Sound policy or attack on health rights: Are laws criminalising deliberate HIV transmission good for public health?
Mulumba Moses, Health Rights Lawyer, Uganda

Can criminalising deliberate HIV infections curb the HIV transmission rate, and so be good for public health? Or would such legislation negatively impact on voluntary counselling and testing (VCT), and therefore be bad for public health? With many countries in east and southern Africa either enacting or amending legislation to criminalise deliberate HIV infections, there has been mixed response to these questions and mixed reaction to such law reform.

Kenya, Tanzania and Uganda are currently introducing or amending laws to criminalise wilful HIV transmission as they view such laws as an effective tool to curb behaviour that carries the risk of HIV transmission and a legal contribution to the supportive environment for behavior change. These laws generally provide for sanctions when an individual who knows their HIV status knowingly and wilfully infects another individual with HIV. They are proposed as a measure to protect people with less power. By providing sanctions against wilful transmission of HIV, such laws are argued to protect the more vulnerable groups, usually women and young girls, in their sexual relations with those who are more powerful - usually men and wealthy people. They intend to reduce the impunity with which the powerful coerce others into sex, through acts such as rape and defilement, or into practicing unsafe sex (for example through commercial sex work), and so act as a deterrent against these practices.

However, a range of stakeholders involved in HIV related work, from legal, health rights and public health backgrounds, argue that ordinary criminal law provides sufficient legal mechanisms to hold someone accountable for wanton and deliberate infection of sexual partners. A special law to mandate criminalisation of HIV transmission could be bad for public health, harming initiatives such as voluntary counseling and testing (VCT) by deterring individuals engaged in high-risk or criminal sexual behavior from finding out their HIV status, in order to avoid prosecution under this law. Knowledge of HIV status is an entry point to many public health interventions to both prevent HIV and manage AIDS. With women commonly tested for HIV status through antenatal programmes, such laws may increase women’s vulnerability. Laws criminalising deliberate HIV infections could increase stigma, and violate the rights of persons living with HIV to life, health, treatment and freedom from cruel, inhuman or degrading treatment if effective care is lacking, or discontinued, through imprisonment. Emmanuel Mziray, GIPA Adviser to UNAIDS in Tanzania, observes that: ‘prohibiting alcohol and other drugs, consensual sex, or prostitution has never succeeded in preventing these behaviors’.

Criminalising deliberate HIV infections also raises a number of issues relevant to application of the law. It raises questions, for example, about the whether people living with HIV have a legal duty to disclose their HIV status before engaging in sexual activities that can lead to transmission of the virus? If so, then how do you prove in court that the person breached this legal duty? Further there are difficulties in proving the link between the sexual activity and the HIV transmission.

In a bid to address these concerns, USAID recently produced a policy options paper (See: http://data.unaids.org/Publications/IRC-pub02/JC733CriminalLaw_en.pdf) proposing some principles to guide thinking about, and development of, law and policy on the question of criminal law and HIV/AIDS. The paper identifies a number of public policy considerations that countries should consider when making decisions about using criminal law to tackle deliberate HIV infections. It warns that government officials and the judiciary involved in the development and implementation of such policies should be knowledgeable of the best available scientific evidence regarding modes of HIV transmission. Risk levels should form the basis for rationally determining if, and when, conduct should attract criminal liability. This is very challenging in settings where the judiciary may not be familiar with latest scientific evidence regarding on HIV transmission, particularly where there may be debate about levels of risk.

USAID propose that any legal or policy responses to HIV, particularly through the coercive use of state power, should not only be pragmatic in the overall pursuit of public health, but should also conform to international human rights norms, particularly the principles of non-discrimination and due process. State action which infringes on human rights must be adequately justified and policy-makers should always assess the impact of law or policy on human rights, choosing the ‘least intrusive’ measures possible to achieve the demonstrably justified objective of preventing disease transmission. As pointed out by Shanaaz Mathews in the April 2006 edition of the South African Medical Journal, international guidelines on HIV and human rights developed by UNAIDS and the Office of the United Nations High Commissioner for Human Rights (OHCHR) point out that criminal or public health legislation should not include specific offences against deliberate transmission of HIV, but that the latter should be tried under general criminal law, a position endorsed by the South African Law Commission (SALC) in 2001.

The development of such laws in Kenya, Uganda and Tanzania, amongst other ESA countries, suggest that these guidelines are not being followed. In Tanzania the proposed law is under debate, and article 47 of the HIV and AIDS (Prevention and Control) Bill, 2007 provides: ‘Any person who willfully and intentionally transmits HIV to another person commits an offence, and on conviction shall be liable to life imprisonment’. In Kenya, section 26 of the Sexual Offences Act, 2006 makes it an offence for any person who with actual knowledge that he or she is infected with HIV or any other life threatening sexually transmitted disease intentionally, knowingly and willfully infects another person. Though Uganda has not enacted specific legislation criminalising deliberate HIV infections, it has amended its Penal Code Act to create the offence of aggravated defilement and aggravated rape where the offender was infected with HIV.

These laws do not appear to have addressed the human rights or public health concerns raised above, and assign the matter to courts who may have weak expertise in assessing the public health evidence. More generally, the public health impact of these measures are not monitored, neither the costs nor the potential benefits raised above. It is thus difficult to argue that they have been adequately justified, or that they are the ‘least intrusive’ measures possible to achieve their intention. The argument that the issue should be tried under general criminal law perhaps provides a legal remedy for clear violations of rights, without the negative consequences of a specific provision.

Policy and legal reforms are important in tackling the HIV epidemic. If human rights and public health issues are to be respected then it is vital that professionals and activists working on AIDS and people living with HIV be involved in and debate the legal reform processes in this area.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. Further information on health rights and AIDS can be found on the EQUINET website at www.equinetafrica.org

How healthy for Africans is the Alliance for a Green Revolution for Africa (AGRA)?
Professor Carol B.Thompson, Political Economy, Northern Arizona University, USA

The Gates and Rockefeller Foundations propose to increase food production on the African continent, “eliminating hunger for 30-40 million people and sustainably moving 15-20 million people out of poverty,” through their initiative of an Alliance for a Green Revolution for Africa (www.agra.com).

We all share in the goal of eliminating hunger on the African continent. However, we are also aware of the risks to health and nutrition posed by the previous green revolution in Asia and Latin America. As farmers dedicated more and more land to growing new varieties of wheat, rice, and maize, less land was available to women to grow vegetables (vitamins, minerals), and the commercial production of pulses (protein) stagnated. How will this proposed “green revolution” affect production, food security and human health in Africa?

Similar to the green revolution of the 1960-70s, increasing yields of a few crops to provide food for the hungry remains the central justification for this proposed African green revolution. The 1960s varieties of seed required fertilisers, pesticides, and water at very specific times or the yield was worse than traditional varieties. Indian farmers, for example, did increase production of wheat ten-fold and of rice three-fold. Learning from this experience, the current AGRA initiative also includes training African scientists, setting up marketing networks of small seed companies, and credit schemes. Other major differences are that the seeds will be genetically modified (GMOs) and patented, in the 1960s in India, they remained in the public domain.

The benefit of increased yields, however, came with many environmental, economic and social costs in the green revolution on the 1960-70’s.. The massive increases in the use of fertilisers and pesticides contaminated the water and soil. Small-scale farmers could not sustain the purchase of all the inputs and had to sell their land. Studies in India show that only farmers with at least 6-8 hectares of land could afford the high-tech agricultural production. Inequality within villages increased, with many moving to the cities. As Secretary General U Thant summarised in 1970, “There is already a growing a body of relevant literature on the experience in various regions and localities which strongly suggests that the prosperity resulting from the Green Revolution is shared by a relatively few.”

The economic and social dangers of a “green revolution” for Africa are similar to those related to the commercialisation of health care: 1) piracy of both indigenous knowledge and plants (used for medicine and/or food); 2) privatisation of bioresources necessary for human health through patenting of plants; 3) privatisation of research which directs priorities and agendas. Rather than reducing hunger, these adverse outcomes could in fact reduce the food security of Africans, increase undernutrition and thus reduce immunity against disease.

Increased yields of one or two strains of one or two crops (“monoculture within monoculture,” as stated by a Tanzanian botanist) will not provide the basis for food security to support nutritional needs. The key to ending hunger is sustaining Africa’s food biodiversity, not reducing it to industrial monoculture. Currently, food for African consumption comes from about 2,000 different plants; in contrast, the US food base derives mainly from 12 plants. Narrowing plant diversity of food increases vulnerability for all because it a) reduces the variety of nutrients needed for human health, b) increases crop susceptibility to pathogens, and c) minimises the parent genetic material available for future breeding.

Manufacturing plants for food is very similar to manufacturing them for medicine. Indigenous knowledge designates a plant as important for nutrition or for medicinal purposes. But often, corporations simply take both the plants and the knowledge with no recognition, monetary or otherwise, to the original breeders of new medicine and foods. This biopiracy of food and medicinal plants is made legal by the patenting of living organisms, through international trade agreements.

Because African farmers will have to buy the new seeds, and the pesticides and fertilisers they require for increased yields, this green revolution initiative becomes a privatisation offensive against small-scale farmers who still retain control over their seeds. Of the seeds used for food crops in Africa, 80 percent is seed saved by the farmer herself or locally exchanged with family and neighbours. Farmers do not have to buy seed every season, with cash they do not have, for they possess a greater wealth in their indigenous seeds, freely shared and developed over centuries. The very best food seed breeders in Africa, the “keepers of seed,” are women who often farm less than one hectare of land. Across Africa, women are also the food producers, tending “gardens” full of diverse crops for local consumption, while the men concentrate on cash crop production. Even when the cash crop fails, food will most likely be available for the family, for those plots are intensively farmed and carefully watered.

The proposed green revolution would shift the food base away from this treasure of seed. Instead, African farmers would have to purchase patented seeds each season, thus putting cash into the hands of the corporations providing the seed, much as already has happened with plants used in medicinal compounds. Loss of control over seed reduces the control women farmers have over production, with risks to food security and nutrition. For AGRA, the seeds will not only be patented, but new varieties will undoubtedly be genetically modified organisms (GMOs). The perils of GMOs to environmental sustainability are well documented. Most African governments have ratified the biosafety protocol which allows them to deter research and production of GM food crops until sufficient data is available about its impact on human health and the environment, but AGRA is lobbying for governments to “fast track” approval for new varieties to be planted.

Research on African food crops certainly needs financing. The US National Research Council concluded in 19996 that a major African food crop, sorghum “is a relatively undeveloped crop with a truly remarkable array of grain types, plant types, and adaptability….most of its genetic wealth is so far untapped and even unsorted. Indeed, sorghum probably has more undeveloped genetic potential than any other major food crop in the world.”

As nutritious as maize is for carbohydrates, vitamin B6, and food energy, sorghum is even more nutritious in a range of essential nutrients for health. One of the most versatile foods in the world, sorghum can be boiled like rice, cracked like oats for porridge, baked like wheat into flatbreads, popped like popcorn for snacks, or brewed for nutritious beer. Because sorghum can tolerate dry areas and poor soil better than maize, it can provide nutritious food security in semi-arid regions and therefore, should become even more important under conditions of global warming.

Engaging African scientists to discover the potential genetic wealth of sorghum would assist African food security. In a first glimpse of foundation expenditures, however, we see funds directed to the Wambugu Consortium (founded by Pioneer Hi-Breed, part of DuPont) for experiments in genetically modified sorghum. By adding a gene, rather than mining the genetic wealth already there, the consortium can patent and sell the “new” sorghum at a premium price for DuPont.

Private expenditure on research and marketing of a few crops directs attention to crops that are profitable. Similar to health care, International Monetary Fund requirements for structural adjustment programs, supported by all donor governments, the World Bank, and the African Development Bank, have been removing African government expenditures on agricultural research and extension. Governments had to spend less on agriculture in order to repay their debts. Now, more two decades later, the private foundations step in to “save” food-deficit Africa.

High-tech answers to Africa’s food crises are no answers at all if they undermine human nutrition, privatise both indigenous knowledge and bioresources through patenting of plants, and transform the genetic wealth of the continent into cash profits for a few corporations. Public policy choices around the AGRA proposals have not yet been made within Africa. There is thus still an opportunity to call for assessment and debate on the health and nutrition impacts of these proposals, including by civil society working in health, and by parliaments, and by UN agencies. We need to openly challenge its goals, motives and methodologies before Africa’s political leaders accept them, and before universities and research centres divert their agendas away from other applied research that may offer a more sustainable and nutritious future for African food production. The future of African health depends on it.

For references used in this editorial and a more detailed analysis of how Africa’s food biodiversity provides alternatives to chemical industrial agriculture, see Andrew Mushita and Carol B. Thompson, Biopiracy of Biodiversity (Trenton, NJ: Africa World Press, 2007), carol.thompson@nau.edu. Further information on nutrition and health issues can be found on the EQUINET website at www.equinetafrica.org or contact admin@equinetafrica.org

Talking development and walking trade – the health consequences of policy conflict in the “Economic Partnership Agreements”
Rene Loewenson, TARSC; Aulline Mabika, SEATINI, Ezekiel Mpapale, Gender Sensitive Initiatives

One by one in December, African countries in east and southern Africa signed interim Economic Partnership Agreements (EPA’s) with the European Union (EU). In a massive fragmentation of regional integration, first these agreements were negotiated in configurations that undermined African regional trading blocks (See EQUINET newsletter editorial May 2007). In November the fragmentation deepened as the east African countries broke from the ESA block to sign interim EU-EPA’s, as did Mauritius, Seychelles, Botswana, Swaziland, Mozambique, Madagascar, Zimbabwe and Namibia, individually. At the same time at the EU – Africa summit in Lisbon in December President Abdoulaye Wade of Senegal said "We are not talking any more about EPAs, we've rejected them", while countries like Namibia signed, but signalled intention to keep negotiating on protections for fledgling industries.

Its not only from Africa that conflicting signals are being sent. From the EU there is stated commitment to the two central goals of the 2000 "Cotonou Agreement": to eradicate poverty and to enhance the gradual integration of African, Caribbean and Pacific countries into the global economy. The EU has signed on to numerous UN and G8 commitments, including those on the Millennium Development Goals, and its own Treaty of Amsterdam. These commit the EU to policy coherence between development objectives and impacts and its policies in other areas, including trade. At the same time the interim EPAs being concluded are clearly focused on establishing free trade agreements strictly compatible with World Trade Organisation (WTO) requirements. While there is some reference to development issues, this is secondary and largely deferred to later dialogue.

Take for example the protection and promotion of public health as a fundamental issue not only for the MDGs, but in the International Covenant on Economic, Social and Cultural Rights (ICESR) (1976) and particularly Article 12. All parties to the agreement have ratified this convention. The EU founding document, the Treaty of Amsterdam commits that “A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities”. The African Charter on Human and Peoples’ Rights (1986) in Article 16, obliges ESA countries to take the necessary measures to protect the health of their people.

Despite this the Interim EPA texts made available in the region:
• Make no mention, as WTO agreements do, of the fact that clauses should be interpreted and implemented in a manner supportive of countries’ right to protect public health.
• Make no provisions for ESA countries to protect their infant industries, especially in small enterprises and in the small scale farming sector that underpins household food security and child nutrition in Africa.
• Make no exceptions to the elimination of import or export prohibitions or trade restrictions in areas such as trade in health workers, health services, essential services and other areas where governmental authorities and restrictions on trade are necessary to regulate provisioning or redistribute resources to meet social development goals, or to protect public health.
• Make no exceptions in clauses relating to internal taxes or charges in the interests of public health.
• Make no reference to “human development” or “social development” in the objectives of the section on economic and development co-operation
• Set no obligations for administrative arrangements or resources to assess or manage the public health implications of the liberalised trade measures proposed, including of obligations to carry out prior health impact assessments of specific areas of trade where there is a likelihood of risk to public health.

Such failure to address human development issues has led to criticism that the current EPA texts do not align with the 2006 adopted European Consensus on Development (2006/C 46/01) or the 2005 adopted EU measures to accelerate the progress towards attaining the MDGs [COM(2005) 132/final 2, COM(2005) 133/ final 2 and COM(2005) 134 final].

While there is pressure to secure WTO compatible agreements, the detailed tariff reduction commitments in the interim EPAs are argued to go beyond the strict demands of multilateral rules for the WTO-compatibility of free trade agreements, with costs to ESA countries. Gains from greater exports to the EU could be overshadowed by the damage done by the largely reciprocal market openings that ACP countries would have to undertake. The interim agreement accessed provides for 80% liberalisation in a period of 15 years. This would allow subsidised European food products, with which local producers would be in no position to compete, to effectively swamp ESA markets. Under the interim deals with East Africa, for example, taxes on two-thirds of imports from the EU would be eliminated with negative consequences for government revenue.

Such agreements are being signed at a time when the Doha Round on development is not yet concluded at the WTO, with Article 24 of GATT still being negotiated. Signing an interim EPA may pre-empt, or worse still weaken these WTO level negotiations. Reminiscent of the days of Structural Adjustment, it has been said that “there is no alternative” to the current trade focused EPAs. But trade experts indicate that alternatives do exist. Beyond significantly greater protection of human development issues in the EPAs’ as exemplified for health above, trade experts suggest that the EU could also have offered alternative trading arrangements under its Generalised System of Preferences (GSP+), particularly given the level of economic poverty and vulnerability in most ESA countries. It was possible for the EU to seek an extension of the waiver at the WTO, particularly given the delay in resolving the Doha round on development, given its significance for Africa. These options were not pursued, suggesting, as noted in an October 2007 analysis by the NordikAfrica Institute, that the primary EU goal for the EPAs was to secure free trade agreements within a strict interpretation of WTO rules.

The interim EPAs send signal an understanding of development and poverty reduction as being essentially driven by trade liberalisation, with development aid as a means of coping with the temporary, negative impacts of this agenda. It suggests that development will follow trade liberalisation and thus that other aspects of development should adjust to the terms of this free trade focused interim EPA.

The singular prioritisation of trade liberalisation, even while argued as “interim” fails to adequately protect basic social rights, such as the rights to health noted earlier. It also fails to adequately meet the EU’s own commitments and treaties and to draw on the EU’s own development experience, and the regulation and subsidies used in the EU to promote industrial and social development and services.

It also contradicts analysis and experience in ESA. After two decades of trade liberalisation policies, Africa Union and UN Economic commission for Africa reports in 2007 highlight uneven growth and growth with poor returns to human development and poverty reduction. Rapid, wide trade liberalisation policies have been associated with falling public revenues, increasing dependency on food imports, increased chronic undernutrition, reduced coverage and quality of and access to essential services, including health care services. In the health care sector, trade liberalization increases growth in formal and informal for profit health care services, with negative impacts on access, quality and segmentation in services, and increased fee barriers to care. Even the World Bank in a 2002 working paper concluded that rapid trade-related integration in Africa had caused or exacerbated social inequality and that those who benefited most were the import/ export firms, transport and shipping companies, large-scale commercial farmers, and financiers and the politicians and bureaucrats who are tapped into these commercial and financial circuits.

A model of development that is driven first through trade liberalization, with later “development” adjustments, negates the lived and historical experience, documented evidence and policy demands of Africa and of many development actors in the EU. Trade Commissioner Peter Mandelson said at a speech to the Civil society Dialogue Group in January 2005, “… I intend this to be a new start for the EPAs – to give the negotiations a new impetus – and to ensure that from now on, until the final implementation of what we will negotiate by 2008, development concerns have pride of place” . It appears his “pride of place” was the same marginalized exclusion the majority of disadvantaged communities in Africa occupy.

The process is not yet over. Some countries have yet to sign. For others, the interim agreements signed in 2007 still need to be ratified and deemed domestically operational, a process that will take to July 1 2008. Ratification in many ESA countries requires parliamentary endorsement. Could the parliaments in Africa and in the EU bring new “people’s” voice to this process and to future negotiations on the EPAs, and with it new attention to the health and development concerns?

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit EQUINET www.equinetafrica.org. or SEATINI (www.seatini.org)

Transforming civil society and community roles in responses to HIV and AIDS in Africa
Johann Barnard, Sizo Majola, Ifor nternational HIV/AIDS Alliance

Civil society and communities should have a far greater direct involvement in the implementation of HIV and AIDS programmes for them to have a meaningful impact. This calls for an effective mechanism to channel funding to support and strengthen the capacity of civil society organisations. This was the resounding consensus at the Civil Society, HIV/AIDS and Africa: capacity, sustainability, partnerships conference being held in Johannesburg, South Africa from December 5 to 7. The meeting was co-hosted by the International HIV/AIDS Alliance and the UK Government's Department for International Development, and co-organised by UNAIDS and the Global Fund to Fight AIDS, TB and Malaria.

‘We need a shift in the way civil society relates to universal access and away from a lesser role to being an equal partner in the implementation of national strategies,’ Mark Stirling, UNAIDS' director for the regional support team for Eastern and Southern Africa, said at the opening ceremony of the conference. Stirling said Southern Africa in particular was hamstrung by bottlenecks that currently translated into an average of more than 80% of interventions falling behind targets to achieve universal access by 2010. There therefore needed to be a properly planned response to significantly ramp up the capacity and participation of civil society organisations to fill this gap.

‘We need funding models to move away from the status quo, and need a quantum shift for an effective response,’ Stirling said. The Chair of the International HIV/AIDS Alliance's Board of Trustees, Callisto Madavo, noted that good models exist for channelling money to support community-based responses, and these need to be expanded: ‘We have many examples of successful models and it is imperative that these experiences are shared so that we can accelerate our responses.’

Madavo said that ‘the most successful responses to HIV and other development challenges are built on local leadership, commitment and responsibility’. As communities are closest to people affected by HIV and often make the first response in addressing HIV, ‘without the active and influential participation of communities there is a real danger that the increased funding now available for HIV could not be well spent and not reach those most in need’. He said this could only be overcome through changes in policies and approaches that incorporated the experience over the past two years.

One of the major funders of HIV and AIDS programmes, the Global Fund, wants to encourage more civil society organisations to be amongst the principal recipients of their funding. Principal recipients are local stakeholder institutions (and there can be more than one in a country) who co-ordinate partnership, provide technical leadership, manage funds and monitor, evaluate and report on programmes. Christopher Benn, the Global Fund's executive director of external relations indicated that change was needed to ‘make sure that civil society is a principal recipient in more countries’. He added that the perception that funds for HIV programmes was drying up was unfounded and that ‘unprecedented’ resources were available. He said that $10-billion had been pledged for the Fund, while PEPFAR was expected to announce the extension of its mandate, to the tune of $30-billion over the next two to five years. Therefore, he said, the availability of resources was not the most critical issue, instead ‘capacity building for scaling up responses is the most critical, and we need to scale up dramatically.’

Although the Global Fund recently approved a budget of US$1,1 billion in Round 7 of funding proposals, only 50% of proposals had been approved and there were concerns about implementation capacity: ‘I hope we don't find ourselves in a position where we had the resources, but could not implement them,’ Benn said.

While the conference provided success stories of civil society roles in effectively reaching communities, both funding organisations and civil society need to take on the challenges of channelling resources to community level on a vastly increased scale. As Madavo indicated, ‘A consensus seems to be emerging on a new paradigm for effective capacity development centred on building effective states and forging engaged societies. The challenge is to unleash, nurture, and retain capacity. That requires a political environment that encourages participation, excellence, learning, and innovation. The new paradigm for capacity development emphasises the dual objectives of building effective states and forging engaged societies.’ And the conference also had a resounding consensus on the test for how successful new approaches are – that they effectively channel resources to communities, where they are most needed for the response to HIV.

The International HIV/AIDS Alliance, established in 1993, is a global partnership of nationally-based organisations working to support community action on AIDS, support south-south co-operation, and undertake operations research, training and good practice development and policy analysis and advocacy. They can be contacted via their website at http://www.aidsalliance.org/. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.

What do we need to do to keep health workers in Africa?
Yoswa Dambisya, University of Limpopo

Recognition of the health worker crisis in Africa has stimulated debate on what works to deploy and retain health workers in critical levels of African health systems. Most east and southern African (ESA) countries suffer a critical shortage of health workers with fewer than 2.5 skilled health workers per 1000 population, less than the level needed for the most necessary health interventions. The shortfall contributes to the persistence of high disease burdens and poorly developed health systems. These factors together with poor management systems and lack of appreciation of health workers drive further losses of health workers in a vicious cycle. With a Malawian woman having a probability of dying during childbirth that is 130 times greater than that of her American counterpart and faltering progress towards achieving millennium development goals in the region, acting on this health worker crisis has become a matter of global concern. While many policies and strategies are being proposed, answering the question what makes health workers stay in African health systems provides one direction for action.

Many factors responsible for health worker shortages, especially those related to global migration of health workers, are beyond the control of individual countries in ESA and call for wider international action. However there are important ways in which ESA countries can act to deploy and retain health workers in the health systems in the region, and there is learning to exchange from the combination of financial and non-financial incentives being used with varying degrees of success to retain available staff.

As an immediate measure many countries are using financial incentives like salary increases and allowances to send an early signal to attract or stem losses of health workers. To stabilize and sustain these, including in more inflationary environments, a range of non-financial incentives are also being used, such as training and career path-related opportunities, housing, transport, childcare facilities, free food, employee support centres, improvements in working conditions, better facilities and workplace security and improvements in management and human resource information systems.

Recognising the specific contexts affecting the approaches used in countries, there is scope for learning from the impact of measures being used in the region.

The Malawian health worker retention strategy, for example, is a combination of financial and non-financial incentives through a six-year, $272 million emergency human resources programme with budget support from the Government of Malawi, the Department for International Development (DFID) and The Global Fund for AIDS, Tuberculosis and Malaria. Blending these significant sources of budget support, the measures have (at least in the short term) managed to overcome the massive absolute shortfall across the system as a whole and to attract and retain health workers in Malawi. Some incentives address the factors that push workers out of the health system more directly. Swaziland responded for example to the high HIV and AIDS burden among the health workforce through the establishment of a wellness centre for health workers in collaboration with the Swaziland Nursing Association and the International Council of Nurses (ICN). Some countries have reduced the bureaucracy slowing the recruitment of health workers. Tanzania and Kenya have for example involved partners from the private sector to implement more easily administered emergency hiring plans for hard-to-staff areas.

Many countries face issues of internal migration and use incentives to more effectively retain workers in remote or underserved areas. Zambia, has for example, been able to attract staff to rural areas using a comprehensive package of financial and non-financial incentives, originally for doctors but currently extended to other health workers. Uganda made government service more attractive than the private sector through salary enhancement and non-financial incentives like training opportunities, support for research and a Yellow Star Award programme that recognises facilities that have consistently excellent performance. South Africa has used financial incentives in the form of rural and scarce skills allowances for under-served areas, in addition to compulsory community service.

Implementing these incentives and monitoring their impact calls for improved strategic management skills with greater flexibility to respond to rapidly changing conditions. A number of countries have set up autonomous health service boards and commissions to address health worker needs independently of the public service commissions to provide flexibility. This has had mixed results, depending on the resources and power that these boards have. The Zambian Health Service Board had a difficult beginning largely because most of the powers remained with the central public service commission. The Uganda Health Service Commission and the Health Board in Zimbabwe have been reported to function more effectively although their impact on health worker outcomes are not yet well assessed. Approaches that have evolved through consultation with all stakeholders, including the health workers and development partners, that are linked to strategic plans and funded from national budget or pooled funds, instead of vertical schemes, have tended to be more successful. Vertical schemes have suffered from lack of continuity and sustainability.

While experience is growing in the region around incentives for retention, assessing and sharing what works and what doesn’t work is constrained by lack of systematic documentation and limited monitoring and evaluation mechanisms. Success stories and success factors are thus not always well recognized locally or accessible to other countries. Weaknesses in monitoring and review systems also slow the response to unanticipated negative outcomes of schemes. For instance, in both Uganda and Tanzania, introduction of better pay for public sector health workers was accompanied by a net movement of health workers from faith-based facilities to government services, leaving many areas where only faith-based services were available to poor communities underserved. Recognising this, national and regional organizations in EQUINET are documenting experience and impacts in selected countries in the region.

There are good reasons for investing in retention incentives and for more effectively managing this aspect of health systems. Firstly, training health workers is costly and takes long; and without measures for retention there is no guarantee that the trainees will stay after completion of their studies. The loss of public sector training investments is an area of high cost of outmigration to the public health systems of Africa. Secondly, failure to retain staff has direct and knock-on costs, such loss of institutional memory, loss of morale and increased workload for the remaining workers and higher costs to the community to seek care at higher levels. In contrast retention strategies send an affirmative message to health workers that they are valued and this sends positive signals to attract more health workers. Further, measures for retention of health workers have positive implications for equity as they direct resources towards hard-to-staff facilities in rural, remote areas or those serving poor populations who have limited capacity to pay for private health care.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. EQUINET Theme work on health worker retention is co-ordinated at Unversity of Namibia and is being implemented in co-operation with the ECSA Health Community. For further information and publications on this issue please visit www.equinetafrica.org.

Closing the gap: from implementing to publishing research in Africa
Rebecca Pointer, Rene Loewenson, Training and Research Support Centre

This past week the Global Forum for Health Research (GFHR) has held its 11th annual Forum in Beijing, attracting hundreds of people from across the world. The GFHR advocates for greater equity in health research, noting that while developing countries that carry the heaviest health burdens; they command only a fraction of global health research funding. Under the theme of “Equitable Access: Research challenges for health in developing countries”, Forum 11 heard that global commitments to improving health will not be reached without significantly greater investments in the health sectors of low income countries. According to Stephen Matlin, the forum's executive director, globally, about $125 billion a year is being spent on health research, a four-fold increase over the past 20 years, "In spite of that increase, a relatively small fraction of the total is devoted to health problems of the poor and to people living in developing countries".

New resources for health are being made available, drawing attention to who influences their use? To what extent will communities in low income countries influence new investments, particularly towards their health needs? How far will new spending be influenced by knowledge generated from within these countries? In a world of competing approaches, how accessible and prominent is local knowledge within policy forums?

There is cause for concern when evidence suggests that the problem of inequitable research funding is compounded by similar inequalities in the publication of research. A recent review of research publication by Smith Esseh (2007) of the “Strengthening African Research Culture and Capacities Project” found that dissemination of developing country research findings is declining. ‘Africa is the second-largest continent, and has over 900 million people, and therefore should be a world leader in global scholarship. In 1960-1979, scholarly publishing began to rise in Africa, a result of gains in social and political independence. However, in 1980-1985 scholarly publishing plateaued. From 1986 to now, scholarly publishing in Africa has been declining steadily.’ (http://scholarlypublishing.blogspot.com/2007/07/strengthening-african-research-culture.html; http://ocs.sfu.ca/pkp2007/viewabstract.php?id=83). The inequalities are not only north-south: they also exist within Africa. Scholarly publishing in Africa was found to be concentrated in only seven countries, accounting for 75% of scholarly publishing in the continent, while the other forty-five countries account for only 25%.

For east and southern Africa, it would be important to follow up whether such a finding also holds for scholarly publishing in health. Publication is vital for research findings to reach wider audiences, for peer review and to build an accessible body of local and regional knowledge to inform policy. The links are not always direct, but it is clear that unpublished work remains hidden from policy processes.

In his opening address to the 22nd Annual Joint Scientific Conference of the National Institute for Medical Research in Arusha, Tanzania on 7 March 2007, Tanzanian Minister for Health and Social Welfare David Mwakyusa described the problem: ‘Researchers must know that if they cannot efficiently and effectively deliver to the stakeholders their research findings, then they have failed to accomplish their mandate. In fact, un-disseminated research findings do not only become useless but also make for multiple losses to the nation; a waste of precious time, a loss of funds invested in the work and human power, a loss of productivity and a loss to people’s welfare.’

Ensuring effective dissemination of research and knowledge is thus even more important in Africa, where research resources are inadequate relative to health burdens. Yet the major global progress made in access to information over the last decade remains elusive to many health professionals, especially those working in rural district and primary health care services, who still struggle to access or disseminate information. According to Couper and Worley (2007), ‘The unequal distribution of health care between developed and developing worlds is matched by a similar unequal distribution of health information [and yet] the health problems of Africa are most likely to be solved by people in and from Africa, who know the right questions to ask to get practical solutions and can then access the necessary information.’ (http://www.rrh.org.au/articles/subviewafro.asp?ArticleID=644)

African scholarly works are poorly distributed, barely marketed, and hardly accessed. Poor access to information has been found to be one factor driving skilled health workers out of service in remote areas. Researchers struggle to access scientific literature. The circulation numbers for African journals are often low. Smith Esseh (2007) reports for example that African universities have very low budgets for journal access and publication, ranging from a budget of 50 cents per student (Ghana) to $2.66 per student (Cape Coast) to the high of $9.00 per student (Dar es Salaam). Lack of access to journals has a two way effect, limiting access to international research in Africa and limiting dissemination of work from Africa. African researchers have raised in EQUINET forums the many other challenges they face in getting their research published, including language barriers, lack of confidence and mentorship in publication, lack of exposure to journals and writing skills. Recognising this, EQUINET has increased its investment in support for publication of research produced in the network and capacity building of writing skills within and across its research networks. A recent EQUINET Writing Workshop for Scientific Publication in Lilongwe, Malawi in October 2007 highlighted the importance of researchers identifying dissemination goals at an early stage of research, and of strengthening capabilities for dissemination within all research programmes.

However the barriers we describe go beyond the capabilities of individual researchers. They also arise in the opportunities available for accessing and disseminating information. Global developments do give some cause for optimism. The massive increase in internet use in Africa, by 625% in the past seven years, suggests new options for accessing and disseminating research. Online journal publishing and open access publication has grown in health, offering new channels for publication and new opportunities for African researchers to obtain information. The growing list of African health journals found at African Journals Online (http://www.ajol.info/) (92 under health and medicine) suggest that the old barriers posed by print production will be less of a limiting factor than they have been in the past.

This raises new questions of how to avoid differentials in access to internet becoming a basis for social differentials in influence over health policies. At the same time as the GHRF researchers were meeting in Beijing, a summit of African politicians, international lenders and leaders of the IT industry met in Kigali, Rwanda on October 31st 2007. They noted that fewer than 4% of Africans currently have an Internet connection. A goal was set at this meeting for interconnection with broadband lines of the capitals of all African states by 2012. As with other resources for health, equitable access to this vital information link across the health research community in Africa, including those in low income rural settings, will depend on public policy and investment to make it more widely accessible within and beyond these capital cities, and specific measures to stimulate its uptake and effective use amongst those currently marginalised.

TARSC is the secretariat for EQUINET. Please send feedback or queries on the issues raised in this briefing or any follow up queries on EQUINET activities to support writing skills to admin@equinetafrica.org.

EQUINET book launch: Reclaiming the Resources for Health
EQUINET Secretariat, TARSC

*Why is life expectancy in some countries in our region 40 years longer then others?
*How well are we meeting commitments made by leaders to spend 15% of government budgets on health?
*What can we do about the loss of health workers due to migration?

These issues are discussed in the new book published by EQUINET “Reclaiming The Resources For Health: A Regional analysis of equity in health in east and southern Africa” launched in the region in Lilongwe Malawi on October 23rd 2007, at an event locally hosted by REACH Trust Malawi and Malawi Health Equity Network, two EQUINET steering committee member institutions. The book was officially launched by the Principal Secretary for Health, Mr Chris Kang’ombe, with the Chair of the Parliamentary Committee for Health, Honourable Austin Mtukula and speakers from the region, followed by dance and drama presenting health challenges in communities. Hastings Banda from REACH Trust chaired the session, attended by people working in health in Malawi and delegates from seven of the 16 countries in east and southern Africa.

After a welcome by Bertha Simwaka, Acting Executive Director of REACH Trust, and an EQUINET presentation by Rene Loewenson outlining the scope of the book, three speakers from the region explored further the issues raised.

Moses Mulumba, a lawyer with the Law Faculty, Makerere University Uganda outlined how rights to health are often not respected in economic and trade policies. This has led to explicit efforts in Uganda to influence negotiations on trade agreements like the Economic Partnership Agreements, sensitise trade officials, and set human rights guidelines for areas of trade, such as the practices of pharmaceutical companies in relation to access to medicines and to advocate for assessment of the health impact of agreements before signing them.

Bona Chitah from the University of Zambia described Zambia’s attempts to achieve a “dream and up our standards for the good of the people”. Recognising that Zambians have a right to better health, he described the efforts to redistribute health resources, improve access to health services and ensure a holistic, horizontally integrated health system. Recent reviews of cost sharing policies showed how they raised barriers and costs for poor people, leading Zambia to abolish user fees and seek increased financial resources from international sources for health. He pointed to a number of challenges still to address in achieving fair financing for health: “We are awakening to the reality that we are in it for the long haul ... to build the bridge between the current and the dream ...”

Kathne Hofnie-Hoebes from University of Namibia highlighted the necessity of tapping the potential for health action that exists within communities. Drawing on experiences of a marginalised community in an informal settlement in Namibia, she described how using participatory reflection and action approaches builds respect between communities and health workers and builds the confidence of communities to act.

Experiences were also presented from Malawi. Hon Austin Mtuluka, MP and Chair of the Malawi Parliamentary Committee on Health, described the advocacy by parliamentarians for health equity in budget and legal processes. This has yielded gains: Malawi has made progress towards meeting the Abuja target in 2007, with a rise from 8% of the total budget to 14% of the total for 2007/8. Parliamentarians were also involved in drafting a new law on HIV and AIDS, drawing experience from the region. He commented that the exchange of information between parliamentarians across the region has been useful in strengthening parliamentary roles and capacities for tackling health inequity.

Finally the Permanent Secretary for Health from the Ministry of Health Malawi, Mr Chris Kang’ombe officially launched the book. He recognised the significant challenges to achieving global Millennium Development Goals in Africa, and the importance of networking researchers, policy makers, officials and civil society members towards promoting health equity and regional co-operation. He observed, “The perspective that guides the report being launched today is based on shared values of equity and social justice in health and a spirit of self determination.”

He pointed to the book as a relevant source of evidence and analysis, and made links between the themes in the book and the focus areas for development set out in the Malawi Growth and Development Strategy, whose overall theme is ‘From poverty to prosperity. The book draws from regional experience: Strategies applied in Malawi, such as the provision of the essential heaIth package are discussed, together with insights and options for improving equity in access to these services. In his words,
“I would like to encourage and urge each and every one of us working in the health sector and beyond to make sure that we have a copy of this report… Let us participate in implementing the activities and recommendations set out in this report to reduce the health inequalities which currently exist in Malawi and in the east and southern Africa region.”

The tempo after the launch was raised with drumming, singing and dancing marking the entry of the Paradiso Home Based Care dance group. The group’s songs reinforced messages around advancing people’s health, with many joining in dancing. The Tipya Drama Group, a community group in Lilongwe, performed a play about poor communities expectations of their community care, and the need for communities, health workers and planners to have dialogue in addressing these needs. The drama group interpreted messages from the book in their own context, with some local twists!

The launch in Malawi was the regional ‘launchpad’ to disseminating the evidence and experience on health equity from and about the region contained in the book. The health equity challenges in Malawi, as in other countries in the region, are significant. The launch sent clear signals, however, of the affirmative intention, options and social resources to act on these challenges from within the region.

Information on where to obtain a copy of “Reclaiming the resources for Health” can be found on the EQUINET website (www.equinetafrica.org) or send queries to admin@equinetafrica.org.

Fighting HIV and AIDS with the law
Priti Patel, Southern Africa Litigation Centre

Mark your calendars. On December 1, the globe will celebrate World AIDS Day. The theme, as it has been for the last two years, is "Stop AIDS: Keep the Promise." This is to serve as a reminder to the world community of its promise to among other things provide universal access to treatment, reduce prevalence rates, and implement effective prevention programs. As the prevalence rate of those living with HIV continues to climb in most countries in southern Africa, it is clear that we are far from fulfilling this promise by 2010, the campaign’s target year.

Almost a third of those living with HIV live in southern Africa. Despite the infusion of funding and the attention of national governments and international bodies, the prevalence rate in the region (surprisingly, apart from Zimbabwe) is continuing to rise. In Botswana, Swaziland, and Lesotho over one-fifth of the population is infected with HIV. The high prevalence rate fails to be matched by adequate access to treatment. Access to anti-retroviral therapy in sub-Saharan Africa has increased in the last year but remains at a miserable 28%.

As anyone living in southern Africa knows, the tentacles of the virus reach across all sectors of the community, but they tend to prey more on those who are the most removed from access to and the protection of the law—among them, women, children, prisoners, and those living in poverty.

Despite this or maybe because of this, the law remains an underused weapon in the fight against the effects of HIV and AIDS in the southern Africa region. Apart from South Africa—where the galvanizing work of the Treatment Action Campaign, AIDS Law Project, and others supported by a robust Constitution and judiciary has resulted in significant legal successes—there have been few cases brought on behalf of those infected and affected by HIVand AIDS in the region. In Namibia, the AIDS Law Unit of the Legal Assistance Centre successfully brought a case challenging the Namibian military’s denial of employment to an HIV positive individual who was otherwise physically fit.

In Botswana, the courts have issued decisions on a handful of cases involving the privacy rights of HIV positive individuals. In the rest of the countries in the region, courts have yet to issue a single significant legal decision on an HIVand AIDS related case.
In recognition of the underutilization of the law and litigation in southern Africa, the Southern Africa Litigation Centre established a new HIV and AIDS programme focusing on providing resources, support, and training to lawyers and advocates in the region to bring cases supporting the rights of those infected and affected by HIV/AIDS in national and regional courts. The programme does not intend to duplicate the groundbreaking work already being done by local, national, and regional organizations on these issues, but will aim to bolster the work of local and other regional actors to increase the use of the law and litigation to advocate for the rights of those living with HIV, and those rendered vulnerable by the pandemic.

Accessing the law through litigation can be a powerful tool for changing policy and social attitudes. Litigation can also provide a public platform on which the voices of those generally silenced can not only be heard but magnified. In South Africa, the role of lawyers and litigation in exposing the hypocrisy of the apartheid state and ultimately contributing to its demise is undeniable. More recently, a Constitutional Court decision, Minister of Health and others v Treatment Action Campaign and others, requiring the South African government to make nevirapine, a drug known to significantly reduce the likelihood of mother-to-child transmission of HIV, available in all public hospitals and clinics resulted in the drastic reduction of mother-to-child transmission.

This is not to say that the law and courts alone can stem the devastating impact of HIV and AIDS, or that litigation is the appropriate strategy all of the time. The use of the law must be pursued in tandem with other advocacy tools, including public education and campaigning. In addition, legal victories have little meaning without the close involvement of local community-based organizations, and networks of people living with HIV, who can ensure the translation of a successful court decision into concrete change in the reality of people’s lives.

I am not naïve. I do not think the use of courts and the law will miraculously change the progression of the pandemic. But if we are to have any chance of turning the tide we need to use all of the tools available to us in fighting this epidemic.

Priti Patel is Project Lawyer for the Southern Africa Litigation Centre’s (SALC) new HIV/Aids Litigation Programme; she can be contacted via the SALC website at http://www.southernafricalitigationcentre.org/salc/. Visit the EQUINET website www.equinetafrica.org for further information on rights as a tool for equity and health systems responses to HIV and AIDS. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.

Reclaiming the resources for health
EQUINET Steering committee

The global attention to equity and to Africa has grown. The 2006 United Nations Human Development Report, the 2005 UN Report on the World Social Situation and the 2006 World Bank World Development Review focused on inequalities and equity, while a WHO Commission on the Social Determinants of Health will report in 2008 on a global inquiry into options to improve health equity through action on the social determinants of health. Africa has been the focus of Commissions and special programmes. In 2007, the World Health Organisation Director General stated that improved health in Africa was one of the organisations’ top priorities.

Within Africa, millions of people experience deprivation of the most basic rights to water, shelter and food, millions of children have lost parents due to early adult death, a majority do not have secure incomes and many live in situations of conflict and social disruption. Also within the continent, health workers, teachers and others provide valuable services, state officials and university staff take on intense workloads with limited resources, and civil society and community organisations implement innovative local ways of improving life.

An enormous gap continues to exist between global attention and local reality.

On October 23 2007, EQUINET is launching a new publication- an analysis of equity in health in east and southern Africa. The book, “Reclaiming the resources for health: A Regional analysis of equity in health in east and southern Africa” explores the challenges and options for overcoming persistent inequalities in health in east and southern Africa (ESA). It is written by the EQUINET steering committee and jointly published by EQUINET with three African publishers, Weaver Press Zimbabwe, Fountain Publishers Uganda and Jacana publishers, South Africa.

The book presents a synthesis of the evidence gathered from a range of sources, including eight years of work in EQUINET, published literature on and from the region, data drawn primarily from government, intergovernmental, particularly Africa Union and UN sources and the less commonly documented and heard experience within the region, found in grey literature, in interviews and testimonials and gathered through participatory processes. In the analysis, we do not seek to simply describe our situation, but to understand it in ways that generate and inform affirmative action from within the region.

The evidence in the analysis points to three ways in which “reclaiming” the resources for health can improve health equity:
• for poor people to claim a fairer share of national resources to improve their health;
• for a more just return for ESA countries from the global economy to increase the resources for health; and
• for a larger share of global and national resources to be invested in redistributive health systems to overcome the impoverishing effects of ill health.

The region has the economic and social potential to address its major health needs. Yet improved growth has often occurred with falling human development indicators and increased poverty. In many ESA countries, widening national inequalities in wealth block poor households from the benefits of growth, while substantial resources flow outwards from Africa, leaving most of its people in poverty, and depleting the resources for health. The analysis adds evidence to the growing call for a more fair form of globalisation, and a more just return to Africa from the global economy. The report maps the trade, investment and production policies and measures that have strong public health impact, the options to address outflows, and to promote access to food, health care and medicines within economic and trade policies. National measures that redistribute these resources for wider economic and social gain provide clear pathways for equitable use of funds released from debt cancellation, improved terms of trade, increased external funding and other global measures.

While many of these actions lie outside the health sector, the analysis argues that health systems can make a difference, by providing leadership, shaping wider social norms and values, demonstrating health impacts and promoting work across sectors.

Drawing on a diversity of evidence and experience from the region, the analysis describes the comprehensive, primary health care oriented, people-centred and publicly led health systems that have been found to improve health, particularly for the most disadvantaged people with greatest health needs. While resource scarcities and selective approaches weakened these universal systems in recent decades, the lessons presented from the roll out of prevention and treatment for HIV and AIDS continue to demonstrate their relevance, particularly at district level.

The persistence of disadvantage in access to health care in those with highest health needs is thus of concern. The analysis explores the reasons for this, within the way health systems are funded and organised, and the barriers that disadvantaged people face in using health services.

Addressing these problems demands a strengthened public sector in health. Current average spending on health systems in the region is below the basic costs for a functional health system, or even for the most basic interventions for major public health burdens. Therefore one priority is for governments to meet the as yet largely unmet commitment made in Abuja to 15% of government spending on health, excluding external financing. We argue, however, for “Abuja PLUS” - for international delivery on debt cancellation and for a significantly greater share of this government spending to be allocated to district health systems.

The analysis presents progressive options for mobilising these additional domestic resources for health systems without burdening poor households, and for increasing spending on district and primary health care systems. One of the areas of increased spending is on health workers. Without health workers there is no health system. In the face of massive shortfalls and significant outflows of health workers, the analysis explores incentives countries in the region are using to train, retain and ensure effective and motivated work of health workers, and the strategic capacities and role of health workers in designing and implementing these plans.

These approaches are not without challenge, whether from local elites, competing approaches or global trade pressures. Yet health is a universal human right, and international and regional conventions call for a ‘bottom line’ of rights and obligations to protect people’s health. One basis for the positive potential for achieving equity in health in the region is in the significant social pressure for these goals, and the social resources, networks and capabilities that exist to achieve them. The analysis points to the many ways health systems can act to empower people, stimulate social action and create powerful constituencies to advance public interests in health. Tapping these potentials calls for a robust, systematic form of participatory democracy and a more collectively organised and informed society.

To champion these values, policies and measures, to monitor progress and enhance accountability, the analysis proposes a set of targets and indicators that signal progress in key dimensions of health equity, and towards meeting regional and global commitments. EQUINET, as a network of institutions in the region, is committed to implementing and supporting the building of knowledge, skills and learning to meet these goals.

The analysis is presented as resource for the people, institutions and alliances working in and beyond the region towards goals of improved health and social justice. EQUINET, as a network of institutions within the region, itself remains committed to generating knowledge, facilitating dialogue and analysis, and supporting practice to deliver on these goals within the region.

The book” Reclaiming the Resources for Health” will be available after its launch on 23rd October from EQUINET (admin@equinetafrica.org)or from the publishers in the region (Weaver Press, Fountain Publishers and Jacana). See EQUINET Updates below for contact information. For feedback on this brief please contact the EQUINET secretariat at admin@equinetafrica.org. For further information on the issues raised in this brief please also visit the EQUINET website at www.equinetafrica.org.

Advancing public health calls for wider public health skills
K Tibazarwa

With the major public health challenges that are found in Africa, making progress in public health clearly demands a significant spread of public health skills. While health workers are making tireless efforts to address preventable diseases across the continent, and many successful experiences exist, revitalizing primary health care oriented systems calls for revitalized public health leadership and skills.

Part of the challenge is filling the gaps created by out-migration. At a conference held in mid-June 2007 on 'Sustaining Africa’s Development through Public Health Education', hosted by the University of Pretoria School of Health Systems and Public Health, Professor Erich Buch, health advisor to NEPAD, depicted the prevailing health worker situation in Africa, including the extensive brain drain, low funding and insufficient, often inadequately compensated, staff. He emphasised the need to shift focus from the current responses taking place country-by-country to building wider continental responses, informed by vision, leadership, and energy. This leadership demands public health skills, and Professor Buch asserted that building 'centres of excellence and networks in Africa are key … to strengthen[ing] public health capacity at public health schools and institutions across the continent'.

The meeting discussed options for how to achieve this. With limited financial and institutional resources, governments and institutions can best maximise what is available by sharing existing African expertise across organisations and countries, and strengthening formal mentorship programmes for public health practitioners. This needs to be backed by investments in user-friendly technology to support the communication, collaboration and networking between research institutions, and to stimulate collaborative research and discussion forums and strong alumni systems.

Networking between institutions and professionals in Africa is sometimes weaker than between Africans and colleagues in the developed world. Building African networks needs active support and investment. One key area of concerned raised in the NEPAD strategy is establishing and maintaining an inventory of public health education capacity in Africa, enabling standardisation and accreditation of training institutions and encouraging innovative methods of training and the use of technology supported learning. As Professor Buch stated “We need to … build more cost-effective capacity on the continent'.

In line with these goals, the AfriHealth Project at the University of Pretoria recently completed a three-year mapping project of public health education and training institutions in South Africa. The project has developed a database of public health workers and educators to inform collaborations in Africa. While the mapping focused on South Africa, the information would be useful to strengthen the networking of institutions and individuals in Africa and to share these institutional resources. The AfriHealth Project seeks to secure a Pan-African Public Health body that is effective, inclusive, scientifically and politically supported, and well-resourced. The project has identified the strategic importance of developing a continental approach to improving public health in line with new socio-political realities, strengthening public health capacity by networking institutions, programmes and individuals, and promoting technology-supported learning and communication.

These initiatives do not see current skills scarcities as being an insurmountable block to development of new skills. Mentors can be drawn from existing academic institutions. But public health education must also move beyond universities, to provide other skills not always available from university education, such as for cultural sensitivity in health practice, or for strategic management. Short courses for public health practitioners can also bridge the gap between different entry levels and Masters' degrees in public health. Public health educators and researchers must also bridge the gap in research to reduce the drop out rate in Masters' courses.

There are new and emerging challenges to public health in the rapidly changing global environment. The content of public health training needs to match the new needs and opportunities for action in public health.

Gender issues have a major impact on health in the continent, and institutions should include gender in public health curricula. Improving women’s rights, eliminating violence against women and advancing health rights more generally calls for recognition of the central role played by women in providing health care. This doesn’t only mean looking at women's roles. As Dr Alena Petrakova from WHO (Geneva) noted at the conference, mainstreaming gender in public health curriculum design and development also means involving men and examining their impact on health. A recently-formed African Network for Public Health Educators on Gender (ANPHEG) is taking the issue of how gender is mainstreamed in the public health curricula on a sustainable basis.

Achieving the commitments set out in the continent and those set globally, like the Millennium Development Goals, calls for clear skills to best protect, use and advance the health resources in the region. Much focus has rightly been placed on retaining and valuing health workers. Beyond this, equal concern is now being voiced in the continent that those who do work in African health systems are adequately equipped at all levels with the knowledge and skills to lead effective and innovative responses to the continent's public health challenges.

K Tibazarwa is a masters' student, School of Public Health at the University of Cape Town. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.