With the major public health challenges that are found in Africa, making progress in public health clearly demands a significant spread of public health skills. While health workers are making tireless efforts to address preventable diseases across the continent, and many successful experiences exist, revitalizing primary health care oriented systems calls for revitalized public health leadership and skills.
Part of the challenge is filling the gaps created by out-migration. At a conference held in mid-June 2007 on 'Sustaining Africa’s Development through Public Health Education', hosted by the University of Pretoria School of Health Systems and Public Health, Professor Erich Buch, health advisor to NEPAD, depicted the prevailing health worker situation in Africa, including the extensive brain drain, low funding and insufficient, often inadequately compensated, staff. He emphasised the need to shift focus from the current responses taking place country-by-country to building wider continental responses, informed by vision, leadership, and energy. This leadership demands public health skills, and Professor Buch asserted that building 'centres of excellence and networks in Africa are key … to strengthen[ing] public health capacity at public health schools and institutions across the continent'.
The meeting discussed options for how to achieve this. With limited financial and institutional resources, governments and institutions can best maximise what is available by sharing existing African expertise across organisations and countries, and strengthening formal mentorship programmes for public health practitioners. This needs to be backed by investments in user-friendly technology to support the communication, collaboration and networking between research institutions, and to stimulate collaborative research and discussion forums and strong alumni systems.
Networking between institutions and professionals in Africa is sometimes weaker than between Africans and colleagues in the developed world. Building African networks needs active support and investment. One key area of concerned raised in the NEPAD strategy is establishing and maintaining an inventory of public health education capacity in Africa, enabling standardisation and accreditation of training institutions and encouraging innovative methods of training and the use of technology supported learning. As Professor Buch stated “We need to … build more cost-effective capacity on the continent'.
In line with these goals, the AfriHealth Project at the University of Pretoria recently completed a three-year mapping project of public health education and training institutions in South Africa. The project has developed a database of public health workers and educators to inform collaborations in Africa. While the mapping focused on South Africa, the information would be useful to strengthen the networking of institutions and individuals in Africa and to share these institutional resources. The AfriHealth Project seeks to secure a Pan-African Public Health body that is effective, inclusive, scientifically and politically supported, and well-resourced. The project has identified the strategic importance of developing a continental approach to improving public health in line with new socio-political realities, strengthening public health capacity by networking institutions, programmes and individuals, and promoting technology-supported learning and communication.
These initiatives do not see current skills scarcities as being an insurmountable block to development of new skills. Mentors can be drawn from existing academic institutions. But public health education must also move beyond universities, to provide other skills not always available from university education, such as for cultural sensitivity in health practice, or for strategic management. Short courses for public health practitioners can also bridge the gap between different entry levels and Masters' degrees in public health. Public health educators and researchers must also bridge the gap in research to reduce the drop out rate in Masters' courses.
There are new and emerging challenges to public health in the rapidly changing global environment. The content of public health training needs to match the new needs and opportunities for action in public health.
Gender issues have a major impact on health in the continent, and institutions should include gender in public health curricula. Improving women’s rights, eliminating violence against women and advancing health rights more generally calls for recognition of the central role played by women in providing health care. This doesn’t only mean looking at women's roles. As Dr Alena Petrakova from WHO (Geneva) noted at the conference, mainstreaming gender in public health curriculum design and development also means involving men and examining their impact on health. A recently-formed African Network for Public Health Educators on Gender (ANPHEG) is taking the issue of how gender is mainstreamed in the public health curricula on a sustainable basis.
Achieving the commitments set out in the continent and those set globally, like the Millennium Development Goals, calls for clear skills to best protect, use and advance the health resources in the region. Much focus has rightly been placed on retaining and valuing health workers. Beyond this, equal concern is now being voiced in the continent that those who do work in African health systems are adequately equipped at all levels with the knowledge and skills to lead effective and innovative responses to the continent's public health challenges.
K Tibazarwa is a masters' student, School of Public Health at the University of Cape Town. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
The EQUINET Secretariat at Training and Research Support Centre with local hosts, REACH Trust (Malawi), invite personnel working on health equity in east and southern Africa to apply for participation for a capacity building workshop on “Writing scientific papers and peer reviewed journals” to be held in Lilongwe, Malawi from 20-24 October 2007. This workshop is designed to support capabilities for effective dissemination of research on health equity. The call closes on 3 September 2007.
This paper represents the first phase of a Canadian initiative on intersectoral action for health and provides an overview of approaches to intersectoral action at the global, sub-regional, national, sub-national, and community levels. It is intended to contribute to the World Health Organisation’s Commission on Social Determinants of Health (SDH) and is the result of collaboration between EQUINET, the Health Systems Knowledge Network of the Commission on SDH and the Public Health Agency of Canada. Experiences documented by academics, policy-makers and practitioners in more than 15 countries are examined in an attempt to improve understanding of questions relating to: the types of problems addressed through intersectoral action (IA); the conditions that shape horizontal and interjurisdictional collaboration; tools, mechanisms and approaches to support IA; and roles played by the health sector and other actors.
3. Equity in Health
More than at any previous time in history, global public health security depends on international cooperation and the willingness of all countries to act effectively in tackling new and emerging threats. That is the clear message of this year's World health report entitled A safer future: global public health security in the 21st century, which concludes with six key recommendations to secure the highest level of global public health security.
4. Values, Policies and Rights
South Africa is one of the youngest democracies in the world, with twelve years of a democratically elected government. Prior to the democratic elections, it was a country marked by oppression and extreme inequality. The democratic government has introduced a range of pro poor and pro equity policies. This paper reviews the system that was inherited by the democratic government, the equity promoting policies of the new government and the strategies adopted to implement these policies. It further analyses if the policy objectives have been met and the challenges that need to be addressed to reach these objectives.
This report by the World Health Organisation, examines the relationship between neglected diseases and human rights. It argues that neglected diseases are both a cause and consequence of human rights violations, and the failure to respect certain human rights, such as the rights to water, adequate housing, education and participation, increases the vulnerability of individuals and communities to neglected diseases.
This paper provides a reflective overview of the eight studies commissioned under the UNRISD project on 'Social Policy in Late Industrializers: Sub-Saharan Africa and the Challenge of Social Policy'. The studies involved subregional and thematic social policy concerns. Within this framework, one study was concerned with overall conceptual issues and macroeconomic policy directions, focusing on the dominant or ruling ideas on development that shaped each phase of sub-Saharan Africa’s post-colonial history, and how these ruling ideas shaped economic and social policies. A second set of studies focused on health, water and sanitation dimensions of social policy, while a third examined education and labour market policies. Using comparative techniques, these studies examined clusters of countries in East Africa, Southern Africa and West Africa.
5. Health equity in economic and trade policies
The UK Prime Minister and German Chancellor Angela Merkel have released a joint statement on a new International Health Partnership, which will bring together major donor countries, including Britain and Germany, and key international agencies such as the World Bank and the World Health Organisation. The agreement was developed with bilateral, international health and funding agencies, developing countries, and foundations; it commits all artners to: working with country owned plans; creating a mechanism to agree donor support to national plans; coordinating their efforts on the ground; and focussing on the creation of sustainable health systems which deliver improved outcomes. Partners will work together to ensure that health plans are well designed, well supported and well implemented.
This book critically analyses the conventional wisdom in the political, economic, and academic establishments of neoliberalism and globalisation as good for people's health and quality of life.
Hundreds of representatives of social and labour organisations, faith based, community-based and health networks, small farmers, traders, women and youth organisations, and developmental, human rights and environmental NGOs from across the whole of the Southern African region gathered in a Peoples Summit in Lusaka, Zambia, 15-16 August 2007, parallel to the SADC Heads of State summit. They discussed many issues of common concern and agreed that there is now an urgent generalised threat hanging over the whole future of SADC. This arises from the insistence of the European Union (EU) that SADC, like other regional groupings in Africa, the Caribbean and the Pacific (the ACP countries) must sign a far-reaching trade liberalisation agreement with the EU. Participants claim this has been misleadingly entitled an Economic Partnership Agreement (EPA), despite already witnessing the damaging effects of trade liberalisation.
Few people are aware how much national and regional food systems are impacted by international policies and trade rules is on national and regional food systems—this report makes these links and offers alternative responses. It also addresses agriculture and global warming, how to move organic and local food models forward, and discusses other emerging issues as well. The International Forum on Globalization (IFG) is a research and educational institution comprised of leading scholars, economists, researchers, and activists from around the globe.
6. Poverty and health
There have been dramatic changes to municipal services such as water and electricity since the end of apartheid in South Africa, with considerable research having gone into the impacts of commercialisation and cost recovery on low-income households. The research has revealed complex and often negative relationships between the marketisation of services and access and affordability for the poor. It has also been shown to have direct and very negative public health implications, most acutely in low-income township and rural areas.Less obvious, and much less researched, have been the impacts of changes in service delivery on the mental health of low-income residents and household members. What, then, might be the links between poverty, mental health and the shift towards market-oriented reforms in basic services? This paper explores the relationship in the South African context with a detailed, ethnographic case study of ten low-income families in Cape Town coping with a serious mental disorder (schizophrenia).
The links between poverty and poor maternal health are well established. Poorer countries experience the highest rates of maternal mortality, whilst maternal death and life-threatening and debilitating illness are higher amongst women from poorer households. However, there is now growing evidence that poor maternal health can also exacerbate poverty.
Water-related diseases are widely recognised as a major threat to public health, especially in the developing world. An estimated 19% of all infectious diseases are related to water, sanitation and hygiene risk factors. In South Africa the provision of basic infrastructure such as water and sanitation has been an important part of the social contract between the government and its constituencies. In 2001 the government became a partner in the Water, Sanitation and Hygiene for All (WASH) campaign, which was designed to attract resources to address the situation of millions of people without access to adequate water supply and sanitation. In Johannesburg, a privately managed parastatal was contracted to deliver water and associated services in the city. As part of their water service delivery and improvement of services, the company opted to deliver services using prepaid water meters and yard taps. But do households respond differently to hygiene and handwashing interventions such as WASH depending on which water and payment systems they have? This paper explores that question.
7. Equitable health services
Improving maternal health remains the most elusive of the Millennium Development Goals. Every minute, at least one woman dies from pregnancy-related causes: 99 percent of these are in developing countries. The majority of these deaths occur in sub-Saharan Africa and south Asia, and are avoidable through using standard interventions and health care which all pregnant women and their newborns need.
The Director-General of the World Health Organisation in an opening address at the International Conference on Health for Development in Buenos Aires, Argentina on 16 June 2007 argued that to realize the great potential of health to drive human development, we must reach the poor with appropriate, high-quality care. The speech explores challenges in the role that primary health care can play in this and how to overcome major barriers, such as weak health systems, inadequate numbers of health care staff, and the challenge of financing care for impoverished people.
Two United Nations agencies have launched a $44 million programme to reduce female genital mutilation/cutting (FGM/C) by 40 per cent by 2015 and to end the harmful traditional practice within a generation. Launched by the UN Population Fund (UNFPA) and the UN Children’s Fund (UNICEF), the initiative will encourage communities in 16 African countries with high prevalence to abandon the practice, which has serious physical and psychological effects. Partnering with the agencies will be Governments, religious leaders, reproductive health providers, media and civil society.
The World Health Organization (WHO) today issued new global guidance for the use of insecticide-treated mosquito nets to protect people from malaria. For the first time, WHO recommends that insecticidal nets be long-lasting, and distributed either free or highly subsidized and used by all community members. Impressive results in Kenya, achieved by means of the new WHO-recommended strategy, show that free mass distribution of long-lasting insecticidal nets is a powerful way to quickly and dramatically increase coverage, particularly among the poorest people. This is the first demonstration of the impact of large-scale distribution of insecticide treated mosquito nets under programme conditions, rather than in research settings, where, in different parts of Africa, reduction observed in overall mortality has ranged from 14 % up to 60 %.
8. Human Resources
This briefing paper explores different ways of addressing the health worker crisis in Africa. It addresses problems of poor training, motivation and retention of health workers, the lack of skilled health workers in remote and hard to reach areas, and poor community engagement with health systems. The authors argue that to tackle the immediate health worker crisis it is important to find models which can quickly deploy and retain workers and ensure they get appropriate training and support. Responses need to expand the cadres of workers with basic clinical and community health competencies, such as enrolled nurses, clinical officers and community health workers.
This paper discusses gender issues manifested within health occupations and across them. It examines gender dynamics in medicine, nursing, community health workers and home carers and explores from a gender perspective issues concerning delegation, migration and violence, which cut across these categories of health workers. Gender plays a critical role in determining the structural location of women and men in the health labour force and their subjective experience of that location. The paper shows that woman are overrepresented in caring, informal, part-time, unskilled and unpaid work and within occupations there are significant gender differences in terms of employment security, promotion, remuneration.
Providing maternal care requires a viable and effective health workforce. In many countries, and certainly in all countries where maternal mortality is high, the size, skills and infrastructure of the workforce is inadequate. The most visible features of the maternal health workforce crisis are the staggering shortages and imbalances in the distribution of health workers. With insufficient production, downsizing and caps on recruitment under structural adjustment and with frozen salaries and losses to the private sector, migration and HIV and AIDS, filling the supply gap will remain a major challenge for years to come.
The East, central and Southern African Health Community College of Nursing (ECSACON) has released a report documenting how health professionals can take the initiative to come together to address regional issues of concern. Documenting the process of developing the ECSACON model also demonstrates how acting together in synergy and partnership can expand the impact of similar networks.
The Namibian Minister of Health and Social Services, Dr Richard Kamwi, will urgently seek Cabinet approval of an agreement that would oblige doctors at State hospitals to be contracted for a stipulated period of time before going solo. The move is intended to stem the current tide where public sector doctors take advantage of existing loopholes tp migrate out or set up private medical practices while working for the State.
9. Public-Private Mix
In a recent meeting with private health care providers and insurers, Health Mininster Dr Tshabalala-Msimang criticised private providers for placing a large burden on health consumers, with out-of-pocket expenditures pushing patients further and further into poverty. She emphasised that a national health system cares for all and urged private providers to work with government to secure a decent national health system.
This study aimed to put forward value-creating strategies and develop a best practice model that strengthened government capacity to provide efficient, effective, economical and equitable health care and thereby impact on plans for HIV and AIDS prevention and treatment roll-out.
10. Resource allocation and health financing
The World Health Assembly has in the past three years passed several resolutions on health financing and health worker shortages - yet there has been an overall increase in annual African deaths resulting from lack of sustainable health finance and health worker shortages. The worlds Health Ministers must now move from passing resolutions to effecting resolutions and emergency action to end the deaths of over 8 million Africans a year from preventable and treatable diseases.
The pace of redressing inequities in the distribution of scarce health care resources in Namibia has been slow. This is due primarily to adherence to the historical incrementalist type of budgeting that has been used to allocate resources. Those regions with high levels of deprivation and relatively greater need for health care resources have been getting less than their fair share. To rectify this situation, which was inherited from the apartheid system, there is a need to develop a needs-based resource allocation mechanism. Principal components analysis was employed to compute asset indices from asset based and health-related variables, using data from the Namibia demographic and health survey of 2000. The asset indices then formed the basis of proposals for regional weights for establishing a needs-based resource allocation formula.
The Africa Public Health Rights Alliance “15% Now!” Campaign has called on the new Chair of SADC President Levy Patrick Mwanawasa to make it a priority of his term of office to ensure that alongside upholding Democracy and Good Governance, all SADC countries emulate the leadership of Botswana and meet the Abuja African Union pledge to allocate at least 15% of national budgets to health. President Mwanawasa assumed SADC leadership at the end of the last summit that ended on the 17th of August. In a statement issued in Lusaka, the Campaigns coordinator Rotimi Sankore stated:“SADC leaders must realise that they have no choice but to follow the lead of Botswana in meeting the Abuja 15% pledge. Its really a choice between meeting the 15% commitment now, or presiding over mass burials of citizens between now and 2015 when they should have met the health based Millennium Development Goals”.
Since 1994, considerable progress has been made in transforming the South African health care system, implementing programmes that improve the health of the population, and improving access to health care services. However, amid escalating health care costs disparities continue to exist between the public and private health sectors. The implementation of a national or social health insurance remains elusive despite three government-appointed committees on the matter.
11. Equity and HIV/AIDS
When it comes to sub-Saharan Africa's devastating AIDS crisis, there is an understandable tendency to latch onto any scrap of good news. Figures suggesting the epidemic is waning in some countries are being trumpeted by governments and international donor agencies as evidence that their prevention efforts are succeeding. But the real story behind increases and decreases in HIV prevalence is far less clear.
In Uganda, the areas worst affected by the violence were close to the border with Sudan, far from the urban centres around which most camps for internally displaced persons (IDP) grew. It is the urban areas, such as Gulu in northern Uganda and Yei in southern Sudan, which have the highest HIV prevalence rates. Years of encampment and dependency on relief handouts have had a profound effect on the traditionally conservative Acholi. Alcoholism and sexual violence have become particular problems, and the heavy presence of soldiers, with money in their pockets, has also helped give rise to a sex industry. Many areas of southern Sudan and northern Uganda are rapidly opening up to trade, and health workers are worried that unless information about HIV reaches these populations early enough, they will be unprepared for the possibility of a rapid spread of HIV.
Scientists at The WorldFish Center reported today that an innovative project to encourage fish farming among families affected by HIV/AIDS in Malawi has doubled the income for 1,200 households and greatly increased fish and vegetable consumption among rural communities. The findings were released in a review of a multi-year initiative by the Malaysia-based WorldFish Center, one of 15 centers supported by the Consultative Group for International Agricultural Research (CGIAR) and World Vision, an international humanitarian aid organization, to promote aquaculture among “vulnerable populations” in Malawi.
12. Governance and participation in health
The research presented in this paper responds to years of academic speculation and subsequent policy concerns about the possible collapse of Africa’s democratic project under the complex waves of impacts introduced by the HIV/AIDS pandemic. It is the result of three years of exploratory studies in seven countries: Botswana, Namibia, Malawi, Tanzania, South Africa, Senegal and Zambia. Anecdotes of Lesotho and Zimbabwe have also been highlighted.
This paper argues that stronger and values-based public sector management and leadership is essential in building health systems that better address health inequities. By considering evidence on existing weaknesses in health system action to redress inequity, it identifies a complex and inter-locking set of problems involving individuals, organisational culture and the ways in which wider political, economic and socio-cultural forces influence public sector organisations. It then examines the particular features of organisational culture in organisations judged to be better performing, and considers how change in organisational culture can be brought about. It also identifies the particular competencies of public sector managers and reviews evidence on how these competencies can be developed.
13. Monitoring equity and research policy
Implementation of known effective interventions would necessitate the reduction of malaria burden by half by the year 2010. Identifying geographical disparities of coverage of these interventions at small area level is useful to inform where greatest scaling-up efforts should be concentrated. They also provide baseline data against which future scaling-up of interventions can be compared. However, population data are not always available at local level. This study applied spatial smoothing methods to generate maps at subdistrict level in Malawi to serve such purposes.
Canada ’s IDRC and the SSHRC have signed an agreement to invest up to $6.27 million over the next six years to support international research alliances. This partnership will engage teams from Canada and developing countries in comparing and collaborating on their research, while working with people in communities that will directly benefit from the research. This partnership is a practical expression of the idea that new knowledge, generated through research, is key for people to improve their futures. The joint program will encourage strategic research in four areas: environment and natural resource management; information and communication technologies for development; the impact of science, technology and innovation policies on development; social and economic policy related to poverty reduction, growth, health and human rights.
14. Useful Resources
There are currently a large number of indicators being collected and used in the health system, however there are certain problems associated with facility-based indicators. In an attempt to demystify the indicators and to make them more accessible to managers of facilities and to those at higher levels of the system who support facility managers, this booklet has taken the top ten key indicators based on routine facility information and has unpacked them. It is hoped that this publication will make these indicators more easily understandable, will promote greater use of these indicators and will therefore ultimately play a role in improving their quality.
Field workers, managers and consultants working with development projects of all sectors will benefit from this new resource launched by Education, Language and Development Training Programmes (ELD). A UK charity working since 2000 conducting hundreds of training courses for NGOs in Asia, ELD brings a wealth of experience and guidance on what really works in his step-by-step, practical and clearly explained handbook. Reports are an essential project management tool. Effective reporting helps to compare the reality in the field with the plan, aids management thinking and increases transparency. This is not a ‘book about reporting skills’. The Handbook looks at the entire reporting process from setting objectives, through data gathering and analysis tools, to planning, drafting, editing and designing the report. The programme is full of clear explanations and examples, frequent practical exercises, and an extended case study to fully apply all the tools presented.
15. Jobs and Announcements
The University of the Witwatersrand's School of Art wishes to announce the launching of the SADC Drama for Life Programme. To begin they offer 28 full scholarships (tuition, residence, medical aid, permits, insurance) at Wits University for outstanding performers/director s and teachers or facilitators in the field of Applied Drama and Theatre. Applications are now open, and details on the university website can be found in English, Portuguese and French. The SADC Drama for Life Programme is about supporting all existing NGOs, theatre groups and ministries of health and education. It is about building capacity, and providing support for quality of life work in all 14 SADC countries. They look forward to forming partnerships with organisations throughout the region, and seek to build a vision of hope.
The next Gender Festival on ‘African Feminist Struggles in the Context of Globalization’ will take place at TGNP’s Gender Resource Centre, Mabibo Dar es Salaam Tanzania from 11th to 14th September 2007. The 2007 Gender Festival is an open space to bring together feminist and gender-focused groups, other civil society organisations, institutions, activists and other development actors working at various levels to meet, reflect and strategise on the progress made in feminist struggles for gender equity, social transformation and participatory democracy in Tanzania. Participants are invited to make submissions for this festival, taking account of issues such as the present context of corporate-led globalisation and ‘free market’ ideology, their impact on development and democracy in Africa and the world over, and examining alternative frameworks and strategies.
As many technologies and much knowledge are proprietary in nature and form the subject matter of patents owned by foreign entities, a key national policy instrument is the intellectual property rights regime. How it reflects and balances relevant international commitments with the goal of advancing the economic and social rights of its citizens is crucial in promoting their best interests. This is a Call for Proposals on how developing countries can access technologies and information contained in existing patents to enhance innovative research at the national level. This call for proposals is limited to developing country institutions. Six grants of approximately $75,000 Canadian will be made after the close of the competition on November 30, 2007.
The Global Health Watch (GHW) are still looking for reviewers for a number of chapters and would like suggestions. As with the first edition of GHW, they want to make sure that the Watch reflects issues from regions around the globe. Each chapter is written collaboratively, and the review process is intended as a further opportunity to ensure that each regions issues are reflected in this next edition of the Watch. Suggestions are needed as soon as possible.
The Oxford Internet Institute ( University of Oxford ) invites applications from the global South to fill two places in its Civil Society Practitioners Programme. This visitor programme is intended for Civil Society Practitioners of distinction or outstanding promise who wish to visit the Institute for a period of six weeks between February and December 2008, to undertake research concerning the social impact of the Internet and related ICTs. Visitors are expected to reside in Oxford during their stay, and to participate fully in the intellectual life of the Institute. Applications will ideally be submitted by Civil Society Practitioners in or from the global South, active in the areas of freedom of expression, media reform, media justice, and communications and information policy in the globalized context of the Internet. The application deadline 26 September 2007 Final notification of an award will occur in November 2007.
The Health Systems Trust will be holding a conference with key stakeholders on 10 and 11 October 2007 in Johannesburg, Gauteng, to celebrate 15 years of work in strengthening health systems in southern Africa. A panel of external experts will be invited to formally review recent HST programmes of work during this conference. Participation in the conference is by invitation.
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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