The Gates and Rockefeller Foundations propose to increase food production on the African continent, “eliminating hunger for 30-40 million people and sustainably moving 15-20 million people out of poverty,” through their initiative of an Alliance for a Green Revolution for Africa (www.agra.com).
We all share in the goal of eliminating hunger on the African continent. However, we are also aware of the risks to health and nutrition posed by the previous green revolution in Asia and Latin America. As farmers dedicated more and more land to growing new varieties of wheat, rice, and maize, less land was available to women to grow vegetables (vitamins, minerals), and the commercial production of pulses (protein) stagnated. How will this proposed “green revolution” affect production, food security and human health in Africa?
Similar to the green revolution of the 1960-70s, increasing yields of a few crops to provide food for the hungry remains the central justification for this proposed African green revolution. The 1960s varieties of seed required fertilisers, pesticides, and water at very specific times or the yield was worse than traditional varieties. Indian farmers, for example, did increase production of wheat ten-fold and of rice three-fold. Learning from this experience, the current AGRA initiative also includes training African scientists, setting up marketing networks of small seed companies, and credit schemes. Other major differences are that the seeds will be genetically modified (GMOs) and patented, in the 1960s in India, they remained in the public domain.
The benefit of increased yields, however, came with many environmental, economic and social costs in the green revolution on the 1960-70’s.. The massive increases in the use of fertilisers and pesticides contaminated the water and soil. Small-scale farmers could not sustain the purchase of all the inputs and had to sell their land. Studies in India show that only farmers with at least 6-8 hectares of land could afford the high-tech agricultural production. Inequality within villages increased, with many moving to the cities. As Secretary General U Thant summarised in 1970, “There is already a growing a body of relevant literature on the experience in various regions and localities which strongly suggests that the prosperity resulting from the Green Revolution is shared by a relatively few.”
The economic and social dangers of a “green revolution” for Africa are similar to those related to the commercialisation of health care: 1) piracy of both indigenous knowledge and plants (used for medicine and/or food); 2) privatisation of bioresources necessary for human health through patenting of plants; 3) privatisation of research which directs priorities and agendas. Rather than reducing hunger, these adverse outcomes could in fact reduce the food security of Africans, increase undernutrition and thus reduce immunity against disease.
Increased yields of one or two strains of one or two crops (“monoculture within monoculture,” as stated by a Tanzanian botanist) will not provide the basis for food security to support nutritional needs. The key to ending hunger is sustaining Africa’s food biodiversity, not reducing it to industrial monoculture. Currently, food for African consumption comes from about 2,000 different plants; in contrast, the US food base derives mainly from 12 plants. Narrowing plant diversity of food increases vulnerability for all because it a) reduces the variety of nutrients needed for human health, b) increases crop susceptibility to pathogens, and c) minimises the parent genetic material available for future breeding.
Manufacturing plants for food is very similar to manufacturing them for medicine. Indigenous knowledge designates a plant as important for nutrition or for medicinal purposes. But often, corporations simply take both the plants and the knowledge with no recognition, monetary or otherwise, to the original breeders of new medicine and foods. This biopiracy of food and medicinal plants is made legal by the patenting of living organisms, through international trade agreements.
Because African farmers will have to buy the new seeds, and the pesticides and fertilisers they require for increased yields, this green revolution initiative becomes a privatisation offensive against small-scale farmers who still retain control over their seeds. Of the seeds used for food crops in Africa, 80 percent is seed saved by the farmer herself or locally exchanged with family and neighbours. Farmers do not have to buy seed every season, with cash they do not have, for they possess a greater wealth in their indigenous seeds, freely shared and developed over centuries. The very best food seed breeders in Africa, the “keepers of seed,” are women who often farm less than one hectare of land. Across Africa, women are also the food producers, tending “gardens” full of diverse crops for local consumption, while the men concentrate on cash crop production. Even when the cash crop fails, food will most likely be available for the family, for those plots are intensively farmed and carefully watered.
The proposed green revolution would shift the food base away from this treasure of seed. Instead, African farmers would have to purchase patented seeds each season, thus putting cash into the hands of the corporations providing the seed, much as already has happened with plants used in medicinal compounds. Loss of control over seed reduces the control women farmers have over production, with risks to food security and nutrition. For AGRA, the seeds will not only be patented, but new varieties will undoubtedly be genetically modified organisms (GMOs). The perils of GMOs to environmental sustainability are well documented. Most African governments have ratified the biosafety protocol which allows them to deter research and production of GM food crops until sufficient data is available about its impact on human health and the environment, but AGRA is lobbying for governments to “fast track” approval for new varieties to be planted.
Research on African food crops certainly needs financing. The US National Research Council concluded in 19996 that a major African food crop, sorghum “is a relatively undeveloped crop with a truly remarkable array of grain types, plant types, and adaptability….most of its genetic wealth is so far untapped and even unsorted. Indeed, sorghum probably has more undeveloped genetic potential than any other major food crop in the world.”
As nutritious as maize is for carbohydrates, vitamin B6, and food energy, sorghum is even more nutritious in a range of essential nutrients for health. One of the most versatile foods in the world, sorghum can be boiled like rice, cracked like oats for porridge, baked like wheat into flatbreads, popped like popcorn for snacks, or brewed for nutritious beer. Because sorghum can tolerate dry areas and poor soil better than maize, it can provide nutritious food security in semi-arid regions and therefore, should become even more important under conditions of global warming.
Engaging African scientists to discover the potential genetic wealth of sorghum would assist African food security. In a first glimpse of foundation expenditures, however, we see funds directed to the Wambugu Consortium (founded by Pioneer Hi-Breed, part of DuPont) for experiments in genetically modified sorghum. By adding a gene, rather than mining the genetic wealth already there, the consortium can patent and sell the “new” sorghum at a premium price for DuPont.
Private expenditure on research and marketing of a few crops directs attention to crops that are profitable. Similar to health care, International Monetary Fund requirements for structural adjustment programs, supported by all donor governments, the World Bank, and the African Development Bank, have been removing African government expenditures on agricultural research and extension. Governments had to spend less on agriculture in order to repay their debts. Now, more two decades later, the private foundations step in to “save” food-deficit Africa.
High-tech answers to Africa’s food crises are no answers at all if they undermine human nutrition, privatise both indigenous knowledge and bioresources through patenting of plants, and transform the genetic wealth of the continent into cash profits for a few corporations. Public policy choices around the AGRA proposals have not yet been made within Africa. There is thus still an opportunity to call for assessment and debate on the health and nutrition impacts of these proposals, including by civil society working in health, and by parliaments, and by UN agencies. We need to openly challenge its goals, motives and methodologies before Africa’s political leaders accept them, and before universities and research centres divert their agendas away from other applied research that may offer a more sustainable and nutritious future for African food production. The future of African health depends on it.
For references used in this editorial and a more detailed analysis of how Africa’s food biodiversity provides alternatives to chemical industrial agriculture, see Andrew Mushita and Carol B. Thompson, Biopiracy of Biodiversity (Trenton, NJ: Africa World Press, 2007), carol.thompson@nau.edu. Further information on nutrition and health issues can be found on the EQUINET website at www.equinetafrica.org or contact admin@equinetafrica.org
1. Editorial
2. Latest Equinet Updates
Over the last two decades there has been growing interest in the potential of social health insurance (SHI) as a health financing mechanism in low and middle-income countries. However, few countries in Africa have implemented SHI. Uganda is currently designing its own SHI scheme, in preparation for its imminent implementation. It is hoped that SHI will bring additional resources for the Ugandan health sector and that its introduction will improve equity in access. Very little was known about the Insurance market in Uganda before this study was undertaken, so one of our main objectives was to provide quantitative and qualitative data that could be used by the Ugandan Ministry of Health as a basis for designing this scheme and for future SHI policy-making.
Drawing on the analytic framework of the regional analysis, an analysis of equity in health at district level was implemented in Tanzania, through secondary review and field work. We found a clear policy commitment to equity, the administrative means to implement it and a political stability that enables this. A number of features of Tanzania’s context and health system make reducing differentials in health and access to health care possible, including the investment of debt relief resources in health and education, increased public spending in health, methods for managing external funds that pool resources for wider reallocation to areas of need and a resource allocation formula that considers access, poverty and disease burden in the allocation of resources and provides guidelines for spending to protect areas of equity oriented spending.
The growth of international trade has significant consequences for public health. The relationship between trade and health is not simple, nor is it unidirectional. In this brief we raise why trade issues need to be understood and managed to promote health and we highlight the main concerns arising from free trade agreements for public health. We draw attention to measures that governments and civil society in the region can take to achieve greater coherence between trade and health policies, so that international trade and trade rules maximize health benefits and minimize health risks, especially for poor and vulnerable populations.
3. Equity in Health
Over 200 million children under five years old in developing countries do not reach their development potential. Whilst risks such as stunting, iodine-deficiency, anaemia and inadequate cognitive stimulation are known, evidence suggests that maternal depression, exposure to violence, environmental contamination and malaria are further potential risk factors. 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. Despite the evidence that comprehensive early development programmes are effective in increasing disadvantaged children’s chances of success, government investment remains low. At the current rate of progress, the disparity between rich and poor countries in pre-school attendance will increase.
Launched on 6 December 2007, 'make medicines child size' is a global campaign spearheaded by WHO to raise awareness and accelerate action to address the need for improved availability and access to safe child specific medicines for all children under 15. To achieve this goal, more research is needed, more medicines need to be developed, and improved access measures are essential. At present, many medicines are not developed for children or available in suitable dosages or formats; and when they are they are not reaching the children who need them most. The 'make medicines child size' campaign is an effort to change that reality.
This article synthesises what is known on equity and tuberculosis (TB) in Malawi and highlights areas for further action and advocacy. Based on a range of published and unpublished reports and analysis of routine data on access to TB services, the authors find that TB cases have increased rapidly from 5,334 in 1985 to 28,000 in 2006. This increase has been attributed to HIV/AIDS; 77 per cent of TB patients are HIV positive. Poor people’s ability to access TB diagnosis services is reduced by the need for repeated visits, long queues and delays in sending results. The costs of seeking care for these people can be up to 240 per cent of monthly income. The paper concludes that the government’s policies to address TB, which are being delivered through the Sector Wide Approach, provide a good opportunity to enhance equity and pro-poor health services. The major challenge is to increase case detection especially amongst poor people. In addition, the Programme needs a prevalence survey which will enable equity monitoring and the development of responsive interventions to promote service access to people with undiagnosed TB.
4. Values, Policies and Rights
Following the recognition that morbidity and mortality due to malaria had dramatically increased in the last three decades, in 2002 the government of Zambia reviewed its efforts to prevent and treat malaria. Convincing evidence of the failing efficacy of chloroquine resulted in the initiation of a process that eventually led to the development and implementation of a new national drug policy based on artemisinin-based combination therapy (ACT). All published and unpublished documented evidence dealing with the antimalarial drug policy change was reviewed. These data were supplemented by the authors observations of the policy change process. Study results suggest that drug policy changes are not without difficulties and demand a sustained international financing strategy for them to succeed. The Zambian experience demonstrates the need for a harmonized national consensus among many stakeholders and a political commitment to ensure that new policies are translated into practice quickly.
Delaying sexual initiation has been promoted as one of the methods of decreasing risks of HIV among young people. In traditional countries, such as Ethiopia, retaining virginity until marriage is the norm. However, no one has examined the impact of this traditional norm on sexual behaviour and risk of HIV in marriage. This study examined the effect of virginity norm on having sex before marriage and sexual behaviour after marriage among rural Ethiopian youth. Maintaining virginity is still a way of securing marriage for girls, especially in rural areas; the odds of belief and intention to marry a virgin among boys was 3-4 times higher among rural young males. As age increased, the likelihood of remaining a virgin decreased. There was no significant difference between married and unmarried young people in terms of number of partners and visiting commercial sex workers. Married men were twice more likely to have multiple sexual partners than their female counterparts. Although virginity norms help delay age at sexual debut among rural Ethiopian youth, and thus reduces vulnerability to sexually transmitted infections and HIV infection, vulnerability among females may increase after marriage due to unprotected multiple risky sexual behaviours by spouses. The use of preventive services, such as VCT before marriage and condom use in marriage should be part of the HIV prevention and control strategies.
5. Health equity in economic and trade policies
With less than seven years to go before the attainment of the universal millennium development goals (MDGs), the southern Africa region is still battling with infrastructure issues which might stifle the region’s progression towards the achievement of the goals. In its January policy briefing Building Bridges Out of Poverty, the Southern Africa Trust examines how transport, energy and water infrastructure in the region can facilitate intra-regional trade and investment as well as sound management and development of water resources. This article discusses how infrastructure development can strengthen regional integration to overcome poverty in southern Africa.
The European Commission’s demand for Most Favoured Nation (MFN) treatment for European Union in all future free trade agreements (FTAs) between SADC EPA countries and any third parties are among the main reasons why Namibia failed to initiate the Interim Economic Partnership Agreement (IEPA) with EU. Acceptance of such an offer, Minister of Trade and Industry, Immanuel Ngatjizeko said at a press briefing in mid-December 2007, would pre-empt Southern African Development Community (SADC) EPA countries’ negotiating space as EPA-plus preferential treatment would be accorded to the EU without any further concession from the EU side.
The UN Food and Agriculture Organization (FAO) has launched a multi million dollar fund for import-dependent poor countries to help adapt their farming industries quickly to cope with galloping global food prices. Concern is mounting at the FAO that poor countries’ food needs will not be met by outside production this year as prices for basic commodities such as wheat are rising and supply is limited, FAO director general Jacques Diouf said in the Burkina Faso capital Ouagadougou on 12 January.
Current debates about the potential positive and negative implications of agricultural biotechnology for human nutrition do not seem to be well informed by lessons learned from the Green Revolution. This paper will examine the following question: what was learned from the Green Revolution concerning its effects on food consumption and/or nutrition? 2) In what respects is the agricultural biotechnology issue similar to the Green Revolution? 3) In what respects is it different? 4) Under what circumstances (if any) do you think it would be appropriate to introduce genetically engineered crops into the farming systems of developing countries? 5) What are the pros and cons of the preceding recommendation?
In the morning of the second day of the EU-Africa Summit representatives from the side-events got the opportunity to present their views to the Heads of States and Governments. Civil Society Organisations, Youth, Trade Unions and the Private Sector got three minutes respectively. Alpha Omar Konaré, president of the African Commission expressed that he was very happy with the fact that there were ‘many voices’ of civil representation - entrepreneurs, the youth and various associations - that are involved in the partnership between the two continents and ready to collaborate so that this cooperation between Europe and Africa can develop in a positive way for all parties. He also quoted the Civil Society Declaration, mentioning the lack of power equilibrium between both Continents.
Have traditional restrictive macroeconomic policies and budget ceilings limited some governments from giving HIV/AIDS the attention it deserves? This paper analyses the links between macroeconomic frameworks provided by the International Financial Institutions (IFIs) and HIV social spending in Ghana and Malawi. It reviews major channels through which fiscal and monetary policies impact on public expenditure frameworks and how this, in turn, affects the ability of the countries to design and implement public programmes for those living with and affected by AIDS. Authors stress the need for a fundamental shift in the design and execution of the macroeconomic framework.
6. Poverty and health
In this paper we review the associations between maternal and child undernutrition with human capital and risk of adult diseases in low-income and middle-income countries. We analysed data from five long-standing prospective cohort studies from Brazil, Guatemala, India, the Philippines, and South Africa. We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits. Chronic diseases are especially common in undernourished children who experience rapid weight gain after infancy.
Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden. This paper presents new analyses to estimate the effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on mortality and disease. The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences.
Lake Victoria supports Africa’s largest inland fishery, and its most valuable product is the Nile perch, much of which is exported. This has given rise to arguments claiming a direct linear relationship between perch exports and disturbingly high rates of malnutrition along the lake’s shores. In this paper, we argue that this argument is seriously flawed for it is unable to explain how it is that the income from the Nile perch fishery fails to translate into a well-fed riparian population. We draw on field work carried out in 2001 that (a) set out to establish exactly how much malnutrition there was on the lake’s shores; and (b) sought to identify what happened to the income the fishery generates. We argue that because men control much of the fishery, and women are held responsible for the upkeep of their families, little of this income makes its way back into the households of the region, giving rise to the levels of malnutrition we observed.
The new Lancet series on nutrition, co-authored and co-financed by the World Bank, depicts the lamentable state of under-nutrition worldwide, and a corresponding negligence on the part of the development community to meet the challenge decisively. Under-nutrition represents the non-income face of poverty. And the world is off track on meeting this goal. Countries with 'higher overall logistics costs are more likely to miss the opportunities of globalization,' say the study’s lead authors Jean Francois Arvis and Monica Alina Mustra of the Bank’s Poverty Reduction and Economic Management (PREM) group.
7. Equitable health services
Health authorities reported the first known cases of virtually untreatable tuberculosis in Botswana, following fears that the highly contagious strain has spread beyond South Africa. For the past few months, health professionals have warned that XDR-TB, although only confirmed in South Africa, had spread to other Southern African nations like Swaziland and Lesotho hard hit by the AIDS pandemic, but hadn't been diagnosed because of lack of laboratory facilities.
Malaria fever is a common medical presentation and diagnosis in Malawi. The national malaria policy supports self-diagnosis and self-medication for uncomplicated malaria with first line anti-malaria drugs. While a qualitative appreciation of the burden of malaria on the health system is recognised, there is limited quantitative estimation of the burden malaria exacts on the health system, especially with regard to human resources and financial burden on Malawi. The burden of malaria was assessed based on estimated incidence rates for a high endemic country of which Malawi is one. Data on the available human resources and financial resources committed towards malaria from official Malawi government documents and programme reports were obtained. Malaria exacts a heavy toll on the health system in Malawi. The national recommendation of self-medication with first-line drug for uncomplicated malaria is justified as there are not enough clinicians to provide clinical care for all cases. The Malawi Ministry of Healthas promotion of malaria drug prescription including other lower cadre health workers may be justified.
A longitudinal study followed approximately 100 randomly selected farming households over six months in Kilombero Valley, Tanzania. Every household was visited monthly and whereabouts of household members, activities in the fields, fever cases and treatment seeking for recent fever episodes were recorded. Fever incidence rates were lower in the shamba compared to the villages and moving to the shamba did not increase the risk of having a fever episode. Children aged 1-4 years, who usually spend a considerable amount of time in the shamba with their caretakers, were more likely to have a fever than adults. Despite the long distances to health services, 55.8% (37.9-72.8) of the fever episodes were treated at a health facility, while home-management was less common (37%, 17.4-50.5). Living in the shamba does not appear to result in a higher fever-risk. Mosquito nets usage and treatment of fever in health facilities reflect awareness of malaria. Inability to obtain drugs in the fields may contribute to less irrational use of drugs but may pose an additional burden on poor farming households. A comprehensive approach is needed to improve access to treatment while at the same time assuring rational use of medicines and protecting fragile livelihoods.
This World Health Organization study describes various activities aimed towards strengthening the management of health service delivery in three countries: South Africa, Togo and Uganda. The paper considers factors that affect management capacity: the number of managers at all levels; opportunities for building existing managers’ own competences; improving management support systems; and creating a more supportive work environment. It also identifies several ways to help managers do their jobs better. These include clarity about their responsibilities; practical reference handbooks; and a regular forum for managers to identify their needs, discuss problems and share ideas. On-the-job support is perceived by many managers as key to improving their performance – this can include technical assistance, mentoring, coaching and learning networks. In terms of management strengthening activities, the study reveals that a range of approaches have been used in recent years, but countries and external development agencies have concentrated mainly on training and some management systems (planning and monitoring) to the detriment of other key conditions for facilitating good management. Medium- to long-term sector-wide budgets and plans for management strengthening are required if good management is to play its appropriate role in scaling up health services.
A descriptive, non-interventive, observational study design was used to audit all public and private sector ICUs and HCUs in South Africa to evaluate the distribution and functioning of South African intensive care units (ICUs) and high care units (HCUs), in particular the extent to which units were ‘closed units'. In the face of already limited resources (financial and human) and given the emphasis on primary care medicine (with consequent limited capacity for further ICU development), it is crucial that existing facilities are maximally utilised.
A descriptive, non-interventive, observational study design was used to audit all public and private sector ICUs and HCUs in South Africa to establish the efficacy of the current system of referral of critical care patients: (i) from public hospitals with no ICU or HCU facilities to hospitals with appropriate facilities; and (ii) from public and private sector hospitals with ICU or HCU facilities to hospitals with appropriate facilities. There was considerable variation (less than 1 hour - 6 hours) in time to collect between provinces and between public hospitals that have or do not have ICU/HCU facilities. A combination of current resource constraints, the vast distances in some regions of the country and the historical disparities of health resource distribution represent a unique challenge which demands a novel approach to equitable health care appropriation.
A descriptive, non-interventive, observational study design was used to audit of all public and private sector ICU and high care units in South Africa to determine the national distribution of intensive care unit (ICU)/high care (HC) units and beds. The most compelling conclusion from this study is the need for regionalisation of ICU services in SA.
There is some evidence from refugees that health care services in South Africa are not responsive to their perceived needs. Using quantitative and qualitative approaches to evaluate the perceptions and opinions of refugees about health care services in South Africa, the authors find that major issues affecting refugees include: discrimination and xenophobic attitudes of health service providers; language barriers leading to inappropriate treatments due to misunderstanding; exclusion from public hospitals due to lack of valid permits or delay in the delivery of such permits. Based on these findings, the authors suggest that refugees should have at least a baseline health related interview and check-up preferably done in a primary health care (PHC) centre dedicated to refugees. Refugee support systems should be established and health care workers should be informed about issues such as refugee permits and policies regarding referral systems. Also, public hospitals should employ qualified translators to help in cases that are referred from PHC centres for refugees.
The researchers analysed the experiences of different countries affected by conflict, including Afghanistan, Cambodia, East Timor, Kosovo, Uganda and Mozambique. They began by looking at the impacts of conflict on public health. They then presented a framework for understanding how programmes for rehabilitating health systems might work in post-conflict countries. The authors suggest three interrelated approaches to health sector rehabilitation: an initial response to immediate health needs (through humanitarian assistance and relief); restoration or establishment of a package of essential health services including immunisation and obstetric care; and restoration of the health system itself. The authors highlight the lack of co-ordination between donor organisations, whose competing needs and projects distract health officials. Non-governmental organisations (NGOs) may also delay progress by continuing to focus on relief when the country has moved on to the next stage.
This report uses the examples of the health and education sectors to consider South Africa's compliance with the various standards and best practices laid down in relation to the functioning of the public service -- including the African Union Convention on Preventing and Combating Corruption, and the Charter for the Public Service in Africa. While South Africa has many examples of best practice on paper, it is struggling to ensure that these policies are fulfilled in practice: this report offers analysis and suggestions on critical problems for attention.
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8. Human Resources
Staff shortages could harm the provision and quality of health care in Uganda, so staff retention and motivation are crucial. Understanding the impact of HIV/AIDS on staff contributes to designing appropriate retention and motivation strategies. This research aimed 'to identify the influence of HIV/AIDS on staff working in general hospitals at district level in rural areas and to explore support required and offered to deal with HIV/AIDS in the workplace'. Its results were to inform strategies to mitigate the impact of HIV on hospital staff. Organisational responses should be integrated into responses to other problematic working conditions and adapted to the local context. Opportunities already exist, such as better use of supervision, educational sessions and staff meetings. However, exchanges on interventions to improve staff motivation and address HIV in the health sector are urgently required, including information on results and details of the context and implementation process.
Twelve percent of the adult population in Malawi is estimated to be HIV infected. The country has a public sector-led antiretroviral treatment program both in the private and public health sectors. Estimation of the clinical human resources needs is required to inform the planning and distribution of health professionals. HAART provision is a labour intensive exercise. Although data in this paper is insufficient to determine whether HAART scale-up has resulted in the weakening or strengthening of the health systems in Malawi, the human resources requirements for HAART scale-up are significant. Malawi is using far less human resources than would be estimated based on the literature from other settings.
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 scrutinise the judgements and attitudes of health workers towards the "tecnico de cirurgia", showed that this cadre is highly appreciated and that the health delivery system does not recognise 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.
A descriptive, non-interventive, observational study design was used to audit of all public and private sector ICU and HCUs in South Africa to determine the profile and number of nurses working in South African intensive care units (ICUs) and high care units (HCUs); (ii) to determine the number of beds in ICU and HCUs in South Africa; and (iii) to determine the ratio of nurses to ICU/HC beds.This study demonstrates that ICU nursing in South Africa faces the challenge of an acute shortage of trained and experienced nurses. Nurses are tired, often not healthy, and are plagued by discontent and low morale.
The migration of doctors and nurses from Africa to developed countries has raised fears of an African medical brain drain. But empirical research on the causes and effects of the phenomenon has been hampered by a lack of systematic data on the extent of African health workers' international movements. This study uses destination-country census data to estimate the number of African-born doctors and professional nurses working abroad in a developed country circa 2000, and compares this to the stocks of these workers in each country of origin. About 65 000 African-born physicians and 70 000 African-born professional nurses were working overseas in a developed country in the year 2000. This represents about one fifth of African-born physicians in the world, and about one tenth of African-born professional nurses. The fraction of health professionals abroad varies enormously across African countries, from 1% to over 70% according to the occupation and country. The authors conclude that these numbers are the first standardised, systematic, occupation-specific measure of skilled professionals working in developed countries and born in a large number of developing countries.
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. 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. The study 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. Moreover, the success of a community health worker programme depends to a considerable extent on a successful interaction with the formal health services sector.
By focusing on the Masters of Public Health course, this study took a pragmatic approach to exploring the interface between public health education and public health practice. The commonly utilized ‘three domains of practice’ framework could provide a robust and explicit link between educational provision and practice for public health. This model provides the workforce, the university, the students and the potential funders of the course with an easily comprehensible framework for understanding how the modules of an MSc can support the development of competency within the context of practice.
9. Public-Private Mix
The International Finance Corporation (IFC), the private sector arm of the World Bank, announced last month that it would coordinate some $1 billion in equity investments and loans to finance private sector health provision in sub-Saharan Africa. The program was explicitly linked to the results of an IFC study, financed by the Bill and Melinda Gates Foundation, which found that the private sector already provides about half of the health care in the region, and that impoverished people are just as likely as the better-off to use private providers.
The SACP is outraged at the plans by some of the big private hospital groups, including the National Hospital Network and Netcare, to hike fees by as much as up to 33% as from this year. The private health care sector is already consuming a much bigger slice of our health resources and is also making huge profits for itself at the direct expense of the majority of the people of our country, feeding like parasites on workers’ already overstretched medical aid schemes.
This report describes opportunities for engaging and supporting a well managed and effectively regulated private sector to improve the region’s health and complementary to traditional public sector approaches.
10. Resource allocation and health financing
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.
Maximising health as the guiding principle for resource allocation in health has been challenged by concerns about the distribution of health outcomes. There are few empirical studies that consider these potentially divergent objectives in settings of extreme resource scarcity. The aim of this study is to help fill this knowledge gap by exploring distributional preferences among health planners in Tanzania. Distribution of health outcomes, in terms of life-years, matters. Specifically, the lower the initial life expectancy of the target group, the more important the programme is considered. Such preferences are compatible, within the sphere of health, with what ethicists call “prioritarianism”.
11. Equity and HIV/AIDS
A survey was administered to 304 respondents participating from three areas near Welkom, South Africa. Face-to-face interviews were conducted with women from randomly selected households to evaluate the impact of a service provision programme targeting women living with HIV/AIDS and gender based violence. Gender based violence (GBV) awareness and knowledge was high. Respondents had high perceived levels of risk. The key findings of this study support the notion of using a holistic approach, targeting more than one issue. There is lower stigma levels associated with combined conditions, which might allow easier access to vulnerable groups. Coordination and collaboration of services are however needed to enable this benefit.
The implementation and evaluation of a peer education and support programme in secondary schools to prevent and reduce high-risk sexual behaviour amongst adolescents is discussed. The aims of the programme were to provide accurate information about HIV, discuss and reconsider peer group norms, and establish support for learners. In the programme that was implemented in 13 secondary schools in Tshwane, South Africa, peer educators were identified, trained and supported to implement the programme in their schools with the assistance of a teacher and postgraduate students as facilitators. The results showed that the percentage of learners in the experimental group who were sexually experienced remained unchanged over the time period of 18 months. In contrast, a significantly increased percentage of learners in the control group were sexually experienced after the same time period. The control group also perceived more of their friends to be sexually experienced. No differences were reported in condom use in either of the groups. The findings of this study suggest that peer education can contribute to a delayed onset of sexual activity, and can therefore contribute to the prevention of HIV amongst adolescents.
Tuberculosis infection rates in Uganda have increased due to the AIDS epidemic in the country, but the scarcity of health centres and over-crowding in camps for the displaced are also to blame, officials said. "The rise in the infection rate is mainly because of HIV. In many countries with a high prevalence of HIV/AIDS, TB cases have gone up because HIV has attacked and weakened the body’s defence systems, which would keep at bay widespread TB infections,” Joseph Imoko, the World Health Organisation (WHO) national professional officer for TB in Uganda said.
South African AIDS activists have called on doctors and nurses to act in the best interests of HIV-positive pregnant women and their unborn children by not waiting any longer for an official directive to switch from single antiretroviral (ARV) treatment to more effective dual treatment for the prevention of mother-to-child HIV transmission (PMTCT). At a meeting of the South African National AIDS Council in November 2007 South Africa’s Deputy President and the Director-General of Health announced that public health facilities would abandon the regimen of administering nevirapine only in favour of a short course of two antiretroviral (ARV) drugs for pregnant HIV-positive women. Nearly two months later, the new PMTCT guidelines have yet to be published and disseminated to health workers at state facilities.
This paper demonstrates the importance of utilising official statistics from the voluntary counselling and testing centres (VCT) to determine the association between gender and HIV infection rates in Kenya.The study design adopted was a record based survey of data collected from VCT sites in Kenya between the second quarter of 2001 and the second quarter of 2004. Of those who were tested, significantly more females tested positive (P<0.0001) and had twice as high a chance of being infected by HIV (Odds ratio 2.27 with CI 2.23 to 2.31) than males.We conclude that VCT statistics may lead to better planning of services and gender sensitive interventions if utilised well.
12. Governance and participation in health
This study set out to understand how the policy of user involvement is interpreted in health service organisations and to identify factors that influence how user involvement is put into practice. The design was that of an ethnographic study using participant observation, interviews, and collection of documentary evidence. Set in a multiagency modernisation programme to improve stroke services in two London boroughs, participants comprised of service users, National Health Service managers, and clinicians. Author conclusions include that user involvement may not automatically lead to improved service quality. Healthcare professionals and service users understand and practise user involvement in different ways according to individual ideologies, circumstances, and needs. Given the resource implications of undertaking user involvement in service development there is a need for critical debate on the purpose of such involvement as well as better evidence of the benefits claimed for it.
There is no standard definition of a community. The term “community” has been used to describe interactions among people in primarily geographic terms. But it is now accepted that people who live in close proximity to one another do not necessarily constitute a community, since they may differ with respect to value systems and other cultural characteristics that are more relevant to the social concept of community. Some have argued that the defining feature of a community is the common identity shared by its members. Thus, a single individual may belong simultaneously to different religious, vocational, or ethnic communities, or communities with distinct values and aspirations may inhabit a single geographic area. Even though community is determined largely by shared traditions and values, communities are not static and may accommodate multiple and even conflicting interpretations of their own traditions and values. Outsiders may also define community differently from insiders. The extent to which a community reflects these features is a measure of its cohesiveness. The authors argue that different levels of community cohesiveness or specific features may warrant different research protections.
`Participation' by community members in health-related programmes is an appealing concept that has not always been easy to achieve. Such programmes are often directed towards communities defined on the basis of neighbourhood or group identity. This article aims to develop an account of participation and identity by drawing on Bourdieu's theory of practice to understand participation as the practice of social identities structured by habitus, capital and field. Examples from interviews with members of one deprived neighbourhood illustrate the theory by showing that people may identify with their neighbourhood for certain social purposes, but have different identity practices in different fields of practice. Implications for community-based health programmes are briefly outlined.
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. The study sought to unpack overlaps and distinctions between social network approaches and research on the experience and management of chronic illness. We outline 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 organisations and technology; and (4) translating theory into method.
13. Monitoring equity and research policy
Health equity has become an increasingly popular research topic during the course of the past 25 years. Many factors explain this trend, including a growing demand from policymakers, better and more plentiful household data, and increased computer power. But progress in quantifying and understanding health equities would not have been possible without appropriate analytic techniques. These techniques can provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity, with worked examples and computer code, mostly for the computer program Stata.
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. Three case studies were undertaken to reconstruct the development and use of databases as policy instruments. Our 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. The databases fulfill control functions that were formerly located within the policy realm. The databases facilitate collaboration between policy makers and physicians, since they enable quality assurance by professionals. Delegating regulatory authority downwards into a network of physicians who control the use of pharmaceuticals seems to be a good alternative for centralized control on the basis of monitoring data.
In countries where routine vital registration data are scarce, Demographic Surveillance Sites (DSS: locally defined populations under longitudinal surveillance for vital events and other characteristics) and Demographic and Health Surveys (DHS: periodic national cluster samples responding to cross-sectional surveys) have become standard approaches for gathering at least some data. This paper aims to compare DSS and DHS approaches, seeing how they complement each other in the specific instance of child and adolescent mortality in Ethiopia. Data from the Butajira DSS 1987-2004 and the Ethiopia DHS rounds for 2000 and 2005 formed the basis of comparative analyses of mortality rates among those aged under 20 years, using Poisson regression models for adjusted rate ratios. Patterns of mortality over time were broadly comparable using DSS and DHS approaches. DSS data were more susceptible to local epidemic variations, while DHS data tended to smooth out local variation, and be more subject to recall bias. Both DSS and DHS approaches to mortality surveillance gave similar overall results, but both showed method-dependent advantages and disadvantages. In many settings, this kind of joint-source data analysis could offer significant added value to results.
This article provides an in-depth description of the methodology that was followed and the quality control measures that were implemented during the audit of national critical care resources in South Africa.
The AIDS epidemic remains of global significance and there is a need to target (a) the adolescent age-groups in which most new infections occur; and (b) sub-Saharan Africa where the greatest burden of the epidemic lies. A focused systematic review of school-based sexual health interventions in sub-Saharan Africa to prevent HIV and Sexually Transmitted Infections (STI) in this age group was therefore conducted. Some 1,020 possible titles and abstracts were found, 23 full text articles were critically appraised, and 12 articles (10 studies) reviewed, reflecting the paucity of published studies conducted relative to the magnitude of the HIV epidemic in sub-Saharan Africa. Knowledge and attitude-related outcomes were the most associated with statistically significant change. Behavioural intentions were more difficult to change and actual behaviour change was least likely to occur. Behaviour change in favour of abstinence and condom use appeared to be greatly influenced by pre-intervention sexual history. There is a great need in sub-Saharan Africa for well-evaluated and effective school-based sexual health interventions.
14. Useful Resources
The updated HRET Disparities Toolkit gives hospitals, health systems, clinics, and health plans the information and resources needed for collecting race, ethnicity, and primary language data from patients. In order to make this invaluable Toolkit more accessible to all health care providers, the Toolkit is now available free of charge. HRET’s Disparities Toolkit helps clinicians and administrators at all levels learn the why and how of collecting race, ethnicity, and primary language data from patients. The Toolkit is useful for educating and informing hospital staff about the importance of data collection, how to implement a framework to collect the data, and how to use these data to improve quality of care for all populations.
Trade justice is about giving poor people and countries the chance to work their own way out of poverty; giving farmers the chance to earn enough to feed their families and to send their children to school; allowing industries to develop, creating jobs and opportunities. But instead of trade justice, free trade is being forced on developing countries. It is hurting poor people, not helping them. And it is undermining democracy by denying poor people a greater say in the decisions that affect their lives. In 2005, unprecedented numbers of people campaigned for trade justice as part of the Make Poverty History campaign. With the UK government starting to question the wisdom of
forcing free trade and liberalisation on developing countries, we are making progress. But there’s still some way to go before trade justice becomes a reality for millions of poor people worldwide. This guide addresses what is meant by trade justice, what needs to change, and how the campaign will help make poverty history.
AcademyHealth launched a new online resource that provides researchers collaborating across disciplines with an easy-to-use tool for understanding health services research methods. The site includes an overview of the language, training resources, and analytic techniques used by researchers from different academic backgrounds and provides a forum for discussing methods used in the published literature. The site is designed as a launching pad for future methods training to improve understanding of HSR across disciplines and support ongoing development and refinement of HSR methods in general.
15. Jobs and Announcements
CIHR's Institute of Gender and Health (IGH) and the Institute of Neurosciences Mental and Addictions (INMHA) are committed to improving mental health, a priority, according to leading national and international experts and policy-makers, for Canadians and the international community. The purpose of this funding opportunity is to address this major gap in knowledge through the launch of CIHR Centres for Research Development in Gender, Mental Health and Addictions. This initiative will provide interdisciplinary teams of researchers and their stakeholders with core infrastructure support to develop integrated programs of research and knowledge translation that examine the influence of gender and sex on mental health and on policies and programs that affect mental health, and design and test new interventions.
The Canadian Coalition for Global Health Research (CCGHR) is pleased to announce the 5th annual Summer Institute (SI-5) for researchers who are new to the field of global health research. By “new” they mean researchers who have become involved in this important area within the past five years. By “global health research” they mean research concerning the problems borne by societies in low and middle income countries (LMICs).The 5th Summer Institute for New Global Health Researchers, to be held in partnership with Network Environments for Aboriginal Research BC of the University of Victoria, Victoria, British Columbia, Canada. The Summer Institute will be held at the Quw'utsun' Cultural and Conference Centre located in the Cowichan Valley, in the southeast corner of Vancouver Island from July 16-23, 2008.
In 2007, an international network of researchers and people involved in building comprehensive primary health care (CPHC) received funding to support research and research capacity-building. This network, associated with the People's Health Movement, includes individuals in India , Africa, Latin America, Europe, Canada and Australia. The ideals of comprehensive primary health care were first launched internationally by the 1978 Alma-Ata Declaration on Primary Health Care. This Declaration was partly based on earlier primary health care successes in significantly lowering infant, childhood and maternal mortality rates and creating over all population health improvements in many parts of the developing world. Since the Alma-Ata Declaration, however, most health systems reform in much of the world has been driven by 'selective' (single-disease or intervention focused) primary health care, and by increased marketization of health care services ( e.g. user fees, privatization). This has led to increasingly complex, inefficient and inequitable health systems driven by an ever larger number of special 'global health initiatives.'This document outlines how this project will set out to change this.
The ACU's Development Partnerships in Higher Education (DelPHE) programme launched it's Third Call for Applications. DelPHE is led by the British Council with the support of the Association of Commonwealth Universities (ACU). DelPHE is designed to support university collaborations which address Millennium Development Goals (MDGs) in any of 25 focus countries across Africa and Asia (details available on the web site). Deadlines for applications will vary by country, as applications must be submitted to the local British Council office in the country of the lead applicant. Each of these offices determine a local deadline, before shortlisted applications are forwarded to the United Kingdom for final evaluation. Local deadlines range between 20 January 2008 and 1 March 2008, with details available on the web site.
The Geneva Forum: Towards Global Access to Health brings together on an equal basis all actors involved in access to health – including international, national and local organizations; government agencies; the private sector; hospitals; universities; civil society; and most importantly those who need care. It provides an interactive and dynamic platform for critical reflexion on the complexity of global access to health. Under the flags of equity, partnership, and capacity building, it strives to link policies and guidelines to actual practice in the field. The Geneva Health Forum 2008 will maintain the broad range of themes considered as priorities: access to health systems; health and inequities; access to drugs, vaccines and diagnosis; civil society and social issues in health; and capacity building and partnerships. The Geneva Health Forum 2008 places special emphasis on the strengthening and integration of health systems and the importance of the global health workforce. Health systems cannot be addressed without a critical look at the current crisis of the global health workforce. The Forum will focus on key initiatives and best practices that address issues such as motivation, working environment, migration, and gaps in competencies. The role that universities, hospitals, and training institutions can play in this domain will be reviewed in light of innovative partnerships and programmes. The conference site provides all relevant details on deadlines for abtract submission and registration.
Research can lead to more cost-effective interventions, better delivery strategies, improved management practices, rational health-system policies, and optimum ways to increase health-seeking behaviour. Research is essential to ensure that new strategies are adapted to fit local political, cultural, and economic contexts. Ultimately, the only truly sustainable way to improve health outcomes is to build local research and innovation capacity so that developing countries can continually improve the effectiveness, equity, and efficiency of their own health systems. To address these issues, a Global Ministerial Forum on Research for Health will be held in Bamako, Mali, Nov 17–19, 2008, that will convene ministers of health, science, and technology, to discuss research and innovation with leading experts and stakeholders in the research process from around the world. The Lancet plans to produce a theme issue on research for health, development, and equity, and is inviting papers that address the core themes of the conference. The deadline for submission of articles is 2 June 2008.
Announcing a new international funding scheme from the Wellcome Trust. To add value to its wide range of international scientific activities, the Wellcome Trust is now providing support for public engagement with health research in developing countries. The International Engagement Awards aim to strengthen the capacity of researchers and communicators in developing countries to facilitate public engagement with health research. From debate about access to treatment to concern around informed consent, health research raises big questions on local, national and global levels. The scheme is open to a wide range of applicants including media professionals, educators, science communicators, health professionals and researchers in bioscience, health, bioethics and history. Partnership projects are also welcomed. Most project activity is expected to take place in developing countries, although partnerships can include individuals based in the UK working with partners based in developing countries. The first deadline for applications is 25 April 2008.
The HIV Collaborative Fund - a partnership of the International Treatment Preparedness Coalition (ITPC) and Tides Center - is seeking applicants to serve as Project Manager for the four funding regions in Africa. The Project Manager provider guidance and oversight to the ITPC/Collaborative Fund Regional Coordinators. This position would be a full-time one. Because of difficulties in putting someone on staff from Africa at US-based Tides Center, this position will either be created as a consultancy or through a contract at an existing organisation in Africa at which the Project Manager would be based. The location of the position would depend on the needs of the person hired and/or the organisation at which the position is based. However, because the job requires significant amounts of travel throughout the continent, the position will most likely be based in either Nairobi or Johannesburg. People living with HIV are encouraged to apply.
Following a very high demand for the workshop run in October 2007, the overseas Development Institute is pleased to announce the 2nd UK workshop on Outcome Mapping (OM) in London in February 2008. Being a 3-day introduction to the basic principles of Outcome Mapping, the emphasis lies in their application to the planning phase of development projects and programmes. It also includes a 1-day OM Surgery to explore ways in which OM concepts and tools can be practically applied within the participants' ongoing projects and programmes. The course fee is £600; which includes lunches and refreshments during the course. To maximize participation and instructional quality, the limit to the number of participants is 24 per workshop. We do this on a first come, first served basis so, to avoid disappointment, register early.
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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