The report launched today, by WHO and UNAIDS, as a status update on where the world stands in the provision of treatment for AIDS is a predictably fascinating document.
There will be comments aplenty. I have five.
First, the 3 by 5 initiative seems to me to be entirely vindicated. Mind you, I can even now hear the curmudgeonly bleats of the detractors, whining that we will fall short of the target of three million in treatment by the end of this year. Tell that to the million people who are now on treatment and who would otherwise be dead. The truth is that the 3 by 5 initiative --- which, I predict, will be seen one day as one of the UN’s finest hours --- has unleashed an irreversible momentum for treatment. I see it everywhere as I travel through Africa. Governments are moving heaven and earth to keep their people alive, and nothing will stop that driving impulse. It is surely noteworthy that 3 by 5 has ushered the phrase “universal treatment” into the language of the pandemic, meaning that we’re now all fixated on getting everyone who needs treatment, into treatment, as fast as possible. It is, I readily admit, both painful and horrifying to see the numbers who are dying as they wait for treatment to be rolled out, but at least there is hope amidst the despair.
Second, it becomes irrefutably clear that treatment has been a boon to prevention. I can recall from many quarters all the caterwauling about the neglect of prevention as the world began to focus on treatment. But the detractors were wrong again. Not only do we continue to emphasize prevention and reinforce it at country level, but the provision of treatment significantly accelerates testing and counseling, one of the primary ingredients of prevention. Buried in the report, is the astonishing statistic from a study of a district in Uganda, showing a 27-fold increase in counseling and testing as a result of the introduction of treatment!
Third, the G8 certainly has its work cut out for it. What this report appears to do is to throw many of the financial estimates of resource needs for Africa into a cocked hat. WHO and UNAIDS categorically assert that we will need an additional $18 billion dollars, over present commitments, for the three years 2005-2007. We know from the recent UNAIDS estimates for 2008, that we will require $22 billion annually, minimum, from that year forward. In the face of these resource imperatives, the idea of doubling foreign aid for Africa by 2010, which would represent another $25 billion per year, is clearly inadequate, some might say paltry. The $25 billion is supposed to address all of the Millennium Development Goals; it will barely address the one goal of defeating communicable diseases. Unless the G8 can do a lot better than the present calculus, Gleneagles will be much like all the G7/G8 summits before it: a rhetorical triumph, a pragmatic illusion.
Fourth: the report has one particularly evocative diagram. It’s a world map portraying the twenty countries with the highest unmet treatment needs … twenty countries where the estimated number of people in treatment is pathetically low. Six of those countries --- South Africa, Zimbabwe, Tanzania, Nigeria, Ethiopia and India --- represent fully half of the unmet treatment needs. Five of them are in Africa. South Africa alone has the largest shortfall in the world, some 866,000 people who should at this very moment be in treatment. The country appears to have something slightly in excess of 100,000 people in treatment, but that represents only 10% to 14% of those who are desperately in need. The numbers for the other African countries, while smaller, are proportionately even more grim. This is where the international community must rally urgent support.
Fifth, the report says, without caveat, that treatment should be provided free at the point where it is given. Finally, we’re building a new consensus around the destructive nature of ‘user fees’, particularly as they prejudice the poor. User fees are a sordid relic of the old economic conditionalities: it will be excellent to see the end of them.
It was a good and illuminating report that was released today. It identifies many of the obstacles and bottlenecks, and with spirited intelligence suggests, in each case, a way around them. It’s a first-rate blueprint at this point in time.
* Click on http://www.who.int/3by5/progressreportJune2005/en/ to read the press release about the report and for a link to the full report,
1. Editorial
The mass media hype about “a new deal between rich and poor”, in response to the powerful Group of Eight industrialised countries’ plan to cancel multilateral debts owed by 18 mainly African countries, has led many people to believe that a new era of international social justice has dawned. The deal is expected to be ratified by G8 leaders in Scotland on July 6-8. The uncritical endorsement of the plan by large international aid agencies like Oxfam, the driving force behind the Make Poverty History (MPH) coalition of non-government organisations, and big-name celebrities like Bob Geldof and Bono, has reinforced this hope. Unfortunately, celebrations to mark what British deputy PM Gordon Brown described as “the intention of world leaders to forge a new and better relationship between the rich and poor countries of the world” are premature.
2. Latest Equinet Updates
EQUINET will place its next call for student grants in July 2005 so watch this space! EQUINET will be calling for students in undergraduate and postgraduate study to apply for grants in work on health and health systems that reflect EQUINET values of equity, social justice and the right to health.
As a follow up to the EQUINET, GEGA and SADC PF August 2003 meeting on “Parliamentary Alliances for Equity in Health” held in Johannesburg, and the June 2004 EQUINET Conference, members of various Parliamentary portfolio committees on Health in southern Africa held a meeting in Zambia to strengthen the networking, work and capacities of parliamentary committees on health to promote SADC objectives in health and to build co-operation with organisations with shared goals. The meeting was hosted by EQUINET, GEGA, SADC PF and IDASA and local hosts CHESSORE.
The Southern and East African Trade information Institute, (SEATINI) and the Centre for Health Policy (CHP) Wits University and Training and Research Support Centre (TARSC) with the Regional network on Equity in Health in southern Africa (EQUINET) will be hosting a technical meeting on promoting health in trade agreements in east and southern Africa on Tuesday 28 to Thursday 30 June 2005 in Dar es Salaam, Tanzania.
3. Equity in Health
Basic sanitation must reach 138 million more people every year through 2015 – close to 2 billion in total - to bring the world on track to halve the proportion of people living without safe water and basic sanitation, the World Health Organization (WHO) and UNICEF warn in a new report. Meeting this Millennium Development Goal (MDG) target would cost US $11.3 billion per year, a minimal investment compared with the potential to reduce human illnesses and death and invigorate economies.
A quarter of all clinical trials are now done in the developing world, but often the research lacks a rigorous ethical framework. Western researchers or funders tend to shoulder the blame for trials that the international scientific community deems unethical, says Gilbert Dechambenoit in this editorial in the African Journal of Neurological Sciences. But, he argues, African scientists should bear just as much responsibility for unethical scientific practices.
In the face of widespread stigma around HIV/AIDS, few people have the courage to go public about their status, but one such person is Mampho Leoma, 28, a mother of two from Mapetla, in the Johannesburg township of Soweto. Leoma recalled the day she found out she was HIV-positive: "It was the 26th of January last year; I was four months pregnant ... It was very sad - I didn't expect the result. At the time I was not going with anyone else but my husband, and I didn't think he was going out with other girls either."
At least 100,000 people living with HIV/AIDS in Tanzania will receive anti-retroviral drugs (ARVs) free of charge by the end of 2006, Prime Minister Frederick Sumaye announced last month. "The target is to ensure at least 400,000 people are on free ARV treatment within the next five years," he said in a speech before parliament in Tanzania's administrative capital, Dodoma.
A company involved in the production of artemisinine, an anti-malaria drug, is due to set up extraction plants in Kenya and Tanzania to make the drug easily and cheaply available to patients, an official for the company said. The factories would be established in East Africa because of the potential in the region for cultivating artemisia-annua, the plant from which the anti-malaria drug is extracted, the managing director of African Artemisia Limited, Geoff Burrell, said at a conference convened by the UN World Health Organization (WHO) in the northern Tanzanian town of Arusha.
The United Nations Human Development Report Office released preliminary figures from the 2005 human development report projecting that the UN’s millennium development goals will be missed by a wide margin in Africa, reports the British Medical Journal. The UN undertook in 2000 to halve the number of people living on less than a dollar a day, to cut infant mortality by two thirds, and to give every child primary education by 2015. Ten African countries have worse infant mortality rates now than in 2000.
This report presents the potential benefits and risks associated with GM foods. It finds that GM foods can increase crop yield, food quality and the diversity of foods which can be grown in a given area. This in turn can lead to better health and nutrition, which can then help to raise health and living standards. The report also recommends that in future, evaluations of GM foods should be widened to include social, cultural and ethical considerations, to help ensure there is no "genetic divide" between groups of countries which do and do not allow the growth, cultivation and marketing of GM products.
Malnutrition can be dealt with, for less than $US 20 per child per year. This has always seemed like quite a lot of money, but the comparison with HIV/AIDS should inspire us to be more ambitious. Children have a right not to be brain damaged by malnutrition. But, in addition, not tackling malnutrition makes achieving the MDGs simply impossible: malnutrition is an indicator for the poverty MDG, but improving nutrition status is also an absolute requirement if the health and education MDGs are to be met.
The Community Working Group on Health will this year commemorate June 6th National Health and Safety day under the theme “Organising People’s power for health”, we do this in solidarity with the Trade Unions of Zimbabwe. The Community Working Group on Health is a network of 30 membership based civic/community based organisations that aim to collectively enhance health and community participation in health in Zimbabwe.
4. Values, Policies and Rights
"It is time to shift the debate over HIV prevention in Uganda. Rather than focusing on the precise combination of A, B, and C that contributed to the country's HIV decline, researchers should condemn censorship of life-saving HIV/AIDS information and discrimination against vulnerable populations such as lesbians and gays. It is bad enough that the USA is exporting ignorance and prejudice to countries already devastated by HIV. Researchers should not ignore these human-rights violations by focusing on the wrong issue." (requires registration)
This article explores the relationship between public health and human rights using as an example the Brazilian policy on free and universal access to antiretroviral medicines for people living with HIV/AIDS. The Brazilian response to the HIV/AIDS epidemic, which arose from initiatives in both civil society and the governmental sector, followed the process of the democratization of the country. If the Brazilian experience may not be easily transferred to other realities, the model of the Brazilian response may nonetheless serve as an inspiration to finding appropriate and life-saving solutions in other national contexts. (abstract only)
This bibliography pulls together recent articles that speak to the relationship between human rights and health, particularly focused on health equity, poverty and community agency. The bibliography was prepared for the EQUINET Health Rights theme and the articles described in the bibliography have informed much of the conceptual approaches developed in EQUINET to harnessing rights approaches to build health equity. The bibliography overlaps to some extent with other bibliographies held by EQUINET on health equity themes. It should prove useful for researchers exploring issues of human rights in relation to equity. The intention is to keep this bibliography updated in future, to support EQUINET’s activities in this area.
The audit aims to 1. conduct a review of the regional and international human rights instruments relevant to health; and 2. review the national commitments that have been made under these human rights instruments.
5. Health equity in economic and trade policies
When the leaders of the world's largest industrial nations meet in Scotland, they will debate how to address the HIV/Aids crisis and whether to significantly increase assistance to Africa. But for the summit to have a real impact on the Aids pandemic, the G8 will have to do more than increase funding; they will have to address the economic and social realities that make women and girls a special, high-risk group. Evidence from Africa shows the importance and cost-effectiveness of this strategy.
Global trade and international trade agreements have transformed the capacity of governments to monitor and to protect public health, to regulate occupational and environmental health conditions and food products, and to ensure affordable access to medications. Proposals under negotiation for the World Trade Organization's General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement cover a wide range of health services. Public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date. (abstract only)
Debt campaigners need to be very clear about what the recent debt deal actually represents and its serious limitations, says a briefing paper from Eurodad. "There is broad agreement among civil society organisations that the deal doesn't go nearly as far as the overblown rhetoric which accompanied its release. And that it has some worrying strings attached.”
The international medical NGO, Medecins Sans Frontieres (MSF), is urging G8 nations and the UN to push for speedy delivery of the cheapest and latest anti-AIDS drugs to developing countries. MSF stressed that this was vital to head off a looming supply and cost crisis, because "access to newer drugs is increasingly critical, as the growing number of people with HIV/AIDS currently on treatment will inevitably develop resistance to first-line treatments".
6. Poverty and health
The agricultural sector has been seriously affected by the HIV/AIDS crisis. In parts of eastern and southern Africa, HIV prevalence rates exceed 15 percent. The disease has contributed to a loss of assets, loss of land, and, in some cases, labour shortages. As a result, crop production has declined for many farm households and rural inequality appears to have increased. Agricultural policies need to take account of these changes. Agricultural growth built on policies sensitive to the impacts of HIV/AIDS is essential if poverty caused by the disease is to be reduced.
7. Human Resources
This paper responds to some central assertions in the paper Country Action Alliances to drive the HRH agenda (circulated as background reading for the Oslo consultation on Human Resources for Health, 24-25 February 2005), which describes the diverse nature of partnerships required to enhance global and country level commitments to expanding human resources for health. In response, this paper describes three examples of human resource development in community-driven HIV/AIDS programmes. The basic proposition is that acknowledgement, inclusion of and support for community based health initiatives is necessary to understand fully where health action is occurring and where potential for expansion lies.
The already inadequate health systems of sub-Saharan Africa have been badly damaged by the emigration of their health professionals, a process in which the UK has played a prominent part. In 2005, there are special opportunities for the UK to take the lead in addressing that damage, and in focusing the attention of the G8 on the wider problems of health-professional migration from poor to rich countries. This article from The Lancet suggests some practical measures to these ends. (requires registration)
"This paper examines policy towards health professionals' migration from economic and governance perspectives. Our aims are conceptual and agenda-setting. In essence, we argue that current policy responses to migration of health professionals from low income developing countries underestimate the pressures and mis-identify the reasons for rising migration, overestimate the impact of recruitment policies on migration flows while ignoring unintended side effects, and mis-specify the ethical dilemmas involved."
8. Public-Private Mix
This Save the Children brief shows that abolishing user fees and covering the relatively small cost of abolition would immediately save nearly a quarter of a million children under five. It argues that user fees for basic healthcare, paid in the poorest countries around the world, are in reality "killer bills". Children and their families either don’t go to the health clinic when they are sick or when they do, and have to pay, they are forced further into poverty and sometimes have to go without food. Some families remove children from school in order to pay for health care.
"...user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible."
9. Resource allocation and health financing
Methods of cost-effectiveness analysis (CEA) have largely been developed for application in Western country settings. Little attention has been paid to the methodological issues in cost valuation in resource-poor settings, where failing exchange rates and severe market distortions require further clarifications of appropriate valuation methods. This paper links insights from social cost-benefit analysis with the current CEA guidelines to develop a more apt approach to cost valuation in resource-poor settings.
10. Equity and HIV/AIDS
The landscape for antiretroviral (ARV) therapy in resource-poor settings has recently changed considerably with the availability of generic drugs, the drastic price reduction of brand drugs, and the simplification of treatment. However, such cost reductions, while allowing the implementation of large-scale donor programs, have yet to render treatment accessible and possible in the general population. Addressing the problem of HIV treatment in high prevalence/high caseload countries may require redefining the problem as a public health mass therapy program rather than a multiplication of clinical situations. (abstract only)
The report uses pre-existing information and indicators from different stakeholders, analysis of sentinel data from Thyolo district, consultations with key informants, participation in meetings and insights from qualitative studies at the Lighthouse (a high burden ART service provision site in the capital Lilongwe) and in Thyolo district.
Whilst the HIV/AIDS epidemic is affecting people all over the world, it affects young and middle-aged adults most seriously. This is the most economically active age group, meaning the disease has a dramatic impact on agricultural production, rural livelihoods and food security in many countries. Labour-saving crops and improved agricultural techniques will be a valuable support measure for such communities to increase agricultural output and food production.
11. Governance and participation in health
The Kenya Partnership for Health (KPH) program began in 1999, and is currently one of the 12 field projects participating in the WHO's 'Towards Unity for Health initiative' implemented to develop partnership synergies in support of the Primary Health Care (PHC) approach. This paper illustrates how Program-linked Information Management by Integrative-participatory Research Approach (PIMIRA) as practised under KPH has been implemented within Trans-Nzoia District, Kenya to enhance community-based health initiatives. It shows how this model is strategically being scaled-up from one community to another in the management of political, social, cultural and economic determinants (barriers and enhancers) of health.
12. Monitoring equity and research policy
The first report published by the Global Forum on an annual meeting, Health Research for the Millennium Development Goals, summarizes the main themes of Forum 8 from plenary presentations and includes a CD-ROM with all the presentations, media and final documentation of the meeting. The report clearly demonstrates that a great deal is known about the kinds of research that are urgently required to accelerate and intensify the efforts necessary to achieve the Millennium Development Goals (MDGs). The Global Forum for Health Research is an independent international foundation based in Geneva. The report and CD-ROM can be ordered or downloaded from the organization's website: http://www.globalforumhealth.org
This second Global Forum assessment responds to widespread interest on the part of those who fund research, manage and set priorities in different institutions and use our results to try to improve the health of populations around the world. The study presents a new estimate of global spending on health R&D for 2001 but also exposes major gaps in the availability of good quality data from all sectors, disease-specific information and the measure of complex determinants such as poverty, inequity, and gender.
13. Useful Resources
An international network of public health practitioners and policy-makers have come together to launch the new journal Globalization and Health. The journal will be an Open Access (i.e. free to the end user), peer-reviewed, online journal providing a forum for debate and discussion on the topic of globalization and its impact on public health. This will be the first journal to deal exclusively with the subject, and aims to draw on a global resource base, producing content which is accessible and relevant to a truly global audience.
Microbicides are products such as gels or creams which could help prevent the sexual transmission of HIV. They are currently being developed and could join the field of HIV prevention methods within the next five to ten years.
14. Jobs and Announcements
The Collaborative Fund for HIV/AIDS Treatment Preparedness in Southern Africa calls for submissions from organisations seeking funding for community-based HIV treatments advocacy and education programs. Grants will be allocated to successful applications for a period of up to one year to a maximum amount of 10,000 US dollars per application.
Please join the People's Health Movement and other organizations in working toward a water-secure future by signing the People's Statement on the Right to Water. Your organization's endorsement will help demonstrate support to establish access to safe, sufficient and affordable water as an international human right. It will also show the breadth of opposition to the commodification of water.
The Southern African Research Centre (SARC) at Queen's University and the Department of History and the Library at the University of South Africa (UNISA) are planning two conferences on this subject during 2006. The first will take place at SARC in Kingston, Canada on May 7-10, with a focus on 'Public Health and the Representation of the HIV/AIDS Epidemic'. The UNISA gathering at the University's Sunnyside campus in Pretoria on August 14-16 will address a related but distinct set of issues: 'HIV/AIDS in Social Context: Historical and Contemporary Perspectives'.
Together, let us build a healthy world! The Second Peoples Health Assembly will be the culmination of a process of local and national reflections, discussions and debates, and of the exchange of experiences of communities and networks the world over. National and regional conferences and workshops centered around all aspects that influence the health and well being of the marginalized will be held in preparation of PHA 2. At the same time, there will be a mobilization of campaigns to help join together organizations and groups of people around the call for Health for All Now, No to War and no to the WTO.
The World Health Organization in December 2004 urged all member countries to consider mechanisms for pooling financing for healthcare, including Social Health Insurance, in order to achieve universal coverage. The Health Economics Unit at the University of Cape Town offers a 5-day short course addressing the changing role of health insurance in low and middle income countries. The course focuses on the financial management of risk pools in diverse settings covering a broad spectrum of insurance arrangements including community-based health insurance, private voluntary insurance for the formal sector and social or national health insurance.
The Alliance for Health Policy and Systems Research is collaborating with the Systemwide Effects of the Fund (SWEF) Research Network in a process based on a competitive Call for Proposals to support research to assess the effects of global health initiatives on the health systems in recipient countries. This collaboration aims to support research to measure the systemwide effects of global health initiatives - such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), the President's Emergency Plan for AIDS Relief (PEPFAR), the World Bank Multi-Country AIDS Program (MAP), and others - on broader health systems in low-income countries in Africa, Latin America and the Caribbean, Asia, and Eastern Europe.
The Head of Project will assume overall responsibility for delivering a major mass media project to address HIV/AIDS in Tanzania. The project will meet agreed targets and objectives, and be delivered on time and on budget. The role will include management of an in-country production team and project office, ensuring the quality and cohesion of media outputs, establishing and managing effective partnerships with local media, government, NGOs and other key stakeholders.
Published for the Network for Equity in Health in Southern Africa by
Fahamu - Networks for Social Justice
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