Introduction
The Global Forum’s annual conference was held in Mumbai, India from 12-16 September 2005, and focused on “poverty, equity and health research”. EQUINET was extremely well represented, with four papers presented, three in full plenary sessions, on EQUINET research in the area of: participation and health, ART, fair financing and policy analysis. The papers presented by the EQUINET conference participants can be found on the Equinet website.
Forum 9 was attended by delegates from around the globe; one of the great attractions of the Global Forum conferences is that it includes participants from a wide range of research disciplines, policy-makers and civil society organisations. The conference had seven main themes: poverty; equity; innovation; neglected diseases and conditions; policies, systems and priorities; research capacity strengthening; and reproduction and human development. Some of the issues discussed and conclusions arising from the two core themes of poverty and equity are summarised below.
Poverty theme
The key role of poverty in contributing to ill health, and the lack of access to health services for the poorest were highlighted in a number of presentations. There was also an emphasis on how out-of-pocket payments for health care leads to further impoverishment for vulnerable households.
One of the most interesting ‘debates’ at the conference related to whether or not the Mexican PROGRESA (now called Opportunades) program has been successful or not. This program involves monthly payments to poor households on condition that the household attempts to improve their education, health and nutritional status.
For example, a household will receive up to US$28 per month per child if the child attends 85% or more of classes, and up to US$12 per month per family in ‘food transfers’ if each child receives 2-4 health checkups per year, each adult receives one health checkup per year and pregnant women receive seven pre-and post-natal checkups.
Findings from evaluations of this program, undertaken in two different sets of villages, were presented in two different sessions and contained divergent results. The one study, undertaken by the World Bank and IMF, claimed very positive results of the program with a very high proportion of beneficiaries being in the poorest section of the population and improvements in health status and educational enrolment, as well as poverty reduction, being attributed to the program.
The other study, undertaken by a team of local researchers in one of the poorest areas of Mexico, found less positive outcomes. In particular, they highlighted that although the program was targeted at the poor, many poor households were not being reached. Very importantly, the program appears to be creating conflicts and “destroying the social fabric” of communities. There appear to be conflicts between those who are benefiting from the program and those who are not, despite being “equally poor”, and there is resentment at the paternalistic monitoring of family education and health choices. Unfortunately, no opportunity was presented to debate these studies or the PROGRESA program in detail. Nevertheless, these presentations highlighted the need to carefully monitor poverty reduction programs and to identify unexpected negative impacts.
One of the key recommendations arising from this theme was that mechanisms of accurately and comprehensively identifying and protecting the poor are urgently needed.
Equity theme
Much of the research presented at the conference again highlighted the extent of inequities at household, community, national and global levels and the effects of inequities on vulnerability and risk of infection, disease and injury; access to care, treatment interventions and health outcomes. Unlike many other conferences which focus almost exclusively on inequities on the basis of socio-economic status, considerable emphasis was placed on gender inequities and inequities related to disability at Forum 9. While this was very positive, it was noticeable that the gender and disability sessions were more poorly attended and it was noted that inequities related to ‘race’, ethnicity, age, language and cultural affiliation received very little attention. There was also quite limited discussion on how to successfully address inequities.
One of the particularly interesting series of papers presented at the conference, which might provide insights on fair financing approaches to be considered in the African context, related to the EQUITAP project. This project has undertaken an extensive analysis of equity in health care financing in a large number of Asian countries. The results very clearly demonstrate that countries, such as Hong Kong, Malaysia and Sri Lanka, which have strong public health systems with general tax revenue being the major source of finance in the health sector are the most equitable. Health systems that have universal health insurance systems, such as Thailand, also fare quite well. The EQUITAP project has also analysed the level of catastrophic out-of-pocket payments in Asian countries. The findings from the EQUITAP and other research projects all highlighted the need to move away from out-of-pocket payments as a health care financing mechanism and to increase tax and insurance funding for health services.
Other observations
In the closing plenary, there was a general sense that many interesting issues had been raised and that there had been valuable engagements between participants. A number of suggestions were made on how to improve on these engagements in future, including:
- Greater care should be taken in the language that we use, to enable communication between different researchers and between researchers and policy-makers. Sometimes unnecessary jargon is used, but more concerning is that certain terms (e.g. equity) are commonly used but may have a number of different interpretations depending on the underlying ideological perspective. In order to ensure effective communication, it is important that everyone clarify their specific definition or interpretation of key terms.
- It is critical to pay greater attention to the context within which particular research has been undertaken, both in interpreting the findings but also in assessing the generalisability of findings.
- Forums such as this should create opportunities for more deliberately structured and challenging debate. Many participants regarded the lack of explicit debate on contradictory research findings, as highlighted above in the case of the PROGRESA program, in order to better understand what works and what does not, and why, as a missed opportunity.
- There was a perceived need to invest more energy in trying to consolidate and synthesise existing knowledge to a greater extent. In particular, there is a need to disseminate information on positive experiences and success stories.
The next Global Forum conference will be held in Cairo, Egypt from 29 October to 2 November 2006 and will focus on “Combating disease and promoting health”.
* Di McIntyre is with the Health Economics Unit, University of Cape Town.
* Please send comments to admin@equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The Health Economics Unit at the University of Cape Town is offering 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 Network for Equity in Health in east and southern Africa (Equinet) participated in a number of sessions at Forum 9 of the Global Health Research Forum in Mumbai, India, 12-16 September 2005. The theme of the meeting this year was Poverty, equity and health research. The Global Forum’s annual meeting provides the opportunity for presentations and exchange of views on key issues on the global health agenda. Participants from a broad range of constituencies were present: health and development ministries, multilateral and bilateral agencies, research-oriented bodies and universities, NGOs and civil society, the private sector, the media. EQUINET has a substantial programme of research work on equity in health and reported on some of this at the Forum. Papers were presented by Grace Bongololo and Lot Nyirenda on theme work on gender equity in Antiretroviral therapy access; by Di McIntyre and Lucy Gilson on equitable health care financing; Rene Loewenson, Itai Rusike and Memory Zulu on The Impact Of Health Centre Committees On Health outcomes in Zimbabwe and Lucy Gilson, Ermin Erasmus; Peter Kamuzora; TJ Ngulube; Verona Phillips and Vera Scott on applying policy analysis in tackling implementation gaps.
EQUINET will award a number of small grants to post graduate students and undergraduate students in East and Southern Africa for research proposals in the areas of
1. Revitalising and building national peoples’ health systems
2. Organising people’s power for health
3. Ensuring fair financing of an equitable health system
4. Ensuring the human resources for health
5. Challenging trade liberalization and encroachment on health
The final date for applications is October 7 2005.
The training course aimed to enable participants to be able to carry out assessments nationally of the key trade and investment agreements that impact on health and identify options for promoting public sector equity oriented health systems within current trade and investment policies and agreements. The workshop aimed to cover
• An introduction to trade and health that outlines major issues affecting the region
• An outline of health systems, their major components of health systems and the challenges posed by commercialisation.
• An introduction to outline of the global major trade systems and the World Trade Organisation and how it agreements that impacts on health, and the options for protecting and promoting health within these trade agreements
• An outline of two major trade agreements - TRIPS and GATS - that impact on health, and the options for protecting and promoting health within these trade agreements
• A guideline for audit of the impact of trade agreements on health systems
• An introduction to analyzing and understanding the health systems context in which policy is developed, designed and implemented.
3. Equity in Health
The Ministry of Health and Social Services (MoHSS) on Tuesday, 13 September, launched a study report on Equity in Health Care in Namibia, which is aimed at generating evidence needed to enhance the health ministry’ endeavors to redressing inequities in resource allocation in the country. The study specifically purports to develop a needs-based allocation formula that will assist the MoHSS to shift its resource allocation mechanism away from the historical incrementalist type.
This report from the World Health Organization (WHO) asserts that if trends established in the 1990s continue, the majority of developing countries will not achieve the health Millennium Development Goals (MDGs) by 2015. None of the poorest regions of the developing world is on track to meet the child mortality target, while maternal mortality has only declined in countries where levels were already relatively low. Targets for reversing HIV and AIDS and reducing incidence of malaria, tuberculosis and other communicable diseases, remain a huge challenge in sub-Saharan Africa.
HIV/AIDS has accounted for huge reversals in human development in Southern Africa, which could impact on the region meeting some of the UN's poverty-slashing Millennium Development Goals (MDGs), according to a new report. The UN's '2005 Human Development Report' released on Wednesday noted that 12 of the 18 countries that have suffered development reversals between 1990 and 2003 were in sub-Saharan Africa, with Southern Africa "hit hardest".
The global pursuit of a vaccine against HIV/AIDS is failing due to a lack of funds and commitment, a delegation of researchers heard on Tuesday. Addressing the '2005 AIDS Vaccine International Conference' in Montreal, Canada, Stephen Lewis the UN Special Envoy for AIDS in Africa urged scientists to emerge from their laboratories to become champions for the cause.
Equity, defined primarily as equality of opportunities among people, should be an integral part of a successful poverty reduction strategy anywhere in the developing world, says the World Bank's annual 2006 World Development Report. "Equity is complementary to the pursuit of long-term prosperity," said François Bourguignon, the Bank's Chief Economist and Senior Vice President for Development Economics, who guided the team that produced the report. "Greater equity is doubly good for poverty reduction. It tends to favor sustained overall development, and it delivers increased opportunities to the poorest groups in a society."
According to the World Health Organisation malnutrition is associated with about 60 percent of deaths in children under five years old in the developing world. The WHO has developed guidelines to improve the quality of hospital care for malnourished children in order to reduce deaths. The guidelines suggest ten steps for routine management of severe malnourishment. These will require most hospitals to make substantial changes.
The 2005 World Summit, a “high-level plenary meeting of the 60th session of the General Assembly of the United Nations”, was the grand title of a dreary and lacklustre meeting held in New York on Sept 14–16, reports the 24 September issue of The Lancet. The summit has been widely derided, mainly for its watered-down outcome document, which was painfully agreed on the eve of the summit. For those most concerned about the fate of the Millennium Development Goals (MDGs), with their aim to halve world poverty by 2015, there were one or two potentially bright spots. UN delegates committed an additional US$50 billion to the MDGs over the next 5 years, with every developing country agreeing to create a national plan by the end of 2006 for achieving the MDGs.
4. Values, Policies and Rights
"Few concepts are as frequently invoked in contemporary political discussions as human rights. There is something deeply attractive in the idea that every person anywhere in the world, irrespective of citizenship or territorial legislation, has some basic rights, which others should respect. The moral appeal of human rights has been used for a variety of purposes, from resisting torture and arbitrary incarceration to demanding the end of hunger and of medical neglect. At the same time, the central idea of human rights as something that people have, and have even without any specific legislation, is seen by many as foundationally dubious and lacking in cogency."
The Initiative for Sexual and Reproductive Health and Rights in Health Sector Reforms is an international research, capacity building and advocacy project (also known as the Rights and Reforms Initiative). It aims to promote health sector reforms that are conducive to implementing the 1994 International Conference on Population and Development's (ICPD) Programme of Action, are driven by in-country actors, and are responsive to the needs of the people of the country, especially poor women. The main purpose of the Initiative is to strengthen understanding amongst activists and decision-makers of the role of global social and economic changes and specifically of health sector reforms (HSR) in facilitating or undermining efforts to achieve sexual and reproductive rights in health policies and programmes.
5. Health equity in economic and trade policies
Bowing to huge international pressure, major pharmaceutical companies have made significant efforts to make their patented antiretroviral drugs available in Africa while ensuring that they – not generic manufacturers – maintain market control in the continent. Globally, the ARV market accounts for less than 3% of pharmaceutical sales worldwide and Africa’s portion of this has been negligible. However, with the World Health Organisation’s campaign to get three million people on ARV treatment by the end of this year (the 3-by-5 campaign), there has been a scramble to ensure improved supplies.
"This paper describes a conceptual framework for the health implications of globalisation. The framework is developed by first identifying the main determinants of population health and the main features of the globalisation process. The resulting conceptual model explicitly visualises that globalisation affects the institutional, economic, social-cultural and ecological determinants of population health, and that the globalisation process mainly operates at the contextual level, while influencing health through its more distal and proximal determinants. The developed framework provides valuable insights in how to organise the complexity involved in studying the health effects resulting from globalisation."
6. Poverty and health
The seventh Millennium Development Goal (MDGs) commits the international community to halving, by 2015, the proportion of people without sustainable access to safe drinking water. The baseline set for most of the MDG targets, including that on water and sanitation, is 1990. As 2002 is the last year for which comprehensive data is available it can be considered the halfway mark towards achieving the 2015 MDG deadline. Based on 2002 data, is the world on course for achieving this goal? A report prepared by the World Health Organization/UNICEF Joint Monitoring Programme (JMP) presents a report on progress made towards fulfilling the MDG commitment. Encouragingly, with 83 percent coverage, the world is set to meet the drinking water MDG. This progress is tempered, however, by slow progress in sub-Saharan Africa.
The authors of this paper present the argument that development occurs only if people make provision for the future. If they see no future, there is no growth. Using development indicators as their data for their research, they examine a basic determinant affecting decision horizons: the risk of premature death. The paper suggests that the causal relationship between mortality and poverty is bi-directional:
- on the one hand, in a poor country, unable to afford sanitation and medical care, people die young;
- on the other hand, where people have a short time horizon because they expect to die young, they have less reason to save and the economy fails to grow.
Mozambique's Food and Nutritional Security Technical Secretariat (SETSAN) says the country could face severe food insecurity as a result of HIV/AIDS. In a report released on Monday in the capital Maputo, at a symposium on the relation between hunger and absolute poverty, SETSAN warned that the agricultural sector might lose 20 percent of its workforce to AIDS-related illnesses by 2010.
7. Human Resources
The United Nations Population Fund (UNFPA) hosted an Expert Group Meeting on International Migration and the Millennium Development Goals in Marrakech, Morocco on 11-12 May 2005. Invited experts were requested to speak on a number of topics relating to migration and development, including: poverty reduction, health, gender, environment, and global partnerships for development with a view towards exploring migration as both a facilitating and constraining factor in the achievement of the Millennium Development Goals (MDGs). This report is a compilation of selected papers presented at the meeting together with a synopsis of the discussion highlighting some of the more salient points raised by the experts.
"In low and middle income countries, health workers are essential for the delivery of health interventions. However, inadequate health-worker performance is a very widespread problem. We present an overview of issues and evidence about the determinants of performance and strategies for improving it. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions." (Requires registration)
"Sub-Saharan Africa faces a human resources crisis in the health sector. Over the past two decades its population has increased substantially, with a significant rise in the disease burden due to HIV/AIDS and recurrent communicable diseases and an increased incidence of noncommunicable diseases. This increased demand for health services is met with a rather low supply of health workers, but this notwithstanding, sub-Saharan African countries also experience significant wastage of their human resources stock."
8. Public-Private Mix
The United Nations-sponsored Financing for Development conference in Monterrey in 2002 concluded that greater cooperation between public and private actors will be required to overcome the inadequacies of development finance and achieve internationally agreed development goals. As a follow-up to this conference, the World Economic Forum's Global Institute for Partnership and Governance in cooperation with the UN Department of Economic and Social Affairs (UNDESA) and the Swiss Agency for Development and Cooperation (SDC) convened a series of nine separate practitioner-driven, multistakeholder roundtable discussions during the period 2004-05. These two day expert roundtables, supplemented by individual meetings and other research, sought to identify where the greatest opportunities and obstacles lay.
User fees are once again a topic of hot policy debate in Africa. They were introduced relatively recently in many countries, but the current call is for their removal, particularly at primary care level. As analysts who have consistently argued against user fees, we broadly support this call. However, we recognise that this action cannot be introduced overnight and, if weakly implemented, may exacerbate the problems facing African health systems.
9. Resource allocation and health financing
This paper is based on a detailed and critical review of the literature relating to health care financing in the African context. The objectives are to:
* Provide an overview of the equity challenges, particularly in relation to poverty concerns, of current health care financing mechanisms in Africa;
* Provide a brief critical review of major recent developments in health care financing in Africa; and
* Identify key issues in promoting equitable and poverty-reducing health care financing options in the African context.
It is important to stress that health care financing mechanisms differ in each African country and that there are no ‘one-size-fits-all’ solutions. This paper attempts to identify some common trends and challenges, illustrate important issues in relation to particular health care financing options through reference to specific country experience and propose principles and possible actions that require further consideration within each country-specific context.
10. Equity and HIV/AIDS
The HIV/AIDS epidemic in sub-Saharan Africa is deeply affecting rural livelihoods. The loss of adults of a working age means lower agricultural production, more households being headed by elderly people or children, and a breakdown in transmission of agricultural skills. The innovative experiences of non-governmental organisations (NGOs) in responding to these needs have rarely been documented or disseminated.
"Poverty and lack of economic opportunity are commonly cited as important contributors to the AIDS epidemic. Thus recent findings from the Tanzania 2003–04 HIV/AIDS indicator survey may come as a surprise. The evidence is just the opposite. This nationally representative survey measured wealth in terms of physical characteristics of the household and household possessions. Household wealth is strongly positively related to HIV prevalence." (Requires registration)
In the past three years, expanding access to antiretroviral therapy (ART) for HIV/AIDS has become a global objective and a national priority for many countries in sub-Saharan Africa. Large-scale treatment programs have been launched in countries spanning the continent from Lesotho to Ghana, paid for by domestic funds mobilized by African governments and by international donor contributions. While these funds, which reach into the billions of dollars, will pay for ART for many thousands of HIV-positive Africans, there is almost no chance that African countries will have the human, infrastructural, or financial resources to treat everyone who is in need.
This paper explores the importance of using research to promote gender and equity in the provision of anti-retroviral therapy (ART) in Malawi. The purpose of the paper is to highlight the importance of operational research in advocating for programmes that are gender sensitive and can contribute to overall national economic growth and poverty reduction. The paper uses a synthesis of the findings of research in Malawi on how gender roles and relations affect access and adherence to anti-retroviral therapy and to illustrate how these can be used to advocate for more equitable policy and practice.
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
Ultimately any policy or health system change, whether generated from within or outside national environments, has to work through those responsible for service delivery, and their interactions with the intended beneficiaries of those changes. Yet we continue to know too little about the experiences of these groups, including how their words, actions and beliefs shape the practice of implementation. This paper used policy analysis to understand these implementation gaps.
13. Useful Resources
Recently, the contested relation between health and human rights has drawn increasing attention. Human rights experts are taking on such issues as HIV/AIDS, abortion, family planning, and sexual violence. Perspectives on Health and Human Rights contains 30 essays that attempt to create a framework for thinking about this complex field. It is a valuable book, for the guidance it provides and for the questions it raises. (Requires free registration)
A new scholarship programme is being run by the International AIDS Society on behalf of the HIV Research Trust. The Scholarship scheme aims to support a broad mix of disciplines while enabling physicians, nurses, scientists, and other health care professionals in resource poor settings to acquire skills relevant to treatment-related research; in order to develop their careers and increase the capacity of their units to carry out research related to treatment and prevention.
ILRIG is an NGO providing education, publications and research for the labour and social movements in South and Southern Africa. ILRIG have a new and informative website that contains news about events, publications and articles.
14. Jobs and Announcements
The Open Society Initiative for Southern Africa (OSISA) is pleased to invite colleagues to submit relevant case studies from different countries and regions in Africa that document attempts to use the law to push states to implement policies relating to the provision of HIV/AIDS and health-related services. While HIV/AIDS is the focus of the project, case studies documenting attempts (successful or otherwise) in addressing other public health challenges are welcomed.
The European Commission now calls for proposals for clinical research projects to address the three diseases - HIV/AIDS, Malaria and TB. Their focus is on developing new effective interventions against three diseases from early discovery through pre-clinical testing and up to early human trials.
In 2004 the STOP-TB Partnership invited proposals to host the Secretariat for the Network for Action in TB and Poverty. The Malawi National TB Programme, in partnership with the REACH Trust won this proposal.
The purpose of the Secretariat for the Network for Action on TB and Poverty is to support best practice in DOTS and TB control programmes. This initiative supports the overall goal of promoting access to DOTS and TB control programmes for poor and vulnerable populations. In its first year, the secretariat is engaging key stakeholders to promote action on TB and poverty in the WHO AFRO region. Coinciding with this active engagement, the global network will be promoted through the creation of a website, quarterly electronic newsletters, and through Working Groups of the STOP-TB Partnership and the annual conference on TB and Poverty.
The Network hopes to encourage discussion on best practice and be a conduit between policy makers and on-the ground workers with respect to TB and poverty. Anyone wishing to be a part of the network, or if you know of an individual or organization that would benefit from being a part of the network, please sign up on the Network website www.tb-poverty.org or email mwayi@equi-tb-malawi.org.
The Lancet has issued a call for papers on sexual and reproductive health. "The last International Conference on Population and Development in Cairo in 1994 marked the beginning of a new era for sexual and reproductive health. There was widespread acceptance of a broad definition of sexual and reproductive health that extended beyond the absence of disease and recognised the rights of women and men of all ages to enjoy a healthy sex life and the freedom to decide if, when, and how often to reproduce. Although there has been some progress since 1994 - a gradual integration of services for family planning and those for the management of sexually transmitted infections (STIs), and the recognition of the need for information and services for adolescents, for example - sexual and reproductive ill-health still accounts for almost 20% of the burden of ill-health for women and 14% for men."
Published for the Network for Equity in Health in Southern Africa by
Fahamu - Networks for Social Justice
http://www.fahamu.org/
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