Recent media attention in South Africa has drawn attention to an outbreak of Extreme Drug Resistant (XDR) TB and the need to contain infectious diseases such as XDR TB by extraordinary methods such as quarantine. Such measures, typical of the public health approach to community health problems, involve the limitation of individual rights in the interests of the public good. In this case, the need to contain a costly, highly dangerous and virtually untreatable form of TB by forcibly quarantining patients with this form of TB, were said to outweigh the rights of the patient to autonomy and freedom of movement. Rightly, discussions in South Africa focused on whether the restrictions of the rights of the individual in the interests of the greater good could be justified.
At one level, this is an important debate because it is typical of many other public health conflicts (e.g. in relation to HIV or claims on scarce resources), where individual rights run into conflict with interests that represent a collective or social benefit. Resolving such conflicts in ways that retain respect for human rights whilst advancing public health is important for public health planners, and methods to do so have increasingly emerged in the human rights and public health literature that help public health practitioners negotiate these difficult trade-offs. Thus, in considering whether a limitation on individual autonomy could be justified in the public interest, one would expect that:
- the objective of the policy, such as quarantine, has an objective of legitimate interest and is provided for in terms of a due legal process;
- the policy will be effective in realising that objective;
- the policy is strictly necessary in a democratic society to achieve that objective;
- there are no less intrusive means available to achieve the same objective; and
- the policy’s application is not arbitrary, discriminatory or unreasonable.
Often many public health measures are applied routinely without careful reflection as to whether these criteria are met. Calls for HIV notification, for example, are often made without clear policy objectives, or, where objectives are intended, without any evidence that notification will meet these objectives better than any other methods that are less restrictive of individual autonomy.
However, it is the case that, under certain circumstances, and given certain requirements being met, limiting rights for the public interest can well be justified in terms of international human rights law. Indeed, the limitation of rights may well be viewed differently when one realises that states have obligations imposed by international human rights law to positively realise various obligations to control the spread of infectious diseases (ICESCR, article 12) and to meet requirements for general welfare (ICCPR, article 4).
However, on another level, the public health objective itself is often the expression of a rights obligation of government to realise, for example, an environment not harmful to health (Section 24 of South Africa’s Bill of Rights), or the right of access to health care. Such socio-economic rights obligations are themselves necessarily collective in nature, and the trade off is not so much between individual civil liberties and public health objectives, but between different kinds of rights, such as individualist rights to autonomy, and social rights such as the those relating to health care access or a safe environment, both of which are needed to realise health. Protecting individual autonomy is important for the effectiveness of treatment programmes to ensure patient adherence and build trust in the health service, as much as social measures being required to control the spread of infectious diseases.
Popular misconceptions of rights as being solely or predominantly about civil liberties and formal parliamentary democracy have been fostered by a combination of the ascendance of neo-liberal economic policies in international policy making, as well as the unopposed exercise of power by the USA and its allies in the post-Cold War period in ways that entrench narrow individualist views of rights. Indeed, recognition of the indivisibility of rights and the equal importance of socio-economic entitlements and equity run counter to market-oriented development policies fostered by international development agencies.
Thirdly, human rights are not just about limits to state power but also speak to realising human potential in ways that confer agency.
When faced with public outcry or a health emergency, public health responses frequently fall back on traditional population interventions that obviate any role for individual and community action. The resort to autocratic traditions of central command and control has a strong anti-democratic history in public health and is based on a deep suspicion that humans can be trusted to make decisions in their own collective interest. It is not surprising, therefore, that many of the pioneering anti-smoking public health measures originated in the health programmes of Germany’s Nazi government and were entirely compatible with the ferociously anti-democratic and inhumane ideology of the Nazi regime. What a human rights approach brings to public health, therefore, is to ensure that social justice is a counterbalance to unchallenged utilitarianism, and that checks on power serve to protect the vulnerable, in ways that confer agency on communities to determine the policies and programmes that affect their health.
Increasingly, human rights advocates are realising that the sources of power in society who must be held accountable are not just states, but non-state actors, including multilateral agencies and multinational corporations whose de facto control of resources determines access to the conditions required for health to a far greater extent than does that of many states. International human rights law is increasingly providing “soft” law guidance through issuing of codes of conduct, norms and standards to ensure non-state actor accountability for human rights. Given that human rights are a product of developmental struggles, these frameworks will only be translated into meaningful instruments for accountability through strong civil society pressure on governments to turn such codes and standards into law.
Rights are not just about empowering vulnerable groups, but are themselves the products of contestation of power, at local, national and international level. And where power is contested, we should expect that the products of this contestation will reflect the relative balance of forces of different actors. For this reason, the exclusive emphasis on good governance, parliamentary democracy and civil liberties that has emerged as the dominant paradigm in some development discourses driven by Western governments has ironically contributed to a depoliticisation of rights and of development, because it strips struggles for health of any dimensions that challenge power imbalances – at local, regional and international levels. Yet power imbalances are what underlie health inequalities. This has led many to question “Why rights, why rights now?” since when the language of rights becomes denuded of power, it is turned into a technical exercise of compliance with norms.
Unchallenged, therefore, we should not be so naïve as to imagine that human rights will of necessity benefit poor people, poor communities or poor countries. Rather, by using and shaping rights towards pro-poor choices, human rights become transformative rather than simply easing human suffering. When human rights discourses, for example, begin to challenge and overturn obstacles posed by trade commitments to the realisation of the right to health, then the transformative nature of human rights emerges.
In this paradigm, the role of civil society organisation (CSOs) is absolutely central to realizing the agency that makes human rights approaches transformative. Yet many CSOs undertaking work in the health sector may 'do' human rights work, but are often not aware of the rights implications of their work on the ground. Is 'doing' human rights enhanced by 'acting' (i.e. conscious awareness of) human rights as well? Pilot research in the Western Cape with three health CSOs points to the multiplicative effect that a rights paradigm adds to their impact. By framing (health) needs as rights to which duty-bearers can be held accountable, not only is the demand for pro-poor services strengthened but beneficiaries of these services are enabled to be active agents in securing the conditions for their health, rather than passive recipients of state or NGO services. Moreover, placing demands in a right framework challenges service providers to see their role as realising states’ human rights obligations rather than simply delivering services. It is particularly in the field of socio-economic rights that the duality of service provision as fulfillment of human rights is evident and where it is clearest that human rights are more than just civil liberties.
CSOs engaging with rights approaches can build much stronger advocacy through sharing experiences and learning best practice. EQUINET, through its health rights theme, plans to explore the establishment of a learning network for CSOs in the region using rights approaches as a mechanism for enhancing civil society participation in the development of national health systems that are comprehensive, people-led and people-centred. We invite participation from CSOs and activists throughout the region in developing this network and look forward to your input and contribution to this debate.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org for attention to School of Public Health, University of Cape Town, Leslie London. Further information and publication on EQUINET work on health rights as a tool for health equity is available at the EQUINET website at www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
This Participatory, Reflection, and Action (PRA) project on occupational health services offered an opportunity for IHRG and a group of unionised health workers to use innovative learning and research methodologies as a means to investigate and intervene in their experiences of workplace injury and illness. Following IHRG’s participation in a regional training workshop hosted by EQUINET with TARSC and Ifakara, IHRG used selected PRA tools in a participatory action research programme. The project consisted of three workshops, workplace-based investigations, and the dissemination of networking resources among the participants. The combination of workplace-based case investigations and the process of critically reflecting on these interventions provided a very powerful action-learning experience. Processes of change were evident even in this short term project. Participants’ workplace investigations uncovered real cases of workplace injury and illness that have been buried under a culture of ignorance, neglect, silence, and denial of workers’ health and safety rights.
This study is a review of the literature and secondary evidence on community participation in central, eastern and southern Africa. It focuses in particular on South Africa, Mozambique, Malawi, Zambia and Kenya, and presents and analyses evidence of the current situation with regard to the role of districts in promoting community participation and articulating community voice. This includes looking at how: • community voice and roles at district level are structured and integrated into planning; • the way districts carry out their functions enables or blocks participation; • districts articulate and represent community interests at national level; and • wider contexts and processes at national and district levels influence and explain these outcomes. The purpose of the review is to identify examples of enabling and blocking mechanisms for community participation at district level and to provide pointers for further research.
3. Equity in Health
To achieve global access to health care requires the participation of a range of actors including patients, well-organized NGOs and governments that are held accountable. This specific symposium covered a range of issues that are critical to providing access to health care for all. It also outlined the civil and social roles, such as that of the People's Health Movement (PHM).
Across countries in sub-Saharan Africa, though socioeconomic inequalities in stunting do exist in both urban and rural areas, they are significantly larger in urban areas. Intra-urban differences in child malnutrition are larger than overall urban-rural differentials in child malnutrition, and there seem to be no visible relationships between within-urban inequities in child health on the one hand, and urban population growth, urban malnutrition, or overall rural-urban differentials in malnutrition, on the other
This session of the August 2006 Geneva Forum on health explored equity in health, including equity of access to essential drugs. Speakers identified constraints to equity, and suggested that equitable access to health care can only be achieved through reformation of the health sector. Measures proposed included a focus on poor geographic areas; the indirect measurement of the recipient's economic status; payments to poor service recipients; mass campaigns; contracting with NGOs and the active involvement of the poor. Inequity is not only due to social determinants and also demands scaling up financing of health systems.
Hon Minister Salih Meky, Minister of Health of Eritrea, spoke with interviewers at the August 2006 Geneva Forum for Health about achievements and challenges in the field of health in Eritrea and in Africa more generally. In Eritrea, health care is free of charge at point of care. The country has managed to keep under control a number of infectious diseases, but faces the increasing challenge of chronic illnesses, such as diabetes, hypertension and cancer. Hospital costs are a major issue. Minister Meky questioned whether there was a simple solution to the brain drain, and urged that it be addressed by the South and by the wealthy countries in the North. He observed that one priority was to improve living conditions and opportunities in the south and another for developed countries to help to train people. He felt that while there ought to be free movement of people, the brain-drain must be solved.
Six years ago, leaders from every country agreed on a vision for the future - a world with less poverty, hunger and disease, greater survival prospects for mothers and their infants, better educated children, equal opportunities for women, and a healthier environment; a world in which developed and developing countries work in partnership for the betterment of all. This report shows where we stand in 2006 toward achieving these goals. The challenges involved in reaching the MDGs are staggering, but there are clear signs of hope.
Mary Robinson, the first woman President of Ireland (1990-1997) and more recently United Nations High Commissioner for Human Rights (1997-2002) shared with the conference team some of the main challenges at hand when it comes to access to health for all: accountability, financing, the brain drain and the responsibility of those who have the means to make a difference, such as the private sector. She pointed out that the high turnout at the Forum was an indicator of the need for it and the urgency of discussing access to health. Access for all is the concern of all.
4. Values, Policies and Rights
Although the estimated 600 million people with disabilities have formally been recognized, in reality they are still often being overlooked and by no means enjoy the same rights as the rest of the world's population. The goal is to ensure that all people, disabled and able bodied alike, have the same access to all kinds of services in society, in particular health care.
For 650 million people with disabilities - roughly 10 percent of the world’s population - a new UN treaty which would extend international human rights to this traditionally marginalised sector of society is finally within reach. After four years and eight sessions of negotiations, the United Nations‘ Convention to Protect the Rights of Persons with Disabilities was recently finalised by the UN General Assembly’s Ad Hoc Committee. The UN disability convention guarantees persons with disabilities non-discrimination and equal recognition before the law; security, mobility and accessibility; the right to health, work and education; and participation in political and cultural life.
Since 2001, Africa’s leaders have committed the African Union and their Governments to promote and protect the right to health in a series of international and continental legal protocols and declarations. These commitments provide a comprehensive package for addressing the challenges of maternal mortality, HIV/AIDS, violence and disease. However, the urgent action needed to address what African Governments have described as a “continental state of emergency” can only be achieved by ensuring firm policy and programme linkages between Sexual and Reproductive Health, HIV/AIDS and Gender Based Violence. The article encourages African Health Experts and Ministers of Health meeting in Maputo to ensure that the draft Action Plan contains targets and indicators that enshrine on key components of the Abuja Declaration.
The United Nations Food and Agriculture Organization (FAO) has in 2004 developed guidelines as a practical tool to assist States to both understand and fulfill their obligations on the right to food. The guidelines were adopted in September 2004. This report and fact-finding mission by Rights and Democracy in collaboration with Foodfirst Information and Action Network in 2006 is an effort to apply the FAO Guidelines in a practical context in Malawi and in doing so, to illustrate the distinct advantages a human rights framework provides for policy and program development in relation to food security. The report identifies a number of legal, policy, institutional and economic constraints to the right to food and makes recommendations to address these.
5. Health equity in economic and trade policies
This petition was prepared in time for the annual meeting of the IMF-World Bank, 19-20 September in Singapore. The Tribunal received a petition from peoples’ organisations, citizens groups, social movements and NGOs from various countries in Asia seeking justice for the impact of debt on the lives, livelihood and well-being, human rights of the peoples of Asia, on the environment, ecological systems, economies and political affairs of many countries in the region. The same petition charges the IMF, World Bank (WB) and ADB of responsibility for the intensification of poverty and deprivation, violation of basic human rights, in addtion to other faults. By so doing, signataries hope that they will be compelled to review their actions and calculate and quantify the damages wrought by their policies or people.
This excerpt contains the text of United Nations (UN) Secretary-General Kofi Annan’s remarks at the official launch of UNITAID, the International Drug Purchase Facility, in New York today, 19 September. The Secretary General began by acknowledging this international facility for the purchase of drugs as a shining example of an innovative source of funding that can help us reach the Millennium Development Goals. The full speech can be found at the weblink above.
International People's Forum organizers issued this press startement to celebrate a successful forum and share plans for ways forward. On 18 September the IPF concluded the International Peoples Forum vs. the International Monetary Fund (IMF) and World Bank (IPF), which was convened in Batam from September 15th to17th. Over 500 Indonesians participated in the Forum as did around 200 individuals from 25 countries representing at least 100 organisations. Amongst several other urgent requests made was that for stopping the imposition of policy conditions that undermine economic sovereignty and exacerbate crises in health and education. The statement ends with a call on the governments that are members of the World Bank and IMF Boards of Directors to keep these institutions fully accountable for their impacts on human rights, equity, and the sustainability of development.
The TRIPS plus provisions called for by the United States are worrisome in as far as access to HIV/AIDS life saving drugs, and SADC leaders should be ary of these provisions. SADC member countries should amend their current legislation to take advantage of the regulatory flexibility permitted by TRIPS before making any Intellectual Property-related commitments. SADC should reject any TRIPS-plus proposals and ensure that the standards of Intellectual Property protection in TRIPS remain the minimum standards.
This research shows not only how GATS conflicts with the National Health Act, but also how General Agreement on Trade in Services (GATS) threatens national sovereignty and impedes the achievement of our constitution’s socio-economic rights. South African trade officials have repeatedly denied that GATS covers South African health services, but this study reveals that it covers almost all health services delivered outside of hospitals. South Africa’s dilemma should serve as a warning that health policy-makers, governments and citizens need to be more attentive to GATS negotiations currently underway in Geneva. Instead of the current negotiations to broaden and deepen GATS coverage, there needs to be an assessment of the treaty’s defects and joint international action to create more democratic international governance frameworks.
The World Bank and the home countries of corporations implicated in corruption in the Lesotho Highlands Water Scheme have many reasons to be shame-faced for the lack of support that Lesotho has been shown in its tenacious efforts to tackle corruption. At the very least the epitaph on the corruption and bribery trials needs to read that the conduct of international finance institutions and corporations in Lesotho must not be allowed to be repeated elsewhere.
6. Poverty and health
This report highlights how building strong public services is key to transforming the lives of people living in poverty. The authors show that developing countries will only achieve healthy and educated populations if their governments take responsibility for providing essential services.
Burundian state hospitals are reported to routinely detain patients who are unable to pay their hospital bills, the Human Rights Watch and the Burundian Association for the Protection of Human Rights and Detained Persons said in a report released in September. The patients can be detained for weeks or even months in abysmal conditions. This practice is reported to highlight broader problems of the health system in Burundi, where patients have to pay for their own treatment. The organisations called on the Burundian government to end the practice and to make access to health care for all Burundians a central part of its new Poverty Reduction Strategy Paper.
For people to be hungry in Africa in the 21st century is neither inevitable nor morally acceptable. The world’s emergency response requires an overhaul so that it delivers prompt, equitable, and effective assistance to people suffering from lack of food. More fundamentally, governments need to tackle the root causes of hunger, which include poverty, agricultural mismanagement, conflict, unfair trade rules, and the unprecedented problems of HIV/AIDS and climate change. The promised joint effort of African governments and donors to eradicate poverty must deliver pro-poor rural policies that prioritise the needs of marginalised rural groups such as small-holders, pastoralists, and women.
Slum-dwellers who make up a third of the world's urban population often live no better, if not worse, than rural people, a United Nations report says. Anna Tibaijuka, head of the UN Habitat agency, urged governments and donors to take more seriously the problems of at least a billion people. The report provides an overview of different countries across the world, and highlights the relevance of this growing problem; for example, with respect to the health of these communities.
Malaria imposes significant costs on households and the poor are disproportionately affected. However, cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time, or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper, a framework indicating the complex links between malaria, poverty and vulnerability at the household level is developed and applied using data from rural Kenya.
7. Equitable health services
More than 2,600,000 deaths have been prevented in 2003 thanks to the Hepatitis B vaccine currently available. This is only one impressive example of the benefits of good vaccination and immunisation programmes. Although vaccination programmes are very cost-efficient, costing as less than 1,000 USD per life saved, the world still faces over 100,000 neonatal tetanus deaths and over 400,000 deaths from measles per year. The international community has a very ambitious plan: to completely eradicate diseases which are preventable by global vaccine coverage. How can such a goal be accomplished?
This story describes the experience of Professor Stanis Wembonyama as director of the main hospital in Democratic Republic of Congo's second city, Lubumbashi, last year. Gecamines, the state-owned mining monopoly used to be in charge - theoretically - of the Jason Sendwe Hospital, but the institution had been left to rot. Most of the beds had been either stolen or stripped down and sold as scrap metal. Doctors and nurses had not been paid their salaries for five years and so they earned their living by demanding cash before treating their patients. The story outlines the steps to clean up the hospital and instil management discipline.
Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices. For example one speaker at this session of the August 2006 Geneva Health Forum noted that the mission of hospitals has shifted from delivering specialized care to our patients; to responsibility for the care in our region; to promoting health to all our citizens.
What is the best way to address the health care needs of an underserved population? Is it through disease prevention or is it through a more comprehensive and coordinated approach? According to a session of the August 2006 Geneva Health Forum integration of the two approaches is the key to a successful health care delivery system, providing wider access to a greater number of the population. The vertical approach is disease-centred, while the horizontal approach is patient-centred. The use of resources in a vertical approach is dictated by a centralized authority, while the horizontal approach encompasses area-wide planning at the centre with final decision-making devolved to the local or district level. Experiences reported from Uganda and Tanzania indicated limitations of the vertical approach and the better results provided by the adoption of a horizontal approach.
The fifth largest nation in the world does not have sufficient access to health. Indeed if migrants were seen as a country, they would represent a significant nation in terms of population. How can we explain that so many people do not have access to health care? The focus of this symposium, chaired by Angela Davies from the International Organization of Migration (IOM) and Sandro Cattacin from the University of Geneva, was on the unequal provision of health services for migrants.
This framework paper is aimed at policy makers who are involved in the development or management of programmes in the health sector in developing countries. It provides a ‘snapshot’ of the type of information and communication technology (ICT) interventions that are being used in the health sector, and the policy debates around ICTs and health. It draws from the experience of use in both the North and South, but with a focus on applicability in the South to identify the most effective and relevant uses of ICTs.
8. Human Resources
Southern Africa’s public health services are in a state of emergency. Bad pay and working conditions, plus the impact of HIV/Aids, are bleeding the system of its most valuable resource: people. With the cost of training a general practice doctor estimated to be $60 000, and that of training a medical auxiliary at $12 000, the African Union estimates that low income countries subsidise high income countries to the tune of $500-million a year through the loss of their health workers. The article touches on the experience in several eastern and southern African countries.
There is a serious human resource crisis in the health sector in developing countries, particularly in Africa. One of the challenges is the low motivation of health workers. Experience and the evidence suggest that any comprehensive strategy to maximize health worker motivation in a developing country context has to involve a mix of financial and non financial incentives. This study assesses the role of non-financial incentives for motivation in Benin and Kenya.
Representatives of Oxfam International, Physicians for Human Rights and Health GAP today called the critical shortage of health workers in developing countries "a major challenge to meeting the promise of universal access to treatment." They demanded massive new investment from government to train and retain health workers. "Campaigns to fulfill the right to health have brought anti-retroviral medicines to hundreds of thousands of people. But without the health workers and health systems to administer these medicines, that right remains unrealized for millions more," said Leonard Rubenstein, JD, Executive Director of Physicians for Human Rights.
The consequences of health professional mobility have become a prominent public policy concern. This paper considers trends in mobility amongst doctors and nurses and the consequences for health systems. Policy responses are shifting from a reactive agenda that focuses on stemming migration towards a more active agenda of managed migration that benefits source and destination countries. Improved working conditions and effective human resource practice are required to encourage retention of health professionals in both source and destination countries.
The global phenomena of massive migration of health professionals and the advent of e-Health solutions are evidence of the fact that significant trends in health are no longer regional. Worldwide, doctors, nurses and ancillary staff are increasingly seeking better prospects for themselves, not only in the northern economic powerhouses but also in developing countries. However, a severe lack of knowledge-sharing mechanisms and appropriate funding has meant that patients and health professionals in poor countries are still denied the opportunity to benefit from pioneering e-Health programmes now being developed in countries such as the UK and Canada.
9. Public-Private Mix
As a medical doctor, working in the field of maternal and neonatal health, Dr. Imtiaz Jehan sees public-private partnerships and the challenges related to access to health from a Southern perspective. She shares with us how she believes progress can be made for the public and the private sectors to working together.
Rich countries must deliver more money directly to poor nations to avert a growing health and sanitation crisis spreading across the southern hemisphere, according to Oxfam. The global charity said investment in health care, water, sanitation and education must be delivered by governments rather than the private sector. The report condemned the World Bank for forcing privatisation or inappropriate private sector projects on developing countries, and criticised Western governments for signing up to the so-called Washington agenda.
Classrooms with teachers, clinics with nurses, running taps and working toilets: these basic public services are key to ending global poverty, according to a new report from Oxfam and WaterAid. And, the agencies say, only governments are in a position to deliver them on the scale needed to transform the lives of millions living in poverty. The report, “In the Public Interest”, calls on developing country governments to devote a greater proportion of their budgets to building these vital services for their citizens - and for rich countries to support their plans with increased, long-term aid commitment.
What conditions lead to efficient PPP's? Should we reject PPP's all together? Should governments do more in terms of Research and Development (R&D)? There are no straightforward answers but the speakers at this symposium offered convincing and interesting solutions.
Whether via international bodies or by means of bilateral agreements, nationally or in PPPs, the public sector would continue to play the key role in terms of setting strategy and providing funds for access to health. With a view to ensuring that a larger percentage of public funds actually reach their intended beneficiaries, Dr Gwatkin of the World Bank urged NGOs to undertake monitoring of government and donor programmes in individual countries, stressing that together, "civil society and the public sector comprise a powerful force for change". He also mentioned that he would like to see efforts by international bodies, such as the World Health Organization (WHO) (www.who.int), to make their health and funding statistics more user-friendly as a means of improving grassroots use of them to increase global access to health.
10. Resource allocation and health financing
Ethical guidelines require that research on effectiveness of HIV chemoprophylaxis be performed in populations where the intervention would be feasible if the trials demonstrate efficacy with acceptable safety. Population effects and cost effectiveness were simulated using a mathematical model that considers heterosexual and homosexual transmission, higher infectiousness in early and late infection, age and sex effects on susceptibility, risk behavior variation, condom replacement, known age-sex partner preferences, and primary and secondary drug resistance. The article describes the findings and relevant conclusions drawn.
Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed.
In a presentation before the parliamentary portfolio committee on health and child welfare yesterday, the health ministry said its budgetary allocation for next year should conform to the declaration. This article presents its argument that in Zimbabwe, the Ministry of Health and Child Welfare budget should at least meet the Abuja Declaration target of a minimum of 15% of the government budget going to Ministry of Health.
In 2005, Wemos together with several Southern organizations conducted case studies in Ghana, Zambia, Kenya and Uganda on the role of the International Monetary Fund (IMF) in determining budgets for health, particularly for health workers' salaries. Achieving the health related Millennium Development Goals (MDGs) requires a substantial financial injection in the health sectors of low-income countries. Public expenditure, however, is restricted by IMF macroeconomic policies and conditions, through ceilings on the public sector wage bill. The report describes the findings and conclusions of the four case studies.
Financing of health systems is well known for raising controversial ideas and provoking stormy debate. Should a prepayment system be applied to deficient health systems in under-developed countries? Different judgements on the global relevance of insurance are presented.
Oxfam International today urged donor nations and developing country governments to scale up their investment in health systems to address the critical shortage of health workers and crumbling infrastructure. "For the first time in human history, we have the resources to stop HIV/AIDS from killing millions of people. What we do not know is whether our leaders will muster the generosity to save these lives," said Dr, Mohga Kamal Yanni, senior health and HIV policy advisor for Oxfam International.
Priority setting of health interventions is often ad-hoc and resources are not used to an optimal extent. Underlying problem is that multiple criteria play a role and decisions are complex. Interventions may be chosen to maximize general population health, to reduce health inequalities of disadvantaged or vulnerable groups, ad/or to respond to life-threatening situations, all with respect to practical and budgetary constraints. This is the type of problem that policy makers are typically bad at solving rationally, unaided. Therefore, the development of a multi-criteria approach to priority setting is necessary, and this has indeed recently been identified as one of the most important issues in health system research.
11. Equity and HIV/AIDS
The Swiss-based Basel giant pharmmaceutical company, Roche, said that it would supply free-of-charge three companies in Africa, with the technical ability to manufacture generic medicine for HIV, the virus that leads to AIDS. In an announcement on 22 September, Roche added that Aspen Pharmacare in South Africa and Cosmos Limited and Universal Corporation Limited in Kenya will receive the necessary technical expertise. The Basel based firm said another 25 companies from 14 countries, including Ghana, Zimbabwe and Nigeria were interested in the initiative. The agreements are the first in a series of planned technology transfers for sub-Saharan Africa and the world's Least Developed Countries, which were announced in January 2006.
This video clip from the Sixteenth International AIDS Conference held in Toronto in August 2006 shows an AIDS activist living with HIV presenting her views on the UNGASS political declaration. The video clip is found among others presented at that conference session.
What happens when there aren't enough doctors to administer treatments? What happens when patients sell their medications to buy food? What happens when people are afraid to get tested for a disease? The International Development Research Centre (IDRC) working with South African researchers are developing techniques to manage AIDS in resource constrained settings.
Throughout the 1990s, Uganda has successfully controlled its HIV epidemic, with falling prevalence and incidence rates. Recent evidence, however, indicates that this decline may not be continuing. Factors influencing recent epidemiological trends are still unclear, but may include increased risk behaviour, the natural epidemiologic cycle and others. To solidify Uganda’s success, the ongoing efforts in HIV prevention need to be re-emphasised.
The prevention of HIV/AIDS in the Armed Forces is a critical task in Central Africa. Since 2002 the US Department of Defense HIV/AIDS Prevention Program has been providing support through the Johns Hopkins Cameroon Program to assist these countries to improve surveillance and prevention of HIV/AIDS in Cameroon, Chad, Congo Brazzaville, Congo Kinshasa, Equatorial Guinea, Gabon, and Sao Tome. The study describes interventions whose innovative effort in the Armed Forces in Central Africa is the first integrated HIV/AIDS prevention program in this region and will allow effective implementation of long-term strategies to fight the disease in this population.
Being an orphan is tough enough at the best of times, but in the working class district of Dagoretti Corner in the Kenyan capital, Nairobi, it often means going without food as well as love. Felista Kibe tries to make sure that doesn't happen. She and a handful of volunteers have been providing food and comfort to children orphaned by AIDS in Dagoretti since 1996. Eighty kids depend on her for a daily meal, 30 of whom are HIV positive, but when word gets out that a donation has been received as many as 200 children can show up.
In Mozambique's Machava Central Prison, the largest jail in the country, sex between prisoners is an unavoidable reality, but little is being done to prevent it, according to inmates and medical staff. Overcrowding, violence and high-risk behaviour, such as sharing drug-use equipment and unprotected sex increase risk of HIV transmission in prisons. Lack of information on HIV and AIDS and inadequate health facilities also contribute to the spread of the disease. This article explores the limits to prevention activities such as condom distribution given the taboo on homosexuality in Mozambique.
The traditional role of care giving and support provided to orphans by paternal and maternal grandparents, uncles and aunts is slowly being eroded. More and more households are becoming nuclear family centred. Challenges facing Orphans and Vulnerable Children (OVC) include serious shortages of housing and exposure to abuse (including ill-treatment and sexual abuse). This study collected information on conditions of OVC in Kweneng West and Serowe/Palapye districts, Botswana, and the services in place that cater for OVC needs.
HIV/AIDS is sweeping through parts of South Africa's east-coast province of KwaZulu-Natal, where researchers are finding alarming HIV prevalence levels among women. 'The study might be considered somewhat biased, as only women were tested, but the figures do suggest a worrying upward trend which could be part of a bigger problem,' Medical Research Council (MRC) researcher Professor Gita Ramjee told PlusNews.
Data collected by the Tanzania Media Women Association (TAMWA) shows a strong correlation between HIV infection and early school exit, teenage marriage and pregnancy. Tanzanian law is reported in this report to allow girls aged as young as 15 to get married with parental consent.
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12. Governance and participation in health
The traditional top-down approach to development is widely criticised as being inappropriate to meet the needs of local populations, especially the very poor. In order to improve this situation, some development organisations and non-governmental organisations (NGOs) favour approaches that integrate local communities in policy formation and implementation. Health, an important aspect of development, necessitates active involvement of the local population. The community remains the key actor in improving its own health standards and communicating its requirements to governments.
The nature of Civil Society Organisations (CSOs) in development work is changing, but how successfully – and leading where? Surprisingly, there is very little systematic research on how CSOs all over the world are influencing policy processes, especially from the point of view of those actually involved in the policymaking process in the South. This paper was written as part of the Civil Society Partnerships Programme (CSPP) to improve the capacity of Southern CSOs to influence pro-poor policy.
In many communities the symptoms of malaria are widely recognised. Decisions about choice and order of treatment are often based on people's experience of the effectiveness of particular treatments and the availability and cost of medication. 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. Further research needs to: * focus on the 'normality' of malaria and the social and political environments that influence how interventions are chosen and how they are used; and * increase understanding of the social, economic, political and historical contexts that shape household and community beliefs and behaviours.
Corruption holds development back. The author proposes that the aid community needs to be more open-minded and to think harder about what works to deal with corruption, rather than prescribing standard formulas. The author reviews of the things we understand and the things we don’t and thence suggests five ways of moving forward.
Draft legislation to create a single public service for national, provincial and local government will be presented to the cabinet by November, says the Director-General of the Department of Public Service and Administration, Richard Levin. The proposed legislation would establish a framework for a single public service and would regulate organisational and human resource matters in all spheres of government. It would deal with conditions of service, labour relations, corruption and service delivery; including health services.
Antimicrobial resistance is a growing threat to public health the world over. Global health governance strategies need to address the erosion of antimicrobial effectiveness on three levels. Firstly, mechanisms to provide incentives for the pharmaceutical industry to develop antimicrobials for diseases threatening the developing world need to be sought out. Secondly, responsible use of antimicrobials by both clinicians and the animal food growing industry needs to be encouraged and managed globally. And lastly, in-country and international monitoring of changes in antimicrobial effectiveness needs to be stepped up in the context of a global health governance strategy.
13. Monitoring equity and research policy
Despite improved supply of health care services in low-income countries in the recent past, their uptake continues to be lower than anticipated. This has made it difficult to scale-up those interventions which are not only cost-effective from supply perspectives but that might have substantial impacts on improving the health status of these countries. Understanding demand-side barriers is therefore critically important.
International collaboration for health system development has been identified as a critical input to meet pressing global health needs. North-South collaboration has the potential to benefit both parties, while South-South collaboration offers promise to strengthen capacity rapidly and efficiently across developing countries. There is an emerging trend to analyze the fruits of such collaboration. This paper builds on this trend by applying an innovative concept-based bibliometric method to identify the international scope of collaboration within the field of health policy and systems research. Two key questions are addressed: to what extent are papers comparing developing countries as against reporting on single country studies? To what extent are papers in either case being produced by researchers within their respective countries or through North-South or South-South collaboration?
As clearly shown in the 2005 UNGASS Country Progress Reports, AIDS resources have grown rapidly in recent years from US$300 million in 1996 to US$8 billion in 2005. One critical need is to ensure that available resources are used effectively, which requires that countries must invest in a sound monitoring and evaluation system to help provide feedback on whether projects, programs, and policies are achieving (or not) their expected results. A major emphasis has been put on integrating the various M&E efforts in support of the three ones principle of “One National Monitoring and Evaluation System”. Four countries were invited to participate in a feedback session, including Botswana of Southern Africa.
Zimbabwe is in the mature stage of a generalised HIV/AIDS epidemic. However, HIV prevalence is unevenly distributed with respect to age, gender and locality. The objective of the mapping exercise was to focus limited project resources for improving linkages and ensuring maximum impact of prevention interventions. Use of GIS systems helped improve linkages between communication activities and product delivery to create informed demand and improve off-take of male and female condoms.
14. Useful Resources
The Office of the Special Adviser on Africa (OSAA) supports the work of civil society organisations in Africa through the publication of a number of reports highlighting their contributions to addressing threats to peace and security as well as development in Africa . OSAA seeks to strengthen African civil society organisations through the annual publication of this NGO directory.
Gapminder is a non-profit venture for development and provision of free software that visualise human development. This is done in collaboration with universities, United Nations (UN) organisations, public agencies and non-governmental organisations. Google Subscribed Links makes it possible to search deep into Gapminder's moving graphs visualizing world development. Important document series available at this site include 'Human Development; Data Animation'and 'The World Chart'- developed in collaboration between WHO and Swedish institutions with the aim of visualising world health development, thereby enable better use of international health data for learning, advocacy and hypothesis generation. Others include a paper on 'Free software for a world in motion', focusing the need for new educational software environments for exploration of global statistics; and World Development Indicators (WDI, a publication of the World Bank's annual compilation of data about development.
This toolkit has been developed to help civil society to increase local authorities’ capacity to deliver change. It’s response to the demand from local authorities for supporting development skills required for managing and delivering successful organisational change. The tools and information on this website include guidance, case studies and methodologies. These tools are coordinated and managed as a unit so that they achieve the intended outcomes and realise benefits. It breaks down into manageable chunks with monitoring and review points for assessing progress and performance in a long-term focus.
This Oxfam 'toolkit' suggests ways to participate in the 'Global Month of Action.' Oxfam describes the goals of poverty reduction and ways to contribute to the global efforts to reduce poverty.
15. Jobs and Announcements
CCPH invites you to share your knowledge, experience and lessons learned with hundreds of colleagues who - like you are passionate about the power of partnerships to transform communities and academe. The deadline for proposal submission is 6 October 2006.
The mission of the APHA International Human Rights Committee is to develop research, education, and policy toward eliminating international human rights violations which relate to public health. IHRC seeks abstracts from students in public health or related fields on topics addressing the intersection between health and human rights. Abstracts related to the 2006 Annual Meeting theme "Public Health and Human Rights" are encouraged. Student papers must reflect work, issues, or activities undertaken while in school, either undergraduate or graduate programs. Poster sessions allow participants to view presentations at will and interact with poster session authors. Complete and submit attached form by email (in Word format) or mail no later than October 10, 2006, 5:00pm (ET).
SAfAIDS is developing a database of experts on various issues on HIV and AIDS. The experts may be called upon to undertake work on behalf of SAfAIDS from time to time for a fee. Established in 1994, SAfAIDS is a regional HIV/AIDS organisation based in Harare, Zimbabwe. Its goal is to disseminate HIV/AIDS information to promote, inform and support appropriate responses to the epidemic. Interested individuals should submit detailed CVs to SAfAIDS at the email adress below.
Possible fields of study for the fellowship include mobilisation, allocation, and management of scarce resources to improve health; and creation of sound strategies for disease control and health promotion. The purpose of the fellowship is to investigate how resources are allocated and used for health purposes and to develop methods for making such policy choices more rational and equitable, especially in developing countries. The duration of fellowship is ten months. The deadline for application is 1 February 2007.
The Medical Research Program seeks to improve the care and treatment of AIDS patients in Africa by supporting clinical research and related capacity-building projects that fill critical gaps. DDCF funds have supported competitive grant programs as well as individual grants. The Duke Foundation gives about 5% of its funding in response to unsolicited applications. Financial provisionsa are up to US$100 000 per year, for duration of two years.
IFPRI Global e-Learning Program the International Food Policy Research Institute (IFPRI) is launching a Global e-Learning Program designed to provide free e-learning opportunities for professionals around the world. The Global e-Learning Program will initially comprise two separate e-learning courses on 'How to Write a Convincing Proposal' and 'How to Communicate Scientific Research'. The methods and materials for both courses were developed by experienced international specialists and were tested extensively in two successful pilot e-learning programmes carried out in 2005. Both courses will be online for four months during 2006. Participants can choose to take either or both of the courses. For further information and registration for the courses, please visit IFPRI at the weblink above.
The profile of non-governmental organisations (NGOs) has increased together with the need for them to assess the long-term impact of their work. In three fruitful days you will explore the current state of the debate about impact assessment and review current methodologies. This workshop will review the developments in the methodologies for assessing the impact of the types of Social Development work undertaken by NGOs. It will analyse the emergence of Impact Assessment as a separate discipline. It will also explore the areas of overlap between evaluations, and impact assessment which aims to identify the longer-term changes associated with Social Development work.
This new site provides access to the best thinking on governance, conflict and social development. The GSDRC supports the knowledge needs of DFID and the wider development community in relation to governance, conflict and social development. The resource centre provides high quality, timely information to support project and programme planning, policy-making, and other activities in the field. A range of services are available to DFID and the public by visiting the links provided at the site printed above.
UNCERD is currently looking for dynamic, creative, dedicated and results-oriented senior managers, financial experts, health specialists, environmental experts, agricultural scientists and other related professionals with outstanding leadership qualities, a track record of succeeding in a multi-cultural environment, the capacity to bring together and respond to work place challenges in our various work area and other partner organisations in creating opportunities and solutions for sustainable socio-economic development.
Through its grant awards, the Foundation seeks to advance and recognise the work of outstanding professionals committed to eradicating pediatric AIDS.This program is for individuals from, and working in, developing countries. The Foundation is especially interested in projects that allow scholars to gain developing country experience while increasing the research capacity of the in-country location. The Foundation is now offering a postdoctoral fellowship for clinicians/scientists from developing countries. The program is aimed at healthcare professionals who have specific training or experience with HIV/AIDS and hold an MD or PhD.
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