Sub-Saharan Africa is the only region in the world where the absolute number and proportion of under-nourished children has increased in the last decade. East Africa is the sub-region experiencing the largest increases in numbers of underweight children –projected to increase by 36% from 1990 to 2005. Findings for stunting (chronic under-nutrition) and wasting (acute under-nutrition) are similar. Under-nutrition is the underlying cause of over half of child deaths. Even mild to moderate malnutrition can lead to significant deficits in cognitive and physical development.
One reason for the dismal nutritional status of children in Africa is the continual lack of food for many in the region. In less than four decades, Sub-Saharan Africa has been transformed from a continent that was a net exporter of food to one that is now heavily dependent on food imports. According to the Food and Agricultural Organisation, Africa’s food imports have risen from 8% in 1985 to 18% of world imports in 2001. A decline in agricultural and rural investment in Africa has led to a 12% decline in agricultural productivity for the workers in the region in the 1990s. Any growth in agricultural output has thus been achieved mostly from expanding the area under cultivation.
The United Nations Millenium Development Goals Hunger Task Team in 2004 summarised the consequences of this path to meeting food needs:
“Expanding the area under food production is inherently unsustainable, as the supply of new lands in densely populated areas of Africa is largely exhausted or must be maintained as natural systems for biodiversity conservation and other ecological services. The first effect in Africa and elsewhere in the tropics has been to expand into land that was previously available for fallows. Leaving land fallow allows land under cultivation the necessary time to recover from the effects of the crops taking nutrients from the soil. As a result of the reduction or elimination of fallows, soil fertility has fallen dramatically in many places, and yields are reducing with time. As the land becomes exhausted, there develops a serious tendency to continually sub-divide land among family members, which leads to smallholdings that are too small to produce a family’s food”.
Significantly, the yields of most important food grains, tubers and legumes (maize, millet, sorghum, yams, cassava and groundnuts) in most African countries are no higher today than in 1980. The environmental impacts of deforestation and drought, floods and the loss of topsoil are being compounded by the lack of investment. Only about 4% of land under cultivation in Africa is irrigated. This compares with 14% in Latin America and the Caribbean, a region with similar population densities and resource endowments. Fertilizer application is 15% lower today than in 1980. The number of tractors per worker is 25% lower than in 1980 and the lowest in the world. Africa’s share of total world agricultural trade fell from 8% in 1965 to 3% in 1996.
However, poor food security or poverty alone is not the whole story. Otherwise how does one explain the experience of many countries and populations that managed to achieve significant reductions in malnutrition before similar reductions in poverty? How does one explain the presence of malnutrition in situations where food is widely available? If one compares, for example, the experience in one region of Sri Lanka, Indonesia, the Philippines and Thailand, in the 1980s and 1990s, Sri Lanka and Thailand showed rapid improvement in nutrition, Indonesia showed slower but consistent improvement, and the Philippines little progress. Malnutrition in Latin America decreased from about 21% in 1970 to 7.2% in 1997, while income poverty decreased by only about 1% over the same time period.
Clearly reducing malnutrition is not solely dependent on increases in income. Gains in Latin America are attributed to good care practices (such as improved complementary feeding) access to basic health services, including family planning, safe water and sanitation and to women’s education and the cash resources they control.
Policies providing for female education, social safety nets, affordable food and public health services have contributed to improvements in nutrition even with minimal changes in poverty levels. In Sri Lanka, high levels of female education have been linked to improved child nutrition and child survival. Sri Lanka’s impressive performance in nutrition is also attributed to the establishment of social safety nets, especially the free or heavily subsidised distribution of rice, providing a minimum consumption floor. More recently, Save the Children UK in 2004 pointed to the universal, equitable and efficient public health system in Sri Lanka as an important reason for the low levels of maternal and child mortality in the country. Thailand incorporated nutrition as an important part of its National Economic and Social Development Plan (NESDP). This led to the establishment of an extensive community-based network of village health communicators and volunteers with existing village committees and leaders. These groups focus in communities on the fulfilment of basic needs such as optimal nutrition, provide education for this and monitor progress this through community-based growth monitoring.
A similar mobilisation of communities, health systems and national resources is required if we are to make a start in combating childhood malnutrition in Africa. This is an essential step if there is to be sustainable development in the region. Co-ordinated by the Health Science Research Council, EQUINET has embarked on a programme in east and southern Africa to collect and share information on case studies of how health systems address the wider social and economic factors affecting nutrition and lever action on these factors.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org. EQUINET work on food security and nutrition is available at the EQUINET website at www.equinetafrica.org. Work by the Medical Research Council of South Africa (MRC) is available at www.mrc.ac.za.
1. Editorial
2. Latest Equinet Updates
The nursing curriculum of the University of Namibia is based on Primary health care approach. However nursing students do not have the skills for a participatory approach to communities and perceive that communities do not know or need to be consulted on their health needs. Communication breakdown between communities and nurses is not in the interest of either. This study aimed to create awareness among the student nurses to help them view the communities as partners in health, and at the same time to empower the communities to be more responsible for own health.
The research was located in Cape Town, South Africa where the need for equity policies to be implemented is great. However ongoing restructuring and change lead to fatigue in the management and staff of the primary health services. Their resistance could block the implementation of equitable staffing plans. It is necessary to understand the management and workplace factors leading to potential resistance of equitable staffing plans and thus these were explored. A policy analysis approach using a case study analysis was sought to provide understandings, approaches and tools to illuminate the processes involved in health policy.
The workshop on Protecting Health in Trade Agreements held in Malawi in June 2006 aimed to build capacities in state, legislative and civil society institutions to understand, analyse and promote public sector equity-oriented health systems within trade and investment policies and agreements. The course aim to enable participants to carry out assessments nationally of the key trade and investment agreements that impact on health and to identify options for promoting public sector equity-oriented health systems within current trade and investment policies and agreements.
3. Equity in Health
Using the most recent data sets available from the Demographic and Health Surveys (DHS) of 15 countries in sub-Saharan Africa (SSA), this paper concludes that to successfully monitor the gaps between urban poor and non-poor, existing data collection programs such as the DHS and other nationally representative surveys should be re-designed to capture the changing patterns of the spatial distribution of population.
4. Values, Policies and Rights
The starting point for this study is the principle that a rights-based approach should be used in framing public policy. The study therefore seeks to address the challenge of combining the ethical aspect of social rights with viable ways of strengthening citizens' entitlement to such rights in highly inequitable and relatively poor societies. It includes an analysis of various aspects of social protection systems (health care, social security and poverty reduction) and their potential to guarantee social rights in structurally heterogeneous societies.
5. Health equity in economic and trade policies
In mid July 2006 Group of Eight leaders called for more AIDS funding to improve monitoring and to give more people access to treatment. However, Eric Friedman, policy adviser for Physicians for Human Rights, raised practical concerns, including the need to double the existing number of health care workers to improve the AIDS situation worldwide. The G8 agreement calls for "building the capacity of health care systems in poor countries through recruitment, training and deployment of public and private health workers," but Friedman said the statement does not say how those goals will be achieved.
In advance of the anniversary of the G8 summit in Gleneagles (6-8 July), the Institute for Public Policy Research (IPPR) is urging G8 countries to rethink their development strategies for Africa in the light of China's growing role. David Mepham, head of ippr's International Programme, said: "...Managed well, China's economic presence could bring real benefits to Africa, with cheaper goods for African consumers and new sources of investment and aid. But managed badly, China's role in Africa could be damaging for development and worsen standards of governance and human rights.
We are pleased that a paediatrician of the stature of Professor Oliver Ransome supports the argument in our letter that equitable distribution of health care is necessary for child health. But Professor Ransome also suggests that equitable distribution of health care can somehow be achieved without impinging on the freedom of those who can afford to choose private care. We challenge the view that such a market-based approach can promote equity in health care in South Africa today.
Policymaking initiatives in agriculture and public health are often pursued in a parallel and unconnected fashion. Yet coherent, joint action in agriculture and health could have large potential benefits and substantially reduce risks for the poor. Among development professionals there is growing recognition that agriculture influences health, and health influences agriculture, and that both in turn have profound implications for poverty reduction. This recognition suggests that opportunities exist for agriculture to contribute to better health, and for health to contribute to agricultural productivity. The policy briefs presented here draw on a wide body of research conducted within and outside the CGIAR. They provide a historical context to the links between agriculture and health, deal with specific health conditions and agricultural systems, and examine the challenges to linking agriculture and health in policy.
Stephen Lewis, UN Special Envoy on AIDS in Africa, calls the failure of the G8 to live up to their promises a "scandalous betrayal". The triumphalism of Gleneagles has given way to shattered dreams and broken promises. At Gleneagles, the G8 promised to cancel the debt of some poor countries and to double development assistance to Africa by 2010. Both initiatives would provide resources for treating people with AIDS. Tragically, too little was promised at Gleneagles; even less has been delivered. By the time G8 leaders reconvened at St Petersburg this month, another 3 million people had perished from AIDS-related diseases.
6. Poverty and health
The free basic water policy is being unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision, concludes an HSRC report which examines the extent to which the response to the cholera epidemic of 2000/1 has led to sustained provision of safe water and improved sanitation to the poor. The original report suggests there is a clear relationship between cost recovery, indifferent municipal management leading to interruptions in supply, and vandalism.
This study examines the impact of the civil war and genocide in 1990s Rwanda on household income and poverty dynamics, particularly the transitory nature of poverty. Main findings of the study include previously land-rich, income non-poor households have fared badly over the decade spanning the conflict - the economic wellbeing and welfare of the surviving household members has deteriorated, and female-headed households have been trapped in poverty - they are more likely to be poor and when poor are less likely to move out of poverty, therefore they should be the prime beneficiaries of development aid.
7. Equitable health services
Antenatal care (ANC) is a widely used strategy to improve the health of pregnant women and to encourage skilled care during childbirth. In 2002, the Ministry of Health of the United Republic of Tanzania developed a national adaptation plan based on the new model of the World Health Organisation (WHO). This study assesses the time health workers currently spent on providing ANC services and compare it to the requirements anticipated for the new ANC model in order to identify the implications of Focused ANC on health care providers’ workload.
In Tanzania, parents seeking treatment for children with severe, often malaria-related, fever vary in their choice of care. Their choice is influenced by a range of social and cultural factors that need to be better understood if children are to be successfully treated. In urban and peri-urban areas of Tanzania, many parents would prefer to take their children to a biomedical facility. However, opening and closing times are not always convenient. Consequently, parents often have no choice but to seek out a traditional healer who can provide treatment and comfort at more convenient hours.
Globally, inadequate sexual and reproductive health services have resulted in maternal deaths and rising numbers of sexually transmitted infections (STIs), particularly in developing countries. Leaders of the World Health Organization (WHO) and UNFPA, the United Nations Population Fund, are coordinating action to reverse the global trend of deteriorating levels of sexual and reproductive health and reduce the adverse impact on mothers, babies and young people.
8. Human Resources
An appropriate and effective response to the HIV/AIDS crisis requires reconsideration of the collaboration between traditional and biomedical health providers (THPs and BHPs). The aim of this paper is to explore biomedical and traditional health practitioners experiences of and attitudes towards collaboration and to identify obstacles and potential opportunities for them to collaborate regarding care for patients with sexually transmitted infections (STIs) and HIV/AIDS.
The current malaria control strategy of WHO centres on early diagnosis and prompt treatment using effective drugs. Children with severe malaria are often brought late to health facilities and traditional health practitioners are said to be the main cause of treatment delay. In the context of the Rectal Artesunate Project in Tanzania, the role of traditional healers in the management of severe malaria in children was studied. Traditional health care is not necessarily a significant impediment or a delaying factor in the treatment of severe malaria. There is a need to foster training on the management of severe cases, periodically involving both traditional health practitioners and health workers to identify modalities of better collaboration.
Past attempts to estimate the cost of migration were limited to education costs only and did not include the lost returns from investment. The objectives of this study were: (i) to estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii)to describe other losses from brain drain. Developed countries continue to deprive Kenya of millions of dollars worth of investments embodied in her human resources for health. If the current trend of poaching of scarce human resources for health (and other professionals) from Kenya is not curtailed, the chances of achieving the Millennium Development Goals would remain bleak. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Kenya and to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing the health human resource crisis.
This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models.
9. Public-Private Mix
Earlier this year, the US Government, through President Bush’s Emergency Plan for AIDS Relief, announced an unprecedented public-private partnership to promote scientific and technical discussions on solutions for pediatric HIV treatment, formulations and access. These partnerships seek to capitalise on the current strengths and resources of both innovator and generic pharmaceutical companies, the US Government, as well as multilateral organisations to facilitate the process.
This paper reviews the experiences of franchising and discusses the opportunities and implications for governments and donors of franchising for HIV and AIDS services. The author details how the private sector can offer huge potential to extend and maintain anti-retroviral therapy (ART) coverage. The author outlines how franchising may offer a way of meeting known challenges and thus, increasing the prospects for universal access to HIV and AIDS services.
Public-private partnerships (PPP) could be effective in scaling up services. The study estimated cost and cost-effectiveness of different PPP arrangements in the provision of tuberculosis (TB) treatment, and the financing required for the different models from the perspective of the provincial TB programme, provider, and the patient. Where PPPs are tailored to target groups and supported by the public sector, scaling up of effective services could occur at much lower cost than solely relying on public sector models.
The study uses a negative binomial regression model to investigate the factors influencing the number of PSP projects in a sample of 60 developing countries with 460 PSP projects. The regression results provide support for the hypotheses that PSP is greater in larger markets where the ability to pay is higher and where governments are fiscally constrained. Several indicators of institutional quality are tested; these are found to be generally significant in determining the number of projects signed per country. Measures of the protection of property rights and the quality of the bureaucracy emerge as the most important institutions that encourage PSP. Rule of law and the control of corruption are significant, albeit at a lower level, while the quality of contract law and political stability are not robustly significant.
More private investment and improvements in productivity will be needed if many developing countries are to reach the Millennium Development Goals. But how can developing countries mobilise more domestic investment and attract more foreign investment? How can the impact of this investment on poverty reduction be increased? The objective of this Policy Guidance is to help Development Assistance Committee (DAC) members use their Official Development Assistance (ODA) more effectively to mobilise private investment for development.
10. Resource allocation and health financing
This paper analyses the programmatic costs of CARE Rwanda's and Bwafwano Zambia's two community-based programmes for children affected by HIV/AIDS in Rwanda and Zambia in order to provide information on the current costs of the two programmes. The paper also discusses additional costs related to scaling up the existing programmes and outlines issues relating to long term sustainability of programmes for children affected by HIV/AIDS.
We share the distress of our colleagues at the large numbers of children in South Africa who suffer and die from surgically correctable heart disease because there are insufficient human and other resources to provide them with the operations they need. But the plight of children with heart disease only gives us a small glimpse into children's health in South Africa generally and into the crisis affecting the public health sector. Our government and health service administrators must provide more explicit policies and frameworks that guide the allocation of health resources according to agreed priorities.
Poverty reduction is the result of several interacting factors, including importantly: redistribution of incomes, assets, and opportunities; pro poor economic growth; and social provision and protection. This issue of IPC's journal Poverty in Focus highlights the importance of social protection in the struggle against global poverty. For South Africa, the implications of income grants are analysed, including both poverty reduction outcomes and the macro-economic feasibility; while cash transfers in Zambia and social protection for pro-poor growth are just some of other areas covered relevant to Southern Africa.
11. Equity and HIV/AIDS
Secretary-General Kofi Annan praised some of the world’s leading pharmaceutical and diagnostic companies for their commitments to expand access to HIV/AIDS treatment and prevention after meeting with their top executives at United Nations Headquarters on Monday 24 July 2006. He said that the companies have committed individually to continue to review their product offerings and the prices of their existing and new HIV medications and diagnostics, especially for children, to make them more affordable, accessible and appropriate for use in low- and middle-income countries.
At present, no UN agency is dedicated exclusively to women's human rights and development needs. A set of under-resourced entities are expected to address the concerns of half the world's population. Nearing the end of his term, the UN Special Envoy for HIV/AIDS in Africa, Stephen Lewis proposed the creation of an independent multilateral agency with the stature and resources necessary to meaningfully improve the lives of women. It is argued that the UN's failure to dedicate the necessary resources to ensure women's systemic equality indicates more than neglect or indifference. It sends a powerful message that women are not worthy of expenditure. It implies that women's lives are not as valuable as the lives of others.
Zimbabwe has been widely hailed as a success story in the fight against AIDS since reporting in October 2005 a decline in HIV prevalence among adults from 25% in 2001 to 20% in 2004. In the face of the devastating impact of HIV/AIDS on the country, a declining economy, growing international isolation, decreased funding from international donors for HIV/AIDS prevention and treatment, and a disintegrating public health sector, Zimbabwe’s achievement was indeed significant. Despite the positive news, however, the HIV/AIDS epidemic in Zimbabwe remains a serious crisis with some three hundred and fifty thousand of the 1.6 million people carrying the virus in immediate need of life-saving antiretroviral (ARV) drugs and another six hundred thousand in need of care and support. The paper argues that the progress gained so far could be undermined by policies and practices that violate the rights of people living with HIV/AIDS (PLWHA) and those most at risk of infection.
This book analyzes successive governments' management (and mismanagement) of the AIDS epidemic in South Africa. The book covers the years 1982-2005, using expert thinking regarding public policy making to identify gaps in the public sector's handling of the epidemic. The book highlights critical lessons for policy makers and other public health managers.
The provision of HIV treatment and care in resource-limited settings is expanding rapidly. Health-worker training is one of many factors critical to the rapid scale-up of high-quality care. Large numbers of health workers require HIV training; yet, few countries have a comprehensive training plan, a clear assessment of ongoing training needs, a plan to operationalize training on a large scale, or adequate funds budgeted for training. In this setting, an extensive variety of HIV-related training programs have sprung up over the past few years. Unfortunately, there are limited data measuring their effectiveness, and there is no consensus about what constitutes effective training.
12. Governance and participation in health
Delegates attending the Community Working Group on Health (CWGH) 13th National Conference in Harare from 5–6 July 2006 compiled this statement to highlight the key points raised and important conclusions. It covers existing positions on the conditions regarding human resources in health, as well as a number of conditions and policy suggestions to improve both community participation in health and public health performance overall.
Each year at least 300 million cases of malaria result in more than a million deaths worldwide. Ninety percent of these deaths are in sub-Saharan Africa and most are children under five years old. Preventing and treating malaria are now firmly on the international public health and global poverty agendas. However, despite a considerable increase in funds over recent years the malaria burden in much of sub-Saharan Africa shows little sign of decreasing. Over recent years there has been emphasis on the idea that improving knowledge about malaria in communities will lead to better use of interventions. Research on managing malaria in communities has been largely concerned either with individual perceptions about the causes and symptoms of the disease or with the implementation of specific interventions. It fails to provide essential information on the context in which communities and households cope with their day-to-day problems, including malaria.
13. Monitoring equity and research policy
This analysis seeks to set the stage for equity-sensitive monitoring of the health-related Millennium Development Goals (MDGs). The MDGs and other development initiatives must become more comprehensive and explicit in their analysis and tracking of inequities, and the design of policies to narrow health gaps must take into account country-specific inequities.
This report provides a strategic solution to the evidence gap in development programming. The report argues that by bringing vital knowledge into the service of policymaking and programme design, it is possible to improve the effectiveness of domestic spending and development assistance. The group was asked to investigate why rigorous impact evaluations of social development programmes, whether financed directly by developing country governments or supported by international aid, are relatively rare; as well as ways to improve on this.
14. Useful Resources
This practical manual outlines how to protect children from sexual violence and sexual exploitation, specifically in disaster and emergency situations. The aim is to provide fundamental information to assist personnel working in emergency situations in responding to protect children: before disaster strikes; in the immediate aftermath; and in the longer term reconstruction phase. The report also includes recommended actions and key considerations to be taken into account in the event of sexual violence or sexual exploitation.
This statistical chart covers the most important issues in the lives of adolescents including gender disparities, child labour, health, and education. Conclusions include the gap between boys' and girls' school enrollments having narrowed in the last decade as girls' enrollments have risen throughout the developing world. But girls still face disadvantages in parts of South Asia, western Asia, and sub-Saharan Africa. Surveys in developing countries reveal that less than half of young people can correctly identify two ways to avoid getting HIV/AIDS and reject common myths about the virus. Young women generally have less knowledge than young men.
15. Jobs and Announcements
The theme of the upcoming International AIDS Conference in Toronto is TIME TO DELIVER. Toronto can be an innovative, problem-solving gathering that generates action - or - it can be another expensive conference that generates little action or sustainable benefit. Let's make it about ACTION! Together, as a community, let's set the tone of the Toronto conference: AIDS Treatment Now - Time To Deliver! We ask you to please join in sending a clear message to the politicians, policy makers, funders, drug companies, activists and NGOs attending Toronto - and to the world watching: It's TIME TO DELIVER.
The Global Health Watch (GHW) is a non-government initiative aimed at supporting civil society to more effectively campaign and lobby for 'health for all' and equitable access to health care. Participate in the second Global Health Watch, by submitting case studies. GHW are calling activists, health workers and academics from around the world to submit case studies and testimonies based on individual or group experiences to supplement the second edition of the report and reinforce its main themes.
The overarching theme for the ISEqH 4th International Conference reflects the central role of social, political, and economic determinants in creating health. The International Society for Equity in Health have over 100 presentations scheduled from various regions of the world plus our keynote address by Dr Shane Houston, special plenaries and workshops. The conference will be held at Adelaide University in the Union House Complex from 11-13 Sept ember 2006.
The SADC Heads of State Summit will be held on 17 and 18 August 2006 in Maseru, Lesotho. Preceding the Heads of State Summit will be meetings for the Technical Experts from 11-13th August followed by the Ministerial Meeting from 14th – 16th August 2006. The Southern African Peoples’ Solidarity Network in collaboration with network members and other social movements and people based organizations in the SADC region will be holding a 'People’s Summit' on 15th and 16th August under the Banner 'Reclaiming SADC For Peoples’ Development: Assessing the Impact of Neo-liberal Policies on the Peoples’ Livelihoods' in Maseru Lesotho.
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
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