or “Health Information for All”. Published to coincide with the launch of the Global Review of Access to Health Information in Developing Countries, the paper argues that access to information is key to meeting the Millennium Development Goals (MDGs). While many initiatives have improved access over the past ten years, there is still much to be done.
As a rising number of HIV/AIDS patients turn to already over-stretched public sector facilities, the ongoing humanitarian crisis is undermining the quality of care in Southern Africa's health system. Two years after committing themselves to respond to the humanitarian emergency, health ministers from the Southern Africa Development Community (SADC) are now faced with "vicious and destructive spirals" of rising HIV/AIDS deaths and deepening poverty, the World Health Organisation (WHO) Regional Office for Africa said in a statement.
Improved measures to tackle acute malnutrition in Mozambique are expected to save the lives of thousands of children and adults. During a five-day workshop supported by the UN Children's Fund (UNICEF) last week, about 100 health workers in the capital, Maputo, adopted a protocol outlining step-by-step guidelines for the management of acute malnutrition in children.
Developed countries are failing to live up to their commitments to fund sexual and reproductive health care leaving poorer countries to pick up the bill, says a new UN report. The United Nations Population Fund (UNFPA) report titled 'The Cairo Consensus at Ten: Population, Reproductive Health and the Global Effort to End Poverty' says poor countries themselves are providing around 40 percent of the money spent on reproductive health programmes and HIV/AIDS prevention and treatment.
Global efforts to control rising levels of tuberculosis are not working and more needs to be done to reduce infections from the deadly airborne disease, public health experts said on Tuesday. The World Health Organization (WHO) introduced a strategy in 1993 aimed at halving deaths over the next decade from the contagious illness that kills about 2 million people each year. But researchers at Harvard University in the United States said a decade after the DOTS (Directly Observed Treatment, Short-course) plan was introduced, the global burden of TB continues to rise.
Dr Luis Gomes Sambo was nominated by the WHO Regional Committee for Africa for the post of WHO Regional Director for Africa. Dr Sambo, 52, of Angolan nationality, is currently the Director of Programme Management at the WHO Regional Office for Africa (AFRO), where he is responsible for the management and operation of the programmes of WHO in the African region.
What does equity in health and health care mean? Equality? A basic minimum standard of service? A system of entitlements?Global health professionals have struggled with a definition for some time. Dr Rene Loewenson, a Zimbabwean epidemiologist, presents a Southern African view: equity in health implies addressing differences in health status that are unnecessary, avoidable, and unfair, she says. This also means understanding and influencing, not only the way society allocates health resources, but the power relations involved.
4. Values, Policies and Rights
The Cairo Agenda – a set of international agreements – which came out of the International Conference on Population and Development in 1994, shifted policy focus away from population control. Access to good quality reproductive health care for both women and men was promoted as a right. The more recently agreed Millennium Development Goals (MDGs) however, narrowed the focus down to maternal mortality. While it is crucial to address maternal mortality, it is important to bring reproductive health back into the picture as without this the MDGs will not be met.
An adolescent woman requests a contraceptive method from a health provider in a country where access for under-aged users is restricted; a couple denounces an involuntary sterilization to a local nongovernmental organization; a woman requests a legal abortion in a context where termination of pregnancy is highly stigmatized and access to safe services is denied her. These are just examples of terribly unfortunate but common features in developing countries, where women, particularly poor women, lack the necessary power to successfully fight for their needs and rights. A meaningful and appropriate response to these complex situations requires a comprehensive approach. As acknowledged by the authors of ‘Reproductive health and human rights: integrating medicine, ethics and law’, no single discipline or perspective will resolve the many dilemmas involved in protecting reproductive and sexual health.
5. Health equity in economic and trade policies
A new report by Medact and Wemos highlights some of the issues that need to be taken into account in order to make the PRSP process work for health. 'Pushing the boundaries: health and the next round of PRSPs' draws on case studies in seven countries: Bangladesh, Bolivia, Ethiopia, Ghana, Kenya, Nicaragua and Uganda. Till now, the PRSP process has failed to make significant improvements to health. But in some areas and in some countries there are positive developments. Ghana's health budget has risen and user fees are abolished in Uganda and Ghana as a result of increased policy attention for the poor. But there is a long way to go. Pushing the boundaries calls for health organisations, ministries of health, donors and international agencies to use the PRSP process to establish equitable and comprehensive health systems. Download the report from either
http://www.wemos.nl/prs or http://www.medact.org
The emergence of an increasingly global economy suggests that the ability of individual countries to shape their own destinies is becoming more difficult. International trends and pressures now influence national, and even local, health care policy making. Researchers from the University of the Witwatersrand, South Africa, together with Oxford University, looked at the effect of globalisation on health issues in South Africa and assessed its influence compared to national and local forces.
Proposals by the US government to re-divert aid funding to pay for the debt cancellation for the world's poorest countries have been criticized by the Catholic Agency for Overseas Development (CAFOD). It is understood that the US Treasury Department is going to call for 100% debt cancellation for highly indebted poor countries. However the American proposal calls for the debt relief to be offset against new aid funding for the poverty-stricken countries. Henry Northover, Public Policy Analyst, CAFOD, said: "It's not so much a 100% debt cancellation as a 100% debt makeover. Debt cancellation for the worlds poorest must be paid for by the world's richest."
6. Poverty and health
This paper is intended both for managers and technical staff working either in food security and livelihoods or in HIV/AIDS and reproductive health who require an introduction to the linkages between the two areas, and as a guide to the many issues that need to be considered when carrying out assessments (or reviewing others’ assessments) and when planning interventions. The focus is specifically on economic impacts of AIDS, and does not address important emotional, psychological and social impacts.
"The composition of world poverty has changed noticeably. Numbers of poor have fallen in Asia, but risen elsewhere. The share of the world’s poor living in Africa has risen dramatically. Not only has Africa emerged in the 1990s as the region with the highest incidence of poverty, the depth of poverty is also markedly higher than that found in other regions - suggesting that without lower inequality economic growth in Africa will have a harder time reducing poverty in the future than elsewhere. Looking forward, if the rates of progress against poverty that we have found for the last two decades of the twentieth century are maintained then we expect that the poverty rate for the developing world as a whole will fall to 15% by 2015, just short of the Millennium Development Goal of halving the 1990 poverty rate."
7. Human Resources
Much has been written about the impact of the HIV and AIDS pandemic on the healthcare delivery systems and resources in central and southern Africa. The unremitting pressure on hospitals and other healthcare facilities, and the disproportionate use of healthcare resources by the ever increasing numbers of patients, are threatening to undermine the capacity of countries such as South Africa to provide a comprehensive health safety net for the rest of the population, says an article in the British Medical Journal.
Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices. They trade decisions related to their career opportunities - and to financial security for their families - against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the "push and pull" nature of the choices underpinning these "journeys of hope". Demotivating working conditions, coupled with low salaries, are set against the likelihood of prosperity for themselves and their families (by remittances), work in well-equipped hospitals, and the opportunity for professional development. An article in the WHO Bulletin points out that young, well-educated individuals are most likely to migrate, especially in pursuit of higher education.
Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment.
8. Public-Private Mix
This report from the Health Systems Trust outlines experience with Antiretroviral Treatment (ART) in a number of sub-Saharan countries. ART is provided through a number of different avenues, which include the public sector, the non-profit sector, the corporate sector and the private sector. ART programmes may involve collaboration between two or more sectors with such partnerships being encouraged in recognition that the magnitude of the task may exceed the capacity of any one sector. Particular attention is paid to Botswana, the first sub-Saharan country to provide ART on a wide-scale through the public sector.
9. Resource allocation and health financing
It should not be assumed that earmarked donor funding automatically increases the allocation of developing-country resources towards programmes that yield the greatest health benefits. Sometimes it does, sometimes it does not - how the funding is designed can influence this. This is true particularly in the longer term, once the earmarked funding has ended. This is according to an article in Volume 82, Number 9, of the Bulletin of the World Health Organization.
This UNAIDS report summarises the most recent data available on spending from all sources of AIDS programmes in low- and middle-income countries. Its purpose is to identify the magnitude of global resources available relative to the estimated resource needs. The report also reviews and compares the methodological approaches used to track HIV/AIDS expenditure at global and national levels, and identify gaps in HIV/AIDS financial information and present ways they can be addressed.
The maturity of the HIV/AIDS epidemic in South Africa has brought competing agendas for prevention and impact mitigation to the table. Given the resource constraints it is imperative that any interventions are thoroughly assessed for their efficacy, costs and benefits. The challenge to succeed with primary prevention of new infections remains the key long-term solution to the epidemic. Ensuring the availability of resources for delivering this intervention in a cost-effective and sustained manner remains a challenge. This report contributes to this by providing an assessment of the cost side of this equation. This research is part of a larger evaluation of the pilot PMTCT programme in South Africa, and has been commissioned by the Health Systems Trust on behalf of the Department of Health.
10. Equity and HIV/AIDS
This report, commissioned by the South African National Department of Health, aims to inform a co-ordinated response to the needs of orphans and vulnerable children in the context of the HIV/AIDS pandemic in South Africa. Divided into two parts, the first details findings from research conducted across five South African provinces and the second offers a set of recommendations. One of the study's objectives was to develop an understanding of the health and social needs of orphans and children at risk, with specific emphasis on access to health, social development and education.
Women and children must be prioritised for treatment for HIV/AIDS, appropriate treatment for children must be developed and healthcare infrastructure must be developed as a matter of urgency. This is according to a report from the Save the Children Fund that aims to examine the implications of expanded access to HIV/AIDS treatment, as exemplified by the 3 by 5 initiative, for prevention of HIV in children and young people, and expanding support and care for orphans and other children made vulnerable by HIV/AIDS.
All people with HIV/AIDS should have equal opportunity to access effective and appropriate treatment. However, in the context of existing social and health inequities, widespread poverty, high rates of new HIV infections, famine and budgetary constraints, increasing access to HIV care and treatment must be organised in a manner that balances HIV prevention and treatment efforts; HIV interventions and the broader strengthening of the health system as a whole; and HIV care and treatment with other public health and social needs.
The emergence of drug resistance in human immunodeficiency virus type 1 (HIV-1) may limit the clinical benefits of antiretroviral therapy. There is no objective evidence that the risk of drug resistance is greater in resource-limited settings than in the developed world. Treatment programmes will be most successful at preventing the spread of drug resistance if they provide healthcare infrastructures to maximize the effectiveness of antiretroviral therapy through the use of potent and convenient combination regimens that achieve durable suppression of HIV-1 replication.
This UNAIDS report, from the Secretary-General’s Task Force on Women, Girls and HIV/AIDS in Southern Africa, presents empirical data on the scale and character of the pandemic in nine countries in Southern Africa with the highest HIV prevalence rates. As the majority of young people aged 15-24 living with AIDS in these countries are women, the report calls for an end to gender inequality, which is key to the spread of HIV among women.
A Zambian government initiative to begin the local manufacture of cheap generic antiretroviral (ARV) drugs has been welcomed by AIDS activists. "We have been lobbying for affordable drugs for 10 years. This is a dream come true," said coordinator of the Network of Zambian People Living with HIV/AIDS (NZP+), Clement Mfuzi. "As NZP+, our hope has not only been accessibility, but also affordable drugs. We also hope the supply will be sustainable, because once you take these drugs, it is for life."
11. Governance and participation in health
This International Community of Women Living with HIV/AIDS (ICW) vision paper argues that, when HIV positive people are involved at all levels of decision-making, an organisation is better able to respond to the concerns of people living with HIV/AIDS. HIV positive women in particular need to be taken seriously by policy makers in order to tackle the HIV/AIDS epidemic effectively. Involvement in national policy making and in regional and local structures is one arena of policy making highlighted. However, ICW argues that other arenas also need to be more open to the views and involvement of HIV positive women. These include faith-based institutions, the private sector, trade unions, women’s organisations, mainstream AIDS organisations, employers’ organisations, political parties, nongovernmental and international organisations and educational institutions.
12. Monitoring equity and research policy
Health systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. This article from The Lancet medical journal is part of a wide-ranging consultation and comment is invited. (Registration is required to access this article.)
This new collection turns a critical anthropological eye on the nature of health policy internationally. The authors reveal that in light of prevailing social inequalities, health policies may intend to protect public health, but in fact they often represent significant structural threats to the health and well being of the poor, ethnic minorities, women, and other subordinate groups. The volume focuses on the "anthropology of policy," which is concerned with the process of decision-making, the influences on decision-makers, and the impact of policy on human lives. This collaboration will be a critical resource for researchers and practitioners in medical anthropology, applied anthropology, medical sociology, minority issues, public policy, and health care issues.
13. Useful Resources
The Medical Research Council of Zimbabwe web page http://www.afronets.org/mrcz.php has just been updated. You may visit this page if you require information on conducting health research in Zimbabwe. Ethics Committee application forms can also be downloaded from our page.
Among the new additions are online books, documents and reports related to leprosy, disability, primary health; etc, some online learning courses and online exhibitions.
Pharmatalk.co.tz will feature a variety of discussion groups and you can post and receive messages online as well as create your own groups as you go along.
14. Jobs and Announcements
Monitoring and Evaluation for Sexual and Reproductive Health examines the underlying principles of monitoring and evaluation for programme managers. Participants explore the steps in establishing effective monitoring and evaluation systems and are guided in how to integrate gender analysis into their monitoring and evaluation plans.
In the context of a joint collaboration between the Zimbabwean Ministry of Health, the French Ministry of Foreign Affairs (MAE) and the Institute of Public Health, Epidemiology and Development (ISPED) of the University Victor Segalen Bordeaux 2, a two-year prevention of mother-to-child transmission of HIV (PMTCT) programme will be initiated at the end of 2004 in three rural districts of Zimbabwe.
Published for the Network for Equity in Health in Southern Africa by
Fahamu - learning for change http://www.fahamu.org/
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