In countries with generalized epidemics of human immunodeficiency virus (HIV) infection, standard statistics based on fertility history may misrepresent progress towards this target owing to the correlation between deaths among mothers and early childhood deaths from acquired immunodeficiency syndrome. To empirically estimate this bias, this study collected child mortality data and fertility history, including births to deceased women, through prospective household surveys in eastern Zimbabwe during 1998–2005. According to the empirical data, standard cross-sectional survey statistics underestimated true infant and under-5 mortality by 6.7% and 9.8%, respectively. These estimates were in agreement with the output from the model, in which the bias varied according to the magnitude and stage of the epidemic of HIV infection and background mortality rates. The bias was greater the longer the period elapsed before the survey and in later stages of the epidemic. Bias could substantially distort the measured effect of interventions to reduce non-HIV-related mortality and of programmes to prevent mother-to-child transmission, especially when trends are based on data from a single survey. A mathematical model with a user-friendly interface is available to correct for this bias when measuring progress towards Millennium Development Goal 4 in countries with generalised epidemics of HIV infection.
Monitoring equity and research policy
The Millennium Declaration, adopted by the United Nations in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations.
Couples should be included in HIV prevention research, but their recruitment in southern Africa is challenging given high levels of migration and non-cohabitation, according to the authors of this pilot study. The study describes the recruitment strategies and experiences in rural South Africa when conducting HIV research. With the aim of recruiting 20 couples at mobile voluntary counselling and testing (VCT) caravans and community venues, 75 index partners were screened with an average of four additional contacts required to schedule interviews. The study found that, despite the care taken to maximise recruitment, recruiting just 20 couples required a substantial investment of time and resources, so recruiting and interviewing couples is a feasible option, but requires substantial resources. Given the need to identify effective HIV behavioural interventions in South Africa, the authors believe that couples-focused studies and interventions can be one possible component in efforts to promote testing and reduce HIV transmission.
This annual collection of key economic and statistical data on states with fewer than five million inhabitants is designed as a reference for economists, planners and policy-makers. The book contains fifty-four tables covering selected economic, social, demographic and Millennium Development Goal indicators culled from international and national sources and presents information unavailable elsewhere. A detailed parallel commentary on trends in Commonwealth small states, looking at growth, employment, inflation, human development, and economic policy, permits a deeper understanding of developments behind the figures. The book also includes three articles focusing on trade in services.
South Africa is one of only 12 countries that has failed to reduce child mortality since 1990, according to the South African Child Gauge 2009/2010, an annual review of the situation of children in the country. The review contains essays by child health experts from across the country. While South Africa is making progress towards meeting the Millennium Development Goal (MDG) target on sustainable access to safe drinking water, this has not trickled down to children: Only 64% of children have access to safe drinking water on site. Progress has been slow for access to basic sanitation, education and gender equality. On the MDG targets for reducing child hunger, HIV, tuberculosis and child mortality, South Africa is not making any progress. South Africa has also failed to submit its reports on progress in relation to implementing the United Nations Convention of the Rights of the Child – the key accountability mechanism aimed at monitoring South Africa’s progress in promoting the maximum survival and development of children. Improving child health outcomes requires concerted action from both within and outside the formal health care system. To reduce child mortality, governments should alleviate poverty and eliminate inequality, as well as improve the performance of its health services, and medical interventions should focus on prevention and encourage the participation of children.
The Commission on Social Determinants for Health has recommended assessment of health equity effects of public policy decisions, and this study provides guidance on assessing equity for users and authors of systematic reviews of interventions. Particular challenges occur in seven components of such reviews: developing a logic model; defining disadvantage and for whom interventions are intended; deciding on appropriate study design(s); identifying outcomes of interest; process evaluation and understanding context; analysing and presenting data; and judging applicability of results. The study concludes that greater focus on health equity in systematic reviews may improve their relevance for both clinical practice and public policy making.
This compilation of case studies in research ethics is designed for use by course instructors and workshop leaders. The editors argue that the use of case studies in workshops and formal courses is an especially valuable teaching tool, as students and workshop participants can grapple with ethical dilemmas and uncertainties in concrete situations. The editors have collected 64 case studies, based on episodes that have occurred in global health research throughout the world. Eight chapters comprise the cases un¬der the following titles: Defining research; Issues in study design; Harm and benefit; Voluntary informed consent; Standard of care; Obligations to participants and communities; Privacy and confidential¬ity; and Professional ethics. Each chapter begins with an introduction that outlines the issues and provides some guidance for the topics addressed in the cases, and ends with a brief annotated list of suggested readings. Questions for discussion follow each case. In each chapter there is cross-referencing to cases in other chapters.
No national South African institution provides a coherent suite of support, available skills and training for clinicians wishing to conduct randomised controlled trials (RCTs) in the public sector. This study assesses the need for establishing a national South African Clinical Trials Support Unit. Key informant interviews were conducted with senior decision-makers at institutions with a stake in the South African public sector clinical trials research environment. The study found that trial conduct in South Africa faces many challenges, including lack of dedicated funding, the burden on clinical load, and lengthy approval processes. Strengths include the high burden of disease and the prevalence of treatment-naïve patients. Participants expressed a significant need for a national initiative to support and enhance the conduct of public sector RCTs. Research methods training and statistical support were viewed as key. There was a broad range of views regarding the structure and focus of such an initiative, but there was agreement that the national government should provide specific funding for this purpose. In conclusion, stakeholders generally support the establishment of a national clinical trials support initiative. Consideration must be given to the sustainability of such an initiative, in terms of funding, staffing, expected research outputs and permanence of location.
According to this article, the latest estimates of under-five mortality from the United Nations Inter-agency Group for Child Mortality Estimation (IGME) show a one-third decline at the global level of under-five mortality rates from 89 deaths per 1000 livebirths in 1990 to 60 in 2009. Over the same period, the total number of under-five deaths has decreased from 12.4 million in 1990 to 8.1 million in 2009. The article argues that this constitutes evidence that progress on child mortality is being made across all regions of the world, with many regions having reduced the under-five mortality rate by 50% or more. With only five years left until the 2015 deadline to achieve the Millennium Development Goals (MDGs), progress needs to be accelerated. These IGME estimates are the latest available information on child mortality to provide a basis for assessing progress and reaching consensus for action.
This paper presents the first comprehensive effort to provide an overview of the research associated with the World Health Organization (WHO) headquarters in 2006/07. Information was obtained by questionnaire and interviews with senior staff operating at WHO headquarters in Geneva. The paper found that 45% of WHO permanent staff are involved with health research and the WHO's approach to research is predominantly focused on policy, advocacy, health systems and population based research. The Organization principally undertakes secondary research using published data and commissions others to conduct this work through contracts or research grants. This approach is broadly in line with the stated strategy of the Organization. The researchers note that the difficulty in undertaking this survey highlights the complexity of obtaining an organisation-wide assessment of WHO’s research activity in the absence of common standards for research classification, methods for priority setting and a mechanism across WHO, or within the governance of global health research more generally, for managing a research portfolio. As the rollout of the WHO strategy on research for health proceeds, the researchers expressed hope that similar exercises will be undertaken at the WHO Regional Offices and in support of capacity building of national health research systems within Member States.