Cereal production in Southern Africa has remained stagnant for over a decade since 1990 at 22 million MT, despite a growth in population of 60 million in the period. This fact highlighted at the SADC Heads of state summit on food security brought sharp attention to unacceptable and mounting shortfalls in food security in the region. Rates of childhood stunting in Africa are predicted to increase to above 25 percent by 2015, more than double the Millennium Development Goal (MDG) for that year. Only 3 out 10 African countries have experienced an improved maternal nutritional status in the last decade.
The EQUINET steering committee highlighted at the June 2004 regional conference its agreement with SADC heads of state that food security and food sovereignty are now an important focus to achieve wider goals of health equity and social justice in the region. The gross statistics were further debated as they mask the fact that it is the lowest income rural and urban communities, women and children who are most at risk of food insecurity and its consequences.
Mary Materu, from the Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Tanzania highlighted the massive inequity of the fact that “when the world is producing enough food to feed everybody, more than 800 million people, most in developing countries, do not have enough food to cover their nutritional needs.”
Mickey Chopra, from the University of the Western Cape School of Public Health, highlighted the wider fallout from this deprivation of the right to food: “Adequate food and nutrition is a basic right. The deprivation of this right has immense consequences for addressing inequities across the region. Poor nutritional status stunts educational development as well as increasing the risk of acquiring, and the severity of, infectious diseases (including HIV/AIDS). The lack of household food security has led to increased vulnerability, especially of women, to diseases such as HIV. If the huge cost of burden of disease suffered by the poorest is to be tackled addressing lack of household food security and malnutrition is essential.”
This deprivation arises from a combination of increasing food prices and falling food production. These immediate causes are driven by macro level factors such as trade relations, domestic food and agricultural polices and micro level factors such as intrahousehold food distribution, gender roles and caring practices.
The EQUINET steering committee noted that the current food insecurity cannot be traced purely to drought or to AIDS. “The 2002/3 food crisis in Southern Africa was more widespread and impacted much more severely on households than could be predicted from rainfall patterns. The destructive effect of AIDS on household labour and incomes clearly compounded other threats to food security, such as inequities in access to productive resources and to market access, particularly for women.”
Current trade policies were identified as having a profound and negative impact on food security in Africa. Chopra highlighted how OECD subsidies to agriculture between 2000 and 2002 of about US$250billion placed protectionist barriers against food imports from Africa, undermining returns from production and thus effectively suppressing production. Kenya, for example, more than doubled production of processed milk between 1980 and 1990. When subsidised milk powder imports could be sold more cheaply than Kenyan processed milk, imports soared, increasing from 48 tonnes in 1990 to 2 500 tonnes in 1998 and domestic production of processed milk plummeted by almost 70 percent. Kenya's ability as a nation to diversify into processing was undermined. More importantly small producers bore the brunt of this decline in demand for local milk. At national level production for export has led to decreasing land areas planted with food crops for domestic consumption. Domestic food production has also been weakened by falling investment in agricultural research.
These trade and economic barriers, harming small producers and thus women farmers, worsen the impacts of HIV/AIDS on household-level labour, assets and skills, on burdens of care and household productive capacities that have set up a vicious interaction between malnutrition and HIV. Mary Materu of COUNSENUTH further highlighted the need for improved nutrition to be supported by access to education, water and sanitation.
This understanding of the immediate and underlying factors driving food insecurity and malnutrition underlined the view at the EQUINET conference that addressing food security and nutrition called for action across a wide range of sectors. At global level it was clear that Millennium Development Goals that call for improved nutrition cannot co-exist with trade policies that undermine the production basis for achieving the goals in the most vulnerable regions of the world. At regional and national level Chopra presented evidence to show that improved food security calls for more equitable access to land, improved investment in small holder farming, and increased access by women farmers to production inputs.
Dr Erika Malekia of the Southern African Development Community (SADC) echoed this call for “an integrated plan of action, focused on addressing inequalities in areas such as land distribution, gender equity.”
The conference delegates resolved to advocate for trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production. EQUINET will be following up on this resolution in a more focused future programme of work on food security and health equity. The conference suggested that EQUINET support for SADC regional strategies for food security should include two critical components, particularly if equity issues are to be addressed. The first is to strengthen and inform from a health perspective the challenges to trade policies that undermine national food production. The second is to inform and strengthen the health dimensions of policies and programmes that support land redistribution, smallholder production and increased access by women smallholder farmers to production inputs.
The EQUINET Conference abstract book and resolutions are available on the EQUINET website at www.equinetafrica.org and the conference report will be posted on this site in the coming month. EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org
1. Editorial
2. Latest Equinet Updates
Following a successful Capacity Building Workshop On Writing For Peer Reviewed Journals in Durban, South Africa, June 4-7 2004 EQUINET is launching the EQUIWRITE programme. EQUIWRITE aims to build skills for effective publication and dissemination of information on equity in health. We are designing this programme based on the needs of researchers, government, civil society and others to support writing for scientific peer reviewed, policy, advocacy and other publications. Email us at admin@equinetafrica.org and let us know your views on the support you need for effective dissemination and publication of your work in equity in health.
Zindaba Yiwombe of the Malawi Health Equity Network is the winner of the award for the best EQUINET student grant proposal. Zindaba, who is studying journalism, presented a proposal to do a content analysis of debates on health in the Malawi National Assembly. The proposal by Zindaba aims to identify the extent to which debates in parliament take up health equity issues, the key areas debated and the trends in such debates. The work is relevant to EQUINET work with GEGA in the region on strengthening and supporting parliamentary oversight, legislative, representation and budget roles in promoting health equity. Malawi Health Equity Network has built close links with the Malawi Parliamentary committee on health in promoting health equity. The award was presented to Zindaba at the EQUINET June Conference.
3. Equity in Health
Of 585 000 maternal deaths worldwide each year, 99% are in developing countries. What factors underlie this striking imbalance? Research involving the Malawi College of Medicine and the Liverpool School of Tropical Medicine studied this issue in a rural community in southern Malawi. Maternal education and access to healthcare facilities influence pregnancy outcomes, it showed.
In a bid to improve access to medical care for millions of poor Kenyans, the government announced it would provide free health services in state-run dispensaries and health centres. "With effect from 1 July, 2004, all charges for prevention services, treatment, diagnosis in public dispensaries and health centres must stop," Health Minister Charity Ngilu told a news conference in the capital, Nairobi.
South Africa's transition to a democracy - characterized by a liberal constitution, a bill of rights, and attempts to pursue reconciliation rather than revenge - has been widely admired as a paradigm shift in human relationships from seemingly inevitable conflict to a negotiated peace. The challenge of narrowing racial disparities in health care is a formidable one for the new government. The high rates of infection with the human immunodeficiency virus (HIV) and full-blown AIDS add another layer of complexity. This review evaluates health care reform and responses to the pandemic of HIV and AIDS during the first decade of the new democracy.
South Africa's department of health will continue to dispense Nevirapine until further research into the reliability of the drug in preventing HIV transmission from mother to child is conducted. Concerns about the safety of Nevirapine surfaced after collaborative research conducted by the Medicines Control Council (MCC), manufacturer Boehringer Ingelheim and the National Institute for Communicable Diseases revealed that some HIV positive mothers had developed resistance to the antiretroviral, making it uncertain whether transmission of the virus was being blocked or not.
As the number of HIV-positive children and AIDS orphans continues to rise in South Africa's east-coast KwaZulu-Natal (KZN) province, AIDS organisations have embarked on community-based projects aimed at generating income for the guardians of children affected by the virus. The goal is to create self-sufficiency and ultimately gain independence from funding agencies. But it has been difficult to sustain the programmes, especially those focusing on traditional crafts, such as beadwork and woodcarvings.
A number of Namibian non-governmental organisations will not be represented at the largest-ever AIDS conference, being held in Thailand this month, because of the "prohibitive" registration fee. The conference is being held under the theme 'Access For All'. Sources from Namibian NGOs working with HIV-positive people this week described the US$1 000 registration fee as "prohibitively expensive".
Angola needs urgent funding for essential drugs if lives are to be saved, particularly among resettling populations, warned a mid-year review of the UN's Consolidated Appeals Process (CAP). The CAP review, prepared by the UN Office for the Coordination of Humanitarian Affairs (OCHA), said that at the end of April, funding for the essential drug component of the Minimum Health Care Package stood at approximately 50 percent.
Despite southern Africa being rich in resources, it had not adequately harnessed these for the people in the region, the Regional Network for Equity in Health in Southern Africa (Equinet) said. Speaking at an international conference on Equity in Health, Rene Loewenson, Equinet's spokesperson, said with the common focus on poverty and ill health, it was often forgotten that southern Africa was one of the richest regions in Africa and - in resource terms - in the world. "Despite this wealth of potential, the value of these resources have not been adequately harnessed for the people of the region," she said.
4. Values, Policies and Rights
The right to health facilities, goods and services specifically includes the provision of essential medicines as defined by WHO. The Human Rights Approach should be incorporated in all national medicine policies and programmes, the selection of medicines for essential public health functions should be further refined, States parties’ international reporting obligations on access to essential medicines should be strengthened, and national NGOs should be empowered to put pressure on governments to fulfil their commitments and obligations under the international and national human rights instruments they have signed and ratified.
5. Health equity in economic and trade policies
One-third of the world’s population lacks access to the most basic essential drugs. For the destitute sick in the developing world, the price of medicines can determine whether they will be treated. Patents drive drug prices up, the resultant monopoly status allowing the producer to charge whatever price the market will bear. The World Trade OrganizationTrade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, which provides 20 years’ patent protection for pharmaceuticals, also includes safeguards such as compulsory licensing, to ensure that countries can override patents whenever they are a barrier to access to medicines. Experience from South Africa, Thailand, Kenya and Guatemala shows the enormous pressures countries face in implementing theTRIPS Agreement in a manner that protects public health and underscores the vital role played by civil society in defending the right to access affordable medicines.
Developing countries are being shackled by regulations formulated and enforced by international organisations. Policies to nurture domestic industry, which were used in Europe, north America and more recently the successful East Asian 'tiger' economies, are becoming illegal. The three major agreements which emerged from the World Trade Organisation (WTO) Uruguay Round of international trade talks - on investment measures (TRIMS), trade in services (GATS) and intellectual property rights (TRIPS) - are narrowing the powers of states. Governments now find it difficult to combine profit-oriented actions of companies within their borders with complementing national development strategies.
PART I of this paper provides a brief introduction of the link between trade and development as related to health in general. The history of the World Trade Organisation (WTO) is also briefly introduced as it relates to the General Agreement of Trade in Services (GATS). Then a brief outline of the contents of GATS is given focusing on those areas relevant to public health generally, to health services and to their financing. PART II presents opportunities and threats posed by GATS for public health and health equity goals and policies in southern Africa, in terms of both general obligations and specific commitments across all modes of supply.
6. Poverty and health
This report is the third of a broader monitoring of food security and social welfare at community level by the Civic Monitoring Programme. Monthly monitoring will be complemented by quarterly monitoring of specific areas of social welfare.
This report from the International Food Policy Research Institute has very focused objectives. It seeks to present the methodology and results of the poverty analysis of the 2002-03 IAF as well as comparisons with the 1996-97 survey results. The results point to a substantially improved poverty picture relative to 1996-97. The national poverty headcount, defined as the share of the population living in poverty, declines to 54 percent, a 15 percentage point decline from the levels registered in 1996-97. Poverty reductions are more rapid in rural than in urban zones, narrowing considerably the differences in poverty between the two zones, though poverty levels remain higher in rural compared with urban zones.
The Summit of Heads of State and Government of the Southern African Development Community (SADC) on Agriculture and Food Security was held in Dar es Salaam, United Republic of Tanzania on 15 May 2004, and was chaired by His Excellency, Benjamin W. Mkapa, President of the United Republic of Tanzania. The Summit was held under the theme: Enhancing Agriculture and Food Security for Poverty Reduction in the SADC Region.
In his official opening statement, President Benjamin Mkapa of Tanzania, the Chairperson of SADC underlined the need for the region to continue to fight together for economic liberation of Southern Africa, especially in finding a lasting solution to the pressing questions of food security and sustainable poverty reduction.
7. Human Resources
The UK is currently prominent as an active recruiter of health workers, most notably doctors and nurses. This is unlikely to change in the short term. The demographics in many developed countries such as the UK- a growing, ageing population and an ageing nursing workforce- make it likely that many of these countries will be actively encouraging inflow of health workers. Stopping migration is unlikely to be a viable option -which essentially leaves two other policy stances - non intervention, or some level of intervention to attempt to manage the migration process so that it is nearer “win –win”, or at least is not exclusively “win- lose”, with the countries that can least afford to lose being the biggest losers.
The provincial health department [Western Cape] has lost nearly 4 000 staff in the past six years - and there are no plans to replace them. But the department does not intend to let the numbers drop further. In his budget speech in the provincial legislature, Health MEC Pierre Uys said the department was losing staff at the rate of 1 000 a year.
Substitute health workers are cadres who take on some of the functions and roles normally reserved for internationally recognized health professionals such as doctors, pharmacists and nurses but who usually receive shorter pre-service training and possess lower qualifications. The findings raise interest in expanding the use of substitute cadres, as the demands of expanding access to services such as antiretroviral treatment requires substantial human resources capacity.
8. Public-Private Mix
One characteristic of discussions about strategies for the provision of services to poor people has been the persistence of ideological debates about the relative roles of public and private sectors. These debates are strongly influenced by the experiences of the advanced market economies and often do not reflect the reality of countries where most poor people live. This paper’s aim is to contribute to the development of common understandings of this reality and to the formulation of practical strategies for meeting the needs of the poor.
The world is entering a new era in which, paradoxically, improvements in some health indicators and major reversals in other indicators are occurring simultaneously. Rapid changes in an already complex global health situation are taking place in a context in which the global public-health workforce is unprepared to confront these challenges. This lack of preparation is partly because the challenges are large and complex, the public-health workforce and infrastructure have been neglected, and training programmes are inadequate.
9. Resource allocation and health financing
This paper presents a model for estimating HIV/AIDS health care resource needs in low- and middle-income countries. The model presented was the basis for the United Nations' call for US$9.2 billion to address HIV/AIDS in developing countries by 2005 with US$4.4 billion to address HIV/AIDS health care and the rest to deal with HIV/AIDS prevention. The model has since been updated and extended to produce estimates for 2007. This paper details the methods and assumptions used to estimate HIV/AIDS health care financial needs and it discusses the limitations and data needs for this model.
10. Equity and HIV/AIDS
Multivitamins costing $15 per person per year significantly reduced the risk of HIV disease progression and death in HIV-positive pregnant women in Tanzania, according to a study published in the July 1st edition of the New England Journal of Medicine. The investigators conclude that multivitamins would be a cheap, simple, and effective means of delaying the need for antiretroviral therapy in HIV-positive pregnant women in resource limited settings. An accompanying editorial praises the rigour of the investigators study, and although it calls for further studies into the benefits of multivitamins involving large populations it says that treatment programmes and doctors would be justified in offering multivitamins.
"The introduction of antiretroviral drugs will bring with it new challenges because this treatment is different from that for opportunistic infections, palliative care, home based care and cotrimoxasol prophylaxis which we have been providing and will continue to provide. It is different in the sense that these drugs are delicate, have a variety of side effects and have to be taken regularly and correctly for life. However, I am confident that Uganda will succeed to roll out this treatment to our people."
The GAIN Issues Brief is being launched in response to a perceived gap in current news analysis on the issues of HIV/AIDS, its implications for democracy and governance in Africa, and the challenges of ensuring that the response to HIV/AIDS is consonant with democratic principles. This Issues Brief is a product of the African Civil Society Governance and AIDS Initiative (GAIN), launched in October 2003. The aim of this Issues Brief is to provide civil society activists, journalists and policymakers with a concise analytical digest of developments in the field of HIV/AIDS, governance and democracy.
In Southern Africa, only 100 000 out of 4.1 million people who need HIV/AIDS anti-retroviral therapy (ART) are able to access it. The drop in the price of ART has led to opportunities to increase the numbers receiving treatment, but problems remain. Increasing health service focus on HIV might poach staff and resource from other important programs like TB, malaria or child health. Developing countries need to balance resources for treatment and prevention.
This paper considers how the design of agricultural policies and programmes might be modified to better achieve policy objectives in the context of severe HIV epidemics and underscores the central role of agricultural policy in mitigating the spread and impacts of the epidemic. It is argued that - even though the absolute number of working age adults in the hardest-hit countries is projected to remain roughly the same over the next two decades - the cost of labour in agriculture may rise in some areas as increasing scarcity of capital (notably, animal draft power for land preparation and weeding) will increase the demand for labour in agricultural production or shift agricultural systems to less labour- and capital-intensive crops.
11. Governance and participation in health
CSOs at national and grassroots level, are involved in mutual support, building citizen capacities, advocating public interests and rights, meeting social needs, providing services and advocating accountability within private and public health services. What is the impact of this input on health gains and informed health action within poor communities and on equity in health? This review of the literature explores whether civil society contributes to improved provision, coverage of and access to health services in low-income communities. The paper further examines whether civil society promotes improved responsiveness of health services, or enhances advocacy for and development of policies that are pro-poor and that enhance health equity.
Although decentralisation is often heralded as a means to promote democracy and poverty reduction, there is little reliable evidence to prove these claims. In fact, ruling parties and ethnic elites in Africa have used decentralisation to further strengthen their own power and influence at a local level. New research argues that on its own, decentralization will not reduce poverty. Just as important are an ideological commitment to the poor and democratic accountability. Research from the Institute of Development Studies looks at the politics of local-central relations in a selected number of African states which have adopted decentralisation.
12. Monitoring equity and research policy
Health impact assessment differs from other purposes for which evidence is collated in a number of ways. This has implications for commissioning and conducting reviews. Methods must be developed to: facilitate comprehensive searching across a broad range of disciplines and information sources; collate appropriate quality criteria to assess a range of study designs; synthesise different kinds of evidence; and facilitate timely stakeholder involvement. Good practice standards for reviews are needed to reduce the risk of poor quality recommendations. Advice to decision makers must make explicit limitations resulting from absent, conflicting, or poor quality evidence.
13. Useful Resources
The Global Health Watch (GHW) is a new project which articulates civil society's vision for global health. It is a platform for the strengthening of advocacy and campaigns to promote equitable health for all. The global community has failed to achieve 'Health for All by the Year 2000'. New targets such as the Millennium Development goals look increasingly unachievable. Questions need to be asked about whether current policies in global health are working. The Global Health Watch for 2005 will not only look at some of the most important problems such as commercialisation of health and access to medicines, but also suggest solutions and monitor the efforts of institutions and governments concerned with promoting health world-wide.
The URL for the unofficial "wiki" for the International HIV/AIDS conference taking place in Bangkok, Thailand, from July
11th-16th, is at http://www.aids2004wiki.org. It will allow posting of notes, comments, introductions, information about sessions, event and presentation listings. For more on the conference itself, which is expected to draw between 11,000 and 15,000 delegates - and whose theme is "Access for All" - please see http://www.aids2004.org. To contact someone about the wiki, please write to Jim Cashel at mailto:cashel@ForumOne.com.
The Alliance on Health Policy and Systems Research Alliance aims to promote the generation, dissemination and use of knowledge for enhancing health system performance. The new Evidence Base aims to broker knowledge between researcher and policy and programme analysts focusing on developing countries.
YouthNet, a program of Family Health International, is pleased to announce Youth InfoNet No. 7, a one-stop monthly source for new publications and information on youth reproductive health and HIV prevention. You can read the newsletter online at the URL provided.
14. Jobs and Announcements
The South African Research Ethics Training Initiative, SARETI, is a joint project by the University of KwaZulu-Natal, the University of Pretoria, faculty from Johns Hopkins University, and the Fogarty International Center of the US National Institutes of Health to offer advanced learning in bioethics and health research ethics. The programme is aimed at scientists, health professionals, members of ethics review committees, public health personnel, social scientists, philosophers, ethicists, health journalists, lawyers, and other professionals whose work impacts on health.
The Alliance for Health Policy and Systems Research is issuing a competitive Call for Proposals (in collaboration with The International Development Research Centre (IDRC), Canada) to strengthen health systems, promote civic engagement, and make research matter. This collaboration aims to support the integration of political, economic, social and policy analysis into research on public health and health care systems and policies in Eastern and Southern Africa. Only proposals focusing on this region will be considered.
Are you committed to equity in health and health care? Do you believe in the importance of translating research into action for greater equity? Would you like to work with skilled and committed individuals in developing countries around the world? Are you willing to travel? This is an exciting opportunity for a committed, enthusiastic, and hard working public health professional to work with world-renowned researchers, advocates and policy-makers focused on cutting-edge public health work.
'To advance the epidemiological analysis of social inequalities in health, and of the ways in which population distributions of disease, disability, and death reflect embodied expressions of social inequality, this volume draws on articles published in the International Journal of Health Services between 1990 and 2000. Framed by ecosocial theory, it employs ecosocial constructs of "embodiment," "pathways of embodiment," "cumulative interplay of exposure, susceptibility, and resistance across the lifecourse," and "accountability and agency" to address the question; who and what drives current and changing patterns of social inequalities in health?' For ordering information visit the URL provided.
* July 26-August 7 - Asian Disaster Preparedness Center, Bangkok, Thailand;
* November 1-14 - Institute of Public Health, Makerere University, Kampala, Uganda.
Please click on the URL below for more information.
'Youth Net and Counselling' will be hosting a conference on youth, children and HIV/AIDS. Below is the synopsis of the conference between August 24 - 27, 2004 at the Sun and Sand Holiday Resort, on the Shores of Lake Malawi, Malawi.
Papers or articles are requested for SAfAIDS News newsletter. The newsletter targets:
- professionals working in the HIV/AIDS sector
- staff in ASOs, NGOs, FBOs, government bodies, UN agencies and
universities in the region
- policy makers
- Community based organisations.
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