Celia Almeida, Paula Braveman, Marthe R Gold, Celia L Szwarcwald, Jose Mendes Ribeiro, Americo Miglionico, John S Millar, Silvia Porto, Nilson do Rosario Costa, Vincente Ortun Rubio, Malcolm Segall, Barbara Starfield, Claudia Travessos, Alicia Uga, Joaquim Valente, Francisco Viacava.
This article will be published in the May 26 issue of The Lancet.
Introduction
The authors of the WHO's World Health Report 20001 have placed on the WHO agenda a commitment to the laudable goals of assessing health systems, monitoring inequalities in health, and achieving equity in health-care financing. Their proposition that health services should be responsive to people's expectations is a welcome one. While these commitments should be sustained, we believe that the approaches taken toward these ends in the World Health Report are seriously flawed. We aim to suggest changes to the approach in the World Health Report to ensure that measurement strategies supporting public health policy throughout the world are scientifically sound, socially responsible, and practical.
Both the conceptual basis and methodological approaches to the World Health Report composite index of health system goal attainment and its individual components, and the indices of health system performance, have major problems. Data needed to calculate four of the five component measures for overall goal attainment were absent for 70-89% of countries, but this was not acknowledged in the report. Because all the measures are new, and imputed values for the 70-89% of countries without data were based on new methods involving multiple non-standard assumptions, readers deserve to know the underlying assumptions, methods, and key limitations, which were not adequately acknowledged. The measures of health inequalities and fair financing do not seem conceptually sound or useful to guide policy; of particular concern are some ethical aspects of the methodology for both these measures, whose implications for social policy are cause for concern. The use of the composite indices for guiding policy is not evident, mainly because of the opacity of the component measures.
In response to criticisms of the report from member states, the WHO Executive Board on Jan 19, 2001, recognised the need to establish a technical consultation process that would obtain input from member states and a small advisory group for the cross-country assessments of health systems (www.who.org, accessed May 15, 2001); we do not know what steps have been taken in that process. The Lancet published an article by Navarro in November, 2000,2 that analysed the World Health Report, focusing mainly on a series of important policy concerns. Little attention was given to methodological discussion. We therefore focus on the methodological and related conceptual issues of the report, in the hope of making an additional, constructive contribution to a thorough process of consultation that must now be opened up by WHO.
Conclusion
The positive contribution of the World Health Report 2000 is its stimulation of fresh thinking about a range of issues relevant to measuring health-system performance. The goals to improve average levels of health as well as distribution of health in populations, and to monitor progress toward these goals, are sound ones. Our comments are offered in the hope that they will help WHO, guided by its member states, to move ahead with an open process of conceptualisation, measurement, and documentation in studying health systems that can serve as a sound basis for policy, planning, and advocacy in the search for health and equity; unfortunately, the World Health Report 2000 does not provide such a basis. As researchers, our recommendations have largely focused on methodological concerns. However, we firmly believe that a strong and sustained response will be needed not only from the research community but from advocates for health and development globally, and particularly from the member states to whom WHO must be accountable. We hope that this paper helps to clarify key concerns on several serious issues related to the methodology of the report. Although we have focused on methodological concerns, these issues are not simply matters of technical and scientific concern, but are profoundly political and likely to have major social consequences.
1. Editorial
2. Equity in Health
THE death of their loved ones from Aids, and the controversy and alienation that followed, has prompted two unemployed women in Kubusi village near Stutterheim to call upon parents and partners to stop discriminating and rejecting people with Aids.
Researchers report that genetic variations in the HIV (news - web sites) strains most common in Africa seem to make it harder for drugs called protease inhibitors to fight them. But the results do not mean that the drugs are powerless against these strains of HIV, according to the study's lead author, who noted that other factors are involved in determining the effectiveness of protease inhibitors.
The daily number of new cholera cases continues to drop, and it appears the epidemic is tailing off, the KwaZulu-Natal health department said in a statement on Tuesday. But, it says, the epidemic can only be considered over if there are no new cases reported for 10 days in a row. The total of new cases in the last 24 hours is 231, a low number compared to January 30, which saw 1 010 new cholera infections in the beleaguered province, the highest figure recorded in one day since the outbreak of the disease in mid-August last year.
American fast food giant McDonald's has been dubbed "McGreed" in Mpumalanga after refusing to supply anti-Aids drugs to a staff member who was raped after working a late shift. The transnational corporation refuses to supply transport for staff who knock off between midnight and 2am, and who are regularly ambushed by criminals. A 29-year-old waitress who was gang-raped in February is so terrified of going home after work at the McDonald's Nelspruit branch that she spends her nights hiding in the local mall and only leaves after sunrise.
A total of 228 new cholera cases have been
reported in KwaZulu-Natal since Saturday, the provincial health department said on Sunday. No news deaths had been reported. The highest number of new cases had been reported in Lower Umfolozi District with 86, followed by Eshowe with 82. The lowest number of cases were reported on the South Coast and Pietermaritzburg with six each.
A PROCEDURAL hearing to limit the issues and determine the trial date and length of the asbestos case against Cape plc began in the London High Court yesterday. The court will determine the timetable of the trial. The high court in London was told at yesterday's hearing that more than 6500 South Africans had registered for claims in the multimillion-dollar compensation battle against Cape plc. However, more than 150 of the claimants have died since the case started.
Attitudes toward sex and sexuality are at the core of the African AIDS pandemic, according to a leading South African health official. He argues that researchers and politicians must involve the African public in an open discussion of human behavior if they hope to combat the disease successfully.``Sex is regarded as a taboo in Africa--you don't speak openly about it,'' said Dr. Malegapuru William Makgoba, president of the Medical Research Council of South Africa. ``We all know that this is a sexually transmitted disease and that's the bottom line, and we're doing everything except focusing on the real major factor that determines whether or not you get the disease.''
EASTERN CAPE, 21 May (IRIN) - The Daliwonga clinic in South Africa's impoverished Eastern Cape province has become the area's best-known
landmark. The pristine brick-built structure stands in stark contrast to the dusty thatched huts that surround it. The clinic, funded by big business, was opened a year ago by former President Nelson Mandela, in his drive to
bring development to communities like Daliwonga, 50 km from the nearest tarred road.
With talks on a draft global plan of action to fight AIDS set to conclude on Friday, two of the chief negotiators said the text was near completion and should be ready for adoption by a General Assembly session next month. Ambassador Penny Wensley of Australia and Ambassador Ibra Deguène Ka of Senegal said agreement remained elusive on certain key issues, including financing the plan of action, but both expressed hope that progress would be achieved before the expected conclusion of the talks on Saturday.
The Democratic Alliance (DA) has set out steps it intends to take around HIV/AIDS that may have far-reaching implications for people living with HIV/AIDS, in its policy document released on Wednesday. Government’s approach has been simplistic and heavy-handed, the DA says. Although the DA accepts the health department's stance that it cannot supply antiretrovirals to all infected citizens, it says that there must be no compromise on providing antiretroviral drugs to pregnant mothers and rape survivors.
Pages
3. Human Resources
This week, Nairobi hosted an important workshop to discuss the International Labour Organisation's Maternity Protection Convention.
A striking feature of the meeting was the low-level of involvement by both the Government and the Central Organisation of Trade Unions (Cotu).
As one speaker reminded the participants, women - biologically the only ones equipped to carry and bear children - should not be penalised for this vital role. Thus the campaign to provide better maternity protection is not a women's issue. It is a social responsibility that should be borne by all. ILO Convention 183 aims to provide better working conditions and terms for expectant and nursing mothers, including adequate paid leave and protection from discrimination, and a working environment that may harm the health of mother and child.
As expected, the traditional toll on human lives and welfare that usually attends doctors' strike has set in nationwide with patients and their
relations running hither and you for succour but getting none-except in private hospitals. Yet, the gladiators - the federal government and the Nigerian Medical Association - are showing no signs of calling a truce.
PUBLIC sector management should brace itself to face a much stronger union if the merger plans by affiliates of the Congress of SA Trade Unions organising in this sector succeed. All Cosatu public service unions will meet in the middle of June to discuss forming a single public sector union. This development is in line with Cosatu's resolution, adopted by the federation's 1991 and 1997 congresses, which called for the establishment of super unions or cartels by way of mergers. Two other Cosatu affiliates, the National Education, Health and Allied Workers' Union (Nehawu) and the SA Municipal Workers' Union (Samwu), are already involved in a merger plan.
Fukuyama, Francis; IMF Institute International Monetary Fund - Working Paper WP/00/74, 2000
Social capital is important to the efficient functioning of modern economies and is the sine qua non of stable liberal democracy. It constitutes the cultural component of modern societies, which in other respects have been organized since the Enlightenment on the basis of formal institutions, the rule of law, and rationality. Building social capital has typically been seen as a task for "second generation" economic reform; but unlike economic policies or even economic institutions, social capital can not be so easily created or shaped by public policy. This paper define social capital, explore its economic and political functions, as well as its origins and make some suggestions for can it be cultivated.
4. Public-Private Mix
Healthcare costs are likely to skyrocket and employers are becoming less and less prepared to carry the burden, according to the fifth in a series of surveys done by Old Mutual and released in Johannesburg on Wednesday. With findings based on in-depth interviews with 60 leading SA companies, representing close to 600 000 medical scheme lives, and focus group discussions with members of medical schemes, Old Mutual's bi-annual survey provides valuable insight into the challenges facing SA's private healthcare industry.
Sholom Glouberman, Director of Canadian Policy Research Networks, May 2001
One characteristic stands out above all in the history of our developing understanding of health, - its complexity. "We now realize that health is shaped by numerous, perhaps countless, forces from many different spheres of influence, ranging from the molecular to the socioeconomic," says Sholom Glouberman, Director of CPRN's Health Network. Glouberman is the author of Towards a New Perspective on Health Policy, the final report of a three-year research project at CPRN. The report ties together a number of separate studies and the results of discussions involving some 3,500 people at more than 90 events held over the course of developing the research conclusions. Judith Maxwell, President of CPRN, says Glouberman's study points to the importance of placing the reform of the health care system in this broader context. "All of us want to feel secure in the knowledge that health care will be there for us should we need it." says Maxwell. "What Sholom's study underlines is that further investment in the health care system should consider how to regain public confidence in it. It is this interactive sense of security that has a significant impact on health along with other factors such as biological condition, social relationships, economic status, work experience and culture."
Paper prepared for WHO’s Commission on Macroeconomics and Health by Adam Wagstaff The World Bank, The University of Sussex, UK
There are three key levels of government action—the macro level, the health system, and the micro level. Government decisions and actions at each level influence the amount households pay for their health care (financing), and the quantity, quality and type of services they receive (delivery). At the macro level, governments decide how much to spend on health care (and related services) and where, and how to raise the revenues to finance them. At the system level, they decide the mode of service delivery and how to regulate the private sector, and how much to charge for different services and how far to exempt the poor from fees. At the micro level, they influence the accountability of providers and the services and interventions they deliver, and how best to implement facility-based revenue collection schemes. There are, in short, many ways that governments can potentially influence both health gaps between the poor and better-off, and the degree to which poor households are affected disproportionately by the costs of health services.
5. Resource allocation and health financing
Millions of people in the developing world are in urgent need of the antiretroviral drugs that suppress HIV and indefinitely postpone symptoms of AIDS. But the majority live in the world's poorest countries and cannot afford the cost of these drugs, medical tests, and consultations. The price of these antiretrovirals is not the only factor preventing treatment for AIDS reaching those who need them. In many countries, health care systems are weak, with far too few doctors, nurses, and medical facilities. This report provides an overview of the issues surrounding HIV in the developing world.
In 1978, from a little-known region of what was then the USSR, emerged a WHO/UNICEF statement of intent with the slogan "Health for all by the year 2000". That year has passed, leaving the Alma-Ata declaration largely unfulfilled. Indeed in some parts of the world the situation has worsened, and not just because of AIDS and civil unrest. Yet the failure of Alma-Ata is often viewed positively: the declaration was never meant to be taken literally as a target that everyone would be healthy by last year, and it is argued, reasonably, that the slogan has kept the issue of primary care to the forefront of the debate in WHO and other United Nations agencies. But this is a card--labelling a failure a success because the matter was worth raising--that must be played sparingly. As this week's Lancet shows (pp 1671,1685), The world health report 2000, published a year ago, continues to attract critical attention. Does it matter that the criticisms are serious provided the underlying objective, which is the use of national performance indices to improve health in all countries, is worthy, as it clearly is? If WHO is to become a science-led global policy body, the answer has to be Yes.
6. Governance and participation in health
NAIROBI, 21 May (IRIN) - The World Bank, representatives of US complementary health institutes and African traditional healers have
agreed to collaborate on the analysis and validation of indigenous health practices, including herbal treatments of HIV/AIDS-related opportunistic infections. Western health institutes and the Bank also agreed to discuss ways in which to build partnerships between traditional health practitioners and the scientific community, according to a press release from the World Bank's Indigenous Knowledge for Development (IK) Programme on 17 May.
NAIROBI, 21 May (IRIN) - The World Bank, representatives of US complementary health institutes and African traditional healers have
agreed to collaborate on the analysis and validation of indigenous health practices, including herbal treatments of HIV/AIDS-related opportunistic infections. Western health institutes and the Bank also agreed to discuss ways in which to build partnerships between traditional health practitioners and the scientific community, according to a press release from the World Bank's Indigenous Knowledge for Development (IK) Programme on 17 May.
The Global Alliance for Women's Health submits the following proposals concerning women and HIV/ AIDS in the revised draft Declaration of Commitment on HIV /AIDS: The DECLARATION OF COMMITMENT ON HIV/AIDS would be greatly strengthened by citing explicitly Article 12 of the CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMATION AGAINST WOMEN (CEDAW) in the pre-ambular section with text from the article and by incorporating equality language in at least the section, "Care Support and Treatment." Care, support and treatment are fundamental elements of an effective response and should be available [equally] to men and women [in conformity with CEDAW, Article 12].States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services. CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMATION AGAINST WOMEN (CEDAW), Article 12.1
If you or your organization would like to sign on to these proposals please contact us by e-mail.
7. Monitoring equity and research policy
by Elaine Baume, Mercedes Juarez, Hilary Standing,
Institute of Development Studies at the University of Sussex, April 2001
A resource from the Gender and Health Equity Network, a partner of the Health and Social Change Programme at IDS. The purpose of this resource guide is to give an overview of gender sensitive interventions and initiatives directly or indirectly related to health that have been tried at macro and micro levels. Through mapping different experiences, the guide provides information on lessons learned, results achieved, and the challenges that have emerged in promoting gender and health equity. It includes information on gender-sensitive approaches, working methods, practical methodologies and tools which can be incorporated into policies and programmes. In pulling these resources together our aim is to create a practical reference mechanism for those involved in implementing programmes and policies worldwide. We felt that a guide to existing resources that could be periodically updated and reviewed would be more useful than commissioning more exhaustive but perhaps less accessible review papers.
Changes in policy at all levels of a healthcare system are often necessary to achieve program objectives and secure the success of performance improvement activities. In the course of our work, JHPIEGO has helped to develop, implement and evaluate policy in many countries and at a variety of levels. The latest technical report, "JHPIEGO's Work In Policy: A Comprehensive Review", documents JHPIEGO's efforts in policy development (particularly through the Training in Reproductive Health Project), and reveals a scope that was underestimated even by many JHPIEGO staff. To obtain a copy of the technical report, please contact Kathleen Hines.
8. Useful Resources
The conference was held in Ouagadougou, Burkina Faso 3-7 May. Conference documentation is now available on-line.
The Sector Network Rural Development (SNRD) is comprised of representatives from different GTZ-supported rural development projects in
Sub-Saharan Africa. At an SNRD annual meeting held in Mombasa in January 2000, participants agreed to form a working group (WG) on HIV/AIDS and its impact on rural development. The purpose of this WG is to further investigate the links between HIV/AIDS and rural development, with a view to making recommendations on how rural development projects can integrate the fight against HIV/AIDS in their range of activities. The focus should be both on reducing the spread of the epidemic, and, as far as possible, its negative impacts. The WG on HIV/AIDS decided to organise a workshop which brought together experiences on the integration of the subject of HIV/AIDS in RD activities, not only in GTZ supported projects, but also in projects supported by other multi-lateral and bilateral organisations, and in similar activities implemented by NGOs and government agencies. This workshop, titled "HIV/AIDS and Rural Development: what can we do?", took place in Harare, Zimbabwe, from 02 to 05 April, 2001. The Executive Summary (12 pages, Adobe PDF format, 62 kb) of the
workshop is available for downloading from the AFRO-NETS server.
The topic of this Nature forum — the impact of the Web on the publishing of the results of original research — has, since the emergence of the Internet, filled volumes in the reports of conference proceedings and reams of individual articles. The main aim of this forum is to bring some of the substance of this Brownian motion of Internet issues to a broader grassroots audience and debate the implications for the future dissemination of scientific information. We have invited leading representatives of the main groups of stakeholders and observers from the mainstream Internet industries to express their views in 1,000-word articles. We hope to help identify some of the best opportunities offered by the Internet, and explore what the best public and private strategies might be, in economic and other terms, to ensure that science reaps the most benefits.
The Nature Publishing Group is pleased to announce the launch of three new review journals: Nature Reviews Immunology and Nature Reviews Cancer will launch in October 2001 and Nature Reviews Drug Discovery in January 2002 - ensuring that you receive high quality overviews whatever your discipline.
Medscape HIV/AIDS has posted a new overview of prescribing information, drug-drug interactions, and resistance data.
This is the first edition of the largest global listing of health information resource centres, with data pertaining to about 1,000 centres. The focus is on their missions and objectives, with particular reference to their attitudes to technology, and their capabilities and requirements. You may consult or download the entire Directory at the site, or just pick out letters of the alphabet to select countries that are of interest. The Directory is an ongoing work, and will be updated. We aim to refine the data, and invite all readers to suggest improvements and provide better information. There are questionnaires available on the site in English, French, Russian, Spanish, Swahili.
9. Jobs and Announcements
The focus of the Workshop will be: Recent, current and future research; Policies and guidelines at Health Management level; Marketing and social acceptance of KMC. For further information please contact: Ms Deborah McTeer.
The overall theme of the 9th International Cochrane Colloquium is 'The evidence dissemination process: how to make it more efficient'. The Colloquium will focus on identifying the barriers preventing the use of evidence, and means of overcoming these.
MIM/TDR is a multi-partner programme promoting research capability strengthening activities in the context of the Multilateral Initiative for Malaria in Africa. The goal is to promote human and institutional resource development by supporting innovative collaborative research projects and networks in malaria endemic countries focused on strategic research areas.
Projects supported to date have addressed critical issues related to chemotherapy, pathogenesis, vector control and epidemiology of malaria transmission and morbidity in Africa. The Task Force is initiating a new cycle of partnership projects expanding the scope of priorities to include the development of new interventions, strategies and policies, and the evaluation of large-scale interventions in support of malaria control.
Universities, research institutions and research organizations in Africa, Asia and Latin America are invited to apply for TDR programme grants to develop training centres/networks for research and training in bioinformatics and applied genomics. The centres will focus on in-
fectious and parasitic diseases, and be developed to support and train scientists from the three regions. The ultimate goal is to establish sustainable research and training facilities by promoting utilization of genomics in developing disease endemic countries.
Global Health Action, a non-profit organization located in Atlanta, Georgia with a strong 29-year history of conducting health and leadership training, offers three courses this year: INTERNATIONAL HEALTH MANAGEMENT COURSE (IHMC), August 6 - September 14, 2001
COMMUNITY HEALTH SERVICES IN RURAL AREAS COURSE (CHS), September 17-28, 2001
HEALTH LEADERSHIP AND MANAGEMENT COURSE (HLMC), October 22 - November 2, 2001
There is a tuition fee for the courses. Some limited scholarships are available for the IHMC and CHS. There are no scholarships offered for the HLMC. Additional information and applications are available from the website or via email.
RESEARCHERS: Health Economics Unit, University of Cape Town
The Health Economics Unit (HEU) is one of the few of its kind in Africa. It conducts a wide range of research applied to health policy and health care evaluation. Current research focuses on health sector reform (financing, public/private mix and decentralisation), health equity issues and economic evaluation of public health problems. The HEU also offers a Masters in Health Economics, a Doctoral program (by dissertation research), short courses and other training programs. The HEU is involved in a range of capacity development and collaborative networks within the African region.
Researchers are required for the followingc ontract posts:
Junior Research Fellow (2-year contract: This is an exciting opportunity for a recent graduate / young researcher. The appointed researcher will conduct original research under the guidance of senior HEU staff, and will also undertake some research assistance activities for, and work closely with, the HEU Director. Applicants should have a Masters in Health Economics or related qualification, an interest in applied research and some research experience. Willingness to participate in HEU training activities would be an advantage.
Senior Researcher/Researcher (3-year contract: This researcher will be responsible for undertaking a substantive research project and for contributing to other research activities, particularly through supporting junior researchers. S/he will also contribute to HEU training programs, particularly the Masters in Health Economics program and the research internship program (devoted to research capacity development for recent South African graduates from historically disadvantaged backgrounds). The successful applicant will also contribute to collaborative capacity development and research activities in the African region. Applicants should preferably have a PhD in health economics and experience in health economics/policy research. Experience in postgraduate teaching would be a distinct advantage.
Application Deadline: July 31, 2001. The purpose of the Program is to promote leadership in international public health by enabling participants to develop a broader vision of international and regional health trends, and a more profound understanding of technical cooperation in this field. The Program is oriented towards young health professionals from the Americas who possess a demonstrated capacity for leadership and an interest in deepening the international dimension of their activities in the health area. Participants in the Program are known as "residents" and are incorporated into the work of PAHO for a period of eleven months starting at the end of January 2002.