Research has consistently shown that gender inequalities and gender stereotypes restrict people’s access to health services. The same is true of treatment for HIV and related problems. Testimonies from women gathered by the International Community of Women Living with HIV/AIDS (ICW) shows the many ways in which this continues to take place, even as access to treatment expands.
HIV-related stigma and discrimination and gender inequalities are rife and when, for example, a woman has to ask relatives for permission to access services her safety and confidentiality are jeopardised. Violence and sexual coercion in the first place put women at risk from HIV infection. An HIV positive diagnosis can lead to increased levels of abuse, violence and abandonment and also lead to a further lack of self-confidence all of which undermine women’s ability to look after their health and assert their rights. When services are centrally located in major urban areas or when they charge fees for service, women are even less likely to access them. In fact even when ART is free women have found that costs associated with travel and treatment for related health problems puts the chance of leading a healthy life with HIV out of their reach.
A further concern arises when women access ARVs and their families do not. This may happen either due to a lack of ART provision for families or a reluctance on the part of family members to be tested. This puts the women who are being treated under severe pressure, through coercion or guilt, to share their treatment. "Most of us as women living with HIV and who are using ARVs we face a common problem that our husbands or partners tend to force us to give them our ARVs dose while he has not tested for HIV and doesn’t know his CD4 counts. They do not want to go for testing while they show all HIV symptoms. Even if you refuse he will find where you keep your medicine and steal them." (ICW members, Tanzania, 2005). Further, if family members are not accessing treatment then the burden to care for them as their health worsens generally falls on women.
Gender and HIV-related stigma and discrimination are also reflected in the health services. Our members have reported that health care workers:
• are often indiscreet and disrespectful;
• put conditionalties on treatment access, for example, making women go on contraceptives;
• fail to understand the context within which women have to put into action advice and treatments given, for example, advice against breast-feeding maybe ignored because of the associated stigma;
• lack specialist knowledge and services about treatment issues for women; and
• do not provide suitable monitoring and follow-up care of treatment and side-effects.
These latter two conditions are worsened in resource poor settings. Women report that they feel better able to deal with a positive diagnosis when health care workers are respectful of women and their rights, refer them to sources of care and support and understand the specific problems they face in terms health; and how they can act on the advice and treatment given them.
"We have been having some changes and interruptions in our treatment regimes because many times when we go for ARVs clinic we are being asked for some money so we tend to miss the dose even for a week or month till we get some money to pay for that service. Another regime is lack of enough food especially to us women who are under treatment. The consequences were; not finishing my dose which caused infections, staying without a dose till the clinic day and lie to the service provider that I have finished my dose, fighting with my husband or even chasing me out of the house when I refuse giving him my dose."
(ICW members, Tanzania, 2005)
Too often information is not tailored to cover the range of concerns that HIV positive have regarding care, treatment and support. Information given may be pushing a government or company line, be written in English and not local languages or may use medical language and dense text. The information may only be available in health centres and not distributed to places where women can access it during their daily routines. It may only be available in written form causing problems for women that are not literacte. The scarcity of relevant information is made worse by the lack of research on the gender-related impact of treatment for AIDS, or on related issues like its interaction with social and clinical factors such as hormonal contraceptives and violence in the family.
That is why ICW calls for knowledge and information tailored to the specific needs of women, delivered in a way that understands that women may not chance upon it on a table in a waiting room at the hospital. Support groups are already doing a wonderful job in this regard. We also call for women-specific clinical and social research that does not just treat participants as research subjects from which information can be extracted, but empowers them to participate in research in ways that enable them to gain skills and to use the information to advocate for change in their communities and countries.
Finally, there are a growing number of HIV positive women who are treatment activists. We feel frustrated when we constantly hear policy-makers tell us that we, as women treatment activists, we do not have the skills to engage with them. We would rather ask whether those in policy positions have the skills to engage with us in a way that is respectful and meaningful. With the challenges we face in reaching universal access, surely it is time that we all challenged our notions of where true expertise lies?
The International Community of Women Living with HIV/AIDS (ICW), set up in 1992, is an international network with over 5000 HIV positive women members worldwide. This article is based on their testimonies. “ACTS” refers to HIV positive women's ability to gain consistent access to all available care, treatment and support services.
Please send feedback or queries on the issues raised in this briefing to ICW http://www.icw.org/tiki-view_articles.php or to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on access to treatment is available at the EQUINET website at www.equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The Regional Network for Equity in Health in east and southern Africa (EQUINET) and the Health Systems Research Unit of Medical Research Council (MRC), South Africa invite interested individuals/groups to apply for grants to prepare commissioned country case studies on existing food security and nutrition programmes in the region that demonstrate good practice in health systems promotion of food sovereignty and equity.
The Regional Network for Equity in Health in east and southern Africa (EQUINET) EQUINET is inviting interested people to apply for a grant to prepare a commissioned paper on district health systems facilitators and barriers to community participation in health. The commissioned author will review and analyse literature and secondary evidence to present evidence and analysis of the current situation with regard to community voice and roles at district level; how district planning, decision making, financing and budgeting, resource allocation, programme implementation enable or block such participation, and how districts articulate and represent community interests at national level. It is hoped that the paper will present positive case studies of community representation and district facilitation of community voice at national level.
Call Closes On March 20 2006
The Regional Network for Equity in Health in Southern Africa (EQUINET) promotes policies for equity in health across a range of priority theme areas (See www.equinetafrica.org). 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 listed below.
3. Equity in Health
Whether or not the scale of a society's income inequality is a determinant of population health is still regarded as a controversial issue. We decided to review the evidence and see if we could find a consistent interpretation of both the positive and negative findings. We identified 168 analyses in 155 papers reporting research findings on the association between income distribution and population health, and classified them according to how far their findings supported the hypothesis that greater income differences are associated with lower standards of population health.
This paper studies the key issues underlying inequalities in health between and within countries as well as poverty and inequality. These include social determinants (poverty, inequality, and the causes of the causes). The paper emphasises that action is not only possible but also necessary. It further highlights the importance of meeting human needs.
4. Values, Policies and Rights
The People's Health Movement (PHM) would like to invite civil society organizations, interested individuals and groups to participate in discussing the possibility of hosting such a campaign in South Africa. It would also contribute to building civil society for the Third People’s Health Assembly, planned for 2010 at an African venue (to be determined). This edition of Critical Health Perspectives sketches the background to the campaign and some of the thinking behind it.
A new British white paper on health suggests that patients should be offered more choice. However, visiting the doctor or phoning the police is simply not like shopping, according to people questioned for a new study funded by the Economic and Social Research Council (ESRC), which found that most of us reject the trend towards treating everyone as 'consumers'.
This paper looks at how approaches based on human rights could accelerate a reduction in maternal mortality, drawing on evidence from case studies. It argues that, despite fifteen years of the global Safe Motherhood Initiative, maternal mortality rates are still high, and attributes this to the status of women, the systematic violation of women's human rights, and failing health systems. A rights-based approach could help policymakers to focus on the economic, social, cultural and political forces that make it harder for poor women to access maternal health care, and especially emergency obstetric care.
A 3D Policy Brief has been released on "Intellectual Property, Development and Human Rights: How Human Rights Can Support Proposals for a World Intellectual Property Organization (WIPO) Development Agenda." It encourages advocates, policy-makers and WIPO Member States to elaborate an actionable, pro-development WIPO intellectual property agenda consistent with States' development commitments and human rights obligations. The Policy Brief is available in English, French and Spanish.
Stigma processes have a dramatic and probably under-recognised effect on the distribution of life chances such as employment opportunities, housing, and access to medical care. We believe that under-recognition occurs because attempts to measure the impact of stigma have generally restricted analysis to one circumstance (eg, AIDS, obesity, race, or mental illness) and examined only one outcome (eg, earnings, self esteem, housing, or social interactions). If all stigmatised conditions were considered together and all outcomes examined we believe that stigma would be shown to have an enormous impact on people's lives.
5. Health equity in economic and trade policies
As countries rush to conclude bilateral and regional free trade agreements, there are growing concerns that these trade agreements could adversely affect the health policies of the developing countries. Against this backdrop, the WHO Executive Board has recommended that the next World Health assembly in May adopt a resolution on trade and health. Member States are asked to include health ministries in negotiations on trade agreements and the WHO Secretariat has been tasked to assist in this process.
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6. Poverty and health
Previous studies have consistently found an inverse relationship between household-level poverty and health status. However, what is not well understood is whether and how the average economic status at the community level plays a role in the poverty–health relationship. The study investigated the concentration of poverty at the community level in Tanzania and its association with the availability and quality of primary health care services, the utilization of services, and health outcomes among household categories defined by wealth scores.
This paper presents a descriptive account of health and economic status in India and South Africa – countries in very different positions in the international hierarchy of life expectancy and income. It analyses the correlates of health and wellbeing in our sites.
This paper outlines the regression analysis addressed to determine variables and factors influencing poverty alleviation in Mozambique and estimate their magnitude; its aim being to support the careful interpretation of poverty estimates and to emphasise the need for policy makers to account for poverty measurement in their work.
This newsflash from Nairobi this week emphasises how "..a searing drought that has put at least 11-million people across East Africa on the brink of starvation risks turning into a catastrophe if donors fail to respond quickly to the situation, an aid agency warned on Thursday".
The United Nations' World Food Programme (WFP) in Southern Africa on Tuesday announced that it spent nearly R600-million ($100-million) in 2005, double the amount in 2004, buying more than half a million tonnes of food in the region to support vulnerable people across Africa. About 337 000 tonnes of food, worth R372-million ($62-million) was purchased in South Africa by WFP's regional headquarters in Johannesburg.
7. Equitable health services
Health literacy is a composite term to describe a range of outcomes to health education and communication activities. This paper identifies the failings of past educational programs to address social and economic determinants of health, and traces the subsequent reduction in the role of health education in contemporary health promotion. A ‘health outcome model’ is presented, which highlights health literacy as a key outcome from health education.
The health systems of nations around the world may be unsustainable if unchanged over the next 15 years. Globally, healthcare is threatened by a confluence of powerful trends -- increasing demand, rising costs, uneven quality, misaligned incentives. If ignored, these trends will overwhelm health systems, creating massive financial burdens as well as health problems for current and future generations.
Inequity in reproductive health between and within countries is well documented, and even where indicators improve, disparities between rich and poor are as likely to be increasing as decreasing. In addition to improving access, it must also be ensured that services are widely used. Because advantaged groups are known to be more apt at using preventive services, the disparity in outcome measures between rich and poor is likely to increase.
8. Human Resources
Botswana: The departure of Cuban volunteer doctors and a shortage of health personnel have seriously affected operations at Maun General Hospital. Patients now wait long hours in queues at the hospital and the situation has been made worse by a faulty computer network and an overburdened laboratory, North West District Council (NWDC) chairman John Benn has said.
Progress towards the Millennium Development Goals (MDGs) in sub-Saharan Africa is slow. There is a growing consensus that human resources are a vital part of improving African health systems and making progress towards the MDGs. Reasons for human resource problems in African health systems are complex. Moreover, they vary greatly between and within countries. This means that solutions will be complex and are dependent on the political, economic, historic and social context of each country. Of particular concern are issues such as capacity and training of health workers, migration of skilled workers out of the region, the impact of HIV and AIDS, as well as the need for massive scale-up of ART
(anti-retroviral therapy) services.
This paper, from PHRplus, examines the state of human resources for health in Zambia. Findings show that the Zambian public health sector has reach a point of crisis and is unable to provide basic health services. This is due to: losing health workers because of better prospects elsewhere; the limited capacity of Zambian medical and professional schools to train additional staff; and the impact of HIV and AIDS. Specific findings include: attrition rates of all health staff have increased dramatically compared to historical trends; looking only at national human resources can obscure trends taking place within the country; and facilities will soon experience severe constrains in expanding their HIV and AIDS services.
Donor aid creates inflated salary scales and benefits: a driver for a US bilateral agency in Addis Ababa might be paid more than a professor in the medical faculty, and a public-health specialist 4–5 times the government salary on joining an international non-governmental organisation. In certain regions of Ethiopia and Mozambique, the budget of a single large non-governmental organisation may exceed that of the government. The projected budget for vertical programmes in HIV/AIDS for 2006 in Ethiopia is US$100 million, or around a third of the annual health budget for the entire country.
This brochure, published by the WHO Africa Regional Office, aims to raise awareness of human resources for health in Africa. It argues that health workers are central to making the best possible use of other resources and investments in the health sector, yet their importance has not been widely recognised. Declining staff salaries have contributed to a brain drain from the public to the private sector and from developing to more developed countries, and few countries have made systematic efforts to ensure that health professionals return home after training abroad. Training in Africa has tended to mimic developed countries, producing highly trained, expensive, elite and hospital-focused professionals.
The number of health workers employed is an indicator of a country’s ability to meet the health care needs of its people, specially the poorest and most vulnerable. Resource-constrained countries committed to the Millennium Development Goals are facing up to the reality that shortages and uneven distribution of health workers threaten their capacity to tackle the HIV/AIDS pandemic, as well as the resurgence of tuberculosis and malaria. Worker shortages are linked to three factors: 1) decreasing student enrollment in health training institutions, 2) delays or freezes in the hiring of qualified professionals and 3) high turnover among those already employed.
The Southern African Development Community (SADC) is pressing for affirmative action to speed up progress towards substantive equality between women and men at all levels of decision-making. 'To realise full implementation of this decision, member states must endeavour to adopt affirmative action to protect women and enshrine it in national constitutions,' said Mathiba-Madibela at a media briefing prior to the Council of Ministers that takes place in Gaborone this week.
DOTS, the internationally-recommended control strategy for tuberculosis (TB), has been applied in South Africa since 1996. But TB cure rates remain at 65 percent - not high enough to control or reverse the epidemic. Could training clinic staff on patient-centred care, critical reflection on practice and quality enhancement improve treatment success? The rates of successful treatment and bacteriological cure for TB improved marginally in the clinics that received the training, compared with the controls. The differences were not statistically significant. The training was well accepted by staff who became more aware of the need to improve provider-patient relations and made some changes to the organisation of care. These changes in attitudes and practices often did not translate into improved provider-patient relations.
This paper outlines the severity and complexity of the Human Resources (HR) crisis in sub-Saharan Africa and criticises donor neglect of the issues. The document was prepared as a background document for a World Bank/World Health Organization meeting on Building Strategic Partnership in Education in Health in Africa.
9. Public-Private Mix
Public-private partnerships are becoming a popular mode of tackling large, complicated, and expensive public health problems. The idea of partnerships for public health has emerged in national and international policy discussions, in both rich and poor countries. Yet we are still learning about how best to manage these new partnerships, as is discussed in this book.
10. Resource allocation and health financing
Lacking the financial support it says it needs to fight the spread of bird flu, Africa has not received any of the money it was promised at the international bird flu conference in Beijing last month. With news of the spread of the deadly H5N1 bird flu virus in northern Nigeria, these funds are now urgently needed to update laboratories, improve diagnostic services on a regional level, and provide the capacity to purchase animal vaccines. Some of the money intended for Africa was also meant to help governments compensate their citizens for any domestic birds that needed to be culled, and to step up information campaigns in rural areas.
This set of health economics learning materials has been prepared by the WHO Regional Office for Europe to assist health policy decision-makers, advisers, planners, managers, practitioners and other concerned groups. Health policy and practice is a large and complex area. It can benefit from a range of perspectives, including that of economics. Economics is particularly useful for decision-makers, since resource limitations and financial constraints apply in all health systems and at all levels. There are always more useful activities competing for priority than can be resourced; and this has significant implications for resource allocation decisions, health outcomes and equity.
This paper proposes a comprehensive framework for projecting public heath and long-term care expenditures. Notably, it considers the impact of demographic and non-demographic effects for both health and long-term care. Compared with other studies, the paper extends the demographic drivers by incorporating death-related costs and the health status of the population.
This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households.
11. Equity and HIV/AIDS
An AIDS epidemic as severe as the one plowing through South Africa will change society. But how and along what lines? "Buckling: The impact of AIDS in South Africa", a new publication by South African writer and journalist Hein Marais, tackles the question in distinctive and critical-minded fashion-and arrives at disquieting conclusions and proposes a minimum package of social adjustments that could reduce the damage.
Having to pay for HIV/AIDS care increases the risk of treatment failure, according to new research from Doctors Without Borders/Medecins Sans Frontieres (MSF) presented this week at the International Conference on AIDS and Sexually transmitted infections in Africa (ICASA), in Abuja, Nigeria. The research revealed that in Lagos, Nigeria, among patients who had to pay for their own AIDS care, 44% had multiple treatment interruptions or took insufficient dosages due to lack of funds. The medical effects of this are extremely worrying.
We are disappointed and frankly outraged that gender equality and strengthening the women's machineries within the UN system are barely noted, and are not addressed as a central part of the reform agenda. Again we must ask how it can be that more than ten years after the commitment to gender parity at the Beijing Conference, the UN is still offering only token representation of women on critical committees, high level expert panels and in senior positions within the organization?
The paper describes the effects of HIV and AIDS on each of the MDGs in turn. This approach does not attempt to capture all the interactions among these development outcome measures.
This publication identifies HIV/AIDS and food insecurity- particularly in the rural areas- as the two most severe and interrelated humanitarian issues currently facing southern Africa. It is argued that the current situation must be contextualised as an "entangling crisis" of climatic factors, chronic poverty, the failure of economic and political governance, and the impact of HIV/AIDS on the ability of individuals to respond independently.
12. Governance and participation in health
This book talks about the changing relations between and roles of development NGOs and donor governmental agencies, based on case studies of 22 western countries, EU and the World Bank.
A new report from the Health Evidence Network shows that empowering socially excluded populations is a viable strategy for improving health. While participatory processes make up the base of empowerment, strategies must also build community organizations and individuals capacity to participate in decision-making and advocacy.
13. Monitoring equity and research policy
There is little consensus about the meaning of the terms "health disparities," "health inequalities," or "health equity." The definitions can have important practical consequences, determining the measurements that are monitored by governments and international agencies and the activities given resource-support to address health disparities/inequalities or health equity. This paper aims to clarify the concepts of health disparities/inequalities and health equity, focusing on the implications of different definitions for measurement and hence for accountability.
This document contains guidelines for assessing the integration of gender, rights and sexuality (GRS) issues into sexual and reproductive health services. The guidelines include a self-assessment GRS questionnaire designed to guide discussions among staff with the aim of producing concrete solutions to improve the integration of GRS issues. The questionnaire is divided into two sections: the needs of staff providers and the needs of clients.
The report stresses that reducing inequities in health requires political will, increased resources and enhanced effort to organize and deliver health products and services effectively. It also needs research – whether biomedical research to create the needed drugs, vaccines, diagnostics and medical appliances; health policy and systems research to understand and improve the organization and functioning of the health sector; social sciences and behavioural research to increase understanding of the factors that determine health and affect health-seeking behaviour; or operational research to examine how effectively systems and interventions are working on the ground and how they can be improved.
Stigma is a pervasive influence on disease and responses of nations, communities, families, and individuals to illness. Too little research has been done in recent years to better understand the pathogenesis and implications of stigma, how beliefs are generated, perpetuated, and translated into behaviours, and the cost of stigma to individuals, families, communities, and nations. The sense that legislation and education against stigma is sufficient may explain the shortage of interest in research in this field.
14. Useful Resources
A project of the Association of African Universities (AAU) since 2000, DATAD aims to develop an electronic index of all African theses and dissertations past and present - using a common format - and to disseminate this index as widely as possible via Internet and CD-ROM for the purpose of promoting and exchanging knowledge. DATAD also aims to increase universities' capacity to respond to requests for data based on the index, to encourage institutions to make entire theses and dissertations - as opposed to abstracts - available on-line, and to encourage the publication of peer-reviewed articles based on African thesis and dissertation research.
Global health research can often fall within the scope of more broad fields. Consequently, this roadmap includes funding sources that support specifically global health research, as well as those that support global research projects that involve health elements and global health projects that involve research elements. Similarly, training opportunities may be for specifically global health research projects, or opportunities that involve health or research components.
This "how-to" guide consolidates the efforts of UN Country Teams (UNCTs) by presenting a step-by-step approach to support country counterparts in MDG-based national development strategies. It recognizes the extensive contributions of all development partners to achieving MDG outcomes.
15. Jobs and Announcements
Join NGOs across the U.S. for a week of education, mobilization and advocacy on a variety of trade justice issues. The week is timed to lead into an important WTO negotiating deadline as well as spring meetings of the World Bank and IMF where trade-related loans, grants, conditionalities and facilities will be discussed. For more information contact Jennifer Cruz at jkurz@interaction.org.
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