This past week the Global Forum for Health Research (GFHR) has held its 11th annual Forum in Beijing, attracting hundreds of people from across the world. The GFHR advocates for greater equity in health research, noting that while developing countries that carry the heaviest health burdens; they command only a fraction of global health research funding. Under the theme of “Equitable Access: Research challenges for health in developing countries”, Forum 11 heard that global commitments to improving health will not be reached without significantly greater investments in the health sectors of low income countries. According to Stephen Matlin, the forum's executive director, globally, about $125 billion a year is being spent on health research, a four-fold increase over the past 20 years, "In spite of that increase, a relatively small fraction of the total is devoted to health problems of the poor and to people living in developing countries".
New resources for health are being made available, drawing attention to who influences their use? To what extent will communities in low income countries influence new investments, particularly towards their health needs? How far will new spending be influenced by knowledge generated from within these countries? In a world of competing approaches, how accessible and prominent is local knowledge within policy forums?
There is cause for concern when evidence suggests that the problem of inequitable research funding is compounded by similar inequalities in the publication of research. A recent review of research publication by Smith Esseh (2007) of the “Strengthening African Research Culture and Capacities Project” found that dissemination of developing country research findings is declining. ‘Africa is the second-largest continent, and has over 900 million people, and therefore should be a world leader in global scholarship. In 1960-1979, scholarly publishing began to rise in Africa, a result of gains in social and political independence. However, in 1980-1985 scholarly publishing plateaued. From 1986 to now, scholarly publishing in Africa has been declining steadily.’ (http://scholarlypublishing.blogspot.com/2007/07/strengthening-african-research-culture.html; http://ocs.sfu.ca/pkp2007/viewabstract.php?id=83). The inequalities are not only north-south: they also exist within Africa. Scholarly publishing in Africa was found to be concentrated in only seven countries, accounting for 75% of scholarly publishing in the continent, while the other forty-five countries account for only 25%.
For east and southern Africa, it would be important to follow up whether such a finding also holds for scholarly publishing in health. Publication is vital for research findings to reach wider audiences, for peer review and to build an accessible body of local and regional knowledge to inform policy. The links are not always direct, but it is clear that unpublished work remains hidden from policy processes.
In his opening address to the 22nd Annual Joint Scientific Conference of the National Institute for Medical Research in Arusha, Tanzania on 7 March 2007, Tanzanian Minister for Health and Social Welfare David Mwakyusa described the problem: ‘Researchers must know that if they cannot efficiently and effectively deliver to the stakeholders their research findings, then they have failed to accomplish their mandate. In fact, un-disseminated research findings do not only become useless but also make for multiple losses to the nation; a waste of precious time, a loss of funds invested in the work and human power, a loss of productivity and a loss to people’s welfare.’
Ensuring effective dissemination of research and knowledge is thus even more important in Africa, where research resources are inadequate relative to health burdens. Yet the major global progress made in access to information over the last decade remains elusive to many health professionals, especially those working in rural district and primary health care services, who still struggle to access or disseminate information. According to Couper and Worley (2007), ‘The unequal distribution of health care between developed and developing worlds is matched by a similar unequal distribution of health information [and yet] the health problems of Africa are most likely to be solved by people in and from Africa, who know the right questions to ask to get practical solutions and can then access the necessary information.’ (http://www.rrh.org.au/articles/subviewafro.asp?ArticleID=644)
African scholarly works are poorly distributed, barely marketed, and hardly accessed. Poor access to information has been found to be one factor driving skilled health workers out of service in remote areas. Researchers struggle to access scientific literature. The circulation numbers for African journals are often low. Smith Esseh (2007) reports for example that African universities have very low budgets for journal access and publication, ranging from a budget of 50 cents per student (Ghana) to $2.66 per student (Cape Coast) to the high of $9.00 per student (Dar es Salaam). Lack of access to journals has a two way effect, limiting access to international research in Africa and limiting dissemination of work from Africa. African researchers have raised in EQUINET forums the many other challenges they face in getting their research published, including language barriers, lack of confidence and mentorship in publication, lack of exposure to journals and writing skills. Recognising this, EQUINET has increased its investment in support for publication of research produced in the network and capacity building of writing skills within and across its research networks. A recent EQUINET Writing Workshop for Scientific Publication in Lilongwe, Malawi in October 2007 highlighted the importance of researchers identifying dissemination goals at an early stage of research, and of strengthening capabilities for dissemination within all research programmes.
However the barriers we describe go beyond the capabilities of individual researchers. They also arise in the opportunities available for accessing and disseminating information. Global developments do give some cause for optimism. The massive increase in internet use in Africa, by 625% in the past seven years, suggests new options for accessing and disseminating research. Online journal publishing and open access publication has grown in health, offering new channels for publication and new opportunities for African researchers to obtain information. The growing list of African health journals found at African Journals Online (http://www.ajol.info/) (92 under health and medicine) suggest that the old barriers posed by print production will be less of a limiting factor than they have been in the past.
This raises new questions of how to avoid differentials in access to internet becoming a basis for social differentials in influence over health policies. At the same time as the GHRF researchers were meeting in Beijing, a summit of African politicians, international lenders and leaders of the IT industry met in Kigali, Rwanda on October 31st 2007. They noted that fewer than 4% of Africans currently have an Internet connection. A goal was set at this meeting for interconnection with broadband lines of the capitals of all African states by 2012. As with other resources for health, equitable access to this vital information link across the health research community in Africa, including those in low income rural settings, will depend on public policy and investment to make it more widely accessible within and beyond these capital cities, and specific measures to stimulate its uptake and effective use amongst those currently marginalised.
TARSC is the secretariat for EQUINET. Please send feedback or queries on the issues raised in this briefing or any follow up queries on EQUINET activities to support writing skills to admin@equinetafrica.org.
1. Editorial
*Why is life expectancy in some countries in our region 40 years longer then others?
*How well are we meeting commitments made by leaders to spend 15% of government budgets on health?
*What can we do about the loss of health workers due to migration?
These issues are discussed in the new book published by EQUINET “Reclaiming The Resources For Health: A Regional analysis of equity in health in east and southern Africa” launched in the region in Lilongwe Malawi on October 23rd 2007, at an event locally hosted by REACH Trust Malawi and Malawi Health Equity Network, two EQUINET steering committee member institutions. The book was officially launched by the Principal Secretary for Health, Mr Chris Kang’ombe, with the Chair of the Parliamentary Committee for Health, Honourable Austin Mtukula and speakers from the region, followed by dance and drama presenting health challenges in communities. Hastings Banda from REACH Trust chaired the session, attended by people working in health in Malawi and delegates from seven of the 16 countries in east and southern Africa.
After a welcome by Bertha Simwaka, Acting Executive Director of REACH Trust, and an EQUINET presentation by Rene Loewenson outlining the scope of the book, three speakers from the region explored further the issues raised.
Moses Mulumba, a lawyer with the Law Faculty, Makerere University Uganda outlined how rights to health are often not respected in economic and trade policies. This has led to explicit efforts in Uganda to influence negotiations on trade agreements like the Economic Partnership Agreements, sensitise trade officials, and set human rights guidelines for areas of trade, such as the practices of pharmaceutical companies in relation to access to medicines and to advocate for assessment of the health impact of agreements before signing them.
Bona Chitah from the University of Zambia described Zambia’s attempts to achieve a “dream and up our standards for the good of the people”. Recognising that Zambians have a right to better health, he described the efforts to redistribute health resources, improve access to health services and ensure a holistic, horizontally integrated health system. Recent reviews of cost sharing policies showed how they raised barriers and costs for poor people, leading Zambia to abolish user fees and seek increased financial resources from international sources for health. He pointed to a number of challenges still to address in achieving fair financing for health: “We are awakening to the reality that we are in it for the long haul ... to build the bridge between the current and the dream ...”
Kathne Hofnie-Hoebes from University of Namibia highlighted the necessity of tapping the potential for health action that exists within communities. Drawing on experiences of a marginalised community in an informal settlement in Namibia, she described how using participatory reflection and action approaches builds respect between communities and health workers and builds the confidence of communities to act.
Experiences were also presented from Malawi. Hon Austin Mtuluka, MP and Chair of the Malawi Parliamentary Committee on Health, described the advocacy by parliamentarians for health equity in budget and legal processes. This has yielded gains: Malawi has made progress towards meeting the Abuja target in 2007, with a rise from 8% of the total budget to 14% of the total for 2007/8. Parliamentarians were also involved in drafting a new law on HIV and AIDS, drawing experience from the region. He commented that the exchange of information between parliamentarians across the region has been useful in strengthening parliamentary roles and capacities for tackling health inequity.
Finally the Permanent Secretary for Health from the Ministry of Health Malawi, Mr Chris Kang’ombe officially launched the book. He recognised the significant challenges to achieving global Millennium Development Goals in Africa, and the importance of networking researchers, policy makers, officials and civil society members towards promoting health equity and regional co-operation. He observed, “The perspective that guides the report being launched today is based on shared values of equity and social justice in health and a spirit of self determination.”
He pointed to the book as a relevant source of evidence and analysis, and made links between the themes in the book and the focus areas for development set out in the Malawi Growth and Development Strategy, whose overall theme is ‘From poverty to prosperity. The book draws from regional experience: Strategies applied in Malawi, such as the provision of the essential heaIth package are discussed, together with insights and options for improving equity in access to these services. In his words,
“I would like to encourage and urge each and every one of us working in the health sector and beyond to make sure that we have a copy of this report… Let us participate in implementing the activities and recommendations set out in this report to reduce the health inequalities which currently exist in Malawi and in the east and southern Africa region.”
The tempo after the launch was raised with drumming, singing and dancing marking the entry of the Paradiso Home Based Care dance group. The group’s songs reinforced messages around advancing people’s health, with many joining in dancing. The Tipya Drama Group, a community group in Lilongwe, performed a play about poor communities expectations of their community care, and the need for communities, health workers and planners to have dialogue in addressing these needs. The drama group interpreted messages from the book in their own context, with some local twists!
The launch in Malawi was the regional ‘launchpad’ to disseminating the evidence and experience on health equity from and about the region contained in the book. The health equity challenges in Malawi, as in other countries in the region, are significant. The launch sent clear signals, however, of the affirmative intention, options and social resources to act on these challenges from within the region.
Information on where to obtain a copy of “Reclaiming the resources for Health” can be found on the EQUINET website (www.equinetafrica.org) or send queries to admin@equinetafrica.org.
Mark your calendars. On December 1, the globe will celebrate World AIDS Day. The theme, as it has been for the last two years, is "Stop AIDS: Keep the Promise." This is to serve as a reminder to the world community of its promise to among other things provide universal access to treatment, reduce prevalence rates, and implement effective prevention programs. As the prevalence rate of those living with HIV continues to climb in most countries in southern Africa, it is clear that we are far from fulfilling this promise by 2010, the campaign’s target year.
Almost a third of those living with HIV live in southern Africa. Despite the infusion of funding and the attention of national governments and international bodies, the prevalence rate in the region (surprisingly, apart from Zimbabwe) is continuing to rise. In Botswana, Swaziland, and Lesotho over one-fifth of the population is infected with HIV. The high prevalence rate fails to be matched by adequate access to treatment. Access to anti-retroviral therapy in sub-Saharan Africa has increased in the last year but remains at a miserable 28%.
As anyone living in southern Africa knows, the tentacles of the virus reach across all sectors of the community, but they tend to prey more on those who are the most removed from access to and the protection of the law—among them, women, children, prisoners, and those living in poverty.
Despite this or maybe because of this, the law remains an underused weapon in the fight against the effects of HIV and AIDS in the southern Africa region. Apart from South Africa—where the galvanizing work of the Treatment Action Campaign, AIDS Law Project, and others supported by a robust Constitution and judiciary has resulted in significant legal successes—there have been few cases brought on behalf of those infected and affected by HIVand AIDS in the region. In Namibia, the AIDS Law Unit of the Legal Assistance Centre successfully brought a case challenging the Namibian military’s denial of employment to an HIV positive individual who was otherwise physically fit.
In Botswana, the courts have issued decisions on a handful of cases involving the privacy rights of HIV positive individuals. In the rest of the countries in the region, courts have yet to issue a single significant legal decision on an HIVand AIDS related case.
In recognition of the underutilization of the law and litigation in southern Africa, the Southern Africa Litigation Centre established a new HIV and AIDS programme focusing on providing resources, support, and training to lawyers and advocates in the region to bring cases supporting the rights of those infected and affected by HIV/AIDS in national and regional courts. The programme does not intend to duplicate the groundbreaking work already being done by local, national, and regional organizations on these issues, but will aim to bolster the work of local and other regional actors to increase the use of the law and litigation to advocate for the rights of those living with HIV, and those rendered vulnerable by the pandemic.
Accessing the law through litigation can be a powerful tool for changing policy and social attitudes. Litigation can also provide a public platform on which the voices of those generally silenced can not only be heard but magnified. In South Africa, the role of lawyers and litigation in exposing the hypocrisy of the apartheid state and ultimately contributing to its demise is undeniable. More recently, a Constitutional Court decision, Minister of Health and others v Treatment Action Campaign and others, requiring the South African government to make nevirapine, a drug known to significantly reduce the likelihood of mother-to-child transmission of HIV, available in all public hospitals and clinics resulted in the drastic reduction of mother-to-child transmission.
This is not to say that the law and courts alone can stem the devastating impact of HIV and AIDS, or that litigation is the appropriate strategy all of the time. The use of the law must be pursued in tandem with other advocacy tools, including public education and campaigning. In addition, legal victories have little meaning without the close involvement of local community-based organizations, and networks of people living with HIV, who can ensure the translation of a successful court decision into concrete change in the reality of people’s lives.
I am not naïve. I do not think the use of courts and the law will miraculously change the progression of the pandemic. But if we are to have any chance of turning the tide we need to use all of the tools available to us in fighting this epidemic.
Priti Patel is Project Lawyer for the Southern Africa Litigation Centre’s (SALC) new HIV/Aids Litigation Programme; she can be contacted via the SALC website at http://www.southernafricalitigationcentre.org/salc/. Visit the EQUINET website www.equinetafrica.org for further information on rights as a tool for equity and health systems responses to HIV and AIDS. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
2. Latest Equinet Updates
The Regional Network for Equity in Health in East and Southern Africa (EQUINET) commissioned this review of current multi-lateral agreements, codes of practice, bi-lateral agreements, regional agreements, and strategies and position statements that govern the migration of health workers from ESA (East and Southern African) countries. The paper provides an overview of the current situation in ESA, and the strengths and weakness of current codes in application in the region.
Call Closes On December 7, 2007!
This call invites applicants to participate and share experiences in a Regional Training Workshop for east and southern African countries on Participatory Methods for research and training for a people centred health system being held on February 27 to March 1st 2008.
3. Equity in Health
Achievement of the Millennium Development Goals is likely to be compromised if inequities in health/ healthcare are not properly addressed. This study attempts to assess trends in inequities in selected indicators of health status and health service utilisation in Malawi using data from the Demographic and Health Surveys of 1992, 2000 and 2004. The widening trend in inequities, in particular healthcare utilisation for proven cost-effective interventions is likely to jeopardize the achievement of the Millennium Development Goals and other national and regional targets. To counteract the inequities it is recommended that coverage in poor communities be increased through appropriate targeting mechanisms and effective service delivery strategies. There is also a need for studies to identify which service delivery mechanisms are effective in the Malawian context.
Gender differentials in health related risks and outcomes are partly determined by biological sex differences. Yet they are also the result of how societies socialise women and men into gender roles. The paper draws together evidence that identifies and explains what gender inequality and inequity mean in terms of differential exposures and vulnerabilities for women versus men, and also how health care systems and health research reproduce these inequalities and inequities instead of resolving them.
The health disparities between rich and poor in the developing world are so stark that reforms premised on "equal access" are inadequate, declared Werner Christie, Counsellor, Science and Technology, Norwegian Embassy, People's Republic of China and former minister of health of Norway. To be most effective, policies should be based on "disparate access," said Christie, speaking at Forum 11, the annual meeting of the Global Forum for Health Research, which this year focuses on equitable access. Such an approach would grant priority to the disadvantaged people who need help most, he said.
The world is likely to fail to meet the United Nation's Millennium Development Goals related to health, the head of the World Health Organization said on Monday at a global forum on health research for poor nations. A rise in funding for research into communicable diseases has not been matched by the power of health systems to deliver, in part because of the failure of governments to invest in the sector, said Margaret Chan.
4. Values, Policies and Rights
In May 2005, the World Health Assembly of the World Health Organization (WHO) adopted the revised International Health Regulations (2005), which have now entered into force for WHO Member States across the globe. These Regulations contain a broad range of binding provisions to address the risks of international disease spread in international travel, trade and transportation. Important elements include multiple provisions, whether denominated in terms of human rights or other terminology, that are protective of interests of individuals who may be subject to public health measures in this international context. With the vast (and increasing) numbers of persons undertaking international voyages and the global coverage of these revised Regulations, they are an important development in this area. This article describes a number of these key provisions and some of the related issues they present.
The organized efforts of the state to protect its citizens from threats to the public's health presuppose some commonality of health beliefs and behaviors, and legislation underpinning public health interventions is premised on the beliefs and behaviors of the population majority. To what extent, in a public health emergency, can members of a cultural or religious minority use human rights arguments to justify exemption from public health measures on the basis of offensiveness of those measures to cultural or religious beliefs? Any such challenge cannot rely on arguments based on autonomy of the individual. The person objecting to the public health measure will need to establish that the burden of compliance will be significantly greater because of offensiveness of that measure to belief, so as to impose on the individual a burden disproportionate to the risk to health of the public as a whole.
At the 2007 World Medical Association (WMA) General Assembly meeting in Copenhagen, Denmark (October 3-6), the WMA adopted a resolution with regards to health and human rights in Zimbabwe. It was prepared by the South African Medical Association. The resolution urges the Zimbabwean Medical Association (ZiMA) to address the violations of health rights in the country and stimulates national medical associations of other countries to offer ZiMA their assistance.
5. Health equity in economic and trade policies
African countries have called for greater voice in the International Monetary Fund (IMF), including not only an increase in formal voting power and representation at its decision-making bodies but also in the diversity of its staff members, to better represent their interests at the institution. In statements during the IMF’s Annual Meetings, African finance ministers and central bank governors have reiterated their calls for at least a tripling of basic votes as an outcome of the current quota and voice reform process to protect the voting shares of low-income countries. They also called for a meaningful and expeditious increase in their representation at the Executive Board, including an amendment to the Fund’s Articles of Agreement to enable Executive Directors representing large constituencies to appoint more than one Alternate Executive Directors.
The representatives of governments within the region, regional trade related organisations, ESA and SADC, parliamentarians, academia, the business sector, SMEs, labour met in Harare on 3-4 October 2007 to assess the readiness of ESA and SADC EPA configurations to sign an EPA; to take stock of the outstanding issues in the negotiations to date and; and to discuss measures to put in place in the event that the EPA is not signed by December 2007. On the basis of close analysis of the sate of EPA negotiations so far, new proposals and the issues arising, the hurdles met thus far, the challenges that lay ahead and the incisive presentations during the two days, further discussions were held.
Rodrigo Rato bowed out as managing director of the International Monetary Fund with effusive plaudits from world financial leaders in public but sharp criticism of his role and the Fund's relevance from the same people when talking outside official news conferences. The emerging consensus among rich and poor countries alike was that the reform process of the IMF had moved backward. Worse, they added that acrimony over the Fund's role in assessing the economic policies of its members, their effects on other countries threatened to create just the disorder in the global economy it is intended to prevent.
This letter to the editor in the Financial Times expresses concern over Economic Partnership Agreements being negotiated between the EU and its African, Caribbean and Pacific (ACP) trading partners. The group of writers claim that the Commission is incorrect to claim that it has no legal choice but to raise tariffs in January 2008, and further recommend that instead of making threats, the Commission should focus on creating accords with the ACP that would genuinely support development.
The European Parliament on 24 October endorsed an amendment to WTO intellectual property rules aimed at easing poor countries' access to essential medicines, after the EU's 27 member governments promised to help developing nations manufacture and import affordable drugs. Legislators from across the political spectrum had thrice postponed voting on the amendment, pending additional pledges of monetary and political support for developing country public health programmes from EU member states and the European Commission.
The struggle to make medicines affordable to the world’s poor, especially in Africa, is raging on at the highest levels. In the last week of October the European Commission took a landmark decision on generic drugs and next week a high-level intergovernmental meeting will look at ways to prevent patents from blocking access to drugs. In an agreement announced on October 23, European Union (EU) governments were told that they are free to make available generic versions of patented drugs for export to poor countries which lack their own manufacturing facilities.
Kenyan authorities are probing who in government may have been “compromised” by the pharmaceutical industry to try strip the African country of its right to produce medicines without patent-holder approval. There have been repeated efforts to delete parts of Section 80 of the Industrial Property Act, which was enacted in 2001. It enabled the government to issue compulsory licenses to local manufacturers to produce generic versions of pharmaceuticals, such as antiretrovirals for HIV/AIDS patients, without seeking approval from the drug company that holds the patent rights.
A landmark case has entered the Kenyan corridors of justice as a group of farmers and a human rights watchdog move to challenge the State over ongoing negotiations for a new trade agreement with Europe. Kenya Human Rights Commission (KHRC), a non-governmental organisation, and small-scale growers contend that though the process of the negotiations for a new Economic Partnership Agreements (EPAs) between Kenya and its key trade partner is of national concern, the State has failed to exhaustively involve all those who stand to be adversely affected by the pact.
The author begins by presenting a brief background on the SADC Regional Economic Integration Agenda and the pertinent decisions made by the Heads of State and Government in this regard, and reminds us of the purpose of the workdhop in preparing for the launching of the FTA in 2008. The author insists the need to create awareness in this process cannot be over emphasised, and elaborates that the process of creating awareness on the SADC Free Trade Area (FTA) would require a meaningful and effective involvement by all the stakeholders.
The literature on world cities has had an enormous influence on urban theory and practice, with academics and policy makers attempting to understand, and often strive for, world city status. In this groundbreaking new work, David A McDonald explores Cape Town’s position in this network of global cities and critically investigates the conceptual value of the world city hypothesis. Drawing on more than a dozen years of fieldwork, McDonald provides a comprehensive overview of the city’s institutional and structural reforms, examining fiscal imbalances, political marginalization, (de)racialization, privatization and other neoliberal changes. The book concludes with thoughts on alternative development trajectories.
6. Poverty and health
The influence of person-related and household related characteristics on the nutritional status of children were assessed, taking into account variables such as, gender of household head, de jure and de facto household head, relationship of child to household head, size of household, type of toilet facility and type of dwelling. Chronic malnutrition and underweight were significantly pronounced in children from households with de jure household heads.
This paper reports the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was signficcantly associated with inconsistent condom use with a nonprimary partner, sex exchange, intergenerational sexual relationships and lack of control in sexual relationships. Associations between food insufficiency and risky sex were much attenuated among men.
This paper estimates the reduction in child mortality as a result of interventions related to the environmental and nutritional MDGs (improving child nutrition and providing clean water, sanitation, and fuels) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients.
This paper produced for a conference at the Overseas Development Institute (ODI) reflects on the experiences of women and girls with poor accessibility to services and markets, and inadequate transport in rural sub-Saharan Africa. It uses examples from field research to look at the impact of these factors on girl’s education before going to examine access to health services.
7. Equitable health services
Experts warn of impending crisis in health systems geared towards epidemics not chronic diseases such as cancer. Unless urgent attention is paid to decreasing the burden of cancer, there are going to be catastrophic results especially in Africa and parts of Asia, experts warned at a gathering in Cape Town in October 2007. Thirty countries in Africa and Asia had no access whatsoever to radiotherapy.
At the close of breast cancer awareness month, cancer organisations say proper testing and treatment services for breat cancer are completely inadequate. Breast cancer organisations are concerned that early detection and treatment services are severely lacking in South Africa where over 3 000 women die from this disease annually. The Breast Cancer Advocacy Coalition have sent a memorandum to the South African health department asking it to improve services. The coalition calls for a comprehensive breast health service that is equitable, available, affordable and accessible to all women in South Africa.
The Director-General of the World Health Organization, Dr Margaret Chan,
on Monday pointed to the failure of governments around the world to invest adequately in basic health systems that make a life-and-death difference to millions of people.
South Africa's public health crisis is deep-rooted in systemic problems. Progress will require far-sighted, sustainable solutions. This requires a massive change in national consciousness. The authors suggest that one of the better measures of the state of a nation is its burden of disease. Health statistics are never just reflections of physical health alone. Instead, they also reflect, often quite precisely, issues like regional poverty, national inequity, unsound governmental policies, the fair distribution of resources, the quality of our leadership and the state of health services, amongst other things.
Traditional health practitioners (THPs) and their role in traditional medicine health care system are worldwide acknowledged. Trend in the use of Traditional medicine (TRM) and Alternative or Complementary medicine (CAM) is increasing due to epidemics like HIV/AIDS, malaria, tuberculosis and other diseases like cancer. Despite the wide use of TRM, genuine concern from the public and scientists/biomedical heath practitioners (BHP) on efficacy, safety and quality of TRM has been raised. While appreciating and promoting the use of TRM, the World Health Organization (WHO), and WHO/Afro, in response to the registered challenges has worked modalities to be adopted by Member States as a way to addressing these concerns. Gradually, through the WHO strategy, TRM policy and legal framework has been adopted in most of the Member States in order to accommodate sustainable collaboration between THPs and the scientist/BHP. Research protocols on how to evaluate traditional medicines for safety and efficacy for priority diseases in Africa have been formulated. Creation of close working relationship between practitioners of both health care systems is strongly recommended so as to revamp trust among each other and help to access information and knowledge from both sides through appropriate modalities. In Tanzania, gaps that exist between THPs and scientists/BHP in health research have been addressed through recognition of THPs among stakeholders in the country's health sector as stipulated in the National Health Policy, the Policy and Act of TRM and CAM. Parallel to that, several research institutions in TRM collaborating with THPs are operating. Various programmed research projects in TRM that has involved THPs and other stakeholders are ongoing, aiming at complementing the two health care systems. This paper discusses global, regional and national perspectives of TRM development and efforts that have so far been directed towards bridging the gap between THPs and scientist/BHP in contemporary health research in Tanzania.
8. Human Resources
Africa is losing its brightest to the First World. Less than 10% of doctors trained in Zambia since its independence in 1964 are still in the country: the other 90% have migrated, mainly to Europe and the United States. No less staggeringly, there are more Sierra Leonean-trained doctors in Chicago alone than in the country itself. These medical examples are merely one facet of the massive loss of skills Africa as a whole continues to suffer. In effect, one-third of the continent’s university resources are serving the manpower needs of Western nations and not those of Africa itself. United Nations estimates suggest that Africa is spending a staggering $4-billion a year training professionals for developed countries. Why this is happening, and what African universities need to do to counter the problem, came under the spotlight in the Libyan capital of Tripoli, which hosted the Association of African Universities’ (AAU) two-yearly conference of rectors, vice-chancellors and university presidents.
This paper analyses the relationship between physician migration from developing source countries to more developed host countries (brain drain) and the developmental and global health profiles of source countries. Source countries with better human resources for health, more economic and developmental progress, and better health status appear to lose proportionately more physicians than the more disadvantaged countries. Higher physician migration density is associated with higher current physician and public health workforce densities and more medical schools. Policymakers should realize that physician migration is positively related to better health systems and development in source countries. In view of the "train, retain, and sustain" perspective of public health workforce policies, physician retention should become even more important to countries growing richer, whereas poorer countries must invest more in training policies.
9. Public-Private Mix
Global public-private health partnerships, as a means of global health
governance, have become increasingly common. Initially, much was
expected of them but enthusiasm has now waned, with concern raised over
costs and unanticipated consequences. What bad habits impact negatively
on their performance and what actions could make them more effective?
This paper explodes Rand Water’s rhetoric about itself as a promoter of “public” services.The paper discusses the context of changes in public sector management and in the water sector. Rand Water (RW), the biggest public water utility in Africa entering the market on the continent engage in other activities that are beyond its core function of providing bulk potable water to local government in the industrial heartland of South Africa. This report examines the expansion of RW into non-core activities in the period 1994-2006, the rationales offered by RW for that expansion, and deliberates on this expansion in the context of similar activities by other public sector operations both in South Africa and in other countries.
At the inception of Uganda's second 5-year Health Sector Strategic Plan (HSSP II), this paper traces the history of the public - private partnership for health (PPPH) in Uganda, giving its justification and mandate. It also gives its current state of the art, outlining the successes scored, the challenges still faced in its implementation and current efforts being made to make it comprehensively institutionalized. The successes include the bilateral acceptance of the principle and need for partnership by both the public and private partners, the overt gestures by the public partner through direct funding of the private providers, the ceding of some responsibilities to private players and the acceptance by the private players to take on some public responsibilities using their own resources. The challenges include the slow formalization of the partnership, skepticism about autonomy, the stagnation of government funding, the poor understanding of the partnership at sub-national levels and poor sharing of information, among others. These challenges are now further compounded by the recent introduction of new policy reforms like fiscal decentralisation to the same local officials who do not fully appreciate the partnership and are therefore not likely to support it. The paper concludes with some useful suggestions on how these challenges may be tackled.
The Health Sector Strategic Plan (HSSP) aims to ensure access to basic health care by the Ugandan population through the delivery of the National Minimum Health Care Package (NMHCP). This requires availability of well-trained health professionals. This study demonstrates that the Private-Not-For-Profit (PNFP) Health Training Institutions - the majority in Uganda - have remained grossly under-funded, which poses a threat to achievement of the HSSP. They are faced with decreasing income from fees, dwindling donor support and over-dependence on government grants which are both uncertain and erratic. Consequently, vital activities for students' training such as field trips, teaching and reading materials are left unsatisfied as a copying mechanism, but not without negative implications for quality. It is recommended that government increases and guarantees its support to these Health Training Institutions as a way of maintaining quality of health worker training. At the same time, the training institutions need to diversify their funding options to include designing short tailor-made courses, mobilizing alumni contributions, research and consultancies, self-help projects like farming, canteens and stationeries as well as fund-raising activities as a way of bridging their funding gap. This should be coupled with more efficiency mechanisms and prudent management to avoid wastage of the already scarce financial resources.
In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of ART. Subsequently, the government created a mechanism to include private practitioners in rolling out ART. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It is estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year.
10. Resource allocation and health financing
A comparative approach was adopted to study four groups of informal economy operators (cobblers, welders, carpenters, small scale market retailers) focusing on a method of prepayment which could help them access health care services. Two groups with a total of 714 operators were organized to prepay for health care services through a group premium, while the other two groups with a total of 702 operators prepaid through individual premium, each operator paying from his or her sources. Data collected showed that the four groups were similar in many respects. These similarities included levels of education, housing, and social services such as water supplies, health problems, family size and health seeking behaviour. At the end of a period of three years 76% of the members from the two groups who chose group premium payment were still members of the prepayment health scheme and were receiving health care. For the two groups which opted for individual premium payment only 15% of their members were still receiving health care services at the end of three years.
This study highlighted financial difficulty as the major obstacle to obtaining treatment in one province of South Africa. There is evidence in support of providing ARV treatment free of charge to HIV positive patients who qualify, as occurs in other provinces in South Africa. It is also suggested that providing ARV therapy at more local clinics in the community would make treatment more accessible. Provision of several months' supply of medicines per visit would help to reduce transport costs and minimise patient expenditure. These interventions may reduce the incidence of patients lost to follow-up in this community.
11. Equity and HIV/AIDS
Up to $42 billion will need to be found by 2010 if universal access to HIV treatment, prevention and care is to be achieved in line with the 2005 commitment by G8 governments, UNAIDS said today. UNAIDS’ estimate has been developed ahead of an international meeting to win increased donor commitments to the Global Fund to Fight AIDS, TB and Malaria which started on 26 September 2007 in Berlin. The Fund currently accounts for one-quarter of all international donor expenditure on AIDS.
The article argues that people and communities perceive and deal with HIV and AIDS as only one of the many problems and tensions they experience as affecting their well being. It is also noted that the discussion of the issues related to HIV and AIDS and sexuality is blocked by deeply held views that men have about women and sex. This is the reason why the issue of gender is central when discussing with people to determine the health they want and how to manage AIDS. The study team brought together rural youth of 13-25 years and men and women of 26-45 years and used participatory action research methodologies to reflect and exchange information, knowledge and skills on the issues related to gender and HIV/AIDS. This empowering knowledge was useful for launching advocacy for attitude and behaviour change toward risky sexual behaviours and for supporting communities in developing visions of healthy communities the people truly cherish.
A new report suggests that 50% of projected HIV infections by 2015 could be prevented if governments and donors increase their HIV expenditure to UNAIDS target levels and implement prevention programmes that have been proven to work. The Global HIV Prevention Working Group’s report, Bringing HIV Prevention to Scale: An Urgent Global Priority, shows that prevention efforts are not keeping pace with expanding access to antiretroviral therapy. For every person who started effective anti-HIV treatment in 2006, six become newly infected with the virus. It is estimated that there will be 60 million new HIV infections by 2015, but the report suggests that 30 million of these could be avoided if scientifically proven methods of HIV prevention were implemented.
This presentation was made at the 10th Anniversary of the Centre for the Study of Globalisation and Regionalisation Centre at Warwick University; specifically in the session called Challenges of globalisation, regional integration and development of Africa. The presentation systematically dissected the following four key issues surrounding HIV and development challenges for Africa: the absence of one African epidemic (emphasis for each country/region to know epidemic and act on it); upstream effects (adressing structural drivers in Africa, poverty versus income equality, which might be more powerful?); downstream impact (specifically long wave impacts on poverty, GDP, human capital, social capital); and, finally, responding to the interaction between HIV and poverty.
A dramatic 41% decline in HIV prevalence has been reported in pregnant women in Zimbabwe, according to the latest survey done in this population. The results were reported in a poster presentation at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago this week. Previous studies have suggested that HIV prevalence is on the decline among adults in Zimbabwe. This study only looked at pregnant women presenting to the Salvation Army Howard Hospital in the Mazowe district of rural northern Zimbabwe, but dramatically confirmed this decline in prevalence among these women.
The executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) urged action on the transmission of HIV to children through sexual abuse, incest and early teenage sex. Many outreach programmes target HIV-positive pregnant women and young children, and progress is being made in this arena, Peter Piot told IPS during a recent conference at Harvard Medical School in Boston, USA.
12. Governance and participation in health
Despite acknowledged curative and preventive measures, child malaria remains a concern in many countries. Does parental empowerment and participation in control efforts offer a way forward? This review of recent literature suggests a unique approach. Successful interventions met the health promotion strategies wholly or partly. Although these interventions were sometimes incomplete, the development took into account people’s perceptions and representations. The authors acted on the belief that empowerment of parents and their participation in the development of interventions to control child malaria, is likely to yield better results and assist in reducing the prevalence of malaria morbidity and mortality in children under 5 years.
Community participation in health has been an elusive concept since the days of the Alma Ata Declaration. Many faltering steps have been taken towards genuine community participation only to be retraced because the programmes were either ill-conceived or derailed by the loss of the spirit of voluntarism. In Yumbe District of north-western Uganda, Village Health Teams (VHT) have been established in line with the national strategy for community involvement in health. The Yumbe VHT programme has won an award for innovative support to strengthening decentralisation. This paper reviews aspects of the programme outlining its successes and challenges. Its success has been mainly due to integration of pre-existing volunteer cadres, intersectoral approach to the monitoring of the teams and involvement of the community in the selection of the top-up team members. Its challenges include the relatively young age of the majority of the volunteers and the likely loss of financial support for the activities of the volunteers. The paper concludes that the VHT programme is a delicate venture requiring both programme support through intersectoral inputs to the Community Action Plans developed by communities and sociological approaches to educate the communities to support the VHT for its sustainability.
13. Monitoring equity and research policy
Most people in Africa and Asia are born and die without leaving a trace in any legal record or official statistic. Absence of reliable data for births, deaths, and causes of death are at the root of this scandal of invisibility, which renders most of the world's poor as unseen, uncountable, and hence uncounted. This situation has arisen because, in some countries, civil registration systems that log crucial statistics have stagnated over the past 30 years. Sound recording of vital statistics and cause of death data are public goods that enable progress towards Millennium Development Goals and other development objectives that need to be measured, not only modelled. Vital statistics are most effectively generated by comprehensive civil registration. Now is the time to make the long-term goal of comprehensive civil registration in developing countries the expectation rather than the exception. The international health community can assist by sharing information and methods to ensure both the quality of vital statistics and cause of death data, and the appropriate use of complementary and interim registration systems and sources of such data.
Nosocomial transmission of XDR strains seems to have contributed to a major outbreak in HIV-positive individuals in Tugela Ferry, South Africa. To better understand how to control XDR tuberculosis, this issue of the Lancet presents a report of a new mathematical model, developed by Sanjay Basu and colleagues, of the transmission of tuberculosis in this region. Their model builds on previous tuberculosis models, and was corroborated by independently collected epidemiological data for the area. Such mathematical models of tuberculosis can be useful instruments for policymaking because they incorporate a representation of the natural history and transmission of infection and disease, and are the only way to rigorously explore the effects of policies before they are field-tested.
Notions of equity are fundamental to, and drive much of the current thinking about global health. Health inequity, however, is usually measured using health inequality as a proxy - implicitly conflating equity and equality. Unfortunately measures of global health inequality do not take account of the health inequity associated with the additional, and unfair, encumbrances that poor health status confers on economically deprived populations. Using global health data from the World Health Organization's 14 mortality sub-regions, a measure of global health inequality (based on a decomposition of the Pietra Ratio) is contrasted with a new measure of global health inequity. The inequity measure weights the inequality data by regional economic capacity (GNP per capita). The least healthy global sub-region is shown to be around four times worse off under a health inequity analysis than would be revealed under a straight health inequality analysis. In contrast the healthiest sub-region is shown to be about four times better off. The inequity of poor health experienced by poorer regions around the world is significantly worse than a simple analysis of health inequality reveals.
This article covers the opening address of the Tanzanian Minister of Health and Social Welfare at the 22nd Annual Joint Scientific Conference of the National Institute for Medical Research, Arusha Tanzania, 7 March 2007.
As reducing socio-economic inequalities in health is an important public health objective, monitoring of these inequalities is an important public health task. The specific inequality measure used can influence the conclusions drawn, and there is no consensus on which measure is most meaningful. The key issue raising most debate is whether to use relative or absolute inequality measures. Our paper aims to inform this debate and develop recommendations for monitoring health inequalities on the basis of empirical analyses for a broad range of developing countries.
WHO publishes the first internationally agreed upon classification code for assessing the health of children and youth in the context of their stages of development and the environments in which they live. The International Classification of Functioning, Disability and Health for Children and Youth (ICF–CY) confirms the importance of precise descriptions of children's health status through a methodology that has long been standard for adults. Viewing children and youth within the context of their environment and development continuum, the ICF–CY applies classification codes to hundreds of bodily functions and structures, activities and participation, and various environmental factors that restrict or allow young people to function in an array of every day activities.
14. Useful Resources
While health systems constraints are increasingly recognized as primary barriers to the scaling up of health services and achievement of health goals, knowledge regarding how to improve health systems is often weak and frequently not well-utilized in policy-making. 'Sound Choices' seeks to better understand and address the capacity constraints in the field of health policy and systems research.
SALC announces the establishment of an HIV/Aids Programme under the direction of Project Lawyer, Priti Patel. The effect of HIV/Aids in the southern Africa region has been catastrophic. As of 2006, more than 30% of all people living with HIV resided in Southern Africa. The promotion and protection of fundamental human rights is critical to stemming the spread and impact of HIV/Aids on individuals and communities. The failure to comply with human rights standards aids in the spreading of HIV and magnifies the negative impact of the disease on communities.
15. Jobs and Announcements
Participants are encouraged to submit abstracts that present concrete and innovative projects, case studies, and direct field/personal experiences relevant to the improvement of global access to health, and more specifically the 2008 theme: ‘Strengthening of Health Systems and the Global Health Workforce’. Preference will be given to abstracts that promote systemic approaches to the problems posed. Abstracts must fall under one of the following categories: Health Services Delivery Equity and Social Issues Patient- and People-Centred Initiatives The Global Health Workforce and Migration Health Research and Policy Health Financing The Role of Universities, Hospitals, and Training Institutions Health Technologies, Health Information, and Biotech Medicines, Vaccines, and Diagnosis. The deadline for submission of abstracts is 15 January 2008.
This analysis has been developed keeping in mind the responsibilities of States, many of its elements are also instructive in relation to the responsibilities of non-State actors, including pharmaceutical companies. The draft Guidelines are grouped into overlapping categories; at the beginning of each group, there is a brief italicised commentary signalling some of the elements of the right-to health analysis that are especially relevant to that category. Importantly, the present Guidelines remain a draft. Comments on this draft are invited and should be sent as soon as possible - and before 31 December 2007.
A call is now made for submission of abstracts for presentation during the First Global Forum on Human Resources for Health. The abstracts should present experiences, lessons learnt and/or other intriguing new information that contribute to the achievement of the forum objectives and should be developed under any of the following Forum Themes: Leadership Education, Training and Skill mix, Migration and Retention, Financing, Management, Partnerships and linking up for action. Abstracts should be submitted to the Forum Organizing Committee (FOC)via email by 31 December 2007.
Sur Journal welcomes contributions to be published in a Special Issue of Sur – International Journal on Human Rights on Intellectual Property and access to medicine. The Journal aims at disseminating a Global Southern perspective on human rights and to facilitate exchange among professors and activists from the Global South without disregarding contributions from other regions. For the next issue, they will prioritize articles which, preferentially but not exclusively, address the following topics related to the debate of intellectual property and access to medicine: Alternative models to stimulate innovation; The impact of Intellectual Property on medicines for neglected diseases; Implications of the adoption of compulsory licenses; Best practices on guaranteeing access to medicine; The Judiciary role in the promotion of access to medicine. Closing date for submissions is 3 December 2007.
The Acacia and Connectivity Africa Initiative goals are to empower sub Saharan communities with the capacity to apply information and communication technologies to their own social and economic development and to improve access to information and communication technologies in Africa, particularly in the sectors of education, health, agriculture and community development. This initiative is designed as an integrated program of research and development with demonstration projects that address issues of applications, technology, infrastructure, policy, and governance. Based at the IDRC head office in Ottawa, Canada, the Program Manager directs the overall development and implementation of its strategic and operating plans and establishes contact with national and international agencies and governments to: develop new partnerships and strengthen existing ones; strengthen and increase fundraising and donor support; and to work towards the achievement of the CCA’s programmatic objectives. The closing date for applications is 18 November 2007.
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) through technical support from Training and Research Support Centre (TARSC). Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org
Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles.
Please contact editor@equinetafrica.org immediately regarding any issues arising.