In 2000/1 South Africa endured a cholera epidemic that spread throughout the eastern coastal region and to other provinces. It resulted in 265 deaths in five provinces and 117,147 people, mostly in the KwaZulu-Natal province, were infected. The epidemic was, according to the World Health Organization, the biggest such outbreak in Africa for the reporting period.
According to rural development researchers and the South African government, the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre, those who could not afford new charges implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease.
The government declared the cholera epidemic an emergency and promised to provide a free six kilolitres of water to every household every month. A Municipal Services Project Occasional Paper 10, “Still Paying the Price: Revisiting the Cholera Epidemic of 2000–2001 in South Africa” examined the extent to which the response to the epidemic has led to sustained provision of safe water and improved sanitation to the poor. The evidence presented in the report suggests that there is a clear relationship between cost recovery for water, indifferent management leading to interruptions in supply, and vandalism.
In two communities - one at Nqutshini, a small settlement near the town of Empangeni on the banks of the Mhlatuzi River; and the other at Nkobongo, a developing low-cost housing area with continued informal settlements near Ballito, 40km north of Durban - there was some concealment and denial of the disease because of the stigma it carries.
In a number of cases where people fell ill, the family members were uncertain how to respond. Often the cholera victim tried to conceal and deny the disease, and this led to significant delays in seeking treatment. In one instance, a young girl died after hiding her symptoms for some time; in another, an older man had to be heavily persuaded before going to the hospital. The stigma associated with cholera complicated the acceptance of the need to avoid using river water, to treat this water, and, if sick, to seek medical assistance.
There were varying responses to the messages put out by the authorities on radio and television and carried by the Community Health Workers. Many in Nqutshini found it difficult to acknowledge that the river, from which they had always collected water, should be the carrier of disease. Some accepted that the water they were collecting from the river may be contaminated and need treatment, but others did not. Some saw the warnings against using river water as a way of forcing people to pay the monthly charges. It appears that for a period water was treated with Jik (bleach) by many, but this dropped off rapidly when the bleach was no longer available for free.
Scepticism about the official view was also associated with ideas reflecting a view of hostile external forces aiming to undermine the community, e.g. the belief by some that whites were spreading the disease through low-flying aeroplanes. In all cases, the MSP report on the epidemic presents vivid personal recollections of those who were afflicted, the dread it evoked, and the speed at which people’s health declined.
Comparisons between conditions during the epidemic in 2000/1 and at the time of fieldwork in 2003 revealed a number of improvements: Most people now accessed piped water closer to their residence or through yard connections and most used Ventilated Improved Privies (VIPs). Most people at the time of the survey felt their water to be safe to drink and did not treat the water.
However, there were ongoing complaints of frequent interruptions in the water supply through vandalism, burst pipes and for non-payment. In the two communities, the state was not providing Free Basic Water as promised, although the communities are both poor and thus generally vulnerable to cholera. At Nqutshini piped water was not flowing at all. Partly because of the dysfunctional water supplies, there was increased water storage by community members - an additional factor associated with cholera.
The incidence of diarrhoea among children in the household was found to be associated with extreme poverty, as were problems with accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors - in particular the continued cycle of water-related disease in households over time - point to poor health conditions and continued vulnerability to disease among those living in extreme poverty.
The government’s policy of Free Basic Water has been 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. Poor communities need a reliable water service, which requires better municipal management. Interruptions lead to long storage of water, which poses a health risk to those who consume this water. Communities and households with a prior experience of water related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water-related disease to end the cycle of disease.
The Municipal Services Project is a multipartner research, policy and educational initiative examining the restructuring of municipal sservices in southern Africa. See http://www.queensu.ca/msp/ to contact the project at Rhodes University South Africa to obtain copies of the full report.
1. Editorial
2. Latest Equinet Updates
The EQUINET and MRC meeting on Food Security and Nutrition in east and southern Africa sought to bring together case study writers and expert facilitators that have been working on nutrition initiatives, policies, and to update them on the prevailing situation, current interventions, equity and policies on food security. The meeting took a focus on how health systems can advance and encourage food sovereignty, including community control and enhanced gender equity in food production. The meeting established the framework for a series of case studies that demonstrate and examine health system approaches to food sovereignty that will be implemented in 2006.
3. Equity in Health
What we today term "health disparities" launched the modern public health movement in the nineteenth century. Yet only in the past two decades have governments begun to focus explicitly on the deep-rooted social determinants of health and disease. What are governments' responsibilities to reduce these disparities? The last of the three symposia included input from a southern African country in examining how official statistics can shed light on modern health inequities.
PHM has released its yearly update one year after PHA II, held in Ecuador a year ago where the Cuenca Declaration was approved unanimously by 1,400 participants. This update discusses progress in the five year plan adopted in the Cuenca Declaration.
Twenty-six years after the formation of the Southern Africa Development Community (SADC), it is estimated that 80% of the people in the region are living below the poverty datum line. What is the level of commitment within SADC towards improving the people’s livelihoods? Is SADC a true representation of African solidarity? Has SADC pursued a neoliberal agenda to the cost of people's wellbeing? As the SADC heads of State met on 14 to 18 August 2006, in Maseru, Lesotho the poor peoples of the region gathered at the Cooperative College in Maseru in order to seek answers to the above questions; as well as to examine the impact of privatisation, market reforms and debt on peoples access to health services, education and other social amenities.
4. Values, Policies and Rights
This is the report from a ground-breaking workshop on sexual rights held in Sweden. Some of the key issues discussed included who defines a right and how they are defined, going beyond identity politics sexuality and morality regarding women, men and transgendered people who sell sex for money.
The document recaps what it means to apply a holistic rights-based lens in development practice, be it in health, in education or in any other sector. It directs us to the corresponding behaviors one would expect to see enacted in health, education or any other development work when applying such an optic. The points within the document present when and under what conditions the adoption of an explicit rights-based approach is more likely to make a lasting difference to equity.
5. Health equity in economic and trade policies
Part 1 of this glossary introduced different health and trade arguments, overviewed the history of the World Trade Organisation (WTO), defined key "trade talk" terms, and reviewed three WTO treaties concerned with trade in goods (GATT 1994, the Agreement on Agriculture, and the Agreement on Sanitary and Phytosanitary Measures). Part 2 reviews five more agreements and the growing number of bilateral and regional trade agreements, and concludes with a commentary on different strategies proposed to ensure that health is not compromised by trade liberalisation treaties.
This paper examines the key areas of concern regarding access to antiretroviral treatment (ART) related to US-negotiated bilateral, regional, and multilateral trade agreements. It examines developments in IP law in the wake of WTO's Doha Declaration, which affirmed the priority of public health over the protection of patents. It looks specifically at those developments with particular salience for health related issues and link this history with the current context of access to antiretrovirals (ARVs) worldwide. It further suggests policy and advocacy strategies to ensure and promote access to ART.
The British Parliament is currently examining changes to company law in what some commentators have billed as potentially the largest shakeup in business law for 150 years. This report observes however that the law protects corporations from serious accountability for their activities, especially where their impact is harshest - on poor people overseas. This report brings evidence together on selected British company activities internationally summarising research by various NGOs, campaign groups and
others. It focuses on a select number of British companies and alleges a range of practices harmful to worker and community health.
6. Poverty and health
This 350-page volume features eleven of the "Reaching the Poor Programme"-commissioned studies, along with introductory chapters explaining why the studies were undertaken, how they were done, and what they found. The book marshals the available evidence about pro-poor strategies that have proven to be effective and that can help in the development of programs to better assist disadvantaged groups. In doing so, it can serve as a resource for policy makers, development practitioners, and policy analysts concerned with health conditions among the poor.
7. Equitable health services
This Briefing Note reviews the extent of emergency livelihoods responses during the most recent drought and resulting food crisis in the Horn of Africa. Drawing on secondary data and interviews with national and international actors in affected areas, it asks why accurate and timely early warning did not lead to a rapid and appropriate response to mitigate the drought’s effects, and highlights how inadequate contingency planning, limited capacity in livelihoods programming and inflexible funding mechanisms resulted in delays and deficiencies in livelihoods interventions, and the predominance of food assistance in the emergency response.
The strengths and weaknesses of the sector wide approach (SWAP) have been extensively analysed, but much less has been written on country experience to inform good practice elsewhere. This technical paper draws some lessons from SWAP in health in Mozambique. SWAP is not a panacea for donor coordination, and cannot address deep-rooted constraints typical of a young national health system. This paper explores how the key elements of the SWAP have been developed, how processes and mechanisms are working now, and studies some of its successes and challenges.
The first "International Expert Consultation on Paediatric Essential Medicines", jointly held by the World Health Organization (WHO) and the United Nation’s Children’s Fund (UNICEF), has delivered a plan to boost access to essential medicines for children. During two days of intensive discussion held 9-10 August at WHO's headquarters in Geneva, a mix of more than twenty developed and developing countries, non-governmental organizations including Médecins Sans Frontières, regulatory agencies, UNICEF and WHO staff prioritised a long-needed approach to overall paediatric care.
8. Human Resources
The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions. This editorial presents – and invites comments on – a technical framework intended to raise awareness among donors and multisector organisations outside ministries of health and to guide planning and strategy development at the country level.
New laws introduced by the British government in mid-August 2006 are unwittingly giving the southern African region a temporary reprieve from the brain drain of medical staff. The new laws stipulate that employers in Britain will only be granted work permits for foreign nurses if they can prove that no suitable British or European Union candidate can be found.
This paper outlines the Human Resources for Health (HRH) issues during the period of reconstruction in post-conflict countries, drawing examples from Afghanistan and Cambodia. It explores issues of restoring a health workforce and outlines key HRH actions for workforce reconstruction, including: identifying available staff; developing HRH management structures, systems and capacity; clarifying HRH roles and responsibilities; establishing health worker equivalencies and upgrading skills; supporting civil service reconstruction; and widely disseminating HRH information.
Many health professionals in Malawi experience overly challenging environments. In order to survive some are involved in ethically and legally questionable activities such as receiving gifts from patients and pilfering drugs. The efforts by the Malawi government and the international community to retain health workers in Malawi are recognised. There is however need to evaluate of these human resources-retaining measures are having the desired effects.
A study conducted by the Department of Nursing at the University of the Witwatersrand has revealed the top 10 reasons for dissatisfaction in the nursing profession. The study was administered over a period of two years (2003- 2005) in a public hospital in Johannesburg. Dr Ansie Minnaar, lead researcher in the study says “generally all the nurses interviewed experienced low satisfaction. Our findings show that it is not only salaries that are a factor in the nursing profession. Other factors are career prospects, policy implementation, the behaviour of supervisors, and relationships with other nurses and patient.”
Canada is a major recipient of foreign-trained health professionals, notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries, while comparatively small, is rising. African countries, meanwhile, have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada?
The East, Central and Southern Africa College of Nursing (ECSACON) is an institution invested with the responsibility of improving the quality of health of the communities in the ECSA region through strengthening the contribution of nursing and midwifery services. ECSACON is conducting a needs assessment for its work and has disseminated a questionnaire for those in Authority at the Ministry of Health (MOH) or those in Nursing Regulatory bodies to complete. They ask that the questionniare found at the url given be completed and returned to ECSACON.
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.
9. Public-Private Mix
The Development Studies Association (DSA) one-day conference titled The Private Sector, Poverty Reduction and International Development will take place on November 11th 2006 at the University of Reading. Health-related topics under one of three main conference themes "Business and Finance and Poverty Reduction" include "HIV and Aids: Technical and policy issues for the private sector" and "Government attitudes to the private sector as an engine of growth: policy issues and debate".
This audit report examines the Department for International Development (DFID)'s approach, policies and financing mechanisms in support of private sector development (PSD). Some of the issues covered in the report include understanding private development, enabling investment climates, financing private sector development: public private partnerships, and how the private sector is contributing to development and how donors can support this work.
10. Resource allocation and health financing
This report presents country experiences in developing and shaping work to address long-term planning for the health sector. It identifies areas of action to which the national commissions have contributed, from mobilising political will and building much-needed evidence, to strengthening national planning processes. These lay the groundwork for sustainable improvements in health for the world’s poor people. The report clarifies the most intractable challenges that have impeded faster health progress, and gives concrete examples of how countries have started to address them through an integrated approach to health sector development and financing.
In some developing countries public health clinics charge patients for medical consultations. These medical fees, together with a loss of earnings due to ill health, have catastrophic consequences for families already living in poverty.
Without taking social and political realities into account, the Gates Foundation patronage of even the most powerful medications cannot meet the goal of reducing global inequities. Recently Warren Buffett has received near-universal praise for his $31 billion donation to the Bill and Melinda Gates Foundation. The foundation has likewise enjoyed wide acclaim for its global health and educational programs, with Buffett's gift the highest tribute of all. So what could possibly be wrong with Gates-Buffett philanthropy, aimed at improving global well-being? Five such issues are highlighted, warranting pause to the all-around backslapping.
In August 2005, the Global Fund to fight AIDS, Tuberculosis and Malaria Secretariat suspended its five grants to Uganda following an audit report that exposed gross mismanagement in the Project Management Unit. How could this have been avoided? How can other countries avoid a similar pitfall? We argue that if a legitimate and fair decision-making process were used, the suspension of funding to Uganda could have been avoided, and that this lesson should be applied to other countries. The “accountability for reasonableness” framework of relevance, publicity, revisions and enforcement would help in implementing legitimate and fair decision-making processes, which would improve effectiveness, accountability and transparency in the implementation of Global Fund programmes, preventing future suspension of funding to any Global Fund projects.
European envoys in the Ugandan capital, Kampala, have asked the government to take "expeditious" action against individuals, including senior politicians, accused of mismanaging HIV/AIDS grants. The diplomats were further concerned at the slow implementation of the judicial commission of inquiry report.
11. Equity and HIV/AIDS
In mid-July 2006, AIDS Healthcare Foundation (AHF) the largest US-based AIDS organisation with free AIDS treatment clinics in the US, Africa, Asia and Latin America/Caribbean, applauded Gilead Sciences, Inc for its recent decision to cut the prices for its lifesaving antiretroviral AIDS drugs by almost two-thirds in middle-income countries such as Mexico and India.
Over the last few years, since the roll-out of antiretroviral therapy (ART), there has been a substantial decrease in HIV-related stigma in Botswana, according to a population-based study presented on Monday at the Sixteenth International AIDS Conference in Toronto. Although there could be several possible explanations for this (including anti-stigma campaigns, the higher visibility of people living with HIV and AIDS and routine HIV testing), survey participants who knew that ART was accessible in Botswana were the least likely to stigmatise people with HIV.
Since the launch of Botswana’s national antiretroviral therapy (ART) programme, there was a decline in the country’s adult mortality rate between 2003 and 2005 according to a report presented on Thursday 17 August 2006 at the Sixteenth International AIDS Conference in Toronto. The declining mortality rate was most pronounced in the districts of the country where ART first became available and where ART coverage is the most extensive.
Dr Paulo Teixeira Senior Adviser of the São Paulo’s STD/AIDS State Program argues the importance of the adoption of clear targets as one of the main factors that accounted for a dramatic change in access to treatment under the 3x5 program. He argues that access to ARV treatment has become an international consensus but that extreme measures still have to be taken to make this process irreversible and universal in the next few years. Some of these measures are technical support, the provision of international funds, the reduction in the prices of second line medications, and the inclusion of the most vulnerable groups like MSM, IDU, SW and inmates. He expressed concern at a weakening of measures towards addressing universal access to prevention and treatment.
In Stephen Lewis's last speech as UN Envoy for HIV and AIDS to the International HIV/AIDS conference in Toronto in August 2006 he comments on areas that have previously been of political controversy in the approach to the prevention of HIV/AIDS, including abstinence-only programmes, harm reduction programmes, circumcision, microbicides and nutrition and to the South African response to AIDS. He gives particular emphasis on gender and child inequalities in the acquisition and management of HIV/AIDS.
Tuberculosis (TB) that is resistant to practically every medication that can be used to treat it is alarmingly common in South Africa, and proved uniformly and rapidly fatal in one outbreak in rural South Africa, warned Dr Neel Gandhi, Assistant Professor of Medicine at Albert Einstein College of Medicine of Yeshiva University, at the Sixteenth International AIDS Conference in Toronto, Canada.
Individuals coinfected with HIV and hepatitis C virus are more likely to develop end-stage liver disease (ESLD) compared to patients with hepatitis C virus, alone, according to a study presented at the Sixteenth International AIDS Conference in Toronto on August 15th. However, the investigators found that coinfected patients who achieved a sustained response to hepatitis C therapy were no more likely to progress to end stage liver disease than their hepatitis C monoinfected peers. This could have important implications for prioritising recipients of hepatitis C therapy in resource-poor settings.
The International Rescue Committee (IRC) in Northern Uganda has begun operating home-based HIV counselling and testing in ten camps for internally displaced persons in the Kitgum region. The IRC intends to reach about 100,000 camp residents in their homes. HIV has spread rapidly in the region because the situation in the camps has adversely changed the way people behave.
Warning signs that Uganda's HIV prevalence may be on the rise again were presented to the Sixteenth International AIDS Conference in Toronto. Data on both HIV prevalence and incidence show rising trends since 2000, which the investigators attribute to increased sexual risk behaviour, the natural epidemiological cycle, and "other factors". These may include a chronic condom shortage and the hotly debated 'ABC' policy which appears to focus on abstinence and faithfulness rather than condom use.
South Africa's Health Ministry spokesman Sibani Mngadi dismissed harsh criticism of its AIDS policy by a top UN official "with contempt" and said he was no Messiah for Africa's HIV/AIDS crisis. UN special envoy on AIDS in Africa Stephen Lewis closed a global conference with probably the most blistering attack ever on South Africa's "lunatic fringe" approach to AIDS, calling it immoral and ineffective.
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12. Governance and participation in health
To address Africa's deep-rooted problems, it's time to reject the superficial male charisma embodied by the likes of Tony Blair and Bob Geldof and instead mobilise the dynamic energies of African and Africa engaged women. The author discusses how Africa at its simplest already has a handful of problems, including, amongst others, HIV/AIDS and gender inequality. For example, the attempt to strengthen national systems in Africa continues to be thwarted by the high incidence of HIV/AIDS which is thinning out cohort after cohort of dynamic young professionals.
The representatives of many economic justice networks, social development movements, women’s, workers, youth and small-scale farmers, human rights, educational and environmental organisations, and many others, from across the Southern African region gathered in Maseru, Lesotho under the auspices of the Southern African Peoples Solidarity Network (SAPSN). They held a People’s Summit to review their situation and share views on the state of regional development and cooperation, and so present their views to the Summit of the Heads of State and government ministers’ meeting in Maseru, 16-18 August 2006.
13. Monitoring equity and research policy
Because researchers and policy-makers work in different spheres, policy decisions in the health arena are often not based on available scientific evidence.This paper describes a model that illustrates the policy process and how to work strategically to translate knowledge into policy actions. Activities were undertaken as part of the Kenyan Ministry of Health’s new decentralised planning-process.
Knowledge brokering is a promising strategy to close the “know–do gap” and foster greater use of research findings and evidence in policy-making. It focuses on organising the interactive process between the producers and users of knowledge so that they can co-produce feasible and research-informed policy options. This paper describes a recent successful experience with this novel approach in the Netherlands and also discusses the potential of this approach to assist health policy development in low-income countries based on the experience of developing the Regional East-African Health (REACH)- Policy Initiative.
14. Useful Resources
Canada's Access to Medicines Regime provides a way for the world's developing and least-developed countries to import high-quality drugs and medical devices at a lower cost to treat the diseases that bring suffering to their citizens. It is one part of the Government of Canada's broader strategy to assist countries in their struggle against HIV/AIDS, tuberculosis, malaria and other diseases. This website has all of the information that developing and least-developed countries, non governmental organisations and pharmaceutical companies need to take advantage of the regime.
A new website for human rights professionals called Human Rights Tools offers four main services: a library of carefully selected and commented resources; key resources for country analysis to rapidly establish the human rights profile of a particular country and to facilitate analysis and follow-up of developments; daily updated human rights headlines; and free newsletter.
This document brings together a diverse collection of maps from different continents and countries, depicting small area estimates of vital development indicators, including health indicators such as infant mortality rate, at unprecedented levels of spatial detail. The atlas of 21 full-page poverty maps reveals possible causal patterns and provides practical examples of how the data and tools have been used, and may be used, in applied decisions and poverty interventions.
The Handbook aims to provide NGOs with a comprehensive and user-friendly guide to the work of OHCHR, including key information on human rights mechanisms, entry points for NGOs and contact details with a view to assisting NGOs in identifying areas of possible cooperation and partnership with OHCHR; it also anticipates the changes of the current United Nations reform process. The Handbook is up to date as of June 2006, and is currently available in electronic format and in the English language only. Efforts are underway to secure its translation in other UN languages in the next few months.
15. Jobs and Announcements
The Economic and Social Research Council (ESRC) Non-Governmental Public Action Programme is calling for applications for practitioner fellowships. These fellowships are aimed at members or representatives of practitioners groups (including developmental NGOs, global coalitions, voluntary sector groups, cooperatives, human rights groups, etc.) that are not directly funded by specific research projects in the programme. The fellow will be based with one of the NGPA project teams (each of which is attached to a different UK university department or research centre/institute) or with the programme director at the London School of Economics for up to three months.
The South African Medical Research Council (MRC) invites applications for Research Fellowships in Health Research. This Career Development Programme is a partnership between the MRC and the tertiary education sector. The purpose of the Research Fellowship is to build research capacity and scientific leadership by creating new positions for senior post-doctoral scientists that have demonstrated a potential to become established researchers. Applications should be received by no later than the 8 September 2006 for internal processes.
The 10th SACOD Forum 2006 will take place from 10 - 14 October 2006 in Swaziland. This is a call for entries for completed films and videos, of any length and of any genre produced after 1 January 2005 that contribute to democracy, peace, popular participation, gender equality, development, environment, human rights and cultural identity. The SACOD Forum is a meeting place where filmmakers, distributors, and related organisations, gather to screen and debate selected film and video productions.
Participate in the second Global Health Watch, by submitting case studies. Global Health Watch 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.
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