Last month, I spent two weeks touring four countries in Southern Africa: Lesotho, Zimbabwe, Malawi and Zambia. The primary purpose was to view the link between hunger and AIDS. I want to look back at that visit, because little will have changed between then and now (except, perhaps, that things will have deteriorated further), and then look forward to the prospects for addressing the pandemic in 2003.
At the outset, however, let me express, yet again, the fundamental conviction I have every time I visit Africa: there is no question that the pandemic can be defeated. No matter how terrible the scourge of AIDS, no matter how limited the capacity to respond, no matter how devastating the human toll, it is absolutely certain that the pandemic can be turned around with a joint and Herculean effort between the African countries themselves and the international community.
I am weary to the point of exasperated impatience at the endless expressions of doubt about Africa’s resolve and Africa’s intentions and Africa’s capacities. The truth is that all over the continent, even in the most extreme of circumstances, such as those which prevail today in the four nations I visited, Africans are engaged in endless numbers of initiatives and projects and programmes and models which, if taken to scale, if generalized throughout the country, would halt the pandemic, and prolong and save millions of lives.
What is required is a combination of political will and resources. The political will is increasingly there; the money is not. A major newspaper in the United States, reflecting on the paucity of resources, used the startling phrase “murder by complacency”. I differ in only one particular: it’s mass murder by complacency.
You will forgive me for the strong language. But as we enter the year 2003, the time for polite, even agitated entreaties is over. This pandemic cannot be allowed to continue, and those who watch it unfold with a kind of pathological equanimity must be held to account. There may yet come a day when we have peacetime tribunals to deal with this particular version of crimes against humanity.
As bad as things are in Southern Africa - and they are terrible - every country I visited exhibited particular strengths and hopes.
The little country of Lesotho has a most impressive political leadership, but is absolutely impoverished. If it had some significant additional resources, with which to build capacity, it could begin to rescue countless lives. I vividly remember the Prime Minister of Lesotho saying to me: “We’re told repeatedly by donors that we don’t have capacity. I know we have no capacity; give us some help and we’ll build the capacity.” It’s worth remembering that Lesotho has a population greater than that of Namibia and Botswana, but it has nowhere near the same pockets of wealth. It has, however, one of the highest prevalence rates for HIV on the continent, higher than Namibia; almost as high as Botswana, and is fatally compromised in its response by the lack of resources.
Zimbabwe, whatever the levels of political turbulence, has created a sturdy municipal infrastructure for the purpose of dealing with AIDS. You will know that for the last couple of years, Zimbabwe has had a 3% surtax on corporate and personal income, devoted to work on AIDS. A good part of that money has been channelled down to district and village level, through a complex array of committees and structures which actually get the money to the grassroots. It’s visible in the work of youth peer educators, outreach workers and home care through community-based and faith-based organisations. In other words, for all the convulsions to which Zimbabwe is subject, there remains an elaborate capacity to implement programmes, if only there were more programmes to implement.
In Malawi, we may be about to see the most interesting of experiments in the provision of anti-retroviral treatment in the public sector. The Government of Malawi had originally intended to treat 25,000 people based on receipt of monies from the Global Fund. They then realized that the calculation of 25,000 was based on the purchase of patent drugs, but now that it is possible to purchase generic drugs, the numbers eligible for treatment could rise to 50,000. There has been, predictably, a great deal of skepticism in the donor and other communities. However, while we were in Malawi, the country was visited by a WHO team which carefully examined the capacity and delivery issues, and came to the conclusion that treating 50,000 people, phased in of course, was entirely possible. This is an exciting prospect: the treatments are meant to be free of charge, and delivered through the public health sector.
Zambia, whatever the difficulties - and they are overwhelming - is emerging from the bleak and dark ages of denial into the light of recognition. The bitter truth is that in the regime of the previous President, nothing was done. He spent his time disavowing the reality of AIDS, and hurling obstacles in the way of those who were desperate to confront the pandemic. I can recall personally attending an annual OAU Summit on behalf of UNICEF, and sitting down with the then President Chiluba, and asking him what he intended to do about AIDS, and he simply wouldn’t talk to me about it. Well there’s a new President in Zambia. And although he’s been in place for only one year, everyone agrees that there’s a dramatic change in the voice of political leadership around the subject of AIDS.
The fact is that in every country, even under the most appalling of human circumstance, there are signs of determination and hope. Whether they can be harnessed in the name of social change will be known in the year 2003. God knows, there are incredible hurdles to leap.
1. Editorial
2. Equity in Health
World Trade Organisation (WTO) talks held late last year failed to resolve the issue of access to generic medicines in developing countries after the United States blocked an agreement on granting easier access to the drugs. "Its a tragedy that there is no solution after one year of talks ... millions of people have died from [infectious] diseases this year. The rich countries don't realise how much this has affected poor countries," head of international affairs for treatment lobby group Act-Up Paris, Gaëlle Krikorian, told PlusNews.
Africa Action has welcomed the announcement of new money to fight HIV/AIDS by the Bush administration, but Africa Action Executive Director Salih Booker noted that this money must be made available immediately if it is to save lives and have a real impact on the course of the pandemic in Africa and globally.
The Southern African Catholic Bishops Conference (SACBC) has appealed for the provision of cheaper antiretroviral drugs for HIV -positive people. In a media statement, issued on Tuesday January 7, 2003, the AIDS Office of the SACBC said it "supports the cause of the National Association of People living with AIDS (NAPWA) in the calling of government and pharmaceutical companies to provide cheaper generic antiretrovirals to all people living with AIDS."
Dr. Jong Wook Lee, 57, of South Korea, was on Tuesday January 28 chosen by a World Health Organisation executive committee vote of 17-15 to take over the position of WHO director general, BBC News reports. Lee, who will succeed Norway's Dr. Gro Harlem Brundtland, narrowly defeated Peter Piot, a Belgian epidemiologist who heads UNAIDS.
Six companies involved with the UNAIDS- and WHO-sponsored Accelerating Access program have said they would increase the antiretroviral drug supply to Africa, "acknowledg[ing] that current efforts only scratched the surface" of the continent's epidemic, Reuters reports.
The EU has launched an initiative to break the current WTO deadlock on developing countries' access to affordable medicines. WTO members failed to meet the end of a 2002 deadline to find a solution for developing countries without manufacturing capacities, namely given the disagreement over the disease coverage. In a letter addressed to all WTO Trade Ministers, EU Trade Commissioner Pascal Lamy proposes a multilateral solution which is workable, sustainable and legally secure, based both on the Doha mandate and on the chair's compromise text of 16 December 2002.
The HIV/AIDS epidemic in Africa could be turned around, despite the devastating toll on human lives, UN Secretary General's Special Envoy for HIV/AIDS in Africa Stephen Lewis, says. Lewis noted that defeating the disease would require a combination of political will and resources.
The United Nations and several major humanitarian agencies have issued a plea to the international community to fund relief efforts for the "dual human tragedy" of HIV/AIDS and famine in Southern Africa, Agence France-Presse reports. A U.N. appeal for $611 million in aid for Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe has reached 58% of its target, Elizabeth Byrs, spokesperson for the U.N. Office for the Coordination of Humanitarian Affairs, said.
Senate Democrats have introduced the Africa Famine Relief Act, which would provide $900 million in emergency relief for Africa, including $600 million in food aid, $200 million in disaster assistance and $100 million in HIV/AIDS-related aid, the Associated Press reports.
US-based AIDS Healthcare Foundation is planning to file a complaint with the SA Competition Commission against pharmaceutical giant GlaxoSmithKline, in a bid to widen access to AIDS drugs. The attorney representing the foundation in SA, Musa Ntsibande of law firm Strauss Daly, said that the complaint would argue that Glaxo abused its dominant market position in contravention of the Competition Act, and was engaging in excessive pricing of its drugs to the detriment of the consumer.
3. Human Resources
How is the AIDS pandemic affecting growth and distribution in South Africa, and what are the economic impacts for workers likely to be? While the overall picture is murky, certain worrying trends and findings present themselves: If firms react by continuing to decrease their reliance on unskilled labour and by moving out of economic sectors whose customer-base comprises lower income consumers, then poor households will find themselves doubly disadvantaged, as their access to the labour market becomes ever more tenuous and the products that they purchase may become scarcer and more costly.
This report is the result of research into the current impact of HIV/AIDS on NGOs and CBOs in KwaZulu-Natal, the worst-affected province of South Africa. A survey of organisations found that most were aware that they eventually would have to grapple with HIV/AIDS among their own staff and volunteers, and they knew this could have serious consequences for their organisations' effectiveness and sustainability. This report aims to provide not just information on the status of the surveyed organisations, but also tools to help organisations in South Africa and elsewhere plan for and manage the epidemic among their own staff and volunteers.
4. Public-Private Mix
In the current environment of shrinking global and domestic resources for health care, there is an overwhelming pressure to achieve financial sustainability in the health sectors of developing countries. Within this context, there seems to be increasing acceptance of the view that individuals need to contribute to some of the costs of public health care through charges such as user fees and other cost-recovery mechanisms. This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care.
The World Bank and International Monetary Fund favour healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a one-month observation period. Trends suggest female children may be less likely to present for care when user fees are imposed. This paper concludes that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.
5. Resource allocation and health financing
There is a growing interest in the use of small area analyses in investigating the relationship between socioeconomic status and health, and in informing resource allocation decision-making. However, few such studies have been undertaken in low- and middle-income countries (LMICs). This paper reports on such a study undertaken in South Africa. It both looked at the feasibility of developing a broad-based area deprivation index in a data scarce context and considered the implications of such an index for geographic resource allocations. The findings demonstrate clearly that in South Africa deprivation is multi-faceted, is concentrated in specific areas within the country and is correlated with ill-health. However, the formula currently used by the National Treasury to allocate resources between geographic areas, biases these allocations towards less deprived areas within the country.
Hailed as a "quantum leap" in the fight against the HIV/AIDS pandemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria has become a focal point for funding efforts to bring the epidemic to heal. But a year after issuing its first call for funding proposals, the Fund remains seriously under-resourced, and concern is mounting over its sustainability. UN Secretary-General Kofi Annan estimated in 2001 that US $7-10 billion a year was needed to fight the HIV/AIDS epidemic. "At the end of the year (2002), we [Global Fund] had received US $2.1 billion in pledges and approximately US $800-850 million was available," Global Fund spokeswoman Mariangela Bavicchi told PlusNews.
Funding for health services is often cited as a major constraint for governments to be good stewards of health systems in their countries. Yet, in most cases, the data to support such claims is lacking. Making progress on a variety of health policy questions requires good national data on the sources and uses of funds in the health system, preferably comparable across countries. With such data, it is possible to begin answering questions such as the best ways to allocate limited resources toward improving health or what level of funding is needed in particular epidemiological and demographic contexts.
6. Governance and participation in health
This is a handbook to help planners and implementors look at the effectiveness of their BCC interventions. Implementors can use the handbook to help them monitor, since the handbook can point out both strengths and potential weaknesses of an ongoing intervention. The handbook can also be used as a planning tool because it highlights important points for the design and development of effective BCC programming.
A Cape Town doctor has dramatically helped the fight against tuberculosis (TB) by introducing a SMS service to remind patients to take their medication. Dr. David Green, a consultant in Managed Care, Disease Management and Information Systems, became so frustrated when his mother constantly forgot to take her medication for hypertension, that he started sending her SMS reminders -- and it worked. It did not take him long to make the connection between the effectiveness that his SMS messages had on alerting his mother, the high incidence of TB in Cape Town, and the possibilities that bulk SMS messages could present.
This paper focuses on the socio-cultural context in which the enactment of 'high risk' youth sexual activity takes place. The author maintains that understanding youth sexual culture and the context of high-risk sexual activity will provide the basis upon which programmes aimed at promoting safer sex practices are designed. It is concluded that the future may quite literally depend on the extent to which the current culture/context in which young people are developing their ideas about sex, and enacting their sexuality, can be transformed.
7. Monitoring equity and research policy
This article describes the Life Course Health Development (LCHD) framework, which was created to explain how health trajectories develop over an individual’s lifetime and how this knowledge can guide new approaches to policy and research. The Life Course Health Development (LCHD) framework offers a new approach to health measurement, health system design, and long-term investment in health development and also suggests new directions for research.
8. Useful Resources
A major training resource designed to help those working in the not-for-profit sector hone their writing skills in order to influence, persuade and bring about positive social change has been made available free of charge on the internet, thanks to the support of IDRC. “The CDROM version has been so popular,” said Firoze Manji, Director of Fahamu, “IDRC and Fahamu decided to make the resource available in the public domain as well.” Writing for Change, originally published as an interactive CDROM by Fahamu and Canada's International Development Research Centre (IDRC), is designed primarily for people working in the not-for-profit sector, including researchers, scientists, project managers, team members, campaigners, fundraisers, social activists and writers. Available in English, French and Spanish from Fahamu's web site (http://www.fahamu.org) the resource is thought to be one of the most comprehensive available, running at about 900 pages per language.
As part of its Advocacy Pack series, the Women, Health and Development Program announces its new Gender Equity in Health Advocacy Pack! The kit consists of a fact sheet, an issue paper and a PowerPoint presentation, which present the ethical and empirical underpinnings of the effort to incorporate the gender perspective in health policies and programs. This objective emphasizes the identification and resolution of gender inequities which impede the exercise of women and men's fundamental right to health.
This supplement includes:
* Health sector reform and equity – learning from evidence? Health Policy Plan. 2002 17: 1-4.
* D McIntyre, D Muirhead, and L Gilson Geographic patterns of deprivation in South Africa: informing health equity analyses and public resource allocation strategies Health Policy Plan. 2002 17: 30-39.
* Nzapfurundi Chabikuli, Helen Schneider, Duane Blaauw, Anthony B Zwi, and Ruairí Brugha Quality and equity of private sector care for sexually transmitted diseases in South Africa Health Policy Plan. 2002 17: 40-46.
ProNut-HIV, a new electronic forum, aims to share up-to-date information, knowledge and experiences on nutrition and HIV/AIDS.
WHO's non-communicable diseases and mental health cluster has launched a resource centre to "alert health leaders" about global increases in chronic conditions such as diabetes, HIV/AIDS, and mental and neurological disorders, and to provide solutions for managing the growing burden.
The RHO website (http://www.rho.org) is designed for reproductive health program managers and decision-makers working in developing countries and low-resource settings. RHO provides up-to-date summaries of research findings, program experience, and clinical guidelines related to key reproductive health topics.
9. Jobs and Announcements
The Training in Africa: Best Practices, Lessons Learned and Future Directions conference information is now available online. On the website you can: Read about the conference; Register for the conference and sign up for workshops; Find information about hotel registration; Link to the hotel's website; See the conference agenda; Print out the conference brochure.
The 2003 Conference will serve as a forum for discussion of a wide range of pharmaceuticals-related intervention strategies that are of concern to developing nations. The conference will also provide the opportunity to share information about the activities of the SEAM Program, which focus on enhancing access to essential medicines through collaboration between the private and public sectors.
The Council on Health Research for Development COHRED is looking for a Coordinator to lead the organisation into the next phase of its development. COHRED's vision is to attain a system of effective health research as a tool for development, based on values of equity and social justice and targeting the health problems of those most in need. COHRED works with numerous developing countries, research networks, UN agencies and other organizations to advocate for country-driven health research, based on the ENHR approach.
The theme of this premier conference will be eMEDICAL SCHOOLS - WAYS AND MEANS. The goals are to discuss the best ways and means to augment medical education in developing countries using telecomputing methods of communication.
Issue No. 5, December 2002/January 2003 of Heard, The Newsletter of the Health Economics and HIV/AIDS Research Division of the University of Natal, Durban, has been released. Issue five of the newsletter provides a mixed-bag of articles, including reports on completed research, new project descriptions, project updates, and other generally useful information. The lead article is a report on HEARD’s flagship annual workshop, “Planning for HIV/ AIDS in sub-Saharan Africa”, which was held at the end of October 2002.
The Research on Knowledge Systems (RoKS) exploratory initiative of the International Development Research Centre (IDRC) is launching its second annual research competition (2002-2003). This year's theme: "Strengthening Knowledge Policy for Small States: How can small states participate more effectively in local, regional, and global knowledge partnerships?" requests concept notes. The competition will award up to seven grants, with a maximum value of CAD$ 80,000 each. For joint proposals where researchers are located in two or more countries a maximum of CAD$ 160,000 will be awarded.
The main goal of this Fellowship is to support training of foreign scientists in rigorous scientific research methodology at a clinical or basic research facility in the United States. The purpose of this training is to prepare these scientists to successfully conduct high-quality research in complementary and alternative medicine (CAM) when they return to their home countries.
The International Society for Infectious Diseases (ISID) is accepting applications for the April 2003 round of Small Grants.
The preparations for the South African Health Review 2003 are underway. The theme for this year is equity. We would like to invite you to submit your suggestions on what you think should be covered in this Review, by 15 Feb 2003.