Sally Theobald, Ireen Makwiza REACH Trust, Malawi; Erik Schouten, Ministry of Health, Malawi and Management Sciences for Health; Andrew Agabu, Andrina Mwansambo, National AIDS Commission, Malawi.
Why the move to universal access when we haven’t yet met the 3 by 5 target? What does universal access actually mean? Does this new focus on universal access offer an opportunity for advocacy for equity?
The focus on universal access has its roots in the Special Session of the UN General Assembly (UNGASS) declaration in 2001 and was further reinforced by discussion at the International AIDS Conference in Bangkok in 2004 and the G8 Summit in Gleneagles, Scotland, 2005. The onus is for countries to define – through consultative processes – what ‘universal’ access means rather than working to global targets and put together plans and processes to meet universal access. These country consultative processes should in theory feed into regional consultation processes. For southern and east Africa, these will be held in Zimbabwe from 7-10 March, 2006 and will, in turn, shape the Africa Wide consultation 4-6 May, 2006 and the Global Steering Committee.
While there are sceptics, this may be seen as an opportunity to raise the profile of equity concerns. EQUINET’s work on antiretroviral therapy (ART) in the context of health systems reported on the EQUINET website (www.equinetafrica.org) raises two overarching and inter-related equity challenges:
1. How can we address barriers to access to quality treatment and care – by gender, age, socio-economic status and geographical coverage?
2. How can we ensure that ART delivery strengthens rather than undermines the broader public health system?
Countries have been asked to consider main barriers to scaling up which will be fed to the Global Steering Committee for action. In Malawi, for example, initial barriers highlighted include:
* Constraints to ensuring adequate sustained financing, and therefore to planning ahead, for scaled up AIDS responses:
This calls for sustainable and responsive funding for the provision of ART and for the strengthening of public health systems. This is critical to ensure that we continue to be able to provide ART to those in need. The current Global Fund for AIDS TB and Malaria process of proposal writing for 5 year programmes and resubmitting after 2 years is problematic, as it can result in decision making delays and risks of interrupted supplies of ART, HIV test kits and other supplies.
* Too few trained human resources, and health and social systems constraints:
We need to build and sustain a healthy and motivated workforce to provide ART and to meet the broader health needs of our citizens. This means investing in training and developing supportive working environments to retain our workers and address the brain drain. However, despite our best efforts the numbers of professional cadres will not be adequate by 2010. We also need to think creatively about who constitutes ‘human resources for health’, and how to deliver services through building partnerships with lay health workers, NGOs, private sector providers and community based organisations. Such partnerships and decentralisation of health provision will enhance the access of poor women and men to HIV and AIDS Treatment and Care.
* Barriers to reliable access to commodities and low-cost technologies (e.g. condoms, injecting equipment, medicines and diagnostics):
There is need for use of TRIPs flexibilities, and for pharmaceutical companies to not only reduce the cost of drugs but also ensure long-term fair access to patient-friendly ART regimens for adults and children. Diagnosis and treatment of paediatric AIDS is made difficult due to the unavailability of simple and affordable technology for diagnosing HIV in children, and the lack of paediatric formula. The current first line regimen for adults is based on fixed dose combinations (FDCs) and with the advantage that patients only have to take 2 tablets a day. Scaling up programmes in resource poor environments relies heavily on these simplified regimens which ease the supply chain and instructions to patients on adherence. If the next generation of regimens is not available as FDCs (our current second line regimen consists of 7 tablets per day) the scale up of ART will be heavily compromised.
* Stigma and discrimination, inequity, gender discrimination and insufficient promotion of HIV-related human rights:
We need to be active in addressing stigma and ensuring that gender equity and rights based approaches underpin action. In Malawi we have a policy on equity and ART. The focus on universal access provides an opportunity to advocate to implement this and monitor progress.
These challenges to universal access resonate clearly with EQUINET’s equity focus and work. Make sure your voice is heard in these consultation processes at country, regional and global level. You can also join an e-mail based consultation with civil society organisations and networks to provide direct input into a Global Steering Committee on Universal Access which is currently being hosted by ICASO. Send your feedback to: universalaccess@icaso.org The ICASO press release for more information on the consultation process is available at:
http://www.healthdev.org/eforums/cms/showMessage.asp?msgid=9701
Please send feedback or queries on the issues raised in this editorial or requests for further information on EQUINET and REACH Trust’s work on equity and health systems strengthening in ART outreach to admin@equinetafrica.org
1. Editorial
2. Latest Equinet Updates
EQUINET invites applicants for small research grants for post graduate and undergraduate students in East and Southern Africa. Students are encouraged to submit focused proposals that look at a specific issue and either organise secondary evidence or gather empirical evidence in one of the priority areas of EQUINET work.
EQUINET will be holding a Workshop on Participatory Methods for for research and training for a people centred health system in Bagamoyo, Tanzania, March 1-4, 2006. TARSC and IHRDC under the EQUINET umbrella and with support from CHESSORE have developed a toolkit of materials on participatory reflection and action (PRA) methods for research and training for a people centred health system. The materials provide information on areas for strengthening community voice and roles in health systems and introduce and provide examples of participatory approaches for training and research that supports this. EQUINEt will also be providing some small grants to support research and training using PRA methods for those who have completed the course.
Those interested in this area of training please contact us at admin@equinetafrica.org
3. Equity in Health
In countries where health care is publicly provided and where equity considerations play an important role in policy decisions, it is often argued that an increase in co-payments is unacceptable as it will be particularly harmful to the less well-off in society. The present paper derives socially optimal co-payments in a simple model of health care where people differ in income and in severity of illness. Increased concern for equity may increase optimal co-payments for illnesses with homogeneous severity across the population. For illnesses where the severity varies strongly across the population, optimal co-payments go down as a response to increased concern for equity, provided income differences in the society are sufficiently small.
Brazil is the country with the third worst income distribution in the world and, as a consequence of the unequal distribution of its main determining factors (income, education, living conditions, sanitation, and health service), the health indicators also present broad inequalities by regions and social classes. The expansion of primary health care in Brazil has been thought to be shaping the agenda for health care policy in the Latin American region. This editorial discusses the importance of a study which performed a longitudinal evaluation, at a national level, of a broad primary health care strategy.
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 and Development, produced by an eight-member team of authors led by economists Francisco Ferreira and Michael Walton, makes the case for equity, not just as an end in itself, but because it often stimulates greater and more productive investment, which leads to faster growth. The report shows how wide gulfs of inequality in wealth and opportunity, both within and among nations, contribute to the persistence of extreme deprivation, often for a large proportion of the population. This wastes human potential and, in many cases, can slow the pace of sustained economic growth. More information on the report is available at: http://econ.worldbank.org/wdr/wdr2006/
4. Values, Policies and Rights
Aimed at policymakers, donors and practitioners working in health and beyond, this Eldis Health key issues guide reviews current policy issues and explores cutting-edge debates relating to sexual and reproductive health and rights. It also highlights current and future challenges for attaining greater levels of sexual and reproductive well-being, and considers the role of innovative technologies and approaches in achieving sexual and reproductive health and rights for all.
The Health Rights of Women Assessment Instrument (HeRWAI) is a strategic tool to enhance lobbying activities for better implementation of women's health rights. It can be used as a tool to analyse a wide range of policies, including those impacting but not directly addressing health issues. A HeRWAI analysis links what actually happens with what should happen according to the human rights obligations of a country. It examines local, national and international influences. The HeRWAI analysis consists of six steps, which analyse a policy that influences women's health rights. Each step consists of information and questions to guide the analysis.
5. Health equity in economic and trade policies
The EPA negotiations in different regions will, or are likely to, include liberalisation of trade and investment in services. Liberalisation of services can have far reaching consequences. Since Article 5 in the GATS requires that regional agreements have to have "substantial sectoral coverage" and eliminate "substantially all discrimination", many services sectors will be included in EPAs that liberalise services, even if Art.5 allows developing countries to liberalise less than developed countries in a free trade agreement. As this is done at the end of the EPA negotiation period, this is a dangerous process because experience has shown that if liberalisation of services is done too swiftly without the necessary assessments and regulations, there might be many negative consequences.
There are acute disparities in pharmaceutical access between developing and industrialized countries. Developing countries make up approximately 80% of the world's population but only represent approximately 20% of global pharmaceutical consumption. Among the many barriers to drug access are the potential consequences of the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement. Many developing countries have recently modified their patent laws to conform to the TRIPS standards, given the 2005 deadline for developing countries.
Headlining this quarter's HAI Africa network newsletter is a fact sheet about the recent World Trade Organization (WTO) amendment to the TRIPS agreement. WTO member states last year agreed to permanently adopt the "30 August 2003 Decision" as an amendment to TRIPS. This Amendment outlines the circumstances and procedures necessary for compulsory licensing in countries that do not have the capacity for pharmaceutical production. Access to medicines campaigners are denouncing the Amendment as an extraordinarily bad deal for poor countries, but representatives from the US, EU and pharmaceutical industry are, not surprisingly, welcoming it. This fact sheet gives an overview of the Amendment and why it is controversial. It's available on the HAI Africa web site.
6. Poverty and health
The poor suffer from far higher levels of ill health, mortality, and malnutrition than do the better-off; and their inadequate health is one of the factors keeping them poor or for their being poor in the first place. The health of the poor must thus be a matter of major concern for everyone committed to equitable development, from policy makers to service providers. Health services can make an important contribution to improved health conditions among disadvantaged groups. Yet as the contents of this volume make clear, the health services supported by governments and by agencies like ours too often fail to reach these people who need them most.
7. Equitable health services
National programmes for palliative care offer the most effective means of improving the quality of life for the greatest number of patients and families, even where resources are severely constrained. Palliative care, however, is low on the list of under-resourced governments' health care priorities. What part can advocacy play in raising its profile and promoting its value? According to the World Health Organisation, a public health approach to palliative care has three foundations: Governmental policy: adoption of a national palliative care strategy; Education: training of health care professionals and creating awareness among the general public; Drug availability: assuring the availability of drugs for pain control and symptom management.
8. Human Resources
Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes.
Harare City Council has recruited 100 nurses to beef up its depleted nursing staff following the departure of several health personnel for greener pastures within the region and overseas. According to the latest full commission minutes, the nurses filled in all the vacant positions for State Registered Nurses. Harare has been losing nurses on a monthly basis to other more paying institutions outside the country.
Close to 30 Home Based Carers from the Andara community in the north are undergoing a four-week training of trainers course being held by the Johanniter-Hilfswerk in Namibia. More than 16 000 Namibians have succumbed to HIV-related complications since the first case was detected in the country in 1986. With over 250 000 people infected with the virus, it is clear that HIV/Aids is the leading cause of death in Namibia.
This paper examines the role of migration in economic, social and political development in Africa, the Caribbean and Pacific (ACP). Following the inclusion of a migration clause (article 13) in the political dimensions chapter of the Cotonou Agreement, migration issues have come onto the EU's development agenda. However, there has been debate as to whether migration is a "development issue" and if it should be addressed through development cooperation. This paper argues that migration is an important aspect of economic and social development and needs to be addressed as a development issue and needs to be addressed from an ACP as well as an EU standpoint.
African public health care systems suffer from significant "brain drain" of its health care professionals and knowledge as health workers migrate to wealthier countries such as Australia, Canada, USA, and the United Kingdom. Knowledge generated on the continent is not readily accessible to potential users on the continent. Advocates are increasingly discussing not just the pull factors but also the "grab" factors emanating from the developed nations. In order to control or manage the outflow of vital human resources from the developing nations to the developed ones, various possible solutions have been discussed. The moral regard to this issue cannot be under-recognized. However, the dilemma is how to balance personal autonomy, right to economic prosperity, right to personal professional development, and the expectations of the public in relation to adequate public health care services in the developing nations.
Ten newly graduated Namibian medical doctors will this week be commissioned into service by the Ministry of Health and Social Services, the Health Minister Richard Kamwi said at a recent meeting with the community here. At times, the Government had to rely on friendly countries such as Cuba and others for medical personnel. He urged parents to encourage their children to take subjects such as mathematics and science in order to qualify for medical training.
The South African Department of Home Affairs (DHA) is responsible for the implementation and management of migration policy and legislation, as well as the registration of births, marriages and deaths and the issuing of identity documents and passports. It is often criticised in the media and in private conversation for being administratively inefficient, cumbersome and unwieldy. The Southern African Migration Project (SAMP) therefore proposed to test current perceptions of the Department through a study.
The delivery of an appropriate quantity and quality of health care in an efficient way requires, among other things, matching the supply with the demand for the services of physicians, over time. Such matching has led to very different levels of physicians per million population across OECD countries ; because of variations, among other things, in: morbidity and mortality, health expenditure as a share of GDP and the design of health systems. Most OECD countries experience inequities in the geographical distribution of their physician workforce. This article discusses how, to tackle this difficulty, a mix of educational policies, regulatory policies and financial policies has been used with some success in a number of countries.
Palliative care should be an integral part of every health care professional's role. A key aspect of palliative care training involves raising the awareness of health care professionals, service providers and users. Palliative care should not just be seen as the compassionate care of dying patients but as an active discipline including assessing and treating pain and other problems. Health care workers need specific training to be able to offer quality palliative care to their patients.
Xenophobia is a distinctive and widespread phenomenon in South and Southern Africa. The print media, in particular, has been accused of exacerbating xenophobic attitudes. This paper discusses press coverage of cross-border migration in Southern Africa from 2000-2003, with a focus on xenophobia. The study revisits research conducted in South Africa by the Southern African Migration Project (SAMP) in the 1990s to
determine what, if any, changes have occurred in that country’s press coverage of the issue.
9. Public-Private Mix
This report, from Rational Pharmaceutical Management (RPM) Plus, examines a number of innovative field interventions to increase access to medicines for child health through the private sector in Tanzania. The first part of the report details a number of programmes and interventions that are currently in operation in Tanzania. These include projects on: shopkeeper interventions; low-interest loans to Accredited Drug Dispensing Outlets (ADDOs); voucher schemes; and microfinance schemes.
10. Resource allocation and health financing
A much larger infusion of resources than those currently available is needed to make headway in the fight to roll back malaria. On cost effectiveness grounds, in most areas in sub-Saharan Africa greater coverage with highly effective combination treatments should be the cornerstone of malaria control. However, treatment alone can achieve less than half the total benefit obtainable through a combination of interventions - scaling up the use of impregnated mosquito nets or indoor spraying with insecticides is also critical. Intermittent presumptive treatment of pregnant women can bring a small but important additional health gain at relatively low cost.
User fees for health care, also referred to as cost sharing, cost recovery or co-payment, are widespread around the developing world, despite mounting opposition to them. Many studies have found them to be among the barriers to the use of health services, and have shown that they affect poor people more than others. Such concerns have led many researchers, advisers, and policy makers to question whether user fees should be applied, especially among poor and vulnerable groups. In particular, there is concern that user fees will hinder access to essential social services and so prevent the Millennium Development Goals from being met.
11. Equity and HIV/AIDS
The expanding HIV/AIDS epidemic represents one of the greatest threats to human health and international development today, and strengthening the global response is imperative. Despite recent progress in expanding access to HIV/AIDS treatment, the world continues to severely under-invest in efforts to fight HIV/AIDS, missing a tremendous opportunity to change the course of the epidemic by bringing proven treatment and prevention interventions to scale. Nowhere is the need for an expanded response more apparent – and the potential impact greater – than in efforts to prevent the spread of new infections.
By the end of 2000, over 36 million men, women and children around the world were living with HIV or AIDS and nearly 22 million had died from the disease. The same year saw an estimated 5.3 million new infections globally and 3 million deaths, the highest annual total of AIDS deaths ever. Currently, there are 15,000 new infections every day. AIDS is now the number one killer in Africa. This Guide, which is intended to supplement IPPF’s Advocacy Guide, describes what advocacy can do, often at little cost, in the prevention of HIV/AIDS.
Universal access to anti-retroviral (ARV) medication for HIV/AIDS is the clarion call of the WHO/UNAIDS 3 by 5 Initiative. Treatment coverage, however, remains highly uneven. This sharpens the question of who exactly is accessing ARVs and whether access is challenging inequality or reinforcing it. Issues of distributive justice have long been debated in health policy, but the practical challenges of ARV distribution are relatively new. In exploring what a more equitable process of ARV distribution could involve, this article draws on a human rights framework using case study material from Zambia.
This note, prepared for a UNAIDS workshop on Vulnerability and AIDS, provides a number of observations and opinions on the feasibility of scaling up anti-retroviral treatment (ART) in sub-Saharan Africa. The document reviews lessons learned from various hospitals and health centres delivering ART in southern Africa, and highlights considerable human resource constraints. For instance, in South Africa, it is estimated that for every 500 ART patients, they need as many as 10 permanent staff. Other pilots have similar staff/patient ratios.
12. Governance and participation in health
After two decades of marketizing, an array of national and international actors have become concerned with growing global inequality, the failure to reduce the numbers of very poor people in the world, and a perceived global backlash against international economic institutions. The essays in this volume explore what forms a new politics of inclusion can take in low- and middle-income countries. The contributors favor a polity-centered approach that focuses on the political capacities of social and state actors to negotiate large-scale collective solutions and that highlights various possible strategies to lift large numbers of people out of poverty and political subordination.
"What factors affect health care delivery in the developing world? Anecdotal evidence of lives cut tragically short and the loss of productivity due to avoidable diseases is an area of salient concern in global health and international development. This working paper looks at factual evidence to describe the main challenges facing health care delivery in developing countries, including absenteeism, corruption, informal payments, and mismanagement. The author concludes that good governance is important in ensuring effective health care delivery, and that returns to investments in health are low where governance issues are not addressed." (Author's abstract)
13. Useful Resources
The first issue of Exchange, previously Sexual Health Exchange, is produced in collaboration with the Royal Tropical Institute of the Netherlands and Novib (Oxfam Netherlands). The main focus of this edition is mainstreaming HIV and AIDS in civil society organisations (CSOs). The magazine also examines issues such as: lack of access to prevention and treatment for mobile population groups; the consequences of abstinence-only programmes for sexual minorities; and youth and the media in South Africa.
The e-newsletter of the International Union Against Tuberculosis and Lung Disease (The Union) is a free monthly newsletter designed to provide news about the activities of The Union, as well as information and resources related to the prevention and control of tuberculosis and lung disease. Please feel free to pass it on to your friends and colleagues. To subscribe, go to our website at www.iuatld.org or send an email to communications@iuatld.org. To unsubscribe, click on the REMOVE link at the bottom of the page.
The World Malaria Report 2005 is the first comprehensive effort by the Roll Back Malaria Partnership to take stock of where the world stands in relation to one of its most devastating diseases. It reveals that the tide may be beginning to turn against malaria as control and prevention programmes start to take effect.
14. Jobs and Announcements
The objectives are to enhance learning and information sharing between program implementers on best practices and lessons learned through presentations, workshops, hands-on training and site visits; Identify gaps in the "value chain" where information on best practices is lacking and
Build and strengthen partnerships for continued learning.
The International Society for Equity in Health, ISEqH, welcomes those interested in promoting equity in health to share experience and expertise at its Fourth International Conference in Adelaide, Australia. The overarching theme for the ISEQH's Fourth International Conference, Creating Healthy Societies through Inclusion and Equity, reflects the central role of social, political, and economic determinants in creating health.
Mobilising the resources in the Diaspora (African's based outside their country of origin) in a constructive and structured manner will result in innovative and practical solutions that will be of added value to Africa’s Healthcare enabling Africa to address its capacity to meet the related Millennium Development Goals (MDGs). For African's in the United Kingdom, United States and other parts of the world, it is important to register online even if you don't plan to attend the event. This is because, the greater the percentage of healthcare professionals in Diaspora who are registered, will ensure that key decision makers are monitoring the event, as well as policy makers involved in these programmes, will have confidence in developing partnerships with African Diaspora to add value to the many ongoing efforts. This will provide an avenue for those of us not yet actively involved to participate in Africa’s healthcare development.
Published for the Network for Equity in Health in east and southern Africa by
Fahamu - Networks for Social Justice http://www.fahamu.org/
and TARSC
Contact EQUINET at admin@equinetafrica.org
To post, write to: equinet-newsletter@equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
Please forward this to others.
To subscribe, visit http://www.equinetafrica.org
or send an email to info@equinetafrica.org
* Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org