The World Trade Organisation (WTO) is concerned with equity and provides regulatory measures to maintain it; it is just not the kind of equity we mean when we talk about social equity or equity in health. The WTO concern with equity is that of trading services and goods, in which services and goods should be treated equally whether produced by multinational corporations or local communities as we have seen in the banana dispute settlement case. At a more general level the WTO social policies are based implicitly on a residualist model, where social policies are seen as poor relief rather than policies dealing with e.g. inequalities. Some agreements, such as the Agreement on Trade-related Intellectual Property Rights (TRIPS), are also considerably biased towards the corporate sector and its needs.
The TRIPS positions reflected in the Doha declaration appear to be a step forward in compulsory licensing in comparison to the positions of the EU and the US some years ago. On the other hand the relevance of the Doha public health declaration - and its interpretation - in practice remains to be seen. Further debates around TRIPS concerning parallel importing, compulsory licensing and exports and differential pricing are also taking place in the TRIPS council. These results of these debates may show to what extent measures to address problems of access to pharmaceuticals have become a means of supporting corporate greed of the pharmaceutical industry via regulatory requests rather than means to address health needs.
In health TRIPS is important, but we can expect that the General Agreement on Trade in Services (GATS) may become even more important. The WTO negotiations on the GATS are underway and pose many important questions both in terms of health services and equity as well as the possibilities to implement broad public policies e.g. regulatory prohibition of advertising of products hazardous to health. One example of the latter is a problem of health regulations and trade in advertising services. Those countries which have included advertising services under GATS commitments may have limited significantly their possibilities of regulating or prohibiting advertising of products hazardous to health. Many aspects of health services are also dealt with under other categories of services, such as professional or financial services. It is also important to note that while GATS is marketed as a regulatory agreement this regulatory role remains in the context of ensuring equity and equal treatment of service providers (NGOs/corporations - local/international). This regulatory role is thus concerned more about service provider interests than with social rights of citizens and equity in access to services.
Other matters relate to the Agreement on Sanitary and Phytosanitary Measures (SPS). Important items in these discussions relate to the extent to which precautionary measures as well as public health policies can be seen as trade barriers of rich countries by poorer countries with high implementation costs to poorer countries. The problem is that these arguments may become means of down regulation in health protection rather than ensure that all countries have sufficient support and resources for implementation of the SPS Agreement. The Doha declaration also successfully broadened the trade agenda to include some new areas, such as competition and investments, to the WTO negotiation agenda. There are some concerns that the negotiations on the new areas may in practice be means for inclusion of aspects of the Multilateral Agreement on Investment (MAI) to the WTO Agreements. These aspects could include such which could allow that in addition to countries also private sector corporations could be able to appeal to WTO dispute settlement.
In many ways health policies are easily undermined by corporate export and trade interests which are in practice an integral part of WTO negotiations. The WTO debates are thus biased towards the promotion of private sector interests. The usual emphasis on countries and their interests in trade policy debates also limits opportunities to see the common systematic health issues that affect most countries. While there is no point of taking all health matters to the WTO, it is a task for health activists to ensure that national and international health policies and measures to maintain equity are not compromised by trade policies.
1. Editorial
2. Equity in Health
Nearly 2 billion people, one-third of the world's population, is infected with the tuberculosis bacillus and at risk of developing active disease. Of the 8.4 million people who develop active TB every year 2 million die from it. There are two types of problems associated with DOTS. One is the non-availability of the treatment program and the other, the less than satisfactory implementation of it. Despite the proven potency DOTS (directly-observed treatment short-course) strategy and widespread agreement on its efficacy, many developing countries have failed proper implementation and expansion of the DOTS program.
AIDS activists welcomed the increased expenditure on HIV/AIDS in the South African 2002-2003 budget released last week, but expressed concern that the funds could be misused at provinical level.
The life expectancy of Africans is set to reach one of its lowest levels ever, it was revealed on Monday. By the year 2005, most Africans will die before they reach their 48th birthday, the fourth general assembly of the African Population Commission (APC) heard.
Researchers at the University of Turin have found that chloroquine and the related compound hydroxychloroquine appear to curb the HI virus in laboratory settings. Dr Andrea Savarino and his team say that chloroquine affects the production of the envelope around the virus. This means that although the virus may be able to hijack human cells to produce fresh viral genetic material, without the envelope it cannot complete the reproduction cycle.
The opening of South Africa's first "AIDS village" on Thursday was not what people living with HIV/AIDS needed, and would cause "more harm than good", the spokesperson for the National Association of PWAs (NAPWA) told PlusNews on Friday.
Health education programmes and free condom distribution have not stopped South African commercial sex workers from having unprotected sex. A study conducted by the London School of Economics found that 69% of local commercial sex workers (CSWs) in the South African gold mining community of Carletonville are HIV-positive.
Nelson Mandela is wading into the increasingly bitter dispute over the South African government's Aids policies by meeting the ruling African National Congress leadership to press for an end to prevarication over a catastrophe he likened to a war.
What was hoped to be key in President Thabo Mbeki changing the face of his government's stance on HIV/AIDS was a dismal disappointment. Though Mbeki acknowledged the fact that HIV/AIDS is a problem in South Africa, he still insisted that his government would not change its policy on administering antiretroviral drugs to reduce mother to child transmission of HIV/AIDS. Mbeki's speech came a day after his predecessor Mandela had rebuked the Mbeki administration's HIV policy.
An African National Congress-dominated (ANC-dominated) parliamentary committee has noted that 25% of young people believe child rape cures AIDS, and urgently called for anti-AIDS drugs to be used to prevent HIV infection by rape.
"Panic breeding" is the inelegant term given to a response by some Swazis to an AIDS epidemic that is decimating the population of the small Southern Africa kingdom. The impulse to make-up for AIDS deaths by having more babies is exacerbating both the health crisis and the kingdom's ongoing problem with overpopulation.
Pages
3. Human Resources
The emerging crisis of health manpower in Africa could defeat the efforts of governments, private health care providers, NGOs, and donors in controlling the HIV/AIDS epidemic. This was one of the principal findings of a consultative meeting on improving collaboration amongst health professionals, government and other stakeholders on health workers issues, recently held by WHO and the World Bank in Addis Ababa, Ethiopia.
Neil Pakenham-Walsh, Moderator, HIF-net at WHO
Many thanks to all contributors on this subject so far. 22 messages have been posted from 30/1/02 to 15/2/02. Further messages are encouraged through to Friday 8 March, in time for the 'eContent for eDevelopment' workshop in Dar es salaam (11-13 March). After that time, I shall post further summaries and a report of the workshop. Here is a list of contributors and a summary of the discussion so far. All contributors to this discussion (through to Friday 8 March) will be offered a complimentary printed copy of INASP Health Links, a gateway to information for health professionals in developing countries (INASP Health Links will be published in early March 2002).
4. Public-Private Mix
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.
Health Systems Trust will be publishing a couple of chapters and indicators covering this area in the upcoming South African Health Review (2001) - but this will only be available at the end of March. Meanwhile you may wish to look at previous editions which also cover the topic.
November 2001
Richard Strouse, Barbara Carlson, John Hall, Center for Studying Health System Change, Washington, DC Peter Cunningham, Mathematica Policy Research, Inc. Princeton, NJ
In this report, the authors describe site selection, sample design, instrumentation and survey preparation, data collection methods, response rates, and sample weights. The Community Tracking Study (CTS) addresses two broad questions that are important to public and private health decision makers:
1. How is the health system changing? How are hospitals, health plans, physicians, safety net providers, and other provider groups restructuring, and what key forces are driving organizational change?
2. How do these changes affect people? How are insurance coverage, access to care, use of services, health care costs, and perceived quality of health care changing over time?
5. Resource allocation and health financing
Musgrove P, Zeramdini R. A summary description of health financing in WHO Member States(CMH Working Paper Series, Paper No. WG3: 3.
Analysed in this paper are national health accounts estimates for 191 WHO Member States for 1997, using simple comparisons and linear regressions to describe spending on health and how it is financed. The data cover all sources—out-of-pocket spending, social insurance contributions, financing from government general revenues and voluntary and employment-related private insurance — classified according to their completeness and reliability.
Health care report cards - public disclosure of patient health outcomes at the level of the individual physician and/or hospital - may address important informational asymmetries in markets for health care, but they may also give doctors and hospitals incentives to decline to treat more difficult, severely ill patients. Whether report cards are good for patients and for society depends on whether their financial and health benefits outweigh their costs in terms of the quantity, quality, and appropriateness of medical treatment that they induce. Using national data on Medicare patients at risk for cardiac surgery, we find that cardiac surgery report cards in New York and Pennsylvania led both to selection behavior by providers and to improved matching of patients with hospitals. On net, this led to higher levels of resource use and to worse health outcomes, particularly for sicker patients. We conclude that, at least in the short run, these report cards decreased patient and social welfare.
Policy makers have long been concerned with improving the performance of their health systems, with reforms targeting all system functions - financing, provision, stewardship and resource generation. An increasing number of studies have assessed the impact of reforms in different settings, but these studies have used varying frameworks and methods to assess and measure the effect of changes in policies and strategies. This makes it difficult to separate out the true variations in impact from variations stemming from the different methods that were used.
WHO, UNICEF, UNAIDS, World Bank, UNESCO, and UNFPA, 2/1/02.
In December 2001, the Commission on Macroeconomics and Health presented the results of its two-year work to the World Health Organization in a publication titled Macroeconomics and Health: Investing in Health for Economic Development. The Commissioners present a new global blueprint for health that is both compassionate and cost-effective. Millions of deaths occur each year in the developing world due to conditions which can be prevented or treated. The Commissioner's outline a plan of action to save millions of these lives every year at a small cost relative to the vast improvements in health and increased prosperity. The Report shows that just a few conditions are responsible for a high proportion of the avoidable deaths in poor countries - and that well-targeted measures, using existing technologies, could save around 8 million lives per year and generate economic benefits of more than $360 billion per year, by 20152020. The aggregate cost of scaling up essential health interventions in low-income countries would be around $66 billion per year, with the costs roughly divided between high-income donor countries and low-income countries. Thus, the economic benefits would vastly outstrip the cost. Scaling Up the Response to Infectious Diseases: A way Out of Poverty takes up the Commission's challenge. It outlines how increased investment in health can be well spent, stressing how interventions, health system strengthening and behaviour change together can help achieve the goals we are setting ourselves. This report takes forward the Commission's action agenda. It will help decision makers see how we can turn increased investment in health into concrete results.
6. Governance and participation in health
‘HEALTH FOR ALL IS POSSIBLE AND NECESSARY’
The participants of this Forum held in Porto Alegre – Brazil, January 29th and 30th, 2002, call on all the people of the world, who feel the imperative to build a fairer and more equitable societies to rally around this declaration to publicize it and to engage on sustained actions along its lines. We understand that this 2nd World Social Forum starts a new step on the fight for the universal respect of social rights, particularly the right to health since we understand health as the expression of the overall quality of life, and not only the issue of access to health services. We denounce to the world the devastating effects the macroeconomic adjustment policies and now the militarization of international relationships are having over the quality of people’s life. We affirm that these effects are not the neoliberal economic policies’ exceptional, accidental outcome, but the real essence of its logic that aims at maximizing profits, regardless of states’ aim at social welfare measures; these policies are dividing the world into a huge social apartheid where countries and regions are relegated to the condition of spectators of the immense accumulation of international capital; they invariably result in deep inequalities and a perpetuating social injustice. The rich ARE getting richer and the desperately poor poorer, more so women, children and the elderly. The poor of the world are left looking at the rich as ‘from the other side of the shopping mall windows’, searching for an elusive paradise which is denied to them by the economic order that socially segregates the world and ecologically disregards it.
The Treatment Action Campaign (TAC) and the Public Service Accountability Monitor (PSAM) call on the Eastern Cape Premier to follow the example of his Kwa-Zulu Natal counterpart and provide the anti-retroviral drug, nevirapine, to HIV-positive pregnant mothers in the province. This joint call is made after careful consideration of the resources available to the Department of Health in the province. Research published by the Eastern Cape Department of Health, in the journal Epidemiological Notes, recognises that over 20% of women attending antenatal clinics in the province tested HIV positive in 2000. As a result it is estimated that in excess of 10 500 babies are born HIV positive in the Eastern Cape each year. TAC/PSAM believe that on the strength of the pilot studies conducted in Kwa-Zulu Natal, which delivered a 100% success rate, the lives of these infants could have been saved through the provision of nevirapine to pregnant mothers in the Eastern Cape.
The first global campaign to end the Catholic bishops' ban on condoms has been launched in Zimbabwe with a billboard in Harare and ad in The Herald carrying the message "Banning Condoms Kills" and "Catholic People Care-Do Our Bishops?" The prominently placed advertisements are part of an unprecedented worldwide public education effort aimed at Catholics and non-Catholics alike to raise public awareness about the devastating effect of the Catholic bishops' ban on condoms in preventing new HIV/AIDS infections. The campaign is being sponsored by Catholics for a Free Choice (CFFC).
7. Monitoring equity and research policy
From the period of September 1999 to date the Biomedical Research and Training Institute (BRTI) based in Harare, with financial support from International Development and Research Centre (IDRC) in Canada has been engaged in a multi-centre study which has strong public health implications: to find out the personal and system related determinants of access to health services by suspected and confirmed tuberculosis patients in developing countries. Tuberculosis being one of the most common killer disease before and present times once again is in the centre of attention of national health authorities, researchers as well as donor community as a re-
emerging phenomenon. To achieve maximum relevance of the study for the Southern African Region, four SADC countries, where tuberculosis is a major public health problem especially in association with HIV/AIDS were selected to participate in this multi-centre study. These countries are South Africa, Swaziland, Zambia and Zimbabwe being the coordinating centre. Research teams of the above mentioned countries held a workshop in Harare last year to discuss and disseminate the results of the study.
The workshop report and recommendations were compiled are now open for further discussion and review from a wider audience.
8. Useful Resources
Opening of the Health InterNetwork website.
Many thousands of doctors, researchers, health policy-makers and others in about 70 developing countries will from today gain free access through the Internet to one of the world's largest collections of biomedical literature. They will benefit from an initiative launched by the World Health Organization and the world's six biggest medical journal publishers, which WHO Director-General Dr Gro Harlem Brundtland has described as "perhaps the biggest step ever taken towards reducing the health information gap between rich and poor countries." The "Access to Research" initiative enables accredited universities, medical schools, research centres and other public institutions in the developing countries to gain access to the wealth of scientific information contained in more than 1000 different biomedical journals produced by the six publishers. Until now, subscriptions to these journals, both electronic and print, have been priced uniformly for such institutions, irrespective of geographical location. Many key titles cost more than US$1500 per year, and the average subscription costs several hundred dollars, putting the journals beyond the reach of the large majority of health and research institutions in the poorest countries. Last year WHO, working with the British Medical Journal, approached the six biggest medical journal publishers: Blackwell, Elsevier Science, the Harcourt Worldwide STM Group, Wolters Kluwer International Health & Science, Springer Verlag and John Wiley. The aim was to bring them together with the countries concerned to seek a more affordable pricing structure for online access to their international biomedical journals. The first stage of the initiative will make more than 1,000 of their journals available free or at significantly reduced charges to institutions in those countries. That availability begins today with the opening of the Health InterNetwork website: A second stage will involve similar access at significantly reduced prices for institutions in the other countries. WHO and the publishers will work with the Open Society Institute of the Soros foundation network and other public and private partners to extend the initiative; for example, through training for research staff, and improving Internetconnectivity.
The Training and Research Centre (TARSC) based in Harare, Zimbabwe has launched a website, Auntie Stella, created specifically for young people related to their reproductive health in order to help them discuss and solve problem related to this issue. The site is an adaptation of the print version of Auntie Stella that has been hugely successful with in and out of school youths.
The Food and Nutrition unit of the Namibia Ministry of Health and Social Services (MoHSS)recently received WHO support to contract a local Web site developer to create a very comprehensive site addressing breast-feeding in Namibia. The site's content was developed by MoHSS staff, and includes a wide variety of information on the Baby and Mother Friendly Facility Initiative in Namibia, Government policies and strategies for promoting breast-feeding and maternal and baby health, facts and figures relating to breast feeding, and a resource guide for health workers that details reasons for and ways to promote breast-feeding.
COHRED regularly receives requests to fund health research projects. Although we are not a donor agency we have a commitment to act as broker for countries applying Essential National Health Research. In response to this, COHRED has compiled a database of development partners in health research. This database is now accessible through the COHRED web site and includes valuable information for each organisation such as the activities most funded, specified priority regions or countries, and a summary of guidelines for proposals. The database is an ongoing project and will be updated continuously. The aim is to refine the data and add development partners to better serve the needs of COHRED's stakeholders. Readers are invited to provide suggestions, improvements and more up-to-date information. Organisations who wish to be included in the database are also welcome to contact us.
9. Jobs and Announcements
2002 Training of Trainers Course for Reproductive Health with emphasis on Family Planning.
52nd Course (Anglophone): 3 June -12 July
53rd Course (Francophone): 23 September - 1 November.
The Mauritius Institute of Health is pleased to announce its Training of Trainers courses for Reproductive Health with emphasis on Family Planning. The present programme, adapted to better meet the WHO Regional Training activities in Family Health initiated in 1982, and those of the UNFPA Regional Project RAF/96/P01.
Offered by: Abt Associates Health Policy Training Institute (AAHPTI)
The first of a series of regional training courses offered by the Abt Associates Health Policy Training Institute (AAHPTI), in addition to AAHPTI's annual US-based course. The first regional course, "Building Skills for Implementing Health Reform and Strengthening Health Systems in East and Southern Africa," will be held at the East and Southern Africa Management Institute (ESAMI) in Arusha, Tanzania, April 8-20, 2002. Details about both the US-based and regional courses can be found on the website.
The guidelines, call for proposals, and proposal format has been finalized and are out! Deadline is March 10th. See attached documents or refer to the GFATM web site mentioned below. Again, this Fund is not for "business as usual". NGOs, including people living with HIV, private sector, civil society are to be full partners in the development and the implementation of the proposal through setting up a country-coordinating mechanism. The Fund is to build, complement, and scale up on existing efforts including innovative and pilot project. The fund will support treatment costs, including anti-retrovirals.
12-15 November 2002, Arusha, Tanzania
Health research is essential to improve the design of health interventions, policies and service delivery. Every year more than US$ 70 billion is spent on health research and development by the public and private sectors combined. However, only about 10% of this is devoted to 90% of the world's health problems, a misallocation often referred to as the "10/90 gap". Throughout the year and particularly at its annual meeting, the Global Forum for Health Research acts as a marketplace where problems of the 10/90 gap can be examined by a broad range of partners, i.e. representatives from governments, multilateral and bilateral aid agencies, international and national foundations and NGOs, women's organizations, research institutions and universities, pharmaceutical companies and the media. Forum 6 is the sixth annual meeting of the Global Forum for Health Research and the first to be held in Africa. Presentations will address the latest thinking on the 10/90 gap and act as a catalyst for action during the coming year. The global objective is to review progress in helping correct the 10/90 gap and plan further actions. In November 2002, Arusha will be the centre of world attention on health research, with Forum 6 followed by the third MIM Pan-African Malaria Conference. The National Institute for Medical Research of Tanzania is the local partner for the organization of both meetings. For further information and registration, please see the website.
Changing Roles And Policy Responses. Applications must be submitted by March 29, 2002.
The International Development Research Centre (IDRC) is launching a competition to support research on the changing balance between public and private sector funding of research, and its implications for developing country governments and research institutions. This research competition is being organized by IDRC as part of a new program of "Research on Knowledge Systems" (RoKS). The competition is open to researchers throughout the developing world, and will award up to seven grants, with a maximum value of CA $80,000 each.
Satellite Meeting, Barcelona, Spain, 5 July 2002
A one-day satellite meeting on vaccines, access to treatment and the law will be held on Friday, 5 July 2002, in Barcelona, Spain, just prior to AIDS 2002. The meeting is being organized by the Canadian HIV/AIDS Legal Network, the AIDS Law Project (South Africa), and the HIV/AIDS Unit of The Lawyers Collective (India), and will be co hosted by UNAIDS. Two issues will be examined in substantial depth:
1. HIV VACCINES: Participants will discuss the inadequacies of current approaches; the obstacles to vaccine development; strategies to mobilize greater support for vaccine development; and strategies to facilitate the widest possible access to HIV vaccines once they are developed.
2. ACCESS TO TREATMENT: Participants will discuss strategies for using the law to advance access to treatment for people living with HIV/AIDS in developing countries – both directly through the use of legal proceedings, and indirectly by using legal norms to complement other forms of advocacy.
Background papers on each issue will be distributed in advance to participants and presented in plenary. Most of the day will be spent in workshops where each issue can be explored in detail. Registration is limited to 100 participants on a first-come, first-served basis. To register or obtain more information, visit the website of the Canadian
HIV/AIDS Legal Network or contact Glen Bugg.
On-line registration is now available for the Third MIM Pan-African Conference to be held in Arusha, Tanzania, November 18-22, 2002. We would like to invite you to participate in the Conference. The Conference is expected to attract more than 600 participants from around the world, making it one of the largest conferences devoted to malaria research and control held on the African continent. The Conference will focus on scientific progress and potential in malaria research with the aim of promoting the exchange of scientific ideas within Africa. It will consist of plenary presentations by world-renowned experts, parallel sessions on a broad range of topics, and daily poster sessions. There will be ample opportunity to ex-
change ideas with malaria research faculty in "Meet-the-Professor" sessions. The diversity of participants will provide a global per-
spective on scientific solutions for effectively preventing malaria and reducing its burden.