One by one in December, African countries in east and southern Africa signed interim Economic Partnership Agreements (EPA’s) with the European Union (EU). In a massive fragmentation of regional integration, first these agreements were negotiated in configurations that undermined African regional trading blocks (See EQUINET newsletter editorial May 2007). In November the fragmentation deepened as the east African countries broke from the ESA block to sign interim EU-EPA’s, as did Mauritius, Seychelles, Botswana, Swaziland, Mozambique, Madagascar, Zimbabwe and Namibia, individually. At the same time at the EU – Africa summit in Lisbon in December President Abdoulaye Wade of Senegal said "We are not talking any more about EPAs, we've rejected them", while countries like Namibia signed, but signalled intention to keep negotiating on protections for fledgling industries.
Its not only from Africa that conflicting signals are being sent. From the EU there is stated commitment to the two central goals of the 2000 "Cotonou Agreement": to eradicate poverty and to enhance the gradual integration of African, Caribbean and Pacific countries into the global economy. The EU has signed on to numerous UN and G8 commitments, including those on the Millennium Development Goals, and its own Treaty of Amsterdam. These commit the EU to policy coherence between development objectives and impacts and its policies in other areas, including trade. At the same time the interim EPAs being concluded are clearly focused on establishing free trade agreements strictly compatible with World Trade Organisation (WTO) requirements. While there is some reference to development issues, this is secondary and largely deferred to later dialogue.
Take for example the protection and promotion of public health as a fundamental issue not only for the MDGs, but in the International Covenant on Economic, Social and Cultural Rights (ICESR) (1976) and particularly Article 12. All parties to the agreement have ratified this convention. The EU founding document, the Treaty of Amsterdam commits that “A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities”. The African Charter on Human and Peoples’ Rights (1986) in Article 16, obliges ESA countries to take the necessary measures to protect the health of their people.
Despite this the Interim EPA texts made available in the region:
• Make no mention, as WTO agreements do, of the fact that clauses should be interpreted and implemented in a manner supportive of countries’ right to protect public health.
• Make no provisions for ESA countries to protect their infant industries, especially in small enterprises and in the small scale farming sector that underpins household food security and child nutrition in Africa.
• Make no exceptions to the elimination of import or export prohibitions or trade restrictions in areas such as trade in health workers, health services, essential services and other areas where governmental authorities and restrictions on trade are necessary to regulate provisioning or redistribute resources to meet social development goals, or to protect public health.
• Make no exceptions in clauses relating to internal taxes or charges in the interests of public health.
• Make no reference to “human development” or “social development” in the objectives of the section on economic and development co-operation
• Set no obligations for administrative arrangements or resources to assess or manage the public health implications of the liberalised trade measures proposed, including of obligations to carry out prior health impact assessments of specific areas of trade where there is a likelihood of risk to public health.
Such failure to address human development issues has led to criticism that the current EPA texts do not align with the 2006 adopted European Consensus on Development (2006/C 46/01) or the 2005 adopted EU measures to accelerate the progress towards attaining the MDGs [COM(2005) 132/final 2, COM(2005) 133/ final 2 and COM(2005) 134 final].
While there is pressure to secure WTO compatible agreements, the detailed tariff reduction commitments in the interim EPAs are argued to go beyond the strict demands of multilateral rules for the WTO-compatibility of free trade agreements, with costs to ESA countries. Gains from greater exports to the EU could be overshadowed by the damage done by the largely reciprocal market openings that ACP countries would have to undertake. The interim agreement accessed provides for 80% liberalisation in a period of 15 years. This would allow subsidised European food products, with which local producers would be in no position to compete, to effectively swamp ESA markets. Under the interim deals with East Africa, for example, taxes on two-thirds of imports from the EU would be eliminated with negative consequences for government revenue.
Such agreements are being signed at a time when the Doha Round on development is not yet concluded at the WTO, with Article 24 of GATT still being negotiated. Signing an interim EPA may pre-empt, or worse still weaken these WTO level negotiations. Reminiscent of the days of Structural Adjustment, it has been said that “there is no alternative” to the current trade focused EPAs. But trade experts indicate that alternatives do exist. Beyond significantly greater protection of human development issues in the EPAs’ as exemplified for health above, trade experts suggest that the EU could also have offered alternative trading arrangements under its Generalised System of Preferences (GSP+), particularly given the level of economic poverty and vulnerability in most ESA countries. It was possible for the EU to seek an extension of the waiver at the WTO, particularly given the delay in resolving the Doha round on development, given its significance for Africa. These options were not pursued, suggesting, as noted in an October 2007 analysis by the NordikAfrica Institute, that the primary EU goal for the EPAs was to secure free trade agreements within a strict interpretation of WTO rules.
The interim EPAs send signal an understanding of development and poverty reduction as being essentially driven by trade liberalisation, with development aid as a means of coping with the temporary, negative impacts of this agenda. It suggests that development will follow trade liberalisation and thus that other aspects of development should adjust to the terms of this free trade focused interim EPA.
The singular prioritisation of trade liberalisation, even while argued as “interim” fails to adequately protect basic social rights, such as the rights to health noted earlier. It also fails to adequately meet the EU’s own commitments and treaties and to draw on the EU’s own development experience, and the regulation and subsidies used in the EU to promote industrial and social development and services.
It also contradicts analysis and experience in ESA. After two decades of trade liberalisation policies, Africa Union and UN Economic commission for Africa reports in 2007 highlight uneven growth and growth with poor returns to human development and poverty reduction. Rapid, wide trade liberalisation policies have been associated with falling public revenues, increasing dependency on food imports, increased chronic undernutrition, reduced coverage and quality of and access to essential services, including health care services. In the health care sector, trade liberalization increases growth in formal and informal for profit health care services, with negative impacts on access, quality and segmentation in services, and increased fee barriers to care. Even the World Bank in a 2002 working paper concluded that rapid trade-related integration in Africa had caused or exacerbated social inequality and that those who benefited most were the import/ export firms, transport and shipping companies, large-scale commercial farmers, and financiers and the politicians and bureaucrats who are tapped into these commercial and financial circuits.
A model of development that is driven first through trade liberalization, with later “development” adjustments, negates the lived and historical experience, documented evidence and policy demands of Africa and of many development actors in the EU. Trade Commissioner Peter Mandelson said at a speech to the Civil society Dialogue Group in January 2005, “… I intend this to be a new start for the EPAs – to give the negotiations a new impetus – and to ensure that from now on, until the final implementation of what we will negotiate by 2008, development concerns have pride of place” . It appears his “pride of place” was the same marginalized exclusion the majority of disadvantaged communities in Africa occupy.
The process is not yet over. Some countries have yet to sign. For others, the interim agreements signed in 2007 still need to be ratified and deemed domestically operational, a process that will take to July 1 2008. Ratification in many ESA countries requires parliamentary endorsement. Could the parliaments in Africa and in the EU bring new “people’s” voice to this process and to future negotiations on the EPAs, and with it new attention to the health and development concerns?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit EQUINET www.equinetafrica.org. or SEATINI (www.seatini.org)
1. Editorial
Civil society and communities should have a far greater direct involvement in the implementation of HIV and AIDS programmes for them to have a meaningful impact. This calls for an effective mechanism to channel funding to support and strengthen the capacity of civil society organisations. This was the resounding consensus at the Civil Society, HIV/AIDS and Africa: capacity, sustainability, partnerships conference being held in Johannesburg, South Africa from December 5 to 7. The meeting was co-hosted by the International HIV/AIDS Alliance and the UK Government's Department for International Development, and co-organised by UNAIDS and the Global Fund to Fight AIDS, TB and Malaria.
‘We need a shift in the way civil society relates to universal access and away from a lesser role to being an equal partner in the implementation of national strategies,’ Mark Stirling, UNAIDS' director for the regional support team for Eastern and Southern Africa, said at the opening ceremony of the conference. Stirling said Southern Africa in particular was hamstrung by bottlenecks that currently translated into an average of more than 80% of interventions falling behind targets to achieve universal access by 2010. There therefore needed to be a properly planned response to significantly ramp up the capacity and participation of civil society organisations to fill this gap.
‘We need funding models to move away from the status quo, and need a quantum shift for an effective response,’ Stirling said. The Chair of the International HIV/AIDS Alliance's Board of Trustees, Callisto Madavo, noted that good models exist for channelling money to support community-based responses, and these need to be expanded: ‘We have many examples of successful models and it is imperative that these experiences are shared so that we can accelerate our responses.’
Madavo said that ‘the most successful responses to HIV and other development challenges are built on local leadership, commitment and responsibility’. As communities are closest to people affected by HIV and often make the first response in addressing HIV, ‘without the active and influential participation of communities there is a real danger that the increased funding now available for HIV could not be well spent and not reach those most in need’. He said this could only be overcome through changes in policies and approaches that incorporated the experience over the past two years.
One of the major funders of HIV and AIDS programmes, the Global Fund, wants to encourage more civil society organisations to be amongst the principal recipients of their funding. Principal recipients are local stakeholder institutions (and there can be more than one in a country) who co-ordinate partnership, provide technical leadership, manage funds and monitor, evaluate and report on programmes. Christopher Benn, the Global Fund's executive director of external relations indicated that change was needed to ‘make sure that civil society is a principal recipient in more countries’. He added that the perception that funds for HIV programmes was drying up was unfounded and that ‘unprecedented’ resources were available. He said that $10-billion had been pledged for the Fund, while PEPFAR was expected to announce the extension of its mandate, to the tune of $30-billion over the next two to five years. Therefore, he said, the availability of resources was not the most critical issue, instead ‘capacity building for scaling up responses is the most critical, and we need to scale up dramatically.’
Although the Global Fund recently approved a budget of US$1,1 billion in Round 7 of funding proposals, only 50% of proposals had been approved and there were concerns about implementation capacity: ‘I hope we don't find ourselves in a position where we had the resources, but could not implement them,’ Benn said.
While the conference provided success stories of civil society roles in effectively reaching communities, both funding organisations and civil society need to take on the challenges of channelling resources to community level on a vastly increased scale. As Madavo indicated, ‘A consensus seems to be emerging on a new paradigm for effective capacity development centred on building effective states and forging engaged societies. The challenge is to unleash, nurture, and retain capacity. That requires a political environment that encourages participation, excellence, learning, and innovation. The new paradigm for capacity development emphasises the dual objectives of building effective states and forging engaged societies.’ And the conference also had a resounding consensus on the test for how successful new approaches are – that they effectively channel resources to communities, where they are most needed for the response to HIV.
The International HIV/AIDS Alliance, established in 1993, is a global partnership of nationally-based organisations working to support community action on AIDS, support south-south co-operation, and undertake operations research, training and good practice development and policy analysis and advocacy. They can be contacted via their website at http://www.aidsalliance.org/. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
2. Latest Equinet Updates
Call for registration for and abstracts of research and practice by January 29 2008.
The first National meeting on Equity in Health in Uganda will be hosted by the HEPS Uganda – Coalition for Health Promotion and Social Development and Makerere University in co-operation with Regional Network on Equity in Health in East and Southern Africa (EQUINET). The meeting will bring together researchers, policy-makers, practitioners and others concerned with equity in health to exchange information and develop an agenda of follow up work to support health equity in Uganda. People interested in attending the Conference are invited to notify the organizing Committee and submit an abstract by January 29th preferably by email to heps@utlonline.co.ug and copy to admin@equinetafrica.org or to HEPS-Uganda P.o Box 2426, Kampala.
This study reviews the Zambian deprivation-based health resource allocation formula and assesses how such a formula has been implemented in terms of achieving the initial desired goals of resource – re-distribution. It further considers the extent of converge or divergence in the equity goals relating to resource re-distribution through the allocation of funding to the districts.
There are large disparities in the health care resources available to different districts, regions and provinces within individual countries. Using a resource allocation formula, that is based on indicators of the relative need for health care within each geographic area, has been found to be helpful in overcoming historical allocation patterns. This report, implemented under the fair financing theme in the Regional network for equity in health in east and southern Africa (EQUINET) assesses whether there has been progress towards equitable resource allocation in four Southern African countries which have adopted such formulae (Namibia, South Africa, Zamibia and Zimbabwe). Researchers in Namibia, South Africa, Zambia and Zimbabwe provided information on implementation progress in their countries.
The Law of Faculty, Makerere University in EQUINET and are carrying out a commissioned review of the Public Health Laws in Kenya, Uganda and Tanzania in relation to policy areas relevant to equity in health. This study will outline for the three countries coverage and gaps to be addressed in law and where relevant, in the enforcement mechanisms; and identify areas for follow up stakeholder consultation and research. The researchers are requesting for published or grey literature on this area of focus. Please contact the principal researcher Mulumba Moses, mulumba_moses@yahoo.com
3. Equity in Health
It is now commonly admitted that the so-called (most) neglected tropical diseases have been given little attention. According to World Health Organization, neglected diseases are hidden diseases as they affect almost exclusively extremely poor populations living in remote areas beyond the reach of health service. The European Parliament recognised that Neglected Diseases have not received the attention they deserve from EU actions or in the Millennium Development Goals. Investing in drugs for these diseases is thought to be not marketable or profitable. However, despite their low mortality, neglected diseases are causing severe and permanent disabilities and deformities affecting approximately 1 billion people in the world, yielding more than 20 millions of Disability Adjusted Life Years (56.6 million according to Lancet's revised estimates) and important socio-economic losses. Urgent pragmatic and efficient measures are needed both at international and national levels.
Social networks have been a central focus of sociological research on inequalities but less has focused specifically on chronic illness and disability despite a policy emphasis on resources necessary to support self-management. This seeks to unpack overlaps and distinctions between social network approaches and research on the experience and management of chronic illness. It outlines four main areas viewed as central in articulating the potential for future work consistent with a critical realist perspective: (1) body–society connections and realist/relativist tensions; (2) the controversy of ‘variables’ and accounting for social and cultural context in studying networks for chronic illness support; (3) conceptualising social support, network ties and the significance of organizations and technology; and (4) translating theory into method.
4. Values, Policies and Rights
This Resource Guide brings together two of the Open Society Institute’s largest priorities: public health and numerous law and human rights initiatives.
This publication covers ten reasons why human rights should occupy the centre of the global AIDS struggle. This declaration, endorsed by 24 nongovernmental organisations and networks around the world, affirms that, now more than ever, human rights should occupy the center of the global struggle against HIV and AIDS.
This volume provides an evidence and rights-based approach to monitoring the well-being of children and adolescents in South Africa. Drawing on international precedents, and extensive peer review processes, experts in various fields have developed this holistic set of indicators to enhance the monitoring of the status of children.
This research report highlights the lack of priority given to tackling gender-based violence against women by the major international HIV funding organisations. The research found that the funding bodies continue to treat violence against women as a supplementary issue rather than as something integral to all aspects of their work on HIV. Funding for programmes which combat gender-based violence is a separate stream and these initiatives have not benefited from the increase in funding for HIV programmes in the last number of years. It is very difficult to track the exact amount of money the major funding bodies are devoting to these initiatives and difficult to hold them accountable on this issue. The report recommends that these institutions develop a clear policy framework that gives priority to violence against women and girls, and the link with HIV.
5. Health equity in economic and trade policies
This study is one further contribution of the ICTSD Programme on Intellectual Property Rights (IPRs)and Sustainable Development to a better understanding of the proper role of intellectual property in a knowledge-based economy. The objective of the study is to generate and expand understanding of the policy of the EU regarding IPRs in bilateral and regional trade agreements. Additionally, it attempts to evaluate the impact of IP provisions proposed by the EU at a critical phase of EPA negotiations.
This Joint Strategy, which will provide an overarching long-term framework for Africa-EU relations, will be implemented through successive short-term Action Plans and enhanced political dialogue at all levels, resulting in concrete and measurable outcomes in all areas of the partnership. The purpose of this Joint Strategy is to take the Africa-EU relationship to a new, strategic level with a strengthened political partnership and enhanced cooperation at all levels. The partnership will be based on a Euro-African consensus on values, common interests and common strategic objectives. This partnership should strive to bridge the development divide between Africa and Europe through the strengthening of economic cooperation and the promotion of sustainable development in both continents, living side by side in peace, security, prosperity, solidarity and human dignity.
The EU and the ACP countries aim to conclude the Economic Partnership Agreements (EPAs) by the end of December 2007. All parties agree that these trading arrangements are meant to be first and foremost “development instruments”. However, their positions differ greatly on how the EPAs will impact on the ultimate goal of poverty reduction. In this policy note Marikki
Stocchetti addresses the key issues of this disagreement.
Have traditional restrictive macroeconomic policies and budget ceilings limited some governments from giving HIV and AIDS the attention it deserves? This paper analyses the links between macroeconomic frameworks provided by the International Financial Institutions (IFIs) and HIV/AIDS social spending in Ghana and Malawi. Authors stress the need for a fundamental shift in the design and execution of the macroeconomic framework and propose policy recommendations.
6. Poverty and health
Malawi hovered for years at the brink of famine. After a disastrous corn harvest in 2005, almost five million of its 13 million people needed emergency food aid. But this year, a nation that has perennially extended a begging bowl to the world is instead feeding its hungry neighbors. It is selling more corn to the World Food Program of the United Nations than any other country in southern Africa and is exporting hundreds of thousands of tons of corn to Zimbabwe. In Malawi itself, the prevalence of acute child hunger has fallen sharply.
In Africa, national governments and international organizations are focusing on rapidly "scaling up" malaria control interventions to at least 60 percent of vulnerable populations. The potential health and economic benefits of "scaling up" will depend on the equitable access to malaria control measures by the poor. This paper analyses the present inequalities in access to malaria interventions in Malawi. The present distribution strategies for ITNs are not addressing the needs of the vulnerable groups, especially the poor. Increasing access to ITNs by the poor will require innovative distribution models which deliberately target the poorest of the poor.
There is a growing concern within the international development community that policies aimed at reducing the number of people living below the poverty line could leave the most disadvantaged groups behind. In line with these concerns, this dossier looks at different strategies for reaching the very poor within the health sector, and at the institutional challenges associated with scaling up health-related interventions to cover broader segments of the population. It also highlights the fact that there are ways outside the health sector to improve health or reduce the impoverishing impact of disease, and that in some contexts these may benefit the poor most.
7. Equitable health services
This study investigates contextual factors associated with treatment-seeking behaviour and higher-risk sexual conduct of men symptomatic of sexually transmitted infections (STIs) in Botswana. At the heart of Botswana's epidemic lies men's reluctance to seek medical treatment, engaging in unprotected sex, and having sex with multiple partners while symptomatic of an STI. The odds of engaging in unprotected sex while symptomatic of an STI were significantly higher among teenage males, males in urban households, where age differences between partners was higher, in married men and men with more than one sexual partner. Having sought medical treatment from hospitals, clinics and health workers, as opposed to consulting traditional healers, significantly reduced the odds of having had unprotected sex while infected with an STI. The results indicate the need to encourage men to utilise public healthcare services. The public health sector in Botswana needs to provide healthcare services that are user-friendly for men. Special attention needs to be paid to boys' socialisation towards gender norms, and men are to be encouraged to play a responsible role in HIV prevention.
This paper assesses strategies to promote child development and to prevent or limit the loss of development potential. The programmes reviewed have been implemented in developing countries since 1990. Thirty-five such studies were identified of which 20 met the researchers’ criteria. They fell into three groups: centre-based early learning, parenting and parent-child programmes, and comprehensive programmes that include health and nutrition interventions. The researchers identify factors that are consistently associated with effective programmes and identify a need to establish globally accepted monitoring indicators for child development and for more evaluation. They conclude with a discussion of priorities and crucial issues for future programmes.
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-utilised in policy-making. This Review addresses a mismatch between what is known about how to respond to particular health problems in poor economies and what is actually done about them. It focuses on one cause of the problems that ensue from the mismatch – capacity constraints.
“Disparity” implies the existence of a “markedly distinct in quality or character,” difference between one group and another. Some groups, due to elevated stigma associated with group membership, are invisible as a disparate minority and therefore, while there may be a great inequity in healthcare between that group and the normative population, the invisible minority is ignored. This chapter addresses the issue of healthcare for the transgender-identified population. It addresses how the normative viewpoint of mental illness and unacceptable religious status, along with lifelong perceived and actual abuse and violence, creates a socially sanctioned inequality in healthcare for this population.
8. Human Resources
This paper, prepared for the International Consortium for Research on Equitable Health Systems, provides an overview of the concepts and practice of Community Health Workers (CHWs) in several developing and developed countries. In doing so it identifies critical factors that influence the overall performance of CHWs including gender, the nature of employment, career prospects and incentives, educational status and training. It finds that the selection of CHWs from the communities that they serve, population coverage and the range of services offered at the community levels are vital in the design of effective CHW schemes. The smaller the population coverage, the more integrated and intensive the service offered by CHWs.
This study examines the opinions of health professionals about the capacity and performance of the 'tecnico de cirurgia', a surgically trained assistant medical officer in the Mozambican health system. Particular attention is paid to the views of medical doctors and maternal and child health nurses. Health workers at all levels voiced satisfaction with the work of the "tecnicos de cirurgia". They stressed the life-saving skills of these cadres, the advantages resulting from a reduction in the need for patient referrals and the considerable cost reduction for patients and their families. Important problems in the professional status and remuneration of "tecnicos de cirurgia" were identified. This study, the first one to scrutinize the judgements and attitudes of health workers towards the "tecnico de cirurgia", showed that, despite some shortcomings, this cadre is highly appreciated and that the health delivery system does not recognize and motivate them enough. The findings of this study can be used to direct efforts to improve motivation of health workers in general and of tecnicos de cirurgia in particular.
The movement of people across and within borders has characterised the development of most global regions, resulting in a rich intermingling of cultures. Such movement is often motivated by the desire for a better life, whether this entails finding new land to cultivate or money making opportunities. In recent years, the process of movement has itself been simplified, opportunities for work in services and industry have boomed and globally, numbers of migrants have increased dramatically . In response, an increasing number of studies are emphasising the impacts of migration, particularly for developing countries, in the form of remittances - money sent by migrant workers back to communities and households. This key issues page looks at some of these perceived impacts, and provides recommendations for further reading on the subject of migration and remittances.
Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries. In nine countries, numbers of NPCs equalled or exceeded numbers of physicians. In general NPCs were trained with less cost than were physicians, and for only 3–4 years after secondary school. All NPCs did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many NPCs were recruited from rural and poor areas, and worked in these same regions. Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes.
Insufficient progress is being made towards the Millennium Development Goals, including those dealing with child and maternal mortality. At the current rate of progress in sub-Saharan Africa, the target of a two-thirds reduction in child mortality by 2015 will only be reached in 2165. Renewed interest in the potential contribution of community health workers may be timely. Evidence suggests that over sixty percent of deaths in children under-five years could be prevented by interventions already in existence. Studies show that 41–72 percent of deaths in newborns are preventable using available interventions if there is high coverage, and about half of this reduction may be possible using community-based interventions. This study reviews the literature for evidence of whether community health workers are capable of carrying out the tasks required of them as part of a sustainable workforce. It concluded that several factors influence programme impact and sustainability and determine whether child death reductions can be realised on a national scale: national socio-economic and political factors, community factors, health system factors and international factors. For instance, particularly if the political context is not a participatory democracy, support within the community for community health workers may be undermined by social class and caste divisions.
9. Public-Private Mix
The paper argues that there is potential for pharmaceutical companies to contribute more substantially and effectively towards increasing access to medicines for poor people in developing countries. This is yet to be achieved because their approaches have been ad-hoc, and they have failed to deliver sustainable solutions or adopt appropriate strategies. Oxfam recommends that the industry must put access to medicines at the health of its decision-making and practices. This is both a more sustainable long-term business strategy and would allow the industry to better play its role in achieving the universal right to health.
The rapid growth of the private health sector in low-resource countries is widely recognized. Private providers commonly deliver a substantial proportion of health services in most settings, particularly outpatient primary care, that include reproductive health services. Whether the reason is convenience,proximity or the perceived higher quality and confidential nature of private healthcare providers, the fact remains that a considerable number of women turn to the private sector for their reproductive health needs. This Guidance Note is based on the proceedings of the meeting and offers policymakers and researchers the latest evidence on private-provider networks and franchises, lessons learned in the field, and policy recommendations on how to mobilize private-provider networks and health franchises to help address reproductive health care needs in developing countries.
Access to health care is a complex issue of constitutional significance. There are significant numbers of people in South Africa who do not have adequate access to health services due to geographical, financial, physical, communication, sociological (such as unfair discrimination and stigmatisation)and other barriers. Access to medical schemes is diminishing in real terms. Medical schemes provide financing for almost 7 million people but over the years membership figures have declined as a percentage of the general population. This is due in part to major increases in non-health expenditure by medical schemes on items such as administration and brokers fees. This Charter commits to move towards a coherent, unified health system offering financial protection for all the population in accessing a nationally affordable package of health care at the time of need and to improve access to health care services.
The 2007 edition of the South African Health Review focuses on broad areas with respect to the role of the private health sector i.e. oversight, pooling of resources and purchasing of health care, delivery of health care services and health and related indicators.
10. Resource allocation and health financing
This article assesses the effectiveness of conditional cash transfers in improving access to and use of health services, as well as improving health outcomes, in low- and middle-income countries. The article provides a description of interventions in Mexico, Nicaragua, Columbia, Honduras, Brazil and Malawi. It finds that overall conditional cash transfer programmes are effective in increasing the use of preventive services. Their effect on health status is less clear as the supply of adequate and effective health services is also an important factor.
The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.
This paper compares the welfare effects of a community based insurance scheme - the Community Health Fund (CHF) - and user fees for public health care in Tanzania. Under the CHF, households pay a predetermined fixed annual premium for free access to public health facilities. The paper summarises the controversies and achievements of user fees in poor countries and Tanzania in particular. The discussion focuses on two issues: whether user fees are better than insurance schemes in public health care financing, and whether it is possible to charge for public health services and at the same time achieve universal access to these services.
This paper re-examines the efficiency-based arguments for optimal health insurance, extending the classic analysis to consider optimal coverage for prevention and treatment separately. The paper considers the tradeoff between individuals’ risk reduction on the one hand, and both ex ante and ex post moral hazard on the other. The authors demonstrate that it is always desirable to offer at least some insurance coverage for preventive care if individual consumers ignore the impact of their preventive care on the health premium. Using a utility-based framework, they reconfirm the conventional tradeoff between risk avoidance (by risk sharing) and moral hazard for insuring treatment goods. Uncompensated losses that reduce effective income provide a new efficiency-based argument for more generous insurance coverage for prevention and treatment of health conditions. The optimal coinsurance rates for prevention and for treatment are not identical.
Save the Children called on African leaders to fulfil their promises made in Abuja in 2001 to spend at least 15% of their annual budgets on health. In the briefing ‘Not another one, not another day’ they look at how African governments, despite commitments in 2001 and 2005, still aren’t spending enough on health. It also shows that the EU is failing to support the development of health systems in Africa, with most member states still falling short of their commitment to spend 0.7% of their gross national income on aid. It includes a list of recommendations to get the AU and EU back on track to meet the Millennium Development Goals.
This paper estimates the impact of South Africa’s Child Support Grant (CSG) on child nutrition as measured by child height-for-age. It finds that large dosages of CSG treatment early in life significantly boosts child height. While income transfers such as those of the CSG should help immediately to redress poverty, the question remains whether they help facilitate a longer-term pathway from poverty. One way that they might contribute to this goal is by enhancing the durable human capital stock of the next generation. These estimated height gains observed in the case of South Africa suggest large adult earnings increases for treated children and a discounted rate of return on CSG payments of between 160-230 per cent.
11. Equity and HIV/AIDS
This report from the World Health Organization (WHO) and UNAIDS contains revised estimates of the number of people with HIV globally. Estimates of the total number of people infected with HIV fell from 39.5m in 2006 to 33.2m in 2007, a reduction of 16 percent. This reduction was mainly due to a change in the method used to measure the size of the epidemic, rather than trends in prevalence or incidence. The biggest drop came from a reassessment of India’s epidemic, with other important revisions being made in Angola, Mozambique, Nigeria, Kenya and Zimbabwe.
This article expresses concern about whether a reauthorised PEPFAR would ramp up prevention efforts. President Bush's target of preventing 12 million new HIV infections means lowered sights in the second five years, as PEPFAR's original goal had been to prevent 7 million new infections in five years. Advocates are now campaigning for the increase to $55 to $60 billion.
This paper is a response to a growing vision of schools as sites of care and support for vulnerable children in the context of HIV and AIDS. The paper is based on a desk review of projects working in schools on HIV and AIDS and document review of a project in a province of South Africa. The authors outline education policies in South Africa related to the care and support of vulnerable children in the context of HIV and AIDS. The misalignment between the policies around schools and vulnerable children, the resourcing of these policies, and their contexts of implementation is brought into relief, as well as the implications for thinking about expanded roles for schools and teachers. The paper offers possible ways forward in considering the role of schools in the context of HIV and AIDS. These include new ways of thinking about resourcing, proper monitoring and evaluation of projects, and a focus on quality teaching and learning.
Children contract HIV infection largely through vertical transmission and are vulnerable to AIDS illness due to an immature immune system. In South Africa, hospitals are often overburdened and thus children with HIV may be directed to the community for care. As a result, non-professional caregivers are a predominant source of care for children living with HIV. Various authors, including the Department of Health, have stipulated the importance of establishing the knowledge and needs of non-professional caregivers of children with HIV. Our research has investigated the extent of non-professional caregivers' knowledge and needs, specifically those within the Potchefstroom district of the North-West Province. The objectives included formulating guidelines for a training programme that can enhance relevant knowledge and skills among these caregivers. Quantitative data were gathered using a questionnaire, which was developed following a literature study. The 109 non-professional caregivers who responded to the questionnaire displayed some knowledge and skills concerning specifically the care of children with HIV or AIDS, although gaps existed concerning their knowledge of community-based referral, caring needs specific to children, and precautionary measures to prevent HIV transmission. Recommendations are made with specific reference to a training programme. We surmise that non-professional caregivers play a pivotal role in the care of children with HIV in the Potchefstroom district — a service that is sometimes rendered in perilous conditions. This study improves our understanding of the support and training needed for non-professional caregivers in their pursuit to care for children with HIV in resource-limited communities, and thus it contributes to the field of nursing science. The findings may generate ideas for future research on this important topic.
This study explores the social representations of HIV and AIDS that circulate among white women teachers in South Africa, a group whose personal risk of the disease is low but who have a major role to play in shaping attitudes to HIV/AIDS among children and young people. The study examines how white women talk about the origin and causes of the spread of HIV in South Africa and their personal and community risk. This was explored through 25 semi-structured interviews and two focus groups with white female teachers in Johannesburg. A thematic analysis of the in-depth interviews revealed a shared private understanding of the disease, wherein the women distanced themselves by anchoring it in the context of racist cultural stereotypes of black sexuality and vulnerability. In contrast, the focus group discussions revealed a type of public talk in which HIV/AIDS is anchored in the contemporary cultural images of the new South Africa and the spirit of ubuntu or togetherness. These contradictory views reflect the racial tensions and social contexts of South Africa and which shape HIV/AIDS discourses. The findings suggest that more needs to be done to create a genuine understanding of HIV and AIDS within contemporary South African contexts.
This paper explores the nature of HIV/AIDS education and information networks in Malawi, with a focus on Dedza district. We consider the role of institutional and personal actors involved in Malawi's recently instated and decentralised behaviour-change intervention strategy, as well as the form and function of interpersonal social networks that mediate this information. The research reveals that the organisational capacity of actors and the conflicting messages regarding promotion of condom use may prevent Malawi from achieving a coordinated and effective decentralised response to the HIV epidemic. The research shows that individuals draw on complex interpersonal social networks, often processing mixed messages regarding HIV prevention strategies and receiving negative messages regarding condom use. The paper discusses the implications of such inconsistencies and conflicts with actors, interpersonal social networks and the nature of the messages themselves for HIV/AIDS education in Malawi.
This narrative review evaluates: 1) viral factors, in particular the aggregation of subtype-C HIV infections in Southern sub-Saharan Africa; 2) host factors, including unique behaviour patterns, concomitant high prevalence of sexually transmitted diseases, circumcision patterns, average age at first marriage and immunogenetic determinants; and, 3) transmission and societal factors, including levels of poverty, degrees of literacy, migrations of people, extent of political corruption, and the usage of contaminated injecting needles in community settings. HIV prevalence data and published indices on wealth, fertility, and governmental corruption were correlated using statistical software. The high prevalence of HIV in Southern sub-Saharan Africa is not explained by the unusual prevalence of subtype-C HIV infection. Many host factors contribute to HIV prevalence, including frequency of genital ulcerating sexually transmitted infections, absence of circumcision and immunogenetic loci, but no factor alone explains the high prevalence of HIV in the region. Among transmission and societal factors, the wealthiest, most literate and most educated, but also the most income-disparate, nations of sub-Saharan Africa show the highest HIV prevalence. HIV prevalence is also highest within societies experiencing significant migration and conflict as well as in those with government systems experiencing a high degree of corruption. The interactions between poverty and HIV transmission are complex. Epidemiologic studies currently do not suggest a strong role for the community usage of contaminated injecting needles. Areas meriting additional study include clade type, host immunogenetic determinants, the complex interrelationship of HIV with poverty, and the community usage of contaminated injecting needles.
Attitudes to voluntary counselling and testing (VCT) for HIV among young men and women in a slum area of Kampala, Uganda, were studied through 22 individual semi-structured interviews and 5 focus group discussions. Attitudes to VCT ranged from having no problem with the procedure to being very reluctant. Despite fear of stigma, the participants perceived ‘positive living' after HIV testing as realistic. VCT was regarded as an important step to avoid HIV infection, but informants expressed the need for the service to be more accessible in terms of cost, time and quality of pre- and post-test counselling. We argue that counselling without HIV testing should be available for those who are reluctant to test. Poverty and gender power imbalances appeared to limit youths' possibility of making rational decisions about sexual behaviour and accessing VCT. The importance of considering the context in which such issues are being negotiated and decided is highlighted.
This report describes the implementation and short-term results of a peer group intervention for HIV prevention on the HIV-related attitudes, knowledge and behaviours of primary school teachers in Malawi. The intervention, based on the social-cognitive learning model, took place in 2000 at two teacher training colleges with a distance-learning programme. Primary school teachers attending a final six-week training session before certification volunteered to participate. The 286 trainee teachers largely reported positive changes in their HIV-prevention-related knowledge, attitudes, self-efficacy, behaviour change and condom-use intentions. However, at post-test immediately after the intervention they did not show a higher level of perceived-risk, a greater hope that people could change their high-risk sexual behaviour, or greater agreement that persons infected with HIV should be allowed in public places. This research demonstrates the feasibility of an HIV-prevention intervention for primary school teachers during their training. The Malawi Ministry of Education has since made the programme available to over 90 per cent of all trainee teachers through an NGO.
This report looks at the armies of Botswana, Swaziland, Tanzania, Zambia and Zimbabwe in the context of the HIV and AIDS epidemic. These armies report HIV rates between 20 to 40 percent, with some sections having a rate between 50 to 60 percent. The report explores approaches to reduce HIV rates among soldiers and recognises that the inherent structure and discipline of armies and their ability to follow set regimes, means that they can become change agents in their societies in the fight against HIV and AIDS.
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12. Governance and participation in health
This paper presents a synthesis of institutional arrangements and issues currently facing National AIDS Commissions (NACs) in 2007. The paper is a work in progress and is based on a literature review and informant interviews with agency-based and NAC staff and independent consultants familiar with NAC issues. It reviews the common features and emerging themes on the following topics: the background to the establishment of NACs, their governance, structure and function, financing arrangements and their role in harmonising and aligning country responses to HIV. To date, many African countries with NACs have experienced significantly improved access to, and coordination of, financial and other resources, and there is a growing diversity of funding mechanisms and a substantial increase in funding.The authors conclude that the increased pressure placed on NACs means that clarity in roles and relationships, and enabling political, legislative, policy and institutional environments are more important than ever.
Most new HIV infections in Africa are acquired from cohabiting heterosexual partners. Couples Voluntary Counselling and Testing (CVCT) is an effective prevention strategy for this group. This paper presents experience with a community-based program for the promotion of CVCT in Kigali, Rwanda and Lusaka, Zambia. Predictors of successful CVCT promotion included strategies that can be easily implemented in Africa. As new resources become available for Africans with HIV, CVCT should be broadly implemented as a point of entry for prevention, care and support.
Organizations that collect substantial data for decision-making purposes are often characterised as being data rich but information poor. Maps and mapping tools can be very useful for research transfer in converting locally collected data into information. Challenges involved in incorporating GIS applications into the decision-making process within the non-profit (public) health sector include a lack of financial resources for software acquisition and training for non-specialists to use such tools. This on-going project has two primary phases. This paper critically reflects on phase 1: the participatory design (PD) process of developing a collaborative web-based GIS tool.
13. Monitoring equity and research policy
This article seeks to identify the role of databases in health policy. Access to information and communication technologies has changed traditional relationships between the state and professionals, creating new systems of surveillance and control. As a result,databases may have a profound effect on controlling clinical practice. The results demonstrate that policy makers hardly used the databases, neither for cost control nor for quality assurance. Further analysis revealed that these databases facilitated self-regulation and quality assurance by (national) bodies of professionals, resulting in restrictive prescription behavior amongst physicians.
Researchers used Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda. Access to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.
Most Ministries of Health across Africa invest substantial resources in some form of health management information system (HMIS) to coordinate the routine acquisition and compilation of monthly treatment and attendance records from health facilities nationwide. Despite the expense of these systems, poor data coverage means they are rarely, if ever, used to generate reliable evidence for decision makers. One critical weakness across Africa is the current lack of capacity to monitor effectively patterns of service use through time so that the impacts of changes in policy or service delivery can be evaluated. Here we present a new approach that, for the first time, allows national changes in health service use during a time of major health policy change to be tracked reliably using imperfect data from a national HMIS. The methodological approach presented can compensate for missing records in health information systems to provide robust estimates of national patterns of outpatient service use. This represents the first such use of HMIS data and contributes to the resurrection of these hugely expensive but underused systems as national monitoring tools. Applying this approach to Kenya has yielded output with immediate potential to enhance the capacity of decision makers in monitoring nationwide patterns of service use and assessing the impact of changes in health policy and service delivery.
Despite widespread use of neonatal hospital discharge data, there are few published reports on the accuracy of population health data with neonatal diagnostic or procedure codes. The aim of this study was to assess the accuracy of using routinely collected hospital discharge data in identifying neonatal morbidity during the birth admission compared with data from a statewide audit of selected neonatal intensive care (NICU) admissions. Although under-ascertained, routinely collected hospital discharge data had high PPVs for most validated items and would be suitable for risk factor analyses of neonatal morbidity. Procedures tended to be more accurately recorded than diagnoses.
14. Useful Resources
Health Research Web provides easily accessible information that will:
* facilitate discussions among stakeholders at country level on strengthening their national health research systems;
* enable donors to better align their efforts to national research priorities
* increase accountability of researchers to national health priorities;
* form of a ‘portal’ for health research systems information in low and middle income countries allowing northern institutions and interested donors to find partners in the South.
For the first time in history, all the significant literary, artistic, and scientific works of mankind can be digitally preserved and made freely available, in every corner of the world, for our education, study, and appreciation and that of all our future generations.
HSRProj a free database coordinated by the National Information Center on Health Services Research and Health Care Technology (NICHSR) for the National Library of Medicine. It carries evidence and expert testimony, links to research partners, and listings on current research projects.
What is the impact of stigma on children? This toolkit aims to help explore and understand the different ways in which children are stigmatised, and to look at strategies to change attitudes and experiences. It provides guidance to help trainers plan educational sessions with community leaders, or to organise groups to raise awareness and promote practical action to challenge HIV stigma and discrimination.
15. Jobs and Announcements
The East, Central and Southern African College of Nursing invites you to submit abstract for consideration to be presented at the Biennial scientific Conference to be held in Zimbabwe from 11th to 13th August 2008. The main theme is: “Transforming Nursing and Midwifery in ECSA: Visions for the Future”; with a number of interesting sub-themes. The deadline for submission of abstracts is 31 March 2008.
The Treatment Monitoring & Advocacy Project (TMAP) is seeking applications for country teams to participate in a research project on civil society engagement in Global Fund Country Coordinating Mechanisms (CCMs). The project is funded by the Open Society Institute, Aids Fonds, and ICASO. Applications are DUE BY 14 JANUARY, 2008 and should be emailed to matilda.moyo@gmail.com and ChrisCSF@aol.com.
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.
Eastern Africa Treatment Access Movement (EATAM) in collaboration with the Collaborative Fund for HIV/AIDS Treatment Preparedness calls for submission of proposals from organizations seeking funding for community-based HIV treatments preparedness programs. Grants will be allocated to successful applications for a period of up to one year to a maximum amount of 10, 000 US dollars per application.
Interested in access to medicines? Interested in governance, transparency and accountability processes? If the answer to either of those questions is yes, and you are working in a civil society organisation in Ghana, Uganda or Tanzania, an upcoming workshop in Entebbe, Uganda in February 2008 may be of interest. The workshop is the first step in a two-year programme of civil society capacity strengthening as part of the work of the international Medicines Transparency Alliance (MeTA). MeTA aims to use a multi-stakeholder approach towards increasing transparency around the regulation, selection, procurement, sale, distribution and use of medicines in developing countries, thereby strengthening governance, encouraging responsible business practices and ultimately improving access to medicines, especially for the poor. Send the completed form and motivational letter to metacso@healthlink.org.uk by 17.00 GMT on 15 January 2008.
The Global Health Workforce Alliance is to convene the first ever Global Forum on Human Resources for Health in Kampala, Uganda from 2-7 March, 2008. The Forum will be attended by up to 1000 participants, including government leaders, eminent health, development, civil society, academic and health professional leaders from around the world. This Forum will provide an extraordinary platform for sharing and exploring solutions, consensus and capacity building, and will further galvanise a global movement that is emerging as a response to the increasingly pertinent human resources for health (HRH) crisis. The deadline for registration is 31 January 2008.
Action Health Incorporated, under the auspices of the African Federation for Sexual Health and Rights, is pleased to announce the third regional conference on Sexual Health and Rights, 4-7 February 2008. The conference seeks to bring together key actors in the field of Sexual Health and Rights to explore how sexuality has affected and can improve development in Africa, especially when working with women and youth. Participants, speakers, and sponsors are expected from the media, academia, civil society organizations, government agencies, development partners, faith based organizations, regional and sub-regional bodies in Africa and international agencies. The goal of the conference is to examine the interrelationships between poverty and sexuality and also how the issue of accountability affects sexual health and social well-being in Africa.
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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